A 64-year-old woman with ovarian cancer

Ramez Eskander, MD: Hello, my name is Ramez Eskander. I am a gynecologist [gynecologic] Oncologist at the University of California San Diego. I am an associate professor of gynecological oncology and also lead gynecological malignancies for our precision immunotherapy clinic and our experimental therapy team. Today we’re going to talk about the case of a 64-year-old woman who presented with progressive symptoms of gas, low back pain, early satiety, and progressive fatigue. It is important that a hysterectomy was diagnosed 5 years ago for benign indications, hypothyroidism, and generalized anxiety, both of which received appropriate medical treatment. The physical exam at the time of their visit to the office showed diffuse lumbosacral pain with movement, but more importantly, abdominal tenderness and significant abdominal bloating with a surge of fluid consistent with ascites. She also had an unintentional 8-lb [3.6-kg] Weight loss. Fortunately, her performance status was retained and her ECOG performance status was 1.

In connection with her symptoms, an examination was performed that included an ultrasound scan of the pelvis, which confirmed the presence of a complex mass of the left ovary about 5 cm in size. This also resulted in a CT scan of the chest, abdomen, and pelvis, and CT imaging confirmed the presence of a complex pelvic mass, but was related to abdominal ascites, an omental cake, and retroperitoneal and inguinal adenopathy related to: a metastatic one primary gynecological malignancy. To facilitate diagnosis, therapeutic and diagnostic paracentesis was performed and a biopsy of the omental lesion was obtained. Paracentesis cytology confirmed high grade serous ovarian cancer, and omental biopsy confirmed the same histological findings. A genetic germline test was expediently carried out on the patient and it was found that it is BRCA1 / 2 wild type, which means that there is no germline mutation. In addition, a somatic examination of the tumor from the omental biopsy was performed, which did not reveal any evidence of a somatic BRCA1 / 2 mutation. And importantly, a homologous recombination test was submitted and the patient was found to be competent in homologous recombination, which means that there is no evidence of homologous recombination deficiency.

In connection with her disease distribution and imaging review, she was advised of options and underwent primary surgical cytoreduction, which included resection of all of her visible diseases so that after surgery was complete, she remained intraperitoneally with no evidence of disease. She then received advice on treatment options and received systemic chemotherapy with a combination of carboplatin and paclitaxel given intravenously every 3 weeks, followed by maintenance therapy with bevacizumab, the antiangiogenic agent, to improve progression-free survival.

Unfortunately, 1 year after completing cytotoxic chemotherapy and while on maintenance bevacizumab, the patient had an increase in her CA-125. established [cancer antigen 125]. Importantly, after completing cytotoxic chemotherapy, her CA-125 normalized after surgery, but with an increase in her CA-125, an x-ray was obtained again which confirmed the presence of progressive retroperitoneal adenopathy, which is indicative of relapsing disease. Due to the distribution of the disease, she was not considered a suitable candidate for secondary surgery and was therefore advised to restart systemic chemotherapy. If platinum-sensitive disease recurred, her carboplatin and paclitaxel were administered intravenously every 3 weeks for 6 cycles. It had a partial response, although some predominantly enlarged lymph nodes appeared despite the completion of 6 therapy cycles. At this point in time, the patient was given further advice on treatment options and, after extensive advice, decided to take rucaparib as monotherapy as a conversion strategy in this situation in order to try to improve her cancer results.

This transcript has been edited for the sake of clarity.

Case: A 64 year old woman with ovarian cancer

First presentation

  • A 64-year-old woman presented with abdominal gas, lower back pain, early satiety, and progressive fatigue
  • PMH: hysterectomy 5 years ago due to benign indication; medically treated hypothyroidism; generalized anxiety disorder medically treated
  • PE: diffuse lumbosacral pain on movement; abdominal tenderness and significant abdominal bloating with fluid weight consistent with ascites; accidental weight loss of 8 lbs
  • ECOG PS 1

Clinical work-up

  • Pelvic ultrasound showed a ~ 5 cm complex mass of the left ovary
  • Chest / abdomen / pelvic CT showed complex pelvic mass and was also known for abdominal ascites, omental cake, and retroperitoneal and inguinal adenopathy
  • Paracentesis (1200cc) cytology confirmed high grade serous ovarian cancer
  • Omental biopsy histology also confirmed high-grade, severe ovarian cancer
  • Molecular germline test: BRCA1 / 2wt
  • Somatic test: BRCA1 / 2 negative; HRD competent
  • CA-125, 360 U / ml
  • Diagnosis: Stage III, severe serous epithelial ovarian cancer

treatment

  • Patient underwent TAH / BSO, lymph node dissection, with optimal debulking; R0
    • Carboplatin / paclitaxel every 3 weeks for 6 cycles; CA-125 normalized; CR
    • Bevacizumab preservation
  • 1 year after treatment, CA-125 increased; imaging showed progressive retroperitoneal adenopathy suggestive of relapsing disease; not considered a candidate for secondary surgery
    • Again exposed to carboplatin / paclitaxel q3 weeks for 6 cycles; PR; predominantly enlarged lymph nodes
    • Maintenance of rucaparib monotherapy