Expert Perspectives on Treating Recurrent Ovarian Cancer - Episode 1

Analysis of Patient Diagnosis and Treatment

Shannon Westin, MD

Shannon Westin, MD, introduces the case patient and highlights the diagnosis and treatment path to combat stage IV ovarian cancer.

Shannon Westin, MD: Hello, everyone, and welcome. My name is Shannon Westin, and I am an associate professor at The University of Texas MD Anderson Cancer Center in the department of gynecologic oncology and reproductive medicine. It is my pleasure to be with you today. We are going to talk a little about the case of a patient who is a 68-year-old woman with newly diagnosed ovarian cancer. We are going to discuss how we treated her and what treatment options she had. Let’s get going.

This woman was 68. She presented to you with abdominal pain, bloating, discomfort, and decreased appetite. Your Spidey sense is already going. Her past medical history is really unremarkable. She is postmenopausal. She has no family history of cancer. She is not taking medications. You examine her, and she is noted to have some abdominal distension as well as, on palpation, some tenderness in the right lower quadrant. That is about it.

What is your work-up? You went right to the pelvic exam—very smart. You do not feel much, maybe a bit of an enlarged ovary. Subsequently, you order a transvaginal ultrasound that demonstrates, quite clearly, a right ovarian mass. You follow that up with some imaging, specifically a CT of the chest, abdomen, and pelvis. This reveals not only a 4-cm right adnexal mass but also inguinal lymph node involvement, enlarged inguinal lymph nodes, and some ascites.

There is no evidence of pleural effusion. You assess her and determine that you would like to move forward with surgery. Because she is having such symptoms from her ascites, you go ahead and get a paracentesis and are able to remove 1.5 L. This does confirm a high-grade probability of ovarian cancer. Her CA125 [cancer antigen 25] is elevated at 385 U/mL. You feel that you are likely looking at a stage IV, high-grade ovarian cancer.

You look at this patient in front of you and you say, “OK, what is my best option?” Yes, she is stage IV; however, you know that you can remove all the disease on the imaging or via surgery based on your imaging. You are ready to move ahead with your surgical plan, but before you do—because you know that this is a high-grade ovarian cancer—you go ahead and get the patient to undergo some testing, specifically germline panel testing, which reveals that she’s BRCA1/2 negative. You then test for homologous recombination deficiency.

I am going to tell you the result, even though you didn’t know that fact when you were starting your surgery. The patient does have evidence of homologous recombination deficiency in the tumor, so she undergoes a total abdominal hysterectomy, bilateral salpingo-oophorectomy, a lymph node dissection—specifically focused on that inguinal lymph node—that were enlarged on the scan. You would then be able to achieve an optimal debulking, specifically to a level where there is no gross residual disease. You have offered her a number of strategies, and she chooses to move forward with IP [intraperitoneal] IV [intravenous] paclitaxel and cisplatin. She has no evidence of disease at the end of this. The patient then moves on and is treated with niraparib for maintenance. There is our case. Many of us have patients just like this patient, right now in our clinics. We are going to walk through the decision-making in this case and what we used to determine the treatment she got.

Transcript edited for clarity.

Case: A 68-Year-Old Woman With Recurrent Ovarian Cancer

Initial Presentation

  • A 68-year-old female presented with abdominal bloating, discomfort and decreased appetite
  • PMH: unremarkable, postmenopausal; no known family history of cancer
  • PE: abdominal distention, right lower quadrant tenderness on palpation

Clinical work-up

  • Pelvic exam with transvaginal ultrasound showed a right ovarian mass
  • Chest/abdomen/pelvis CT with contrast revealed a right adnexal 4-cm mass, inguinal lymph node involvement and ascites, no pleural effusion
  • Lymph node, adnexal mass biopsy, and paracentesis (1500 cc) cytology confirmed high-grade epithelial ovarian cancer
  • Germline molecular testing: HRD+, BRCA1/2-
  • CA-125, 385 U/mL
  • Diagnosis: Stage 4, high-grade epithelial ovarian cancer
  • ECOG PS 0

Treatment

  • Patient underwent TAH/BSO, lymph node dissection, with optimal debulking; R0
  • IP/IV paclitaxel/carboplatin; PR
  • Followed by niraparib maintenance