an interesting case of metastatic clear cell carcinoma ovary treated with targeted therapy
TRANSCRIPT
Interesting Clinical Cases
Dr Alok GuptaMD, DM,
Consultant Medical Oncologist
Max Super Speciality Hospital, Saket
Max Hospital, Gurgaon
Ex-Asst. Professor, AIIMS, New Delhi
Case 1
Targeted Therapy in a patient with Relapsed/Refractory
Advanced Ovarian Clear Cell Carcinoma
Outcome in Ovarian Clear Cell Carcinoma
Outcome in Ovarian Clear Cell Carcinoma
Presentation
59 /Lady
No family history of breast and ovarian cancer
Diagnosed with Ovarian clear cell carcinoma in
March 2014.
She underwent total abdominal hysterectomy
with bilateral salpingo-ophorectomy at Kolkata.
Thereafter, went to Singapore for treatment.
Presentation
Evaluation at Singapore in April 2014 revealed FDG avid
mass in left pelvis 1.5 x 2.2 cm.
Treatment
Started on Standard Chemotherapy with Paclitaxel and Carboplatin.
Pet CT done 3rd June 2014 showed FDG avid mass in left adnexa
has increase in size 4.0 x 4.5cm.
Treatment
She Underwent debulking surgery on 10thJune 2014.
The mass was consistent with a clear cell carcinoma.
Second Line chemotherapy with Liposomal Doxorubicin
was started after surgery.
Treatment
PET CT post three cycles of Doxil showed recurrence of pelvis mass now measuring
5.0 x 6.0cm.
There were also new FDG-avid peritoneal nodules in the posterior to midline scar, left
perivascular region, and right internal iliac region, and right pelvis, all consistent with
recurrence in the pelvic region.
Treatment
Third line chemotherapy with Gemcitabine and Avastin
(Bevacizumab) for 3 cycles
Treatment
Fourth line chemotherapy with Irinotecan with capecitabine was started in
March 2015
Disease progression in May 2015
Fifth line therapy with Everolimus (mTOR inhibitor) was started in June
2015.
Disease progression in September 2015.
Patient was sent back to India in September 2015 after there was disease
progression after 5 LINES of Therapy.
Presentation in India
Very poor general condition
Sepsis with pan-cytopenia
Admitted in ICU for 1 month in Kolkata
Disease progression on Everolimus
At this point, all cancer treatment was stopped
and patient was treated for sepsis.
Treatment in INDIA
Came to us for second opinion in Nov 2015
Literature search was done
Molecular Pathways in Pathogenesis of Cancer
Proteins highly expressed or activated in clear cell carcinoma
Targeted Therapies: The Revolution
Treatment
Patient was started on Pazopanib on 16 Nov 2015
July 2016
November 2016
Lessons Learnt
Synchronous colorectal cancer in a patient presenting with oesophageal cancer
Case 2
Presentation
58 year female
Comorbidities: hypertension and type-2 diabetes
mellitus
No history of addictions
No family history of cancer
Presented with dysphagia to solid food and
weight loss of five kg over last two months.
No lower GI symptoms
Work Up
CT Thorax-Thickening of lower third oesophagus
extending into GE junction and proximal
stomach.
Upper GI scopy-ulceroproliferative lesion from
33 cm till 38 cm with involvement of GE junction
and extending to cardia.
Biopsy-poorly differentiated adenocarcinoma
Work Up
PET-CT- metabolically active disease at lower
third oesophagus and GE junction. Also showed
increased uptake in splenic flexure of colon.
Colonoscopy-ulceroproliferative lesion at splenic
flexure with mild luminal compromise.
Biopsy-moderately differentiated
adenocarcinoma.
PET/CT
(a) (b) (c)Oesophagus tumor showed groups and cords of carcinoma cells(a & b), with focal gland formation(c)
Tumor in the colon was a typical colonic-type of adenocarcinoma.(a & b) (a) (b)
Oesophageal and Colonic Tumor were different histopathologically
Treatment
6 cycles of FOLFIRI regimen (5- fluorouracil,
leucovorin and irinotecan) as neoadjuvant
chemotherapy.
Repeat PET-CT showed partial metabolic and
morphological regression of circumferential
thickening in both lower third oesophagus and
splenic flexure of colon.
PET-CT imaging showing active disease in lower third oesophagus and splenic flexure of colon pre(a) and post(b) neoadjuvant chemotherapy
(a) (b)
Treatment
Patient underwent transhiatal oesophago-
gastrectomy and left hemicolectomy (R0
resection).
Then patient received adjuvant chemotherapy
with six cycles of FOLFIRI regimen.
Presently on Surveillance
The patient was then kept on regular followup
with repeat CEA levels, upper and lower
gastrointestinal endoscopy and scans planned
at every six months for two years.
After two years of followup the patient remains
asymptomatic and negative for disease relapse
on investigations.
Lessons Learnt
Thank You
Dr Alok Gupta MD, DM,
Consultant Medical Oncologist
Max Super Speciality Hospital, Saket
Phone No. 9167164364
Email: [email protected]