Neo-adjuvant chemotherapy in primary ovarian cancer: A case

presentation

Dr Andre Vos

University of Cape Town

ESMO Feb 2018

I have no conflict of interest to declare

Background

• Ms AC, 56 year old female

• Medical History: Nil noted. In good health overall

• Surgical History: TAH 23 years ago

• Gynaecological History: G3P3, all NVD, no HRT usage at present

• Social History: Divorced, lives with her daughter, works as receptionist, non smoker

History and examination

• 6 month history of lower abdominal pain and constipation

• On examination, 16 week pelvic-abdominal mass felt

• No other adverse findings on examination

Special Investigations

• Bloods: Hb 10 Creat 69 ALP 164 GGT 138 RVD negative VDRL negative CA-125 207

• Ultrasound: 15cm heterogeneous mass arising from the pelvis, Liver and kidneys appear normal, Retroperitoneal lymph nodes noted

• CT Scan: Bulky inhomogeneous mass with central necrosis displacing bladder posteriorly with clear plane of separation, both ovaries appear enlarged, several hypodense lesions to liver in keeping with cysts/?necrotic metastasis, multiple PALN and para-iliac nodes, diffuse peritoneal deposits present

Pre-chemotherapy

Management

• Pt underwent an explorative laparotomy:

• Obvious tumour on right ovary, 7Χ5cm – biopsy taken. Large mass seen on left – assumed to be left ovary, covered by bowel and retroperitoneal; unable to resect.

• Numerous tumour nodules noted in omentum – biopsy taken. Nodule noted in POD – biopsy taken. No peritoneal deposits noted

• Numerous hard para-aortic nodes greater than 2cm noted

PRIMARY OPTIMAL DEBULKING NOT POSSIBLE

Pathology

• Biopsy right ovary: High grade serous carcinoma

• Biopsy omentum: metastatic serous carcinoma

• Biopsy Pouch of Douglas: metastatic serous carcinoma

• Immunohistochemistry: p53, p16, ER, WT1, CK7 positive

CK20, Calretinin negative

Management

• Discussed at weekly Multidisciplinary Clinic (MDC)

• Decided to administer 3-4 cycles of Carboplatin AUC 6 q 3weekly and review for Interval Debulking Surgery (IDS)

• After 2 cycles of Carboplatin CA 125 found to be increasing ( 132 from 122 )

• Decided to change to Carboplatin & Taxol (3weekly)

Management

• After 2 cycles of Carboplatin & Taxol CT Abdo/Pelvis was done

• Significant interval decrease seen in size of pelvic mass as well as size and number of para-aortic nodes. Liver lesions seem unchanged – now most likely regarded as hepatic cysts

• 2 more cycles of Carboplatin & Taxol were administered and proceeded with IDS

Post chemotherapy

Management

• Findings at IDS: Right ovary appeared normal

• Left sided tumour 6 cm adherent to sigmoid colon

• Left sided necrotic tumour nodule seen

• No palpable lymph nodes

• Liver, peritoneal surfaces appeared normal

• Right adnexectomy, left pelvic tumour debulking and omentectomy performed

• NO MACROSCOPIC TUMOUR LEFT BEHIND

Pathology

• Right ovary and tube: simple ovarian cyst

• Left ovary and tube: Minimal residual carcinoma, extensive tumour necrosis

• Left tumour nodule: Positive for metastatic carcinoma

• Infracolic omentum: Positive for metastatic carcinoma

Management

• MDC decided to give 3 more cycles of Carboplatin & Taxol

• Pt given 4 month follow up after last cycle of chemo – next date for assessment May 2018

Discussion points

• Single agent (Carboplatin) vs 2 agents (Carboplatin & Taxol) for neo-adjuvant chemotherapy

• What is the ideal scheduling of chemotherapy and surgery for this patient?

• How many cycles of chemotherapy should be considered post-op?