Case Overview: High-Risk Ovarian Cancer

Ramez N. Eskander, MD: Today we’re going to be talking about ovarian carcinoma. Specifically, we will be reviewing the case of a patient diagnosed with recurrent advanced-stage high-grade serous ovarian cancer.

This patient is a 71-year-old female who presented to her primary care physician for a follow-up visit. She reported progressive fatigue as well as abdominal pain. Importantly, the patient had a history of ovarian cancer that was initially diagnosed in 2017. Based on her initial disease distribution, she was presumed to have stage IVa disease and was treated with a primary surgical cytoreduction. Unfortunately, she had a suboptimal resection with residual tumor greater than 1 cm in the abdominal peritoneal cavity.

In the context of her initial disease stage and after her surgical intervention, she was counseled and treated with adjuvant chemotherapy using carboplatin, paclitaxel, and the antiangiogenic agent bevacizumab. She received 6 cycles of the triplet combination regimen and was subsequently treated with bevacizumab maintenance therapy. Thankfully, she achieved a complete response on bevacizumab maintenance therapy and was subsequently in remission.

Now, the patient presented to her primary care physician, as outlined above, with these nonspecific symptoms. These nonspecific symptoms presented 2 years after her initial surgical resection and after completion of her frontline therapy. Unfortunately, her CA-125 [cancer antigen 125] , which was drawn at that point in time, was elevated at 456 [U/mL]. And in parallel, radiographic imaging in the form of a CT scan of the chest, abdomen, and pelvis was obtained and showed suspicious lung lesions that were suggestive of disease recurrence. These were subsequently biopsied, helping confirm that this patient had recurrent high-grade serous ovarian carcinoma to the lung.

Tissue was subsequently submitted for molecular characterization, specifically assessing homologous recombination deficiency, LOH [loss of heterozygosity] status, as well as potentially other genomic aberrations. This patient’s tumor was found to be homologous recombination deficient, based on loss of heterozygosity assessment. The patient did previously have germline testing done and was BRCA wild-type without a known genetic inherited aberration or mutation, and no other actionable alterations were noted.

In follow-up after the patient was diagnosed with this disease recurrence, based both on imaging and biopsy, she was counseled regarding therapy. She had platinum-sensitive disease recurrence, given her prior disease-free interval, and the decision was made to proceed with a combination platinum-based regimen with carboplatin and pegylated liposomal doxorubicin. She received 4 cycles of systemic cytotoxic chemotherapy, had a response to treatment, with a reduction and resolution of her CA-125 to normal levels, and radiographic imaging showed no definitive evidence of residual or metastatic disease. Importantly, after 4 cycles of carboplatin and pegylated liposomal doxorubicin, the patient was counseled about the opportunity for maintenance therapy in this platinum-sensitive recurrent setting. She chose to proceed with maintenance single-agent rucaparib at 600 mg orally twice daily, and she remains on that regimen without evidence of disease recurrence.

Transcript edited for clarity.

Case: A 71-Year Old Woman With High-Risk Ovarian Cancer

Initial presentation

• A 71-year old woman presented to her PCP for a routine annual checkup, she complains of increasing fatigue
• PMH:
  • Hypertension, controlled on a thiazide
  • 2017 diagnosed with stage IV ovarian cancer; BRCAwt; underwent TAH/BSO, lymph node dissection, with suboptimal debulking; treated with paclitaxel/carboplatin/bevacizumab followed by maintenance bevacizumab; achieved CR

Currently

• CA-125, 456 U/mL
• Chest/abdomen/pelvis CT with contrast shows a suspicious lung lesion
  • Lung biopsy confirmed recurrent epithelial ovarian cancer
• Molecular testing showed HRD+, LOH high
• ECOG: 0

Treatment and Follow-Up

• She was started referred to an oncologist and started on carboplatin/doxorubicin, treatment was well tolerated for 4 cycles; CA-125 35 U/mL;
  • Rucaparib 300 mg BID maintenance was initiated
• At 2 months follow-up
  • CA-125 was undetectable
  • Chest/abdomen/pelvis CT showed no gross masses or nodes
  • Pelvic exam was unremarkable