Ovarian cancer
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Ovarian Cancer. Annette Chen, MD Division Gynecologic Oncology UMass Memorial Medical Center. The Case of Olivia Carson. You are a generalist in the community. You have a new patient. She is a 65 year old with a large pelvic mass arising from the right adnexum. The Case of Olivia Carson.

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Ovarian Cancer

Annette Chen, MD

Division Gynecologic Oncology

UMass Memorial Medical Center


The Case of Olivia Carson

  • You are a generalist in the community.

  • You have a new patient.

  • She is a 65 year old with a large pelvic mass arising from the right adnexum.


The Case of Olivia Carson

  • What is the likelihood that she has ovarian cancer?


The Case of Olivia Carson

  • What is the likelihood that she has ovarian cancer?

    • Age

    • Menopausal status

    • Mass characteristics


Ovarian Neoplasms

  • 90% benign

  • 10% malignant


Incidence of Ovarian Cancer


Incidence of Ovarian Cancer


Predictive Value of Menopausal Status

Vasilev. Obstet Gynecol 1988


The Case of Olivia Carson

  • The only other data you have is that she underwent an imaging study.

  • Which study do you hope she has had?


Imaging of Ovarian Masses

Scoutt. Clin ObstetGynecol 1991


Imaging of Ovarian Masses

Scoutt. Clin ObstetGynecol 1991


Transvaginal Ultrasound

  • Cost effective

  • High frequency

  • Improved resolution


Simple cyst

Complex cyst

Ultrasound Evaluation of Adnexal Masses


Simple cyst

Anechoic

Smooth walls

Complex cyst

Cystic and solid

Irregular outline

Septa

Papilla

Heterogeneous

Ultrasound Evaluation of Adnexal Masses


Ultrasound Findings


Ultrasound Findings


Ultrasound scoring system

1-3 = benign

4-6 = equivocal

7-10 = malig


Transvaginal ultrasound: predictive value

Finkler. Obstet Gynecol 1988


The Case of Olivia Carson

  • Her ultrasound shows a solid mass.

  • If this were cancer, predict the histology.


Cancer Rule of Thumb

Oncology recapitulates ontogeny


Embryology of the Ovary

3 cell types


Embryology of the Ovary

Coelomic

epithelium

Mesenchyme

Germ cells


Embryology of the Ovary

Coelomic

epithelium

Mesenchyme

Germ cells

Epithelium

Stromal cells

Ova


Stromal Tumors: Histologic Subtypes

  • Fibroblasts

  • Granulosa cell tumors

  • Thecal cells

  • Sertoli-Leydig cells


Stromal tumors: Histologic subtypes

  • FibroblastsFibromas

  • Granulosa cells Granulosa cell tumor

  • Thecal cellsThecoma

  • Sertoli-Leydig cellsSertoli-Leydig cell tumor


The Case of Olivia Carson

  • 65 year old with a large pelvic mass arising from the right adnexum.

  • Solid mass on TV US.

  • You do a careful history and determine that she has had new onset of vaginal bleeding.


Granulosa Cell Tumors

  • Hormonally active

    • Estrogen

    • Inhibin

    • MIS


The Case of Olivia Carson

  • 65 year old with a HARD large pelvic mass arising from the right adnexum.

  • Solid mass on TV US.

  • Extensive ascites on TV US.

  • Right pleural effusion.


Meig’s syndrome

  • Fibroma

  • Ascites (>200 ml)

  • Hydrothorax


The Case of Olivia Carson

  • 25 year old with acute pain and a HARD large pelvic mass arising from the right adnexum.

  • Solid mass on TV US.

  • Extensive ascites on TV US.

  • Right pleural effusion.

  • You note multiple skin lesions.


Gorlin’s Syndrome

  • Ovarian fibromas

  • Young women

  • Multiple basal cell nevi and carcinomas

  • Dental cysts

  • Skeletal abnormalities

  • Autosomal dominant


The Case of Olivia Carson

  • 65 year old with a large pelvic mass arising from the right adnexum.

  • Solid mass on TV US.

  • What will you do to treat her?


Management of Stromal Tumors

  • Washings

  • USO

  • Consider TAH BSO, nodes

    • Granulosa cell tumors

    • Sertoli-Leydig cell tumors

    • Suspicious for malignancy


The Case of Olivia Carson

  • You are a generalist in the community.

  • You have a new patient.

  • She is a 15 year old with a large pelvic mass arising from the right adnexum.

  • What is the most likely tumor?


Histologic Subtypes: Germ Cell Tumors

Germ cell


Histologic subtypes: germ cell tumors

Germ cell

Embryo

Fetus

Yolk sac

Placenta


Histologic subtypes: germ cell tumors

Germ cell

Dysgerminoma

Embryo

Embryonal ca

Fetus

Teratoma

Yolk sac

Placenta

Endodermal sinus tumor

Choriocarcinoma


The Case of Olivia Carson

  • 15 year old with a large pelvic mass arising from the right adnexum.

  • What pre-op labs do you want?


Tumor Markers: Germ Cell Tumors

  • LDH

  • AFP

  • hCG


Histologic Subtypes: Germ Cell Tumors

Germ cell

  • Dysgerminoma

    • LDH

Embryo

  • Embryonal ca

    • AFP/hCG

Fetus

  • Teratoma

    • AFP

Yolk sac

Placenta

  • Endodermal sinus tumor

  • Choriocarcinoma

    • hCG


The Case of Olivia Carson

  • 15 year old with a large pelvic mass arising from the right adnexum.

