Case Study: Suspected Brain Metastases in a 57-Year-Old Female with Stage IV Ovarian Cancer

Case at a Glance

A 57-year-old female with a history of FIGO Stage IVa serous ovarian carcinoma, maintained on Avastin, presented with rising tumor markers and new neurological symptoms. A brain MRI revealed findings concerning for metastatic disease, prompting a complex discussion about the risks and benefits of further treatment versus prioritizing quality of life.

Patient's Story

The patient is a 57-year-old female who has been actively managing a diagnosis of advanced ovarian cancer for over a year. Despite the challenges, she has maintained a high level of function, including a daily walking regimen and regular exercise. Recently, she began experiencing intermittent light headaches and several episodes of vomiting. While physically feeling relatively well, she became concerned about her rising tumor marker levels and the implications of new findings on a brain scan. She expressed significant apprehension about pursuing aggressive treatments that might diminish her quality of life, questioning whether the potential survival benefits would outweigh the side effects.

Initial Assessment

The patient was diagnosed approximately 18 months prior with FIGO Stage IVa serous carcinoma of the right ovary. Her initial treatment consisted of six cycles of chemotherapy followed by debulking surgery. A trial of PARP inhibitor (Lynparza) was discontinued due to poor tolerance. For the past year, she has been on maintenance therapy with bevacizumab (Avastin) administered every three weeks. Routine surveillance revealed a progressively rising CA-125 level, most recently at 350 U/mL, and a positive ctDNA (Signatera) test at 1.6 MTM/mL, indicating disease progression.

The Diagnostic Journey

A full-body PET/CT scan performed one month prior to this consultation was reported as negative for extracranial metastatic disease. Due to the onset of mild headaches and emesis, a contrast-enhanced brain MRI was ordered. The MRI report noted: 'A few punctate foci of enhancement within the bilateral centrum semiovale with associated punctate FLAIR signal abnormality.' The interpreting radiologist concluded these findings were concerning for metastatic disease in the context of her known primary malignancy. The small and punctate nature of the lesions made definitive characterization difficult on a single scan.

Final Diagnosis

Suspected Brain Metastases Secondary to Ovarian Carcinoma. The findings are highly suspicious but require follow-up imaging for confirmation and to assess for progression, which would further support the diagnosis of metastatic disease over other differential diagnoses.

Treatment Plan

The primary oncology team discussed a potential treatment plan should the lesions be confirmed as malignant and progressive, which would involve radiation therapy and a change in systemic chemotherapy. However, given the patient's expressed priority for quality of life and the indeterminate nature of the small lesions, a consensus was reached to first proceed with active surveillance. This decision was supported by consulting specialists who agreed that for very small, asymptomatic, or mildly symptomatic lesions, a short-interval follow-up MRI is a reasonable first step to confirm the diagnosis and assess the rate of growth before committing to treatment.

Outcome and Follow-up

The immediate plan is a repeat brain MRI scheduled in several weeks to evaluate for any interval change in the lesions. The patient's neurological symptoms will be closely monitored. The results of the follow-up scan will be critical in guiding the next steps. A comprehensive discussion will follow, weighing the imaging results, the patient's clinical status, and her well-articulated goals of care to make a shared decision regarding the initiation, type, or potential deferral of further treatment.