Newly Diagnosed Advanced Ovarian Cancer: Case Reactions

Bradley J. Monk, MD, FACOG, FACS:I’d like to present a 54-year-old woman with newly diagnosed advanced epithelial ovarian cancer. She represents sort of the typical scenario: 54 years old, comes to her gynecologist, thinks that she has some symptoms in her pelvis—urinary frequency, a little early satiety, kind of bloated—and it’s been gradual over the last handful of months. So she goes to see her gynecologist. Her gynecologist does a physical examination and feels a mass. The gynecologist notes her past medical history of obesity, prediabetes—so diabetes that’s controlled with diet—and also some controlled single-medication hypertension. A CT [computed tomography] scan confirms there is an 11-cm pelvic mass. Interestingly, there is some ascites and some carcinomatosis on the CT scan, and, as is routine, the physician does a CA-125 [cancer antigen 125 test], which is elevated at 785 U/mL.

So what’s the right step? Well, the right step is a referral to a gynecologic oncologist. She’s evaluated by the gynecologic oncologist. The gynecologic oncologist recommends that she have a midline laparotomy with a surgery, planning a hysterectomy with the preemptive diagnosis of ovarian cancer and, ultimately, likely a debulking surgery and maybe even a bowel resection. So she undergoes an exploratory laparotomy, a full abdominal hysterectomy, a bilateral salpingo-oophorectomy, an omentectomy, and debulking; and indeed, the pathology shows a high-grade serous ovarian cancer.

Interestingly, the entire debulking was not successful. There was just over a centimeter of residual disease—what we would call large-volume residual disease. And the reason that it was not completely resected is because it involved the porta hepatis right there next to the gallbladder, next to the portal vein, or peritoneal disease if you will. And so she had large-volume residual disease and is sent for the evaluation of adjuvant chemotherapy. At that time, she undergoes genetic counseling and has germlineBRCAtesting, and she is found to be negative for deleterious or suspected deleteriousBRCA1orBRCA2mutations.

So the patient under consideration again is 54 years old, and is prediabetic, hypertensive, mildly obese, and recovering from a midline laparotomy debulking surgery. The first thing we do is we look at histologic subtype. Her histology is a high-grade serous ovarian cancer. That represents about 85% of newly diagnosed cases. Secondly, we look at the molecular signature. She does not have a germlineBRCAmutation, and I could just add that she should have had somaticBRCAtesting, and she’s also somaticBRCAnegative. And then finally we look at the residual disease, and she has large-volume residual disease just over a centimeter.

The consideration now is to consider adjuvant therapy. But first I want to comment that the most difficult decision that we make when confronted with a woman who is suspected to have an advanced ovarian cancer is whether to begin with chemotherapy or to begin with an operation. When we begin with chemotherapy, that’s called neoadjuvant chemotherapy. Then the surgery is interdigitated between the third and the fourth doses, typically with the plan ultimately of either 6 continuous doses of chemotherapy or 3 doses, surgery, and 3 doses.

So how do you figure out whether a patient should have neoadjuvant chemotherapy or primary debulking? Again, that’s the hardest decision that we make. In this particular patient, she had large-volume residual disease, so one could argue that she should have had neoadjuvant therapy. It’s a tough decision. More and more, the surgeon is looking in with a laparoscope to get an assessment. This particular patient did not have a laparoscopic assessment. The decision was made to go directly to debulking surgery. You really can’t be critical that the surgeon tried, and it’s understood that occasionally there is unresectable residual disease.

Transcript edited for clarity.

Case: A 54-Year-Old Woman Diagnosed With Advanced Ovarian Cancer

H & P

• A 54-year-old woman presents after referral from her gynecologist for widespread tenderness, abdominal discomfort, and urinary symptoms. Pelvic exam performed by the gynecologist revealed a suspicious mass on her right ovary.
• Postmenopausal with two children
• PE: reveals an obese woman (BMI = 31 kg/m²) with mild hypertension and pre-diabetes; abdomen shows dullness to percussion
  • BP = 130/85 mm Hg
  • Fasting glucose = 115 mg/dL
  • Waist: hip ratio = 0.90

Imaging

• CT with contrast of the pelvis, abdomen, and chest reveals widespread peritoneal lesions and abdominal lymph node involvement
• Malignant ascites present

Biopsy and labs:

• Pathology, high-grade serous adenocarcinoma, ovarian primary
• BRCA1/2 status: negative
• CA-125: 785 U/mL

Treatment

• She underwent hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and tumor debulking; residual disease after cytoreduction = 1.1 cm
• Diagnosis, stage IIIC ovarian cancer, grade 3
• Started on every-3-week carboplatin and paclitaxel IV plus bevacizumab every 3 weeks