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ONCAlert | Upfront Therapy for mRCC

Case 3: Recurrent Ovarian Cancer, Platinum-Sensitive, BRCA WT

Targeted Oncology
Published Online:12:32 PM, Wed June 5, 2019


EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Robert L. Coleman, MD: OK, I’m going to present another case. We’re going to move now into the recurrent space. I’m interested in hearing your thoughts on this particular patient. So this is a 68-year-old Caucasian woman who was seen by her primary care physician for a recent onset of chest pain and shortness of breath, and she reported some recent vaginal bleeding, early satiety, and a weight loss of 12 pounds. She has a past medical history that’s significant for hypertension and arrhythmias, both of which have been medically managed and are stable. Her family history is significant for cardiac disease history on her mother’s side, and her father died of pancreatic cancer.

She’s morbidly obese. There’s dullness to percussion on the right, and she has a kind of asymmetrical chest expansion. And on pelvic exam, there’s a mass or a suspicious mass in the pelvis. Laboratory findings are significant for a CA 125 [cancer antigen 125] of 445 [U/mL], and on imaging she has a CT [computed tomography] scan of the chest that shows this effusion, which confirms what we found on the chest exam. Her abdomen shows this 4-cm mass in the area of the left ovary with some residual omental caking and peritoneal implants, and there appears to be some involvement of the mesentery.

She has a thoracentesis, 1500, and that cytology was positive for high-grade adenocarcinoma; and then ultimately has a pelvic mass biopsy with a core specimen that shows a high-grade serous carcinoma that has immunohistochemistry, which was nicely presented in some of the other cases that seem to be consistent with p53, PAX8 positive, CK7 positive, CK20 negative. And in this patient, it is noted that she has a germline mutation that’s wild type for BRCA.

The patient has undergone some treatment before. Her treatment history consists of debulking in primary surgery, which was incomplete. She had residual disease of 1.5 cm and was given the program of GOG-0218 with paclitaxel, carboplatin, and bevacizumab followed by bevacizumab maintenance for 15 months, and she achieved a complete clinical response to that.

Then she undergoes nearly or a little over 2 years in which she’s disease-free but comes back with symptoms that are very similar to what we see in patients with recurrent disease. She has severe abdominal bloating and fatigue, an elevated CA 125 of 255 [U/mL], and at least 3 sites of recurrence on imaging, and her performance status is 1. So she’s given carboplatin-docetaxel. After 6 cycles of therapy, she has a partial response and her residual disease is at 1.5 cm.

So this case has a lot of discussion items. I hope we can get through many of them, and we want to talk about them. But before we go too far, I want to talk about the potential molecular information we might want to gain. So we know that she is a germline BRCA wild-type patient. Would you guys get any somatic testing at this point? She is platinum sensitive and recurrent. Dave?

David O’Malley, MD: So we try to test up front, when we do the somatic and the germline, as we talked about before. However, many of our patients, particularly within this time frame, would not have had somatic testing. So if they had not had somatic testing, we would absolutely look to 1 of the commercially available tests and/or internal next-generation sequencing of the tumor.

Robert L. Coleman, MD: Susana, the same?

Susana M. Campos, MD, MPH: Same thing. We have, in our institution, a clinical trial in which we do next-generation sequencing up front. And so if we did not have that Foundation Medicine, Inc test, MSK- IMPACT, or anything of the sort, we would absolutely get somatic testing on her, yeah.

Robert L. Coleman, MD: Shannon?

Shannon N. Westin, MD: Yeah, the same. Previously, we were really focusing on doing the somatic testing in the platinum-resistant setting, because we felt like that was really where you utilize that information. But now, as we’re moving these targeted therapies up earlier in the line, we’re trying to do it as soon as possible.

Transcript edited for clarity.


EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Robert L. Coleman, MD: OK, I’m going to present another case. We’re going to move now into the recurrent space. I’m interested in hearing your thoughts on this particular patient. So this is a 68-year-old Caucasian woman who was seen by her primary care physician for a recent onset of chest pain and shortness of breath, and she reported some recent vaginal bleeding, early satiety, and a weight loss of 12 pounds. She has a past medical history that’s significant for hypertension and arrhythmias, both of which have been medically managed and are stable. Her family history is significant for cardiac disease history on her mother’s side, and her father died of pancreatic cancer.

She’s morbidly obese. There’s dullness to percussion on the right, and she has a kind of asymmetrical chest expansion. And on pelvic exam, there’s a mass or a suspicious mass in the pelvis. Laboratory findings are significant for a CA 125 [cancer antigen 125] of 445 [U/mL], and on imaging she has a CT [computed tomography] scan of the chest that shows this effusion, which confirms what we found on the chest exam. Her abdomen shows this 4-cm mass in the area of the left ovary with some residual omental caking and peritoneal implants, and there appears to be some involvement of the mesentery.

She has a thoracentesis, 1500, and that cytology was positive for high-grade adenocarcinoma; and then ultimately has a pelvic mass biopsy with a core specimen that shows a high-grade serous carcinoma that has immunohistochemistry, which was nicely presented in some of the other cases that seem to be consistent with p53, PAX8 positive, CK7 positive, CK20 negative. And in this patient, it is noted that she has a germline mutation that’s wild type for BRCA.

The patient has undergone some treatment before. Her treatment history consists of debulking in primary surgery, which was incomplete. She had residual disease of 1.5 cm and was given the program of GOG-0218 with paclitaxel, carboplatin, and bevacizumab followed by bevacizumab maintenance for 15 months, and she achieved a complete clinical response to that.

Then she undergoes nearly or a little over 2 years in which she’s disease-free but comes back with symptoms that are very similar to what we see in patients with recurrent disease. She has severe abdominal bloating and fatigue, an elevated CA 125 of 255 [U/mL], and at least 3 sites of recurrence on imaging, and her performance status is 1. So she’s given carboplatin-docetaxel. After 6 cycles of therapy, she has a partial response and her residual disease is at 1.5 cm.

So this case has a lot of discussion items. I hope we can get through many of them, and we want to talk about them. But before we go too far, I want to talk about the potential molecular information we might want to gain. So we know that she is a germline BRCA wild-type patient. Would you guys get any somatic testing at this point? She is platinum sensitive and recurrent. Dave?

David O’Malley, MD: So we try to test up front, when we do the somatic and the germline, as we talked about before. However, many of our patients, particularly within this time frame, would not have had somatic testing. So if they had not had somatic testing, we would absolutely look to 1 of the commercially available tests and/or internal next-generation sequencing of the tumor.

Robert L. Coleman, MD: Susana, the same?

Susana M. Campos, MD, MPH: Same thing. We have, in our institution, a clinical trial in which we do next-generation sequencing up front. And so if we did not have that Foundation Medicine, Inc test, MSK- IMPACT, or anything of the sort, we would absolutely get somatic testing on her, yeah.

Robert L. Coleman, MD: Shannon?

Shannon N. Westin, MD: Yeah, the same. Previously, we were really focusing on doing the somatic testing in the platinum-resistant setting, because we felt like that was really where you utilize that information. But now, as we’re moving these targeted therapies up earlier in the line, we’re trying to do it as soon as possible.

Transcript edited for clarity.
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