case presentation on epithelial ovarian cancer with good learning points

1. EPITHELIAL OVARIAN CANCER
DR SADIA SADIQ
CONSULTANT ONCOLOGIST
AECH,INMOL

2. LEARNING OBJECTIVES

3. PATIENT HISTORY
• Patient Profile
• 55 years old woman
• BMI: 28 (overweight)
• G4P3A1,Menopause at 48 years
• No comorbidities
• No family h/o cancer
• No allergies , No addictions

4. • Abdominal pain and bloating..6 months
• USG: Right adnexal complex cystic mass with solid areas measuring
9x8 cm .Mild ascites. No focal lesion in liver.
• CA 125 : 262 units/ml
• CT:8 x 6.5 x 5 cm right adnexal mass with ascites
• liver and lungs normal. No lymphadenopathy
Timeline
May,19
Diagnosis
INITIAL PRESENTATION

5. Risk of Malignancy Index (RMI)
M x U x CA-125
> 200
> 450
USG features:Multilocular cyst,
solid areas,bilateral lesions,
ascites,metastasis
The RMI 2 was significantly better at predicting malignancy than RMIs 1 3; however, there
was no statistically significant difference in performance of RMIs 2 4.

6. • IOF: 10 x 12 cm multiloculated cyst of right ovary with intact capsule
• left ovary and tube,Uterus,Bladder,Gut loops normal looking
• TAH + BSO + infracolic Omentectomy done.
• Ascitic fluid taken and random biopsies taken from pelvis,para colic
gutters and undersurface of diaphragm.
• No enlarged pelvic or para aortic lymph nodes.Lymph node dissection
not done.
Timeline
May,19 July,19
Diagnosis Surgery
SURGERY

7. • Histology:
• High grade serous carcinoma
• PAX 8+,WT1 +,ER +,CK7+,CK20-,
• Involving right ovary,capsule intact.
• Ascitic fluid –ve for malignant cells
• cervix,endometrium, left ovary,both tubes,peritoneal biopsies and
omentum free of tumor
• FIGO Stage IA ,HIGH GRADE
May,19 July,19
Diagnosis Surgery
Timeline
OBS/ADJ CHEMO

8. OBSERVATION OR ADJUVANT
CHEMOTHERAPY
ICON1 TRIAL
ACTION TRIAL

9. The question of whether platinum-based adjuvant chemotherapy can improve outcomes in patients
with early-stage epithelial ovarian cancer is an important one.
We carried out a multicenter, open randomized trial to determine whether adjuvant chemotherapy
would improve overall survival and prolong recurrence-free survival in women with early-stage
epithelial ovarian cancer.

10. 10% (60%–70%) improvement in RFS and a 9% (64%–73%) improvement in OS
ICON1 :. Optimal treatment of early-stage ovarian cancer.

11. EORTC ACTION (Adjuvant ChemoTherapy in
Ovarian Neoplasm Trial) TRIAL
• We performed a prospective unblinded, randomized phase III trial to
test the efficacy of adjuvant chemotherapy in patients with early-
stage ovarian cancer, with emphasis on the extent of surgical staging.

12. • 5-year RFS of 68% for patients in the
observation arm and 76% for patients
in the adjuvant chemotherapy arm, a
difference of 8%
• 5-year overall survival figures of 78%
for patients in the observation arm and
85% for patients in the adjuvant
chemotherapy arm, a difference of 7%

14. • A combined analysis of two parallel randomized clinical trials in early
ovarian cancer, ICON 1 and ACTION, comparing platinum-containing
adjuvant chemotherapy to observation following surgery was performed,
with survival as primary end point and time to recurrence as a secondary
one. A total of 924 patients were randomized. With over 4 years median
follow up for survivors, the hazard ratio for recurrence-free survival is 0.64
(95% CI, 0.50-0.82; P = 0.001) in favor of adjuvant chemotherapy, with an
absolute difference of 11%. For overall survival, the hazard ratio is 0.67
(95% CI, 0.50-0.90; P = 0.008) in favor of adjuvant chemotherapy. These
results translate into an absolute difference of 8% in the adjuvant
chemotherapy group and indicate that adjuvant platinum-containing
chemotherapy improves the survival and disease-free survival.

15. • Adjuvant chemotherapy (Aug 2019 – Dec 2019)
• Carboplatin/Paclitaxel q3w x 6 Cycles
• Carboplatin AUC 5
• Paclitaxel 175 mg/m2
• Toxicity:G2 alopecia , G2 fatigue,G1 nausea,G2 peripheral neuropathy
Adj chemo
Timeline
May, 19 Aug Dec, 19
Diagnosis Surgery
July
Follow up:
CA 125 ,USG abdomen pelvis

16. • USG:Abdominal mass arising from pelvis 10 x 12 cm
• CT: Pelvic 10 x 9 cm mass reaching upto umbilicus.Liver normal.Lungs
clear.No lymphadenopathy
• CA 125: 72 units/ml
• DFS: 14 months
RECURRENCE
Feb,21
Recurrence

17. AGO Score based on good ECOG PS (0),
complete resection during first-line therapy,
ascites < 500 mL
2ND SURGERY: Feb 2021
9.5 x 8 cm solid mass
Completely excised
High grade serous carcinoma
2ND SURGERY

19. 2nd Surgery
• 2nd Line Chemotherapy (Feb,2021 – July,2021)
• Gem/Carbo q3w x 6 cycles
• Gemcitabine 1000 mg/m2 D1,D8
• Carboplatin AUC X 5 D1
• Toxicity:G2 Thromcocytopenia,G1 neutropenia, G1 fatigue,G1 nausea
2nd line chemo
July,21
2ND LINE CHEMO

20. • patient developed shortness of breath and abdominal pain
• CT: Right Moderate Pleura Effuson, Mild Left Pleural Effusion. Ground
Glass Haze, Consolidation. Omentomesenteric Nodularity with
extensive Omental Thickening.Multiple liver metastasis
• DFS: 4 months
• PLATINUM RESISTANT RECURRENCE … Unresectable
• ECOG 1
2ND RECURRENCE
Nov,21
2nd Recurrence

21. CA OVARY : PLATINUM RESISTANT
2ND LINE THERAPY : RESPONSE RATES
Bevacizumab 20 %
Topotecan 20 %
Gemcitabine 19 %
Liposomal doxorubicin 26 %
Oral Etoposide 27 %
Docetaxel 22 %
Weekly Paclitaxel 21 %
Nab Paclitaxel 23 %
Ifosfamide 12 %
Vinorelbine 20 %
Pemetrexed 21 %
Pazopanib 18 %

22. Addition of Bevacizumab to Chemotherapy
Platinum Sensitive Platinum Resistant

23. CURRENT STATUS
• Patient was started on Topotecan + Bevacizumab ( Jan,2022)
• Topotecan 1.5 mg/m2 weekly
• Bevacizumab 10 mg/kg q2W
• Toxicity:G2 fatigue,G1 hypertension,G2 Diarrhea
• 8 cycles completed
• CT: Good Partial Response..minimal residual peritoneal
disease,minimal pleural effusion and decreased liver mets
• ECOG 1

24. WHAT TO DO NEXT ?
• Bevacizumab maintenance
• PARP Inhibitors
• Single agent chemotherapy
• Hormones
• Clinical Trial
Performance status
Financial Constraints
Tolerability
Ease of administration