The Direction of Ovarian Cancer Management

Ramez Eskander, MD: This is a very exciting time for us in the treatment of patients with advanced-stage ovarian cancer. We have made significant gains over the last several years with the approval of olaparib in the frontline setting following the SOLO-1 trial, with incorporation of bevacizumab as a maintenance opportunity for patients with advanced-stage disease, and now, with a better understanding about these molecular predictors of potential response to therapy.

Not long ago, BRCA assessment, both in germline, and more important recently, somatic assessments, were not germane to the care of our patients. But this has transformed the paradigm of treatment in patients with advanced-stage ovarian cancer. I anticipate that this paradigm will continue to evolve over the coming years. Certainly the data that emerge from the various front-line combination trials, the ATHENA and FIRST trials, looking at combinations of immuno-oncology plus PARP inhibitor, or antiangiogenic therapy plus immune checkpoint inhibitors, IMagyn050 trial, all of which are going to help inform the path forward, and hopefully, with incorporation of translational end points on these studies, guide our design of future trials.

Transcript edited for clarity.

Case Overview:

Initial Presentation

• A 68-year-old postmenopausal woman presented with fatigue, urinary frequency, early satiety, abdominal bloating and distention
• PMH: HTN, medically treated with lisinopril
• SH: retired; grandmother of 3; never-smoker; social alcohol use
• PE: abdominal distention, bloating, and a positive fluid wave test; otherwise unremarkable

Clinical work-up

• Pelvic exam with transvaginal ultrasound showed a right ovarian mass
• Chest/abdomen/pelvis CT with contrast revealed a right adnexal 5.3-cm complex mass, a suspicious intraparenchymal liver lesion, retroperitoneal lymph node enlargement and concurrent pleural effusion
• Lymph node and adnexal mass biopsy confirmed high-grade, epithelial ovarian cancer; positive cytology of pleural effusion
  • T1N1M1
• Germline molecular testing showed BRCA1/2 wild-type, HRD+
• CA-125, 438 U/mL
• ECOG: 1

Treatment

• Patient underwent TAH/BSO, lymph node dissection, with suboptimal debulking; residual disease 1.3 cm
• Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab
  • After 3 cycles, patient underwent second debulking surgery, R0
• Continued on bevacizumab for 6 more cycles
  • Achieved partial response, post treatment CA-125, 40 U/mL
     

Follow-up

• At 3 months
  • CA-125, 18 U/mL
  • Chest/abdomen/pelvis CT showed no gross pelvic masses or nodes
  • Pelvic exam was unremarkable