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Case history

image A 45-year-old woman presented with recurrent right iliac fossa pain. Her medical history included a total abdominal hysterectomy and left salpingo-oophorectomy previously for chronic pelvic pain. She was otherwise fit and her performance status (PS) was 0. Both her sister and paternal grandmother had breast cancer in their 50s and her father had prostate cancer in his 50s. Pelvic ultrasound and CT chest, abdomen and pelvis revealed a 5 cm right ovarian mass with no evidence of regional or distant spread. Her CA-125 was 77 kU/l. She underwent a laparotomy and right salpingo-oophorectomy. The ovarian mass was adherent to the pelvic wall but complete excision was achieved. Omental biopsies were negative and peritoneal washings were positive for malignant cells. She was diagnosed with stage IIC high-grade serous ovarian carcinoma (HGSOC). Her postoperative CA-125 normalized to 17 kU/l.

She received six cycles of adjuvant carboplatin and paclitaxel, which she tolerated well. She was referred for genetic testing and was found to have a deleterious BRCA1 mutation. She underwent bilateral risk-reducing mastectomies a year later.

Twenty months after diagnosis, she presented with an asymptomatic rise in her CA-125 from 17 to 37 kU/l. A CT scan revealed two peritoneal soft tissue masses (12 mm and 8 mm) within the small bowel mesentery. She underwent surgical removal of both masses; there was no residual disease post procedure. Final pathology confirmed relapsed HGSOC. She received a further six cycles of postoperative carboplatin and paclitaxel chemotherapy. Her post-treatment CA-125 normalized to 16 kU/l.

She remained clinically well for 21 months after which her CA-125 rose to 58 kU/l. A CT scan confirmed low-volume peritoneal recurrence. She was referred for tertiary debulking surgery; however, she was found at laparotomy to have disease that could not be completely resected and the procedure was abandoned.

The patient was PS 0 and was re-challenged with a further six cycles of carboplatin and paclitaxel. She suffered a carboplatin-related allergic reaction at cycle 2 and her regimen was changed to 3 weekly cisplatin, which she completed uneventfully. She had a good response in her CA-125 (454 to 18 kU/l) and on her CT scan. She was subsequently commenced on maintenance olaparib and remains in clinical remission.

What is the evidence for the chemotherapy choice at each stage of this patient's disease?

What were the chances (before genetic testing) of this patient having a deleterious BRCA1 or BRCA2 mutation? What are the implications for this patient?

What is the evidence for secondary cytoreductive surgery in ovarian cancer?

What is the role of maintenance olaparib in the platinum-sensitive setting?

What is the evidence for the chemotherapy choice at each stage of this patient's disease?

Adjuvant chemotherapy

This patient received adjuvant chemotherapy for completely resected stage IIC HGSOC (stage IIB; International Federation of Gynecology and Obstetrics, 2014). Two pivotal trials of adjuvant chemotherapy in early ovarian cancer are the International Collaborative Ovarian Neoplasm (ICON) ...

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