Advanced Ovarian Cancer: Case Perspectives

Thomas C. Krivak, MD:So this patient, she presented with advanced-stage ovarian cancer. She presented with abdominal bloating, ascites. She had on CT scan what appeared to be multiple peritoneal nodules, pleural effusion. So by looking at the [CT scan], looking at her CA 125 being elevated to 600 [U/mL] and seeing her symptoms, we knew that this patient most likely had advanced-stage ovarian cancer at this point.

So seeing somebody who’s 70 years young coming into the office with these complaints, the CT scan findings as well as the laboratory studies, I think at that point we can safely assume it’s advanced-stage ovarian cancer, but there [are] other things in the differential diagnosis.

So at this point I would have a discussion with a patient saying, we could do surgery, which is primary debulking surgery. We could consider neoadjuvant chemotherapy. Really, the goal of surgery is to get patients to as minimal disease as possible. And when you look at [CT scans], you look at PET scans, it’s not always what you see on the [CT scan] or the PET scan that’s going to correlate with it at the time of surgery. So it’s a lot of clinical judgment. And using surgery is like using a drug. We have to make sure and select the appropriate patient and try to get the most efficient surgery we can.

And when I was a younger doctor, at times we would do surgery, give chemotherapy, and do additional surgery. We’re really trying to get away from that and trying to select our patients for primary debulking surgery, or select patients for neoadjuvant chemotherapy. Neoadjuvant chemotherapy is, well, we’ll look at a patient, we’ll say, “We don’t think we can get this patient to optimally debulked, and so we’ll go ahead [and] give them chemotherapy first.”

So chemically debulking with the chemotherapy, and then do a cytoreductive surgery and then additional chemotherapy afterward. And so I think that that’s how we want to approach the patients, because really for an advanced stage of ovarian cancer patient, the best outcomes are going to be to get a good-quality surgery as well as to make sure we have a good response to chemotherapy. If you operate on patients and you do a very aggressive surgery, but they don’t recover from surgery and receive chemotherapy in a timely fashion, it may be considered a surgical success; however, by not getting their chemotherapy, they’ll launch an [oncological] outcome; it may not be as optimal. So to me, I really think we have to be very selective when we look at how we want to do primary debulking surgeries and really select the candidates appropriately.

The implications of ascites and having high-risk factors, when I look at patients, I would say ascites is a risk factor for poor prognosis, and really that may be a marker of aggressiveness of disease. There are studies that look at ascites and outcomes, the volume of ascites and outcomes, and really I think a lot of times that correlates with the amount of miliary disease. So [with] high-risk features you think about ascites, you think about advanced stage, about pleural effusions, disease metastatic in the liver or in the paramecium of the spleen.

And also with this patient, she’s age 70, and we’re seeing an aging population, but age is a risk factor for patients with ovarian cancer. So looking at this patient, and you know collectively, you know seeing somebody who’s 70 years young, [at an] advanced stage of ovarian cancer with her radiographic findings, some of these high-risk features, there’s no doubt that many would consider this patient for neoadjuvant chemotherapy or for primary debulking. It’s really going to be up to that surgeon, as well as the patient and the family, how they want to approach on a risk basis, [a] type of model to choose her surgery as well as chemotherapy.

So the risk of recurrence is really based [on] the stage. And you bring up a very good point. You know stage I cancer is fairly rare in ovarian cancer and, and a lot of us will consider stage II, stage III, stage IV as advanced stage. But how I look at it and when I talk with patients, that about 70 to 80 of patients will have stage III or stage IV.

So this patient who presented at 70 years young with her ascites, the symptoms that she had, this is very typical for somebody with advanced-stage ovarian cancer. And the prognosis for advanced-stage ovarian cancer is that we get patients into remission; again, remission is no evidence of disease by blood tests, CA 125, by [CT scan], and by physical exam. However, how long is that remission going to be? Ovarian cancer seems to be very chemo-sensitive, but it wants to be virulent and it wants to recur. And so what I usually tell folks is that 80% [to] 90% of these patients will go into remission. However, 70% to 80% of those patients will suffer relapse at some point.

And so unfortunately with this patient, seeing what she’s going through and seeing her stage of disease, that’s a risk factor for her to have a recurrence. [But for] patients with stage I cancer, negative lymph nodes, thoroughly staged, who undergo chemotherapy at times, curability is 90% [to] 95%.

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
• BRCA1/2status: 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