Epithelial Ovarian Cancer Page 1 of 7

This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
NOTE: If available, clinical trials should be considered as preferred treatment options for eligible patients (www.mdanderson.org/gynonctrials). Other Co-morbidities are taken into consideration prior to treatment selection.

CLINICAL INITIAL PRIMARY

PRESENTATION EVALUATION TREATMENT

● Pelvic ultrasound ● Hysterectomy/BSO1 with

Page 2 for
● CA 125 ● Consider laparoscopic comprehensive staging2, or
treatment by
● CXR assessment for ● If Stage II through IV –
stage2
● CT scan if concern for disease resectability Yes cytoreductive surgery
malignancy and biopsy to confirm Able
● Other tumor markers if diagnosis to achieve
Pelvic Mass indicated ● Consider video- complete resection
● Colonoscopy if indicated assisted thoracoscopic (R0)?
Interval Page 2 for
● Family history with surgery (VATS) in No
cytoreductive treatment by
referral to genetic those with moderate Yes surgery stage2
counseling if non-mucinous or large effusion Neoadjuvant
EOC confirmed/suspected chemotherapy3 Response?
for 3-6 cycles
No Page 3 for
Yes
Relapsed/
Progression
● Chest X-ray treatment
Diagnosis ● CA125 Incomplete
Page 2 for treatment
by previous ● CT chest, abdomen and pelvis surgery and/or No
by stage2
surgery ● Genetic Counseling staging?
for non-mucinous EOC

EOC = Epithelial Ovarian Cancer

1
If Stage I and patient desires fertility preservation – consider USO and staging
2
See Appendix A for FIGO staging
3
See Appendix B for Chemotherapy Regimens

Department of Clinical Effectiveness V7

Copyright 2016 The University of Texas MD Anderson Cancer Center Approved by the Executive Committee of the Medical Staff on 06/28/2016
 Epithelial Ovarian Cancer Page 2 of 7
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.

NOTE: If available, clinical trials should be considered as preferred treatment options for eligible patients (www.mdanderson.org/gynonctrials). Other Co-morbidities are taken into consideration prior to treatment selection.

Low
No adjuvant therapy
risk1

Stage Ia or Ib

High
risk2
Reassessment
3 See
Taxane and platinum doublet ● CA 125
Stage Ic, II consolidation
for at least 6 cycles ● CT abdomen and pelvis
on page 3
● Chest imaging if indicated
Greater than or
equal to
1 cm residual

Stage III, or IV

Less than
1 cm residual – IV Taxane and platinum doublet3
or IV/IP for at least 6 cycles

1
Low risk – Grade 1 endometrioid; or low grade serous histology
2
High risk – Grade 3 endometrioid; high grade serous, or clear cell histology
3
See Appendix B for chemotherapy regimens

Department of Clinical Effectiveness V7

Copyright 2016 The University of Texas MD Anderson Cancer Center Approved by the Executive Committee of the Medical Staff on 06/28/2016
 Epithelial Ovarian Cancer
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
Page 3 of 7
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.

NOTE: If available, clinical trials should be considered as preferred treatment options for eligible patients (www.mdanderson.org/gynonctrials). Other Co-morbidities are taken into consideration prior to treatment selection.

Consolidation Treatment

Stage III and IV ● SurveillanceOR

1
Complete remission ● Consolidation therapy

Surveillance
● Continue taxane and/or platinum agent, OR
Stage III and IV
● Second line chemotherapy OR
Partial remission
● Hormonal therapy

Relapse / Progression

Serially rising CA125 Delay until clinical relapse2

or treat as clinically indicated
Yes

● Progression or no response on primary chemotherapy3, or ● Consider supportive care for selected patients
● Relapse less than 6 months after stopping chemotherapy
● Salvage chemotherapy/biotherapy4
Progression?
● Hormonal Therapy
(taxane and platinum resistant)3
● Re-evaluate at appropriate intervals
No
Continue treatment as
clinically indicated

Relapse greater than or equal to 6 Consider cytoreductive Platinum based doublet Consider XRT in
months after stopping chemotherapy3 surgery or XRT in with or without biotherapy4 selected patients
selected patients
1
Paclitaxel, hormonal therapy, or biologic therapy
2
Symptomatic or radiologic
3
Consider MD Anderson Approved Biomarkers https://www.mdanderson.org/education-and-research/resources-for-professionals/clinical-tools-and-resources/practice-algorithms/clin-management-biomarkers-web-algorithm.pdf
4
See Appendix B for chemotherapy regimens
Department of Clinical Effectiveness V7
Copyright 2016 The University of Texas MD Anderson Cancer Center Approved by the Executive Committee of the Medical Staff on 06/28/2016
 Epithelial Ovarian Cancer Page 4 of 7
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.

