Case Review: Ovarian Cancer and the Initial Treatment Options

Benedict Benigno, MD:I’m Benedict Benigno. I’m a gynecologic oncologist in Atlanta, Georgia, and I’m the founder and CEO of the Ovarian Cancer Institute.

The patient I’ve been asked to discuss is 58 years old and was in her usual state of good health until she discovered that her abdomen was distending and she had some cramping abdominal pain. This is unfortunately the way most of these patients with ovarian cancer present. She had a CT [computed tomography] scan, which showed a 4-cm adnexal mass. She underwent an operative procedure. Ovarian cancer was found. There was a papillary serous adenocarcinoma, and she was debulked, which means that all the tumor that is even outside the pelvis is removed. Unfortunately, there was residual disease down to 1½ cm.

She was treated postoperatively with intravenous chemotherapy, with cytotoxic chemotherapy with carboplatin and paclitaxel, and with bevacizumab, or Avastin. She had 6 cycles, and the chemotherapy was stopped. Then she developed symptoms of cramping abdominal pain exactly the way she presented originally. She had an elevated CA-125 [cancer antigen 125]. A diagnosis of a recurrent cancer was made, and she was treated with carboplatin-paclitaxel and bevacizumab again. Then about 18 months later, she had another recurrence and was treated once again with carboplatin-paclitaxel and bevacizumab.

Unfortunately, her course is the way it almost always is. Depending upon whom you read, the recurrence rate is 70% to 80%, so we expect the patient to develop a recurrence. She wasBRCA-negative, but she was also HRD [homologous recombination deficiency]—positive, and I’ll get back to that aspect in just a moment. But the reason the diagnosis is almost always made in advanced stage is that the ovary is the only organ in the body that has its functioning cells facing the interior of the abdomen. So long before a tumor forms in the ovary, cells flit off and implant on all peritoneal surfaces, and they favor the surface of the small bowel. The patient presents, for all practical purposes, with an intermittent, partial small-bowel obstruction.

Almost everybody is given intravenous carboplatin and paclitaxel. This has been going on for well over 30 years. It’s very disgraceful; there’s nothing new in over 30 years. The operation changes in intensity, the dosages and the interval between infusions may change, but the carboplatin and paclitaxel has remained distressingly stable throughout most of my career.

I give carboplatin at an AUC [area under the curve] of 6 mg and also Taxol in a dose of 175 mg/m²intravenously every 3 weeks. Both drugs are given every 3 weeks. Sometimes people choose to give the paclitaxel every week. In that case, the dose is lowered.

Two years is right around the time that you would expect a recurrence—1 to 2 years. The later the recurrence following the cessation of chemotherapy, the better the prognosis is.

Transcript edited for clarity.

Case: A 58-Year-Old Female With Progressive Ovarian Cancer

H & P

• A 58-year-old female presents to the clinic for bloating, pelvic pain, early satiety, and urinary urgency. She reports intolerance to strenuous activity at the gym for the past four months but is still able to carry out daily activities such as work, and house chores.
• PE: controlled HTN, abdominal distension;
  • BP: 130/70 mmHg
  • ECOG: 1

Imaging

• CT with contrast of the pelvis, abdomen, and chest reveals bilateral serous cystadenocarcinomas

Biopsy and Labs

• Pathology: high-grade serous carcinoma, epithelial ovarian cancer
• BRCA1-/2wt
• HRD/+
• CA-125: 280 U/mL

Treatment

• Diagnosis: stage IV ovarian cancer
• Patient underwent hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and tumor debulking
• Received IV paclitaxel and carboplatin and bevacizumab, 6 cycles

Follow-up

• CA-125, 43 U/mL upon completion of 6 cycles chemotherapy
• Ten months later at routine follow up, patient presented with recurring symptoms; CA-125, 565 U/mL
• Started on carboplatin/paclitaxel for 6 cycles plus bevacizumab
• Patient achieved a partial response, started on niraparib maintenance therapy
• Four months later:
  • CBC: WNL, SCr: 0.8, AST: 10 u/L, ALT: 7 u/L, and ANC: 1.7 x 10⁹/L
  • BP, WNL
  • ECOG 1