Ramez N. Eskander, MD, discusses a challenging cervical cancer case, highlighting treatment advances and decision-making in recurrent and metastatic settings.
Ramez N. Eskander, MD: Hello. My name is Ramez Eskander. I’m a gynecologic oncologist at the University of California San Diego, where I also help lead the fellowship program. It is a pleasure to be with you here today. Thank you for joining me to discuss therapeutic advances in the cervical cancer arena for this Targeted Oncology program. I‘d like to start our conversation by discussing a patient case that reflects treatment opportunities in the management of advanced-stage or recurrent cervical cancer.
In this particular scenario, a 67-year-old [woman] presented with clinical stage IIB squamous cell cervical carcinoma. Importantly, at the time of presentation, a PET/CT scan was ordered, and the results of the PET/CT were notable for 2 important things. There were FDG [18F-fluorodeoxyglucose]-avid pulmonary nodules measuring 1.5 cm in largest diameter, and there was also an enlarged FDG-avid sternoclavicular mass. In the context of these PET/CT findings, an IR [interventional radiology]-guided biopsy was recommended and completed. The IR-guided biopsy of the pulmonary mass, which was amenable to biopsy for diagnostic consideration…returned consistent with metastatic squamous cell cervical carcinoma. Importantly, the biopsy of the lung mass was compared with the primary cervical cancer biopsy, and they appeared to be consistent with metastatic primary cervical carcinoma.
Based on the fact that this patient had stage IVB disease and that she was diagnosed before the results of the KEYNOTE-826 trial, she was started on systemic chemotherapy based on GOG [Gynecologic Oncology Group] protocol 240 and received cisplatin, paclitaxel, and bevacizumab treatment. After 3 cycles of systemic therapy with cisplatin, paclitaxel, and bevacizumab, the patient had a repeat PET/CT scan, which showed a response to treatment with a reduction in the size and \ FDG uptake of the pulmonary metastatic nodule, the sternoclavicular mass, [and] the primary cervical lesion. As such, the patient [received] an additional 3 cycles of chemotherapy, and after 6 cycles of treatment, repeat radiographic imaging showed what appeared to be a complete radiographic response. Clinical exam showed resolution of her cervical cancer on palpation and visual inspection.
So we have a patient who was initially diagnosed with stage IVB disease; was subsequently treated with systemic chemotherapy with cisplatin, paclitaxel, and bevacizumab therapy; and had a clinical response and a radiographic complete response [CR]. We discussed treatment management options. The patient had a bit of a tough time with cytotoxic chemotherapy because of hematologic adverse events, so the decision was made to proceed with a maintenance bevacizumab treatment. Unfortunately, follow-up imaging after completion of cytotoxic chemotherapy and while [the patient was] on maintenance bevacizumab therapy showed evidence of new pulmonary nodules, which were concerning for metastatic disease recurrence. These were once again amenable to IR-guided biopsy. A biopsy was completed [and confirmed] metastatic disease recurrence.
At this juncture, importantly, the patient’s tissue was also examined for a PD-L1 CPS score, and her PD-L1 CPS [combined positive score] was elevated at 50. So based on the FDA approval of pembrolizumab in this patient population, this patient was started on 400 mg of pembrolizumab IV [intravenously] every 6 weeks. [She] tolerated the immunotherapy reasonably well, although unfortunately, after cycle 3 of pembrolizumab, repeat radiographic imaging once again appeared to show disease progression, and the patient developed what appeared to be immune-related hepatitis while on immune checkpoint inhibition.
So…[we have] a patient who was treated with systemic chemotherapy, developed disease recurrence after a CR, had a positive CPS score of 50, was then treated with single-agent pembrolizumab, and after 3 cycles of therapy had radiographic imaging showing disease progression. And at this point, the patient is sitting in the office and we’re talking about treatment and management options and opportunities for her…. Independent of enrollment on a clinical trial, [I was thinking,] “What standard of care options do we have?” I thought she was an excellent candidate for tisotumab vedotin, an antibody-drug conjugate as a single-agent treatment. So she was started on tisotumab vedotin and thankfully benefited. She had 9 total cycles of therapy with what appears to be a partial response followed by stable disease, and after cycles of therapy was identified to have radiographic disease progression. And so we had to transition her to an alternate treatment strategy.
Transcript is AI generated and edited for readability.