Ovary Flashcards
Mean time to recurrence after primary treatment
18 months
What fraction of epithelial ovarian cancers (EOC) are high vs low grade?
2/3 HGSC, 1/3 LGSC
Main histological types of EOC
serous, clear cell, endometrioid, mucinous, other (brenner, transitional cell, etc.)
Staging procedure for ovarian cancer
TAH, BSO, omentectomy, PPALND, biopsies (anterior and posterior cul de sac, left and right pelvis, left and right paracolic gutters, left and right diaphragm), and washings
What additional surgical procedures do you do if a mucinous tumor is identified?
Appendectomy
Make sure colonoscopy is UTD
Histological types of EOC associated with Lynch syndrome?
Clear cell, endometrioid
Histological types of EOC associated with BRCA?
Serous
Ovarian stage I
I - limited to ovaries or tubes
IA - limited to one ovary/tube, capsule intact
IB - limited to both ovaries/tubes, capsule intact
IC - limited to one or both ovaries/tubes, with positive cytology
IC1 - surgical spill
IC2 - capsule rupture before surgery, or tumor on surface of ovary or tube
IC3 - positive washings
Ovarian stage II
II - extension below the pelvic brim, or primary peritoneal (within the pelvis)
IIA - extension/implants to uterus or surface of tubes/ovaries
IIB - extension/implants to other pelvic tissues (sigmoid, bladder, peritoneum etc)
Ovarian stage III
III - metastases outside the pelvis
IIIA1 - positive RP LNs only (i - up to 10mm, ii >10mm)
IIIA2 - microscopic extrapelvic peritoneal involvement +/- positive RP LNs
IIIB - macroscopic peritoneal metastasis beyond pelvis up to 2cm, +/- positive RP LNs
IIIC - macroscopic peritoneal metastasis beyond the pelvis >2 cm, +/- positive RP LNs (includes extension to capsule of liver and spleen without parenchymal involvement)
Ovarian stage IV
IV - distant metastases
IVA - malignant pleural effusion
IVB - liver or splenic parenchymal metastases, metastases to extra-abdominal organs (inguinal LNs), transmural involvement of the intestine
AURELIA
Adding bevacizumab to single-agent chemotherapy improves PFS in PR recurrent ovarian cancer.
Chemo (paclitaxel, topotecan, doxil) +/- bevacizumab
Inclusion: recurrent PR ovarian cancer
Exclusion: >2 prior regimens, refractory dz, hx bowel obstruction/perf/fistula
Median PFS: 6.7 vs 3.4 months (SS)
ORR: 30.9% vs 12.6% (SS)
Adverse effects: higher rates HTN and GI perf w/ bev
Options for platinum resistant recurrence
AURELIA ([taxol or topotecan or doxil] + bev)
PS/PR/PRef ?
> 6 months or <6 months to progression, or progression on treatment
Options for platinum sensitive recurrence
OCEANS (carbo/gem/bev), CALYPSO (carbo/doxil)
OCEANS
Gemcitabine/carboplatin plus bevacizumab followed by bevacizumab maintenance extends PFS compared to gemcitabine/carboplatin alone in PS recurrent ovarian cancer.
Gem 1000 D1,8 + Carbo AUC 4 D1 q21d x6
Plus: bevacizumab 15 or placebo
Inclusion: first recurrence PS, measurable dz
Exclusion: prior VEGF, hx GI perf/fistula/obstruction, surgery w/i 28d
PFS: 12.4 (bev) vs 8.4 months (SS)
ORR: 78.5% vs 57.4% (SS)
Duration of Response: 10.4 vs 7.4 mos (SS)
OS: 33.3 vs 35.2 mos (NS)
Bev: worse HTN and proteinuria
CALYPSO
Carbo/Doxil is non-inferior to Carbo/Taxol in recurrent PS ovarian cancer with a favorable side effect profile.
Carbo AUC 5 + Taxol 175 q3w x6
Carbo AUC 5 + Doxil 30 q4w x6
Inclusion: measurable disease, 1-2 prior lines, PS
Exclusion: preexisting cardiomyopathy or neuropathy
PFS: 11.3 (CD) vs 9.4 (CT) months (SS)
CD: worse thrombocytopenia, N/V (SS)
CT: worse alopecia, neutropenia (SS)
PAOLA-1
Olaparib added to frontline bevacizumab maintenance prolonged PFS in unselected cohort with advanced ovarian cancer. Greatest benefit in BRCAm or HRD patients. (Not for HR-proficient.)
Bev maintenance +/- olaparib 300mg (or placebo)
Inclusion: HGSC or endometrioid ovarian cancer, primary treatment with bev resulting in NED/CR/PR
Exclusion: delays due to hematologic toxicity
PFS all: 22.1 vs 16.6 months (SS)
PFS BRCAm: 37.2 vs 21.7 (SS)
PFS HRD: 28.1 vs. 16.6 (SS)
PFS HR proficient/unknown: 16.9 vs. 16.0 (NS)
Anemia, fatigue, nausea more common in olaparib arm.
PRIMA
Treatment with niraparib maintenance improved PFS in all considered populations, including the whole cohort.
Placebo vs niraparib 300/200mg
Inclusion: Stage III/IV HGSC or endometrioid, prior platinum tx with CR/PR
PFS HRD: 21.9 vs 10.4 months (SS)
PFS HRD/BRCAm: 22.1 vs 10.9 months (SS)
PFS HRD/BRCAwt: 19.6 vs 8.2 months (SS)
PFS HR-proficient: 8.1 vs 5.4 months (SS)
PFS: 13.8 vs 8.2 months (SS)
Grade >3 adverse events: 70.5% vs 18.9% (most common: anemia, thrombocytopenia, neutropenia)
GOG 218
Chemotherapy plus bevacizumab followed by bevacizumab maintenance improved PFS by 4 mos in advanced stage ovarian cancer after surgical resection.
1 - Carbo AUC 6 + Taxol 175 + bev + placebo mt
2 - Carbo AUC 6 + Taxol 175 + bev + bev mt
3 - Carbo AUC 6 + Taxol 175 + placebo + placebo mt
Inclusion: Stage III with any residual, and Stage IV
Exclusion: borderline, recurrent, prior RT
PFS: 11.2 vs 14.1 vs 10.3 months (SS)
OS: NS. HTN: 16.5% vs 22.9% vs 7.2% (SS)
GOG 158
Carbo/paclitaxel is not inferior to cis/paclitaxel with regard to PFS in patients with optimally resected, stage III epithelial ovarian cancer.
Ctrl: cisplatin 75 + paclitaxel 135 (over 24hrs) q21d x6
Exp: carbo AUC 7.5 + paclitaxel 175 (over 3hrs) q21d x6
Inclusion: stage III, optimally cytoreduced (<1cm)
PFS and OS not SS. Completion of 6 cycles similar.
Carbo/taxol less grade 3/4 leukopenia, GI, renal, metabolic toxicities, but more thrombocytopenia than cis/taxol (SS)
Optimal/suboptimal debulking
complete - no residual disease
optimal - <1cm remaining disease
suboptimal - >1cm disease remaining