NOTE: If available, clinical trials should be considered as preferred treatment options for eligible patients (www.mdanderson.org/gynonctrials). Other Co-morbidities are taken into consideration prior to treatment selection.

APPENDIX A: FIGO Staging

Stage Description
Tumor confined to ovaries or fallopian tube(s)
IA: Tumor limited to 1 ovary (capsule intact) or fallopian tube; no tumor on ovarian or fallopian tube surface; no malignant cells in the ascites or peritoneal
washings.
IB: Tumor limited to both ovaries (capsules intact) or fallopian tubes; no tumor on ovarian or fallopian tube surface; no malignant cells in the ascites or
I peritoneal washings
IC: Tumor limited to 1 or both ovaries or fallopian tubes, with any of the following:
IC1: Surgical spill
IC2: Capsule ruptured before surgery or tumor on ovarian fallopian tube surface
IC3: Malignant cells in ascites or peritoneal washings
Tumor involves 1 or both ovaries or fallopian tubes with pelvic extension (below pelvic brim) or primary peritoneal cancer
II IIA: Extension and/or implants on uterus and/or fallopian tubes and/or ovaries
IIB: Extension to other pelvic intraperitoneal tissues

Tumor involves 1 or both ovaries or fallopian tubes, or primary peritoneal cancer, with cytologically or histologically confirmed spread to the peritoneum outside the pelvis
and/or metastasis to the retroperitoneal lymph nodes
IIIA1: Positive retroperitoneal lymph nodes only (cytologically or histologically proven)
(i) Metastasis up to 10 mm in greatest dimension
III (ii) Metastasis more than 10 mm in greatest dimension
IIIA2: Microscopic extrapelvic (above the pelvic brim) peritoneal involvement with or without positive retroperitoneal lymph nodes
IIIB: Macroscopic peritoneal metastasis beyond the pelvis up to 2 cm in greatest dimension, with or without metastasis to the retroperitoneal lymph nodes
IIIC: Macroscopic peritoneal metastasis beyond the pelvis more than 2 cm in greatest dimension, with or without metastasis to the retroperitoneal lymph nodes
(includes extension of tumor to capsule of live and spleen without parenchymal involvement of either organ)
Distant metastasis excluding peritoneal metastases
IV IVA: Pleural effusion with positive cytology
IVB: Parenchymal metastases and metastases to extra-abdominal organs (including inguinal lymph nodes and lymph nodes outside of the abdominal cavity)

Department of Clinical Effectiveness V7

Copyright 2016 The University of Texas MD Anderson Cancer Center Approved by the Executive Committee of the Medical Staff on 06/28/2016
 Epithelial Ovarian Cancer Page 5 of 7
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.

NOTE: If available, clinical trials should be considered as preferred treatment options for eligible patients (www.mdanderson.org/gynonctrials). Other Co-morbidities are taken into consideration prior to treatment selection.

