Bradley J Monk, MD, FACOG, FACS Antiangiogenesis Therapy

Bradley J. Monk, MD, FACOG, FACS, discusses case studies in ovarian and cervical cancer. He explains that s

he had a recurrence 18 months after initial therapy. This is termed ‘platinum-sensitive’ disease and is generally treated with a platinum doublet. The CALYPSO trial showed that carboplatin plus pegylated liposomal doxorubicin (PLD) outperforms carboplatin plus paclitaxel in PFS, toxicity, and convenience. A third platinum combination would include gemcitabine, which gained US Food and Drug Administration (FDA) approval in 2006. Adding bevacizumab to this regimen in the OCEANS trial improved PFS (hazard ratio [HR] 0.48) but had no impact on OS, given the long postprogression survival. Bevacizumab can also be safely combined with carboplatin and paclitaxel or PLD. I think all patients with epithelial ovarian cancer should receive bevacizumab at some point. The risk of bowel perforation increases with each successive round of treatment, making earlier antivascular endothelial growth factor (VEGF) therapy safest. In November 2014, bevacizumab gained FDA approval in combination with single-agent chemotherapy when the platinum-free interval is less than 6 months (platinum-resistant disease).

CASE 1: Epithelial Ovarian Cancer

Sarah W. is a 62-year-old Caucasian woman who works as a travel agent.

In June of 2013, the patient presented with bloating and abdominal distension. Prior medical history is notable for nulliparity, and medication-controlled hypertension.

• Physical exam revealed palpable, fixed nodular 10-cm pelvic mass with abdominal ascites, and patient’s CA-125 level was 895 U/mL
• She underwent total abdominal hysterectomy, bilateral salpingo oophorectomy, omentectomy, low anterior resection with anastomosis and complete cytoreduction of all gross metastatic disease. There was no gross residual disease. Stage was FIGO 3C epithelial ovarian cancer
• Patient was negative forBRCA1or2mutation
• She received 6 IV q3-week cycles of paclitaxel/carboplatin
• Her symptoms resolved and CA-125 levels decreased to 9 U/mL; she remained disease free for approximately 18 months

In December of 2014, the patient presents for her 6-month evaluation with rising CA-125 level, mild abdominal distension and fatigue, and inability to work.

• CT scanning reveals metastatic involvement of liver surface, an isolated splenic lesion, and a small amount of ascites
• She was retreated with carboplatin/paclitaxel
• Patient showed improvement in symptoms and performance status (ECOG 0) after 3 cycles of therapy