A 63-Year-Old Woman With Recurrent Ovarian Cancer - Episode 1

Case Presentation: A 63-Year-Old Woman With Recurrent Ovarian Cancer

Erin Crane, MD, provides an overview of a 63-year-old female patient diagnosed with recurrent ovarian cancer, discussing the initial presentation, clinical work-up, treatment, and her initial impression of the case.

Erin Crane, MD: Hello, my name is Erin Crane. I am one of the gynecologic oncologists here; I am in Charlotte, North Carolina, and I am in practice at the Levine Cancer Institute. Today, we are going to discuss the case of a patient who has recurrent epithelial ovarian cancer. This case presentation is about a 63-year-old woman who presented with early satiety and abdominal discomfort. Her past medical history was otherwise unremarkable. She was postmenopausal and had no family history of any known cancers. On a physical examination, she had some left lower quadrant tenderness on palpation, and her ECOG performance status was 1. Part of her clinical work-up included a pelvic exam with a transvaginal ultrasound; she was found to have a left ovarian mass. A CT of the chest, abdomen, and pelvis with contrast showed a left adnexal mass measuring 4.4 cm, with paraaortic lymph node involvement and ascites. A paracentesis was performed, which yielded 1000 cc, and cytology confirmed the diagnosis of a high-grade epithelial ovarian cancer.

She underwent germline and somatic molecular testing, which showed that she was BRCA1/2 negative, but she did have homologous recombination deficiency [HRD]. Her initial CA-125 [cancer antigen 125] was 370 U/mL, and her final diagnosis was stage IIIC high-grade epithelial ovarian cancer. As part of her treatment, she received the standard of care, which included an abdominal hysterectomy, bilateral salpingo oophorectomy, and lymph node dissection with optimal debulking to R0, or no gross residual disease. She took paclitaxel and carboplatin every 3 weeks in standard dosing for a total of 6 cycles. Her CA-125 decreased, and she had a partial response on imaging. Seven months later at a post-treatment follow-up, she was found to have disease progression. She started taking paclitaxel and carboplatin with bevacizumab every 3 weeks for 6 cycles. At 14 months, her CA-125 increased. She was started on cisplatin and gemcitabine; again she had a partial response, and she was then treated with niraparib maintenance.

In terms of my initial impressions of this patient, she presented how most of our patients do, which unfortunately is with advanced-stage diseases because we lack an effective screening method for these types of ovarian cancers. When patients present, their prognosis depends largely on the success of their surgery. This patient had an R0 resection. It seems she did have a platinum-sensitive disease. It is a little concerning that she only had a partial response to initial treatment, because about 80% of patients will have a complete response. That gives you an indication that something is coming down the line.

To treat platinum-sensitive diseases, typically we would rechallenge patients with a platinum-based treatment, which was the case for this patient. She got bevacizumab, which we will often incorporate into the regimen as well. Her overall treatment was appropriate. We know that when patients present with ovarian cancer, about 50% will have 5 years of survival, or will still be alive at the 5-year mark, so these cancers can be difficult to treat. Then in the setting of recurrence, of course a patient’s prognosis is related to their platinum-free interval. We arbitrarily set up a cut-off of platinum sensitivity at 6 months, but we know that is not necessarily a hard and fast rule; if patients have a shorter time until recurrence after platinum, their disease-free interval is going to subsequently shorten.

If they have a longer progression-free interval while they are on a platinum-based treatment, their prognosis is probably better, and they will have a better progression-free survival rate with subsequent regimens, or overall. In the recurrent setting, when patients have platinum-sensitive disease, their progression-free survival average when they are rechallenged with a platinum-based regimen is about 9 to 10 months, and their overall survival expectancy is about 10 years. This patient is still considered platinum-sensitive. Of course, in a platinum-resistant setting, we know that the prognosis is not as good. But it looks like she has received all the appropriate treatments we would recommend if she were to be seen in the office.

One thing I would comment on is that at the time of initial diagnosis, she underwent somatic testing and was found to be HRD positive. The results of the PRIMA and PAOLA trials may not have been available at that point, but from the results of those trials, we know that patients who are HRD positive can benefit from a PARP inhibitor and frontline maintenance. Now, with the results of the PAOLA trial, which incorporated both the PARP inhibitor olaparib and bevacizumab, we did see an improvement in progression-free survival rates. Since she is someone with those high-risk features who has a partial response and may have some residual disease at completion of treatment, especially in the context of having HRD positivity, it would have been reasonable to put her on a trial similar to PAOLA, with bevacizumab and olaparib.

This transcript was edited for clarity.

Case: A 63-Year-Old Woman With Recurrent Ovarian Cancer

Initial Presentation

  • A 63-year-old female presented with early satiety and abdominal discomfort
  • PMH: unremarkable, postmenopausal; no known family history of cancer
  • PE: left lower quadrant tenderness on palpation
  • ECOG PS 1

Clinical work-up

  • Pelvic exam with transvaginal ultrasound showed a left ovarian mass
  • Transvaginal U/S showed a left ovarian mass
  • Chest/abdomen/pelvis CT with contrast confirmed a left adnexal 4.4-cm mass with paraaortic lymph node involvement and ascites
  • Paracentesis (1000 cc) cytology confirmed high-grade epithelial ovarian cancer
  • Germline molecular testing: HRD+, BRCA1/2-
  • CA-125, 370 U/mL
  • Diagnosis: Stage III, high-grade epithelial ovarian cancer

Treatment

  • Patient underwent TAH/BSO, lymph node dissection, with optimal debulking; R0
    • Paclitaxel/carboplatin q3 weeks for 6 cycles; CA-125 decreased; PR
  • At 7-month post treatment follow-up imaging showed progression of disease
    • Paclitaxel/carboplatin + bevacizumab was initiated q3 weeks for 6 cycles
  • At 14-months CA-125 had increased
    • Cisplatin/gemcitabine was initiated, PR
    • Initiated niraparib maintenance