  • What will you do to treat her?


Germ Cell Tumors: Treatment

  • USO plus staging

  • Chemotherapy


The Case of Olivia Carson

  • 15 year old with a large pelvic mass arising from the right adnexum.

  • She underwent a USO at an outside hospital. A germ cell tumor was found on final path.

  • What do you recommend?


The Case of Olivia Carson

  • You are a generalist in the community.

  • You have a new patient.

  • She is a 65 year old with a TV US showing a 5 cm right ovarian cystic mass with one septation.

  • Her CA-125 is 40.

  • Do you refer her or keep her?


CA-125: Predictive Value

Finkler. Obstet Gynecol 1988


Combination US + CA-125: Positive Predictive Value

Finkler. Obstet Gynecol 1988


Combination US + CA-125: negative predictive value

Finkler. Obstet Gynecol 1988


The Case of Olivia Carson

  • 65 year old with a TV US showing a 5 cm right ovarian cystic mass with one septation.

  • Her CA-125 is 40.

  • You explore her and find a smooth, benign-appearing cyst on the ovary.

  • There is no extra-ovarian disease.

  • What procedure do you do?


Ovarian Masses: Surgical Management

  • Cyst aspiration

    • Ultrasound guided

    • Laparoscopic

  • Laparoscopy

  • Laparotomy


Ovarian Cyst Aspiration

  • Benign appearing cyst


Ovarian Cyst Aspiration

Bret. Radiol 1992


Cytology of Ovarian Aspirates

  • Cannot distinguish between primary and malignant disease

  • 10 - 66% false negative rate

Ganjei. Acta Cytol 1984


Ovarian Cyst Aspiration

  • Limited value

  • High recurrence rate

  • Unreliable cytology

  • ? Upstaging a malignant tumor


Ovarian cancer staging


Effect of Intraoperative Rupture

Sainz de la Cuesta. ObstetGynecol 1994


The Case of Olivia Carson

  • 65 year old with a TV US showing a 5 cm right ovarian cystic mass with one septation.

  • Her CA-125 is 40.

  • You do an RSO. Frozen section shows serous papillary carcinoma.

  • There is no extra-ovarian disease.

  • What do you do?


Apparent Stage I Disease

40% will have more advanced disease due to occult metastases.

  • Peritoneal cytology19%

  • Aortic nodes12%

  • Peritoneum10%

  • Pelvic nodes 9%

  • Diaphragm 8%

  • Omentum 7%


Survival and Staging


Surgical Staging Procedures

  • Pelvic washings

  • Systematic exploration of all intra-abdominal surfaces and viscera

  • Peritoneal biopsies

  • Diaphragmatic sampling

  • Infracolic omentectomy

  • Bilateral pelvic and para-aortic lymph node dissection


The Case of Olivia Carson

  • 65 year old with a TV US showing a 5 cm right ovarian cystic mass with one septation.

  • Her CA-125 is 40.

  • You explore her and find a smooth, benign-appearing cyst on the ovary.

  • There is no extra-ovarian disease.

  • You do an RSO. Frozen section shows borderline tumor.

  • What do you do?


Borderline Ovarian Cancer

  • Earlier age at presentation

  • Fertility sparing surgery (USO or cystectomy) is appropriate

  • Avoid bivalving or wedge resection of grossly normal ovary

  • Ideal to surgically stage, however does not change management

  • Chemotherapy has no role


Cytoreductive Surgery

Removal of the maximum amount of tumor possible.


Basis of Cytoreduction

Griffiths. Natl Cancer Inst Monogr 1975


Surgical Procedures

  • Bowel resection

  • Ureteral/bladder resection

  • Pelvic/aortic node dissection

  • Peritoneal stripping

  • Diaphragm stripping

  • Liver/spleen/kidney/stomach resection


Survival and Aggressive Surgery

N=163

Eisenkop. Gynecol Onc 1998


The Case of Olivia Carson

  • What is the likelihood that she has ovarian cancer?

    • Age

    • Menopausal status

    • Mass characteristics

    • CA-125


Ovarian Cyst Aspiration

  • Limited value

  • High recurrence rate

  • Unreliable cytology

  • ? Upstaging a malignant tumor


Summary: Ovarian Cancer


Summary: Stromal Tumors

  • Fibroblasts Fibromas

  • Granulosa cells Granulosa cell tumor

  • Thecal cells Thecoma

  • Sertoli-Leydig cells Sertoli-Leydig cell tumor


Summary: Germ Cell Tumors

Germ cell

  • Dysgerminoma

    • LDH

Embryo

  • Embryonal ca

    • AFP/hCG

Fetus

  • Teratoma

    • AFP

Yolk sac

Placenta

  • Endodermal sinus tumor

  • Choriocarcinoma

    • hCG


Summary:Surgical Staging Procedures

  • Pelvic washings

  • Systematic exploration of all intra-abdominal surfaces and viscera

  • Peritoneal biopsies

  • Diaphragmatic sampling

  • Infracolic omentectomy

  • Bilateral pelvic and para-aortic lymph node dissection


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