Presentation of Stage IIIc Ovarian Cancer

Jubilee Brown, MD:There are a lot of really important points in this case that are fairly reflective of what we tend to see in women who present with ovarian cancer. For example, this patient presented with new onset early satiety, abdominal bloating and discomfort. That is what we tend to see as a constellation of symptoms in patients with advanced ovarian cancer. As you know, they typically present with advanced disease at the time of diagnosis. Her age as well, at 59 in a postmenopausal setting, is very typical for epithelial ovarian cancers.

With the physical examination, patients often present with abdominal distension, with left lower quadrant tenderness or diffuse tenderness. In this patient, she did have left lower quadrant tenderness and shifting dullness on percussion. That really is very typical of what we tend to see. It’s important to point out that a pelvic examination is very important for the generalist or the family practice doctor, the internist, whoever sees patients who fit this description. It’s a really important component of the work-up.

Other things that are necessary in the clinical work-up or notable, I would say, are the transvaginal ultrasound, and that is the imaging of choice for women in whom you really want to look and see what the adnexa look like. In this patient, as with most with ovarian cancer, this patient had an ovarian mass that was identified. Now, we don’t usually recommend a CT [computed tomography], MRI [magnetic resonance imaging], or PET [positron emission tomography] CT scan as the first option for screening these patients. But certainly the appropriate work-up includes a chest, abdomen, and pelvis CT, as this patient had, to really define the extent of the disease.

This patient it looks like had extension to the liver capsule without parenchymal involvement. She also appears to have had retroperitoneal lymph node involvement and some ascites. We can see that she really did have extensive ovarian cancer. One of the things that we look at as well is to see if there’s a pleural effusion, and fortunately for this patient she did not appear to have a pleural effusion or parenchymal disease, so not stage IV, so that’s good news.

This patient had a high-grade epithelial ovarian cancer, and that of course is the most common type of ovarian cancer that we see. It looks like likely a high-grade serous carcinoma. Some of the details, we do recommend obtaining a CA-125 [cancer antigen 125] level, and hers is elevated, 385 U/mL, and again that is very typical for what we see with women with epithelial ovarian cancers. Also important in determining how we manage these patients is her performance status, and fortunately her performance status is 1. That can play into any decision that we make with regard to neoadjuvant chemotherapy versus upfront surgery.

Something that’s very important in today’s testing is that once we have diagnosis of ovarian cancer, we really want to know about germline genetic testing, as well as molecular testing of somatic mutations. This patient had a germline genetic testing that showed she was HRD [homologous recombination deficiency]-negative andBRCA1andBRCA2wild-type. We’ll get into that a little bit later why that’s so important.

This patient had specific treatment involving an abdominal approach to a total hysterectomy—bilateral salpingo-oophorectomy and lymph node dissection with optimal debulking. She was able to get down to an R0 resection status, which of course means that there’s no visible tumor remaining. That’s really the goal for any patient with surgery. Now, this patient did have retroperitoneal lymph node involvement. We wouldn’t necessarily do a lymph node dissection with every patient with bulky disease in the abdomen, but of course this patient had enlarged nodes, and so that is the justification for her lymph node dissection.

She received IP [intraperitoneal] IV [intravenous] paclitaxel and carboplatin with bevacizumab every 3 weeks for 6 cycles, followed by bevacizumab for 6 more cycles and obtained a complete response as the majority of patients do. Her post-treatment CA-125, though not quite normal, was down to 48 U/mL. I think that brings into the conversation whether we should incorporate intraperitoneal chemotherapy in every patient and if we should incorporate bevacizumab into the treatment of every patient.

Certainly we have some information with regard to the use of intraperitoneal therapy. We have 3 trials that suggest that there’s an improvement in outcome compared to IV paclitaxel and carboplatin alone. But we know that that benefit sometimes can be overcome by the use of bevacizumab. So here the use of IV IP paclitaxel/carboplatin plus bevacizumab with bevacizumab to follow is a little bit different from the standard approach that many would use in the current treatment strategy.

This patient had follow-ups every 3 months with a CA-125 level, and that is incorporated into our routine management of surveillance, because we want to be able to identify a trend of rising CA-125 that would prompt us to be able to detect an early recurrence. This patient had no gross pelvic masses or nodes on her follow-up, a normal exam, and a normal performance status, so that’s great news for her.

Transcript edited for clarity.

Case: A 59-Year Old Female With Stage IIIC Ovarian Cancer

Initial Presentation

• A 59-year old female presented with new onset early satiety, abdominal bloating and discomfort
• PMH: unremarkable, postmenopausal
• SH: schoolteacher; no tobacco, alcohol or drug use
• PE: abdominal distention, left lower quadrant tender on palpation, shifting dullness noted on percussion

Clinical work-up

• Pelvic exam with transvaginal ultrasound showed a left ovarian mass
• Chest/abdomen/pelvis CT with contrast revealed a left adnexal 4.8-cm mass, extension to liver capsule without parenchymal involvement; retroperitoneal lymph node involvement and ascites noted; no pleural effusion
• Lymph node, adnexal mass biopsy, and paracentesis (2000 cc) cytology confirmed high-grade epithelial ovarian cancer
• Diagnosis: high-grade epithelial ovarian cancer; stage IIIC — T3cN1M0
• Germline/molecular testing showed HRD-,BRCA1/2wild—type
• CA-125, 385 U/mL
• ECOG PS 1

Treatment

• Patient underwent TAH/BSO, lymph node dissection, with optimal debulking; R0
• IP/IV paclitaxel/carboplatin + bevacizumab every 3 weeks for 6 cycles
  • Followed by bevacizumab for 6 more cycles
  • Complete response; post treatment CA—125, 48 U/mL

Follow-up

• 3-months CA-125, 30 U/mL
• Chest/abdomen/pelvis CT showed no gross pelvic masses or nodes
• Pelvic exam, unremarkable
• ECOG PS 0