a 49-year old woman presented in october 2007 with abdominal bloating , pain , and obvious ascites . after imaging data was obtained , in december 2007 the patient underwent total abdominal hysterectomy ( tah)/bilateral salpingo - oophorectomy ( bso ) and debulking surgery to remove as much of the tumour as possible . after surgery the patient was diagnosed with serous ovarian adenocarcinoma , stage iii c. first - line chemotherapy was the recommended taxol / carboplatin combination standard - of - care for 3 cycles , which finished in march 2008 . in june 2010 the patient relapsed and there was recurrence of disease , presenting as rapidly accumulating ascites . the patient was rechallenged with platinum second - line ; treatment was taxol / carboplatin for 6 cycles , which was completed in october 2010 . the patient then agreed to participate in a phase ii study investigating the ca-125 doubling time in patients with advanced disease treated with tamoxifen citrate . in april 2011 there was recurrence of disease , and in august 2011 the patient received trabectedin + pld combination for 5 cycles as fourth - line therapy . the patient achieved a good clinical response according to ca-125 measurement , and the chemotherapy was stopped given the good clinical status of the patient . in january 2012 the patient experienced disease progression and received subsequent treatment with gemcitabine / carboplatin / bevacizumab combination therapy for 6 cycles , plus bevacizumab 15 mg / kg every 3 weeks as maintenance therapy . in june 2013 the patient experienced further disease progression and received taxol / carboplatin as weekly treatment for 6 cycles until january 2014 , after which the patient 's disease was stable . disease recurrence occurred in march 2014 , with ascites , para - aortic lymph node involvement , and peritoneal disease . the patient was subsequently re - challenged with trabectedin + pld as seventh - line of chemotherapy . 1a ) , and ct imaging showed a clinical response and improvement in symptoms ( fig . the dose of trabectedin + pld was adjusted for this patient due to grade 3 fatigue . the trabectedin dose was reduced from 1.1 to 0.9 mg / m , and pld was reduced from 30 to 25 mg / m . the management plan for this patient is to continue treatment with trabectedin + pld until disease progression . the patient has finished 11 cycles so far and is still in remission , and continues to do well . in summary , this case study describes a new concept in the management of a roc patient who has received 7 different lines of chemotherapy and has experienced recurrent disease . trabectedin + pld combination was effective as a non - platinum / non - taxane alternative to intercalate between platinum - based therapies . in fact , trabectedin has been administered for 6 or more cycles in 52% of patients treated with the combination dose and schedule respectively . the combination regimen has been used for up to 21 cycles , and no cumulative toxicities have been observed in patients treated with multiple cycles . so whilst doxorubicin is limited by its cumulative dose due to cardiotoxicity , trabectedin plus pld can be used to disease progression . in the case study described here the patient is doing well , and will continue maintenance treatment with trabectedin + pld , with repeat echo every 12 weeks , until disease progression . as with all cytotoxic regimens there are some practical considerations to treating patients with trabectedin + pld . infusion at a dose of 1.1 mg / m , immediately after pld 30 mg / m , for the treatment of ovarian cancer ( fig . the following steps must be taken when administering the combination : 
 all patients must receive corticosteroids e.g. 20 mg of dexamethasone i.v . infusion of trabectedin 1.1 mg / m , immediately after pld , every 3 weeks through a central venous line all patients must receive corticosteroids e.g. 20 mg of dexamethasone i.v . infusion of trabectedin 1.1 mg / m , immediately after pld , every 3 weeks through a central venous line as with other cytotoxic regimens , monitoring of patients receiving trabectedin + pld is recommended ( box 1 ) . the patient must satisfy the following criteria for initiation of treatment and prior to each re - treatment : 
 absolute neutrophil count ( anc ) 1,500/mmplatelet count 100,000/mmbilirubin  upper limit of normal ( uln)alkaline phosphatase 2.5  uln ( consider hepatic isoenzymes 5-nucleotidase or gamma glutamyl transpeptidase ( ggt ) to determine whether the elevation is of hepatic or osseous origin.albumin 25 g / l.alanine aminotransferase ( alt ) and aspartate aminotransferase ( ast ) 2.5 mol / l ) or creatinine clearance 60 ml / mincreatine phosphokinase ( cpk ) 2.5 ulnhaemoglobin 9 g / dl absolute neutrophil count ( anc ) 1,500/mm platelet count 100,000/mm bilirubin  upper limit of normal ( uln ) alkaline phosphatase 2.5  uln ( consider hepatic isoenzymes 5-nucleotidase or gamma glutamyl transpeptidase ( ggt ) to determine whether the elevation is of hepatic or osseous origin . alanine aminotransferase ( alt ) and aspartate aminotransferase ( ast ) 2.5  uln serum creatinine 1.5 mg / dl ( 132.6 mol / l ) or creatinine clearance 60 ml / min creatine phosphokinase ( cpk ) 2.5  uln otherwise treatment should be delayed and/or reduced for up to 3 weeks until the criteria are met , as highlighted in the case study above ( box 2 ) . a single institution 's experience with trabectedin + pld combination , as a non - platinum / non - taxane alternative to intercalate between platinum - based therapies is reported here . a real - life case study is presented of a heavily - treated patient with advanced disease who was treated with trabectedin + pld fourth - line and subsequently rechallenged at seventh - line , who continues to do well on treatment . this case study demonstrates the utility of the combination at any line of relapse in roc patients with advanced disease . professor tahir received speaker fees from pharmamar for his participation at the bgcs 2014 symposium .
the goal of recurrent ovarian cancer ( roc ) treatment is no longer just palliation , but prolonging survival . 
 this is usually through administering a new line of chemotherapy at each relapse . 
 a novel treatment sequencing strategy to achieve this is through the intercalation of an effective non - platinum alternative , in between platinum - based therapies . 
 trabectedin in combination with pegylated liposomal doxorubicin ( pld ) has been fully available privately in the uk since 2009 for treating patients with roc . 
 a single institution 's experience with the trabectedin + pld combination , as a non - platinum / non - taxane alternative , to intercalate between platinum - based therapies is reported here . to date 6 patients 
 have been successfully treated with trabectedin + pld at broomfield hospital , chelmsford , essex . here 
 we describe a new , practice - changing treatment approach in a real - life case study of a heavily - treated patient with advanced roc treated with trabectedin + pld at fourth - line and then subsequently rechallenged at seventh - line ; with treatment continuing until disease progression .