Case-Based Overview: Pretreated Recurrent Ovarian Cancer

Thomas Krivak, MD:The case that we’re going to talk about today is a 58-year-young female diagnosed in 2014 with stage IV ovarian carcinoma. Her final pathology was a high-grade serous carcinoma from epithelial ovarian cancer. Her initial CA [cancer antigen] 125 was about 460 upon presentation. The CAT scan that was obtained prior to surgery—it was a CT scan to the abdomen, pelvis, and chest, which revealed a 4-cm mass of the left ovary, peritoneal carcinomatosis, and some ascites.

She underwent surgery, which included exploratory laparotomy. She was suboptimally debulked with residual disease greater than 1.5 cm. Postoperatively, the patient received combination intravenous [IV] intraperitoneal chemotherapy with carboplatin and paclitaxel for 6 cycles. She achieved a complete remission with a normalization of her CA 125, CT scans, and physical examination.

Approximately 2 years later, in 2016, she had some symptoms of recurrence, some bloating, and some early satiety. Her CA 125 had risen to 255. She had an ECOG status of 1. At that point, the decision was made for the patient to be treated with chemotherapy. She was treated with carboplatin/paclitaxel for 6 cycles, along with bevacizumab. She had a good partial response at that time and went into remission. She had a good partial response at that time with a CA 125 of 45, and she continued on bevacizumab maintenance.

About a year and a half following the second-line chemotherapy—we’re now into 2017—she again presented with symptoms of early satiety and of bloating, as well as some pelvis discomfort. Her CA 125 had risen to 515, and she had an ECOG status of 0. Genetic testing at the time was noted to be germlineBRCA 1and2wild-type.        

Currently, the patient has a CA 125 of 620. Her CT scan shows several small masses within the lung as well as abdomen, and she has an excellent functional status of the ECOG of 0.

I would say this is somebody that’s typical, that we see with ovarian cancer. This is a young woman who developed some symptoms of ovarian cancer, and then, unfortunately, presented with that advanced stage disease where she had stage IV disease, based off not just her CT scan findings of abdominal disease but also pleural effusions or something within the liver parenchyma or upper abdomen, such as a pleural effusion.

When we see young women like this that have a good functional status…I like how they treated her. They treated her very aggressively and took her for primary surgical cytoreduction, which, again, candidates for patients with stage IV—at this point a lot of people would consider neoadjuvant chemotherapy, which is 3 cycles of chemotherapy, interval debulking surgery, and then 3 to 4 additional cycles of chemotherapy, and then consider maintenance therapy up front. This patient was treated aggressively with up-front surgical debulking. Unfortunately, she was suboptimal midbulk. That meant that the disease that was left was greater than a centimeter, and a lot of folks would consider any gross residual disease to be suboptimal.

I think this case brings up a couple points. First, she had a primary debulking. It sounds to me like the surgeons felt that could get everything, so they their best to do so. Secondly, with that neoadjuvant chemotherapy, should she get 3 cycles or 4 cycles and then interval debulking? Most people would say 3 cycles of chemotherapy and then interval debulking followed by additional chemotherapy.

I think that in 2019, we have lots of options for these patients. It’s about how functional the patient is, what the risk the patient really wants to take is, and then…the surgical skill and what they’re willing to risk for trying to do a primary surgical cytoreduction. In my opinion, when taking somebody to the operating room, I would try to get that patient to microscopic residual. To do a laparotomy, realize that you may not be able to get the patient to complete surgical cytoreduction. Maybe abandoning that and giving them chemotherapy could have been a choice. I think what they did was completely fine.

I think the other thing that was outside of the kind of new way of thinking is giving somebody combination IV/IP [intraperitoneal] chemotherapy who was suboptimally debulked. In most of the studies that we’ve done, looking at in the United States, they were with patients who had gross resistant disease of less than a centimeter. You know, GOG-252 is the most recent trial that really showed marked improvements in progression-free survival in the 26, 27, 28-month range, which was a combination of aggressive surgery, a combination IV/IP chemotherapy in 2 arms, and then weekly IV chemotherapy in 1 arm, and then placing the patients on maintenance bevacizumab.

I think what we can say is that this patient was treated very aggressively with primary debulking surgery, given combination IV/IP chemotherapy to achieve remission. Again, she did that. She is like 80% to 90% of folks who come in with this new diagnosis that will achieve remission, which is defined as normal CA 125, normal physical examination, and normal imaging studies such as a CAT scan. I think that this was a very well aggressively managed patient up front.

Transcript edited for clarity.

Case: A 58-Year-Old Female With Heavily Pretreated Recurrent Ovarian Cancer

H & P

• 58-year-old female diagnosed in 2014 with stage IV ovarian cancer
  • Pathology: high-grade serous carcinoma, epithelial ovarian cancer
  • CA-125: 460 U/mL
  • CT with contrast of the pelvis, abdomen, and chest revealed a 4-cm mass in the left ovary and peritoneal carcinomatosis
  • Patient underwent suboptimal debulking surgery; residual disease 1.5 cm
  • Received IV/IP carboplatin/paclitaxel (6 cycles); achieved complete remission
• 2 years later (2016) symptoms returned; CA 125, 255 U/mL; ECOG: 1
  • Received carboplatin/paclitaxel (6 cycles) and bevacizumab; achieved good partial remission; CA 125, 45 U/mL; continued on bevacizumab maintenance
• 1.5-years following second-line therapy (2017), again presented with symptoms; CA 125, 550 U/mL; ECOG: 0
  • Genetic testing;gBRCA1/2wild-type
  • Received carboplatin/gemcitabine (6 cycles); CA 125, 46 U/mL; achieved complete remission
• Currently:
  • CA 125, 620 U/mL
  • CT shows several small masses in the lung left lower lobe (largest is 3 cm)
  • ECOG: 0