A Case of Platinum-Sensitive Epithelial Ovarian Cancer

Shannon Westin, MD:Today we’re dealing with a case of a 49-year-old African American female who presented to a clinic complaining of increasing abdominal bloating, early satiety, and generally not feeling well. Her past medical history was really unremarkable. She had a hepatitis-B chronic infection that really didn’t bother her or cause any medical issues. She did have an interesting family history, where her mother had been previously diagnosed with ovarian cancer and her remote cousin was diagnosed with breast cancer. Ultimately, she underwent a workup that included a serum CA 125 level that was elevated to about 250 U/mL. She had imaging with a CT scan of her chest, abdomen, and pelvis that demonstrated ovarian masses, as well as ascites and omental caking.

She was taken to the operating room by a gynecologic oncologist who performed an optimal tumor-reductive surgery that consisted of removal of the uterus, hysterectomy, bilateral salpingo-oophorectomy, omentectomy, lymph node dissection and removal of any observed tumor nodule. The final pathology was consistent with high-grade serous ovarian cancer involving the lymph nodes in the omentum, ovaries, and fallopian tubes.

This patient had a very typical presentation in that the majority of patients we see with newly diagnosed high-grade serious ovarian cancer are going to be diagnosed at an advanced stage, stage 3 or 4. This particular patient is stage 3C, and we often see this because patients have very nondescript symptoms. They may not come in as quickly as they would for something like bleeding. It’s somebody feeling a little bit fuller, their clothes not fitting as well, or that they’re not eating as well. Those kinds of things can be easy to blow off or attribute to a change in food or a change in diet. And so, we often see these patients come in at stage 3 or 4. This is quite common.

One thing that’s a little bit unique about this situation is certainly the age of the patient. She’s a little bit younger than what we see as our average of diagnosis for ovarian cancer, which approaches about 62 years of age. In addition, the family history worries us and certainly makes us wonder if there might be a hereditary cancer component to this particular situation.

This patient’s surgical outcome was absolutely optimal. That’s the word we throw around when we talk about removing as much tumor as possible. There are a couple of levels of optimal, one being an optimal level with less than 1 cm of residual disease—that’s disease left behind at the time of surgery. Our ultimate goal is really to get the patient to what’s called “no gross residual disease,” which is no visible disease. That’s what we were able to achieve with this patient. I would say that from a standpoint of the goal of oncologic outcomes, this patient had an exceptional surgery and had the outcome that we hoped for.

Now in regard to neoadjuvant chemotherapy, we certainly have been seeing an increase in the use of neoadjuvant chemotherapy, which is chemotherapy before surgery. What we’re struggling with and trying to identify is which patients really benefit the most from surgery first and which patients should get chemotherapy first.

Generally, one of the rules that we utilize to determine if a patient gets chemotherapy first involves the patients who we know we cannot get to no gross residual disease. This might be a tumor in the chest, either in the lungs or the mediastinal lymph nodes. Or, it could be a tumor involving the porta hepatis, something that’s very difficult for us to resect to no gross residual disease. The way we figure that out is with multiple things. We can use imaging or we could potentially use laparoscopic surgery to determine that. But bringing it back to this patient, she was certainly able to have all tumor removed and achieved no gross residual disease. That is an ideal outcome for her.

The risk of recurrence for any patient who is diagnosed at an advanced stage, whether that’s stage 3 or 4, approaches about 70%. It’s awfully high. Even in a patient population where we can completely get them to a beautiful response after surgery and chemotherapy, the majority will recur, which is a huge issue for this disease. Regarding molecular testing or additional testing that can be done, the standard of care now for high-grade ovarian cancer is that the patient be tested for the presence of aBRCAmutation, whether that’sBRCA1orBRCA2, for multiple reasons.

There are reasons for her family. This patient has a family history of ovarian and breast cancer. This could potentially impact the remainder of her family if they’re found to be at high risk. In addition, there’s potentially a way we can drive treatment or guide treatment based on the results of that testing. So, that is definitely something we would want to do.

Transcript edited for clarity.

A 49-Year-Old Woman with Platinum-Sensitive Epithelial Ovarian Cancer and GermlineBRCA1Mutation

March 2013

• A 49-year-old African American woman presented to her primary care physician complaining of abdominal bloating
• PMH: chronic HBV infection, mild HTN
• FH: mother died of breast cancer at age 59, cousin on mother’s side died of ovarian cancer at age 65
• CT, ascites and bilateral 8-cm adnexal masses
• CA 125, 285 U/mL
• She underwent exploratory laparotomy followed by omentectomy, bilateral salpingo-oophorectomy, pelvic lymph node dissection, appendectomy, and resection of pelvic nodules
  • No gross residual disease (R0)
  • Germline molecular testing showed aBRCA1alteration
• Pathology: high grade epithelial ovarian cancer involving omentum, both ovaries, and 3 micro-metastatic lymph nodes
• She was treated with IV/IP paclitaxel/cisplatin; after completion, CA 125, 14.2, clinically NED

September 2015

• 18 months later, on routine follow up, CA 125, 203 U/mL
• Lymph node disease and carcinomatosis on imaging  
• She was treated with gemcitabine/carboplatin for 6 cycles
  • CA 125, 11.3; clinically NED
• The patient was started on rucaparib maintenance therapy while enrolled on a clinical trial
• After 2 cycles of therapy, the patient’s live enzymes rose transiently and then returned to normal
  • AST, 127 U/L
  • ALT, 142 U/L
  • Creatinine, 1.5 mg/d            

November 2017

• The patient complained of worsening fatigue and bloating
• CA 125, 1004 U/mL