APPENDIX B: Chemotherapy Regimens

● Paclitaxel 135 mg/m2 IV over 3 hours Day 1; CISplatin 75-100 mg/m2 IP Day 2; Paclitaxel 60 mg/m2 IP Day 8.
Every 3 weeks for 6 cycles
2
● Paclitaxel 175 mg/m IV over 3 hours with Carboplatin AUC 5-6 IV over 1 hour every 3 weeks for 6 cycles
2
● Docetaxel 75 mg/m IV over 1 hour with Carboplatin AUC 5 IV over 1 hours every 3 weeks for 6 cycles
2
Adjuvant ● Paclitaxel 80 mg/m IV over 1 hour on Days 1, 8 and 15 with Carboplatin AUC 5-6 IV over 1 hour on Day 1. Repeat every 3 weeks for 6 cycles.
2
Therapy ● Paclitaxel 175 mg/m IV over 3 hours with Carboplatin AUC 5-6 IV over 1 hour every 3 weeks for 6 cycles. Starting Day 1 of cycle 2 give
Bevacizumab 15 mg/kg IV over 30 minutes ever 3 weeks.
● Option for patients with mucinous ovarian cancer:
○ Oxaliplatin 130 mg/m2 IV infusion over 2 hours on Day 1 every 21 days
○ Capecitabine 850 mg/m2 orally twice daily on Days 1-14 followed by 7-day rest period
● Paclitaxel 175 mg/m2 IV over 3 hours with Carboplatin AUC 5-6 IV over 1 hour every 3 weeks for 3-6 cycles
2
● Docetaxel 75 mg/m IV over 1 hour with Carboplatin AUC 5 IV over 1 hours every 3 weeks for 3-6 cycles
Neoadjuvant 2
● Paclitaxel 80 mg/m IV over 1 hour on Days 1, 8 and 15 with Carboplatin AUC 5-6 IV over 1 hour on Day 1. Repeat every 3 weeks for 3-6 cycles.
Therapy 2
● Paclitaxel 175 mg/m IV over 3 hours with Carboplatin AUC 5-6 IV over 1 hour and Bevacizumab 15 mg/kg IV over 30 minutes
every 3 weeks for 3-6 cycles. Bevacizumab should not be given in the cycle prior to surgery.
Platinum Sensitive Platinum Resistant
● Paclitaxel and Carboplatin ● Docetaxel ● Bevacizumab and Oral Cyclophasphamide
● Carboplatin and weekly Paclitaxel ● Oral Etoposide ● Bevacizumab
● Carboplatin and Docetaxel ● Gemcitabine ● Topotecan
Recurrence
● Carboplatin and Gemcitabine ● Liposomal Doxorubicin ● Vinorelbine
Therapy
● Carboplatin, Gemcitabine and Bevacizumab ● Weekly Paclitaxel ● Hormonal Therapy
● Carboplatin and Liposomal Doxorubicin ● Cisplatin and Gemcitabine
● Carboplatin single agent
● Cisplatin and Gemzar

Department of Clinical Effectiveness V7

Copyright 2016 The University of Texas MD Anderson Cancer Center Approved by the Executive Committee of the Medical Staff on 06/28/2016
 Epithelial Ovarian Cancer Page 6 of 7
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.

SUGGESTED READINGS

Barakat R.R., Berchuck, A., Markman M., et al. (2013). Principles and Practice of Gynecologic Oncology. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins.
Gershenson, D.M., McGuire, W.P., eds. Ovarian Cancer: Controversies in Management. New York: Churchill Livingston; 1998.
Gynecologic Cancer Foundation Web site. Available at: http://www.thegcf.org/.
National Comprehensive Cancer Network. (2013).NCCN Clinical Practice Guidelines in Oncology: Ovarian Cancer Version 2.2013
Available at: http://www.nccn.org/professionals/physician_gls/PDF/ovarian.pdf.
Prat J. Staging Classification for cancer of the ovary, fallopian tube, and peritoneum. Int J Gynaecol Obstet. 2014 Jan;124(1):1-5
Society of Gynecologic Oncologists Web site. Available at: http://www.sgo.org/
Women’s Cancer Network Web site. Available at: http://www.wcn.org.

Department of Clinical Effectiveness V7

Copyright 2016 The University of Texas MD Anderson Cancer Center Approved by the Executive Committee of the Medical Staff on 06/28/2016
 Epithelial Ovarian Cancer Page 7 of 7
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.

DEVELOPMENT CREDITS

This practice consensus algorithm is based on majority expert opinion of the Gynecologic Oncology Center Faculty at the University of Texas MD Anderson
Cancer Center. It was developed using a multidisciplinary approach that included input from the following medical, radiation and surgical oncologists.

Michael W. Bevers, MD Ann Klopp, MD

Diane C. Bodurka, MD
Jubilee Brown, MD
Thomas W. Burke, MD
Jennifer K. Burzawa, MD
Robert L. Coleman, MD
Patricia Eifel , MD
Nicole Fleming, MD
Ŧ
Michael M. Frumovitz, MD
David M. Gershenson, MD
Anuja Jhingran, MD
Charles F. Levenback, MD
Karen H. Lu, MD
Larissa Meyer, MD
Pedro T. Ramirez, MD
Lois M. Ramondetta, MD
Kathleen M. Schmeler, MDŦ
Pamela T. Soliman, MDŦ
Anil K. Sood, MD,
Shannon N. Westin, MDŦ

Ŧ
Core Development Team

Department of Clinical Effectiveness V7

Copyright 2016 The University of Texas MD Anderson Cancer Center Approved by the Executive Committee of the Medical Staff on 06/28/2016