Krishnansu S Tewari, MD, FACOG, FACS Change in Recurrent Ovarian Cancer Over 5 Years

Krishnansu S. Tewari, MD, FACOG, FACS says

here are 3 areas in which treatment for ovarian cancer has changed over the last 5 years. Recognizing the importance of cytoreductive surgery, the benchmark of ‘optimal cytoreduction’ has now become achieving zero gross residual disease after surgery rather than no greater than 1-cm volume residual disease. Secondly, there are several new chemotherapeutic agents that have been studied in prospective clinical trials, including pemetrexed, trabectedin, and the hypomethylating agent decitabine. Unfortunately, none of these new chemotherapeutic agents are FDA approved. Thirdly, biologic agents have been studied extensively, particularly antiangiogenesis agents and PARP inhibitors. Despite 8 phase III, randomized trials involving 5 different antiangiogenesis agents in primary advanced and recurrent ovarian cancer, only bevacizumab has been recently approved for platinum-resistant recurrent disease. The PARP inhibitor olaparib was approved by the FDA on December 19, 2014, for fourth-line therapy of women with BRCA 1/2 mutations. Other targeted/biologic agents being studied include vascular disrupting agents, aurora kinase inhibitors, and Notch pathway inhibitors (gamma secretase inhibitors).

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CASE 1: Epithelial Ovarian Cancer

Sarah W. is a 62-year-old Caucasian woman who works as a travel agent.

In June of 2013, the patient presented with bloating and abdominal distension. Prior medical history is notable for nulliparity, and medication-controlled hypertension.

• Physical exam revealed palpable, fixed nodular 10-cm pelvic mass with abdominal ascites, and patient’s CA-125 level was 895 U/mL
• She underwent total abdominal hysterectomy, bilateral salpingo oophorectomy, omentectomy, low anterior resection with anastomosis and complete cytoreduction of all gross metastatic disease. There was no gross residual disease. Stage was FIGO 3C epithelial ovarian cancer
• Patient was negative forBRCA1or2mutation
• She received 6 IV q3-week cycles of paclitaxel/carboplatin
• Her symptoms resolved and CA-125 levels decreased to 9 U/mL; she remained disease free for approximately 18 months

In December of 2014, the patient presents for her 6-month evaluation with rising CA-125 level, mild abdominal distension and fatigue, and inability to work.

• CT scanning reveals metastatic involvement of liver surface, an isolated splenic lesion, and a small amount of ascites
• She was retreated with carboplatin/paclitaxel
• Patient showed improvement in symptoms and performance status (ECOG 0) after 3 cycles of therapy