Approaching a Case of Stage 3C Ovarian Cancer

Robert L. Coleman, MD:This case is really interesting because, first of all, this patient’s quite young: 38 is many standard deviations below what median ages are at diagnosis. Generally, when you find a pelvic mass in a woman who’s 38, you think about benign conditions first. You also think about nonepithelial tumors: so, germ cell tumors or sex cord-stromal tumors. However, in her imaging this patient shows some features that are very suspicious for a high-grade malignancy. She has an omental disease that’s often termed as “caking.” What that means is that there’s essentially a plaque of tumor that’s essentially replaced the fat that is normally there, which on a CAT scan would ordinarily just show up as a darker grey. Now, it’s thicker and can be seen. And then, of course, then she has a pelvic mass and an elevated CA 125. All these factors are consistent with what you would expect to see in a patient who has metastatic epithelial ovarian cancer, but those other conditions should be kept in mind.

Another aspect that’s quite interesting in this patient who’s young at diagnosis—and this should go through any clinician or healthcare provider’s mind—is that of her family history. We see that she has no family history of breast or ovarian cancer, but it would be important to make sure that discussion is thorough because it may not be in the immediate history. It may be even a generation separated. Many patients sometimes have had the diagnosis of a family member; or, they had a situation where a family member actually has an abdominal cancer; or, a family member may have undergone an open-and-close procedure and they never really identified the disease. Importantly, there may actually be a strong history of, for instance, of prostate cancer in men, and those would still be associated with this potential familial history.

A patient like this who presents with what looks to be obvious metastatic disease will generally undergo a surgical procedure to remove the disease. The one caveat is that if we feel as though the disease is in a distribution that couldn’t be resected completely or is too small a volume as this patient ultimately turned out to have, there may be the consideration of doing what’s called neoadjuvant chemotherapy. I think with the available data we feel that there are certainly subgroups of patients who probably do just as well whether they have their surgery first or chemotherapy first.

We do know that using chemotherapy first in that neoadjuvant setting can reduce not only the surgical extent that’s required to get a good surgical outcome but also the postoperative and perioperative morbidities. That’s an important consideration. But I think from the standpoint of establishing the diagnosis and potentially interfering with the symptomatology that the patient’s experiencing—for instance, bloating—surgery can sometimes be the best first approach for this. As we can see in this case, she did have a good surgery and it appears that her tumor volume was reduced down to a centimeter of residual disease.

Transcript edited for clarity.

December 2016

• A 38-year old female presented with bloating and pain
• PMH: unremarkable
• FH: no malignancy
• Abdominal/pelvic CT scan: pelvic mass (9-cm) arising from the right ovary, omental cake (15-cm), and extensive peritoneal carcinomatosis
• CA-125: 1027 U/mL
• The patient was diagnosed with stage IIIC epithelial ovarian cancer
• She underwent hysterectomy, bilateral salpingo-oophorectomy, and omentectomy
  • Scattered residual peritoneal nodules (<1 cm) remained following surgery
• Following surgery, treated with 6 cycles of IP/IV carboplatin/paclitaxel
  • After 6 cycles of therapy, CA-125 level declined to 2.5 U/mL
  • Symptoms were ameliorated

March 2017

• Patient reported bloating and abdominal pain
• Lab results showed elevated CA 125 (985 U/mL)
• CT scan confirmed recurrence with ascites and visible disease (2-cm peritoneal mass)
• She was treated with bevacizumab and topotecan for 4 cycles
  • Patient had good response therapy
  • After 4 cycles, she was switched to bevacizumab maintenance

October 2017

• Patient returned with complaint of abdominal pain
• CT scan revealed ascites and several 1- to 2-cm peritoneal masses in the pelvis and upper abdomen