Obgyn · Year 3 · from Obgyn

Case 1: Advanced Ovarian Cancer

Patient Demographics

  • Age: 58 years
  • Sex: Female
  • Occupation: Retired teacher

Chief Complaint

"I've had progressive bloating and abdominal swelling for the past 3 months."

History of Present Illness

The patient presents with a 3-month history of progressive abdominal distension, early satiety, and a 15-pound unintentional weight loss despite the increasing abdominal girth. She reports feeling full after eating only small amounts and has noticed her pants becoming tighter around the waist. She describes vague, constant lower abdominal discomfort and pelvic pressure. She also notes increased urinary frequency over the past 6 weeks. She initially attributed her symptoms to irritable bowel syndrome but became concerned when symptoms persisted despite dietary modifications. She denies vaginal bleeding, nausea, vomiting, or change in bowel habits. Her last menstrual period was at age 52, and she has been postmenopausal for 6 years without hormone therapy.

Past Medical History

  • Hypertension, well-controlled on lisinopril
  • Hyperlipidemia on atorvastatin
  • G2P2, both vaginal deliveries
  • No prior surgeries
  • Never used oral contraceptives
  • Family history of breast cancer in maternal aunt (age 62)

Family History

  • Mother deceased at 68 from ovarian cancer (diagnosed at age 65)
  • Maternal aunt with breast cancer at age 62
  • Father deceased at 78 from lung cancer (smoker)
  • Sister alive at 56, healthy
  • No known genetic testing in family

Physical Examination Findings

  • Vital Signs: BP 138/82 mmHg, HR 78 bpm, BMI 26 kg/m2
  • General: Cachectic-appearing woman with notable abdominal distension
  • Lymph Nodes: No palpable cervical, supraclavicular, axillary, or inguinal lymphadenopathy
  • Chest: Clear to auscultation, decreased breath sounds at right base
  • Abdomen: Markedly distended with positive fluid wave indicating ascites, umbilicus everted, diffuse fullness on palpation, no distinct masses palpable due to ascites, no hepatomegaly appreciated
  • Pelvic: External genitalia normal, vaginal mucosa atrophic, cervix atrophic-appearing, uterus not well delineated due to ascites, bilateral irregular nodular masses felt in the adnexa, fixed nodularity in the cul-de-sac (cul-de-sac implants)

Diagnostic Workup

  • CA-125: 1,842 U/mL (markedly elevated; normal <35 U/mL)
  • HE4: 428 pmol/L (elevated)
  • ROMA Score: High probability of malignancy
  • Complete Blood Count: Hemoglobin 10.2 g/dL (mild anemia), WBC 8,200/microL, Platelets 412,000/microL (reactive thrombocytosis)
  • Comprehensive Metabolic Panel: Albumin 2.8 g/dL (low), otherwise normal
  • CT Chest/Abdomen/Pelvis with Contrast:
  • Large-volume ascites throughout the abdomen and pelvis
  • Bilateral complex adnexal masses, right measuring 8.5 cm and left measuring 6.2 cm
  • Omental thickening and nodularity consistent with omental caking
  • Multiple peritoneal implants along the paracolic gutters and diaphragmatic surfaces
  • Small right pleural effusion with pleural nodularity suspicious for metastatic disease
  • No parenchymal liver or lung metastases
  • Mildly enlarged pelvic and para-aortic lymph nodes
  • Chest X-ray: Small right pleural effusion
  • Paracentesis: 3.5 liters of serosanguinous fluid removed
  • Cytology: Positive for adenocarcinoma, immunohistochemistry consistent with high-grade serous carcinoma (PAX8+, WT1+, p53 mutant pattern)

Diagnosis

High-Grade Serous Ovarian Carcinoma, FIGO Stage IVA

  • Stage IVA based on malignant pleural effusion
  • Histology confirmed via ascitic fluid cytology as high-grade serous carcinoma
  • Strong family history concerning for hereditary breast-ovarian cancer syndrome

Staging (FIGO 2014)

  • Stage IV: Distant metastases
  • IVA: Pleural effusion with positive cytology
  • Extensive peritoneal carcinomatosis with omental involvement
  • Bilateral adnexal masses

