By Johanna Hynninen, MD, PhD, & Seija Grénman, MD, Prof., Head of Department of Obstetrics and Gynecology, Turku University Hospital, Finland
The Turku Ovarian cancer team is a lively group of doctors, nurses and biologists at Turku University Hospital and University of Turku. We are happy to be part of the HERCULES consortium and wish to be able to improve the outcome of ovarian cancer – the most lethal gynecologic cancer.
The patients recruited to the HERCULES study arrive to Turku University Hospital (TUCH) a day before planned surgery. They meet the operative team and the study nurse and get all the information needed about the operation as well as about participating in the study. The next day, usually Thursday, is a busy and long day for us. Both surgery as well as coding and processing of the samples takes several hours. The following story describes a typical operation day.
7.00 am: Blood samples needed for both treatment and the HERCULES study are taken at the ward.
7.30 am: Study nurse Tiina comes to work. She fills in the patient’s clinical information to a database, prints code stickers and checks that everything is ready for sample collection in the operating theater.
8.00 am: The doctors come to the morning meeting of the Department of Obstetrics and Gynecology.
8.30 am: The study nurse and the operating doctors have time for a quick meeting and a cup of coffee. Meanwhile the study patient is transferred to the operating theater for preoperative procedures.
9.00 am: The patient is asleep and the surgery begins. Samples to the study are collected in a specific order. First, ascites, which is fluid that has accumulated inside the abdomen, typical for ovarian cancer, is drained into 2 liter sterile bags. In order to confirm the patient’s diagnosis, a piece of tumor tissue is sent to the Department of Pathology for frozen sample examination.
If the patient has very advanced, inoperable disease, only laparoscopy is performed and the ascites fluid and small tumor samples are taken. Then the patient is scheduled for chemotherapy to first reduce the tumor mass, and a new surgery is planned for later.
If the doctors think that they can achieve a good result with surgery, they continue to extensive radical operation to remove all visible tumor. Today’s patient is treated with such an upfront operation.
9.20 am: The surgeon has taken samples from multiple sites, such as the right ovary and the omentum, which is a ‘sheet’ of peritoneum, fat and lymphatic tissue below the stomach and in front of the small intestine. It is a typical place of ovarian cancer metastasis: the whole omentum can form a large tumor called “omental cake”.
The study nurse is in a hurry: all samples should be carefully recorded and labeled and part of the tumor tissue should be frozen as quickly as possible for future RNA/DNA sequencing.
In five minutes after the tumor tissue is removed, the study nurse cuts pieces of it for freezing and for single cell analysis performed in HERCULES. The aim is to get the most fresh looking, vital tissue for further processing, the necrotic parts of the tumor with mainly dead cells are avoided.
9.30-11.30 am: Removal of tumor tissue continues: some new samples from the abdominal cavity (peritoneum) and lymph nodes are taken and processed. Usually the operation goes according to plans, but every now and then tight adhesions, heavy bleeding, poor visibility interfering sample collection etc. can cause problems. Sometimes the surgical team is so focused on performing the operation that they need to be reminded to take the study samples.
10.30 am: Pathologist calls to surgeon: the frozen sample taken from the omentum suggests high grade serous carcinoma with ovarian/peritoneal origin.
12 noon: All the HERCULES samples are ready. The study nurse gets some fresh air while carrying the samples to the Carpén lab, a project partner in the University of Turku, located 500 meters away from the hospital in the Biocity Turku campus. The operative team continues the surgery for some hours to achieve optimal results for the patient and dreams of a cup of coffee and a sandwich.
When the operative team finishes, the work of the team in Biocity has just started….