Management of Platinum-Sensitive Recurrent Ovarian Cancer

Authored by Natalia Gandur, published on 2026-06-23 02:46:15.0

  1. Recurrent epithelial ovarian cancer
    • Platinum-free interval > 6 months?
      • Platinum-sensitive recurrence
        • First relapse?
          • Assess for secondary cytoreductive surgery
            • Candidate for complete gross resection (R0)?
              • Refer for secondary cytoreduction at experienced center
                • Then proceed to systemic therapy
                  • Platinum re-treatment appropriate?
                    • Platinum-based doublet ± bevacizumab
                      • Carboplatin + paclitaxel
                        • Response to platinum-based therapy?
                          • Maintenance strategy
                            • If bevacizumab used
                              • Continue bevacizumab maintenance
                            • BRCA-mutated and PARPi appropriate
                              • Consider PARP inhibitor maintenance
                                • PARPi-after-PARPi: clinical equipoise
                            • Prior PARPi or non-BRCA setting
                              • Individualize by prior therapy, region, and benefit-risk
                          • Proceed to platinum-resistant / later-line algorithm
                      • Carboplatin + gemcitabine
                        • Response to platinum-based therapy?
                          • Maintenance strategy
                            • If bevacizumab used
                              • Continue bevacizumab maintenance
                            • BRCA-mutated and PARPi appropriate
                              • Consider PARP inhibitor maintenance
                                • PARPi-after-PARPi: clinical equipoise
                            • Prior PARPi or non-BRCA setting
                              • Individualize by prior therapy, region, and benefit-risk
                          • Proceed to platinum-resistant / later-line algorithm
                      • Carboplatin + PLD
                        • Response to platinum-based therapy?
                          • Maintenance strategy
                            • If bevacizumab used
                              • Continue bevacizumab maintenance
                            • BRCA-mutated and PARPi appropriate
                              • Consider PARP inhibitor maintenance
                                • PARPi-after-PARPi: clinical equipoise
                            • Prior PARPi or non-BRCA setting
                              • Individualize by prior therapy, region, and benefit-risk
                          • Proceed to platinum-resistant / later-line algorithm
                    • Platinum inappropriate
                      • Use non-platinum biomarker-directed options
                        • FRα-positive
                          • Consider MIRV + bevacizumab
                        • PD-L1 positive
                          • Consider cyclophosphamide + bevacizumab + pembrolizumab
                        • HER2 3+
                          • Consider trastuzumab deruxtecan
                        • No actionable biomarker or unsuitable
                          • Clinical trial or non-platinum chemotherapy
              • Proceed directly to systemic therapy
                • Platinum re-treatment appropriate?
                  • Platinum-based doublet ± bevacizumab
                    • Carboplatin + paclitaxel
                      • Response to platinum-based therapy?
                        • Maintenance strategy
                          • If bevacizumab used
                            • Continue bevacizumab maintenance
                          • BRCA-mutated and PARPi appropriate
                            • Consider PARP inhibitor maintenance
                              • PARPi-after-PARPi: clinical equipoise
                          • Prior PARPi or non-BRCA setting
                            • Individualize by prior therapy, region, and benefit-risk
                        • Proceed to platinum-resistant / later-line algorithm
                    • Carboplatin + gemcitabine
                      • Response to platinum-based therapy?
                        • Maintenance strategy
                          • If bevacizumab used
                            • Continue bevacizumab maintenance
                          • BRCA-mutated and PARPi appropriate
                            • Consider PARP inhibitor maintenance
                              • PARPi-after-PARPi: clinical equipoise
                          • Prior PARPi or non-BRCA setting
                            • Individualize by prior therapy, region, and benefit-risk
                        • Proceed to platinum-resistant / later-line algorithm
                    • Carboplatin + PLD
                      • Response to platinum-based therapy?
                        • Maintenance strategy
                          • If bevacizumab used
                            • Continue bevacizumab maintenance
                          • BRCA-mutated and PARPi appropriate
                            • Consider PARP inhibitor maintenance
                              • PARPi-after-PARPi: clinical equipoise
                          • Prior PARPi or non-BRCA setting
                            • Individualize by prior therapy, region, and benefit-risk
                        • Proceed to platinum-resistant / later-line algorithm
                  • Platinum inappropriate
                    • Use non-platinum biomarker-directed options
                      • FRα-positive
                        • Consider MIRV + bevacizumab
                      • PD-L1 positive
                        • Consider cyclophosphamide + bevacizumab + pembrolizumab
                      • HER2 3+
                        • Consider trastuzumab deruxtecan
                      • No actionable biomarker or unsuitable
                        • Clinical trial or non-platinum chemotherapy
          • Systemic therapy selection by prior exposure and patient factors
            • Platinum re-treatment appropriate?
              • Platinum-based doublet ± bevacizumab
                • Carboplatin + paclitaxel
                  • Response to platinum-based therapy?
                    • Maintenance strategy
                      • If bevacizumab used
                        • Continue bevacizumab maintenance
                      • BRCA-mutated and PARPi appropriate
                        • Consider PARP inhibitor maintenance
                          • PARPi-after-PARPi: clinical equipoise
                      • Prior PARPi or non-BRCA setting
                        • Individualize by prior therapy, region, and benefit-risk
                    • Proceed to platinum-resistant / later-line algorithm
                • Carboplatin + gemcitabine
                  • Response to platinum-based therapy?
                    • Maintenance strategy
                      • If bevacizumab used
                        • Continue bevacizumab maintenance
                      • BRCA-mutated and PARPi appropriate
                        • Consider PARP inhibitor maintenance
                          • PARPi-after-PARPi: clinical equipoise
                      • Prior PARPi or non-BRCA setting
                        • Individualize by prior therapy, region, and benefit-risk
                    • Proceed to platinum-resistant / later-line algorithm
                • Carboplatin + PLD
                  • Response to platinum-based therapy?
                    • Maintenance strategy
                      • If bevacizumab used
                        • Continue bevacizumab maintenance
                      • BRCA-mutated and PARPi appropriate
                        • Consider PARP inhibitor maintenance
                          • PARPi-after-PARPi: clinical equipoise
                      • Prior PARPi or non-BRCA setting
                        • Individualize by prior therapy, region, and benefit-risk
                    • Proceed to platinum-resistant / later-line algorithm
              • Platinum inappropriate
                • Use non-platinum biomarker-directed options
                  • FRα-positive
                    • Consider MIRV + bevacizumab
                  • PD-L1 positive
                    • Consider cyclophosphamide + bevacizumab + pembrolizumab
                  • HER2 3+
                    • Consider trastuzumab deruxtecan
                  • No actionable biomarker or unsuitable
                    • Clinical trial or non-platinum chemotherapy
      • PFI ≤ 6 months
        • Proceed to platinum-resistant / partially sensitive algorithm
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