Management Plan

Multidisciplinary Team Discussion:

  • Gynecologic oncologist, medical oncologist, interventional radiology, genetic counselor

Assessment of Resectability:

  • CT findings suggest extensive disease with omental caking and diaphragmatic implants
  • Laparoscopic assessment recommended to determine feasibility of primary cytoreduction vs. neoadjuvant chemotherapy

Selected Treatment Pathway - Neoadjuvant Chemotherapy:

Given extensive peritoneal disease and patient's nutritional status (low albumin, weight loss):

  1. Neoadjuvant chemotherapy (NACT) x 3-4 cycles followed by interval debulking surgery
  2. Benefits of NACT approach:
  • Similar overall survival to primary debulking in trials
  • Lower surgical morbidity
  • Allows assessment of platinum sensitivity
  • Time for nutritional optimization

Chemotherapy Regimen:

  • Carboplatin AUC 5-6 intravenously Day 1
  • Paclitaxel 175 mg/m2 intravenously Day 1
  • Cycle every 21 days for 3-4 cycles before interval surgery

Add Bevacizumab:

  • Consider adding bevacizumab 15 mg/kg IV q3 weeks to first-line chemotherapy and as maintenance (ICON7 and GOG-218 data support improved PFS in advanced disease)

Interval Debulking Surgery (after NACT):

  • Goal: Complete gross resection (R0) - no visible residual disease
  • Procedures may include:
  • Total abdominal hysterectomy and bilateral salpingo-oophorectomy
  • Omentectomy
  • Peritoneal stripping of affected surfaces
  • Diaphragm stripping or resection if involved
  • Splenectomy if splenic hilum involved
  • Bowel resection if necessary for complete cytoreduction
  • Pelvic and para-aortic lymphadenectomy

Post-Surgical Chemotherapy:

  • Complete 6 total cycles of carboplatin/paclitaxel
  • Continue bevacizumab maintenance for up to 15 months total if used

Maintenance Therapy:

  • PARP inhibitor maintenance if tumor demonstrates BRCA mutation or homologous recombination deficiency (HRD)
  • Send tumor tissue for BRCA1/2 somatic mutation testing
  • Germline BRCA testing given family history (mother with ovarian cancer, aunt with breast cancer)

Genetic Testing and Counseling:

  1. Refer to genetic counselor urgently
  2. Order germline BRCA1/BRCA2 testing
  3. Consider expanded panel including RAD51C, RAD51D, BRIP1
  4. If BRCA positive:
  • Patient qualifies for PARP inhibitor maintenance (olaparib, niraparib)
  • Family members should be offered testing
  • Risk-reducing surgery for sisters/daughters if carriers

Supportive Care:

  1. Nutritional support with dietitian referral
  2. Serial paracentesis as needed for symptom control
  3. DVT prophylaxis (high VTE risk with ovarian cancer)
  4. Psychological support

Follow-up and Surveillance:

  • CA-125 with each chemotherapy cycle
  • CT imaging after 3 cycles to assess response before interval surgery
  • Post-treatment: CA-125 every 3 months for 2 years, then every 6 months
  • CT imaging only if CA-125 rises or symptoms develop

Prognosis

  • Stage IVA high-grade serous ovarian cancer
  • 5-year survival approximately 20-30%
  • BRCA mutation (if present) associated with better response to platinum chemotherapy and PARP inhibitors
  • Optimal cytoreduction to no residual disease is the most important prognostic factor

Clinical Image

Image Description: Contrast-enhanced CT scan of the abdomen and pelvis demonstrating advanced ovarian cancer. Key findings include large-volume ascites, bilateral complex adnexal masses with solid and cystic components, omental thickening ("omental cake") representing peritoneal carcinomatosis, and peritoneal implants along the paracolic gutters. These findings are characteristic of stage III-IV epithelial ovarian cancer.

Attribution: CT imaging findings in ovarian cancer as described in Radiopaedia (https://radiopaedia.org/articles/ovarian-tumours) and RadioGraphics imaging literature.

All cases for this lecture as Markdown