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Gynecologic Cancer Case Studies

Managing Toxicities in Advanced Ovarian Cancer

Thomas C. Krivak, MD
Published Online:Mar 15, 2019
Thomas C. Krivak, MD, reviews the case and optimal management of a 70-year-old woman with advanced stage IV platinum-resistant ovarian cancer.

Platinum-Resistant Advanced Ovarian Cancer


Thomas C. Krivak, MD: I think toxicity management is very, very important. You know patients are undergoing surgery, then they’re getting chemotherapy. When you’re combining Avastin with carboplatin [and] paclitaxel, I think they are very well tolerated. When you think of carboplatin [and] paclitaxel, you can have intermittent nausea [and] vomiting. You have to watch their white blood cell count. You may have to use Neupogen or Neulasta or something of that sort to help support their white blood cells. Mild fatigue, intermittent nausea, vomiting, intermittent diarrhea. When you combine Avastin with these drugs, I think that the [adverse] effects of the chemotherapy are very separate from the Avastin. So they’re very well tolerated. So it’s really managing the [adverse] effects of their chemotherapy, whether you’re using Zofran [or a] low-dose steroid. I try to break the cycle, so even before they’re getting their chemotherapy, we’ll be giving these patients anti-nausea medications.

We’ll be looking at the urinalysis and looking for hypertension. Again, in combination with the carboplatin [and] paclitaxel. But I have to say in managing like hypertension and proteinuria, it seems [as if] it’s further down the line when we’re treating patients with Avastin on that maintenance therapy for that. And I would have to say, roughly 40 to 50 percent of the patients may get some mild to moderate hypertension. So I tell the patients to be prepared for that. They need to get started on metoprolol or some types of beta-blocker to help with their hypertension. I think that’s very reasonable.

But I think the up-front setting with carboplatin [and] paclitaxel and Avastin [is] very well tolerated. [For] patients…who have diabetes, Taxol can have some significant neuropathy. So substituting Abraxane or some other taxane may help, and it’s something that we want to watch. Unfortunately, most of these patients suffer from alopecia or hair loss. And when we see those patients, we kind of tell them, “Expect hair loss. You know [that] after 1 dose it starts to thin a little bit. After 2 doses you may see clumps of hair coming out as you brush. And by the third dose you’ll have empty spots on your head.” So a lot of patients will get prepared to have a wig placed or have their head shaved and kind of manage that way. But I’d have to say [that] the management is really managing the toxicities, that the chemotherapy and the Avastin [are] very combined with chemotherapy, [and] the toxicity profile is very well tolerated.

When you look at prolonged exposure to bevacizumab, the 2 [adverse] effects that I think you’re most commonly going to see are going to be hypertension and proteinuria. And again, that’s where you need to really start to manage the hypertension, working with the patient’s internal medicine physician and primary care physician to keep that hypertension under good control. If patients develop a certain amount of proteinuria, sometimes you need to discontinue the Avastin, let the kids in recovery, and then they can get started back on Avastin at that time.

Transcript edited for clarity.

Case:  A 70-Year-Old Woman Presenting With Advanced Ovarian Cancer

H & P:

  • A 70-year-old woman presents for evaluation of left-ovary mass discovered during a recent pelvic exam. She reports abdominal tenderness, urinary symptoms, and a “bloated” or “full” feeling, despite normal diet and bowel movements
  • Postmenopausal, no children
  • PE: reveals a woman of low normal weight (BMI = 19 kg/m2) with hypertension; abdomen is distended and shows dullness to percussion 
    • BP = 135/80 mm Hg on metoprolol
    • Fasting glucose = 95 mg/dL
    • LDL = 90 mg/dL

Imaging

  • CT with contrast of pelvis, abdomen, and chest reveals multiple peritoneal lesions and spread to outside of liver
  • Malignant ascites present

Biopsy and labs:

  • Pathology: high-grade epithelioid adenosarcoma, ovarian primary
  • BRCA1/2 status: unknown
  • CA-125: 656 U/mL

Treatment

  • She underwent hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and tumor debulking; residual disease after cytoreduction: 1.25 cm
  • Diagnosis: stage IV ovarian cancer, grade 3
  • Started on carboplatin and paclitaxel plus bevacizumab; achieved a partial response
  • She was continued on maintenance bevacizumab

Follow up:

  • Follow up imaging at 6 months showed disease progression in the liver
  • She was started on paclitaxel plus bevacizumab

 

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