Diagnostic Workup for Ovarian Cancer

Thomas Herzog, MD:So, this is a 56-year-old woman who presented to her gynecologist with urinary frequency and some abdominal bloating. She reports otherwise that she has been able to maintain her normal activities. Her past medical history is significant for hypertension that’s controlled on a diuretic. Abdominal ultrasound showed a complex mass in the right pelvis that measured 4.5 x 5.0 x 7.5 cm. Physical exam showed a fluid weight on her abdomen. She was diagnosed with ascites, and her CA-125 was 622. She was referred to a gynecologic oncologist for further evaluation and workup, and they performed a CT scan of the pelvis and the abdomen that showed a complex pelvic mass confirming what we saw on the ultrasound. It showed ascites and omental cake as well. No other peritoneal lesions were identified, however.

Based on these findings, she was scheduled for surgery, and she underwent a complete resection, meaning no residual disease at all. So, she didn’t have any residual at the end of this—we call that “R0.” She then received 6 cycles of chemotherapy, consistent with carboplatin every 3 weeks, with an AUC of 6. She underwent weekly paclitaxel, receiving 80 mg/m², and that went on for 6 cycles. She had an excellent response with her CA-125, normalizing at 10. She was doing very well all along this time. She then was in surveillance, being seen every 3 months for the first 2 years. And it was almost 2 years out where she re-presented with symptoms consistent of abdominal bloating once again. She had some distensions and early satiety, and she was more tired. She had fatigue and complained of having to take more frequent naps during the day.

Unfortunately, her CA-125, which had again nattered under 10, was found to be 330. So, this triggered scanning. She had a CT scan that showed peritoneal carcinomatosis and small volume ascites. She was thus diagnosed with platinum-sensitive recurrent ovarian cancer. At this point, she was started on carboplatin/paclitaxel/bevacizumab. The carboplatin was at an AUC of 5, the paclitaxel was 175 mg/m², and that was given every 3 weeks. The bevacizumab was administered at 15 mg/kg. She did very well. After 2 cycles of therapy though, she was found to have grade 2 hypertension. Her blood pressure was elevated to 156/94 mm Hg. At this point, we were able to control that by just simply adding an ACE inhibitor in addition to her baseline diuretic that she received. So, that was able to be controlled with just that intervention. And she continues on treatment, at this point doing very well and tolerating therapy well.

When you think about this patient—and I always think of ovarian cancer as being on a timeline or a spectrum—she’s highly platinum-sensitive, being that it has been over 2 years since her original disease was diagnosed. And she has had no intervening treatment. So, she has done quite well. There are some things about this that are very promising. There are other things about this case that are troubling, one being that she represented with fairly widespread disease—small volume disease, widely distributed—and that certainly is more difficult.

One of the things that you certainly think about in a patient who presents this late is the role of interval cytoreduction. Would there be value in taking her back to the operating room? And so, that’s certainly something that would be considered in a patient like this. There are things that speak against that though. There is the fact that she has ascites and the fact that she has multiple recurrences in terms of the number of sites. Her timeline is perfect. We’re considering taking her back. Her performance status being the same, her comorbidities, all those things, would say ‘Take her back”. So, in my estimation, she’s in that gray area of how much benefit she would have from going back.

The patients that clearly benefit the most are the ones with very long intervals, such as we’ve seen here, and patients with more isolated disease. Also, there are some studies that suggested large-volume ascites are associated with patients who do not do as well with interval site of reduction. So, these are some important things that you need to consider in this patient.

In terms of prognosis, I think there are several things to think about. One is her platinum-free or treatment-free interval and then, again, her volume of disease and the sites of disease. There are a couple of things that are very promising, but a couple of things that are troubling. So, it’s a bit of a guarded prognosis. It’s unlikely that we will be able to cure her at this point. Occasionally, you’ll have patients who do recur with an isolated mass, in which case your chances for a long-term remission or cure are higher. Basically, recurrent ovarian cancer is extremely difficult to cure.

Transcript edited for clarity.

May 2015

• A 56-year-old woman presented to her gynecologist with urinary frequency and persistent abdominal bloating. The patient reports maintaining normal activities and a moderate exercise.
  • PMH: Hypertension, well-controlled or spironolactone
  • Abdominal ultrasound showed a complex mass in the right pelvis measuring 4.5 X 5.0 X 7.5 cm
  • Physical exam: fluid wave test positive for ascites
  • CA-125, 622 U/ml
• She was referred to a gynecologic oncologist for further evaluation.
• CT of the pelvis and abdomen showed a right complex pelvic mass, ascites, and omental cake. No other peritoneal lesions were visualized.
• Based on CT findings, she was scheduled for surgery.
• The patient underwent complete resection with no residual disease remaining.
• Diagnosis, epithelial ovarian cancer, stage IIIC
• She received 6 cycles of carboplatin every 3 weeks (AUC 6) and weekly paclitaxel (80 mg/m²) for 18 weeks.
• Follow up labs showed normalization of CA-125 to less than 10 U/ml

April 2017

• Almost 2 years later, the patient reported having symptoms of persistent abdominal distention and weight loss. She reports feeling tired and napping during the day.
  • CA-125 level, 330 U/ml
  • CT scan showed peritoneal seeding consistent with carcinomatosis
• Diagnosis: platinum-sensitive recurrent ovarian cancer
• The patient was started on bevacizumab (15 mg/kg) plus 6 cycles of carboplatin (AUC 5) and paclitaxel (175 mg/m²) every 3 weeks with a plan for bevacizumab maintenance therapy.
• After 2 cycles of therapy, she developed grade 2 hypertension (156/94 mm Hg); this was subsequently controlled by adding an ACE inhibitor to her diuretic.
• The patient has continued therapy without incident.