Case Presentation: A 64-Year-Old Woman With Ovarian Cancer

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Ramez Eskander, MD: Hi, my name is Ramez Eskander. I’m a GYN [gynecologic] oncologist at the University of California San Diego. I’m an associate professor of gynecologic oncology, and I am also the lead in gynecologic malignancies for our precision immunotherapy clinic as well as our experimental therapeutics team. Today we’re going to be discussing a case of a 64-year-old woman who presented with progressive symptoms of abdominal bloating, low back pain, early satiety, and progressive fatigue. Importantly her past medical history was notable for a hysterectomy 5 years prior for benign indications, hypothyroidism as well as generalized anxiety, which were both appropriately managed medically. Physical examination at the time of her office visit showed diffuse lumbosacral pain with movement, but more importantly, abdominal tenderness and significant abdominal distension with a fluid wave consistent with ascites. She also had an unintentional 8-lb [3.6-kg] weight loss. Thankfully her performance status was preserved, and her ECOG performance status was 1.

In the context of her presenting symptoms, a work-up was performed that included a pelvic ultrasound confirming the presence of an approximately 5-cm complex left ovarian mass. This also prompted a CT scan of the chest, abdomen, and pelvis, and CT imaging confirmed the presence of a complex pelvic mass, but in conjunction was notable for abdominal ascites, an omental cake, as well as retroperitoneal and inguinal adenopathy, concerning for a metastatic gynecologic primary malignancy. To facilitate diagnosis, a therapeutic and diagnostic paracentesis was performed, and a biopsy of the omental lesion obtained. Cytology from the paracentesis confirmed a high-grade serous ovarian cancer, and the omental biopsy confirmed histologically the same findings. Appropriately the patient had germline genetic testing performed and was found to be BRCA1/2 wild type, meaning no germline mutation. Somatic testing of the tumor from the omental biopsy was additionally conducted, showing no evidence of a somatic BRCA1/2 mutation. And importantly homologous recombination deficiency testing was submitted, and the patient was found to be homologous recombination proficient, meaning no evidence of homologous recombination deficiency.

In the context of her disease distribution and in review of her imaging, she was counseled regarding options and underwent primary surgical cytoreduction, which included resection of all her visible disease, leaving her without any evidence of disease intraperitoneally at completion of the surgical procedure. She was then counseled regarding treatment management options and was treated with systemic chemotherapy using a combination of carboplatin and paclitaxel administered intravenously every 3 weeks, followed by maintenance bevacizumab, the antiangiogenic agent, to help improve progression-free survival.

Unfortunately, 1 year after completion of cytotoxic chemotherapy and while on maintenance bevacizumab, the patient was found to have an elevation in her CA-125 [cancer antigen 125]. Importantly, her CA-125 did normalize at completion of cytotoxic chemotherapy after surgery, but with elevation in her CA-125, radiographic imaging was obtained once again, which did confirm the presence of progressive retroperitoneal adenopathy suggestive of recurrent disease. Given the disease distribution, she was not deemed a good candidate for secondary surgery and was therefore counseled regarding resumption of systemic chemotherapy. Given platinum-sensitive disease recurrence, she was rechallenged with carboplatin and paclitaxel administered intravenously every 3 weeks for 6 cycles. She did have a partial response, although there did appear to be some predominantly enlarged lymph nodes despite completion of 6 cycles of therapy. At this juncture the patient was counseled once again about treatment options, and after extensive counseling elected to proceed with single-agent rucaparib as a switch maintenance strategy in this setting to try to improve her cancer outcomes.

This transcript has been edited for clarity.

Case: A 64-Year-Old Woman With Ovarian Cancer

Initial Presentation

• A 64-year-old woman presented with abdominal bloating, low back pain, early satiety and progressive fatigue
• PMH: hysterectomy 5 years ago for benign indication; hypothyroidism managed medically; generalized anxiety disorder managed medically
• PE: diffuse lumbosacral pain with movement; abdominal tenderness and significant abdominal distension with a fluid weight consistent with ascites; unintentional weight loss of 8 lbs
• ECOG PS 1

Clinical work-up

• Pelvic ultrasound showed a ~5-cm complex left ovarian mass
• Chest/abdomen/pelvis CT revealed a complex pelvic mass and was also notable 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 serious ovarian cancer
• Germline molecular testing: BRCA1/2wt
• Somatic testing: BRCA1/2 negative; HRD proficient
• CA-125, 360 U/mL
• Diagnosis: Stage III, high-grade serous epithelial ovarian cancer

Treatment

• Patient underwent TAH/BSO, lymph node dissection, with optimal debulking; R0
  • Carboplatin/paclitaxel q3 weeks for 6 cycles; CA-125 normalized; CR
  • Bevacizumab maintenance
• At 1 year post treatment, CA-125 increased; imaging revealed progressive retroperitoneal adenopathy suggestive of recurrent disease; not deemed a candidate for secondary surgery
  • Rechallenged with carboplatin/paclitaxel q3 weeks for 6 cycles; PR; predominantly enlarged lymph nodes
  • Rucaparib monotherapy maintenance