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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
Ovarian Cancer

Annette Chen, MD

Division Gynecologic Oncology

UMass Memorial Medical Center

the case of olivia carson
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 carson1
The Case of Olivia Carson
  • What is the likelihood that she has ovarian cancer?
the case of olivia carson2
The Case of Olivia Carson
  • What is the likelihood that she has ovarian cancer?
    • Age
    • Menopausal status
    • Mass characteristics
ovarian neoplasms
Ovarian Neoplasms
  • 90% benign
  • 10% malignant
predictive value of menopausal status
Predictive Value of Menopausal Status

Vasilev. Obstet Gynecol 1988

the case of olivia carson3
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
Imaging of Ovarian Masses

Scoutt. Clin ObstetGynecol 1991

imaging of ovarian masses1
Imaging of Ovarian Masses

Scoutt. Clin ObstetGynecol 1991

transvaginal ultrasound
Transvaginal Ultrasound
  • Cost effective
  • High frequency
  • Improved resolution
ultrasound evaluation of adnexal masses1
Simple cyst

Anechoic

Smooth walls

Complex cyst

Cystic and solid

Irregular outline

Septa

Papilla

Heterogeneous

Ultrasound Evaluation of Adnexal Masses
ultrasound scoring system
Ultrasound scoring system

1-3 = benign

4-6 = equivocal

7-10 = malig

transvaginal ultrasound predictive value
Transvaginal ultrasound: predictive value

Finkler. Obstet Gynecol 1988

the case of olivia carson4
The Case of Olivia Carson
  • Her ultrasound shows a solid mass.
  • If this were cancer, predict the histology.
cancer rule of thumb
Cancer Rule of Thumb

Oncology recapitulates ontogeny

embryology of the ovary1
Embryology of the Ovary

Coelomic

epithelium

Mesenchyme

Germ cells

embryology of the ovary2
Embryology of the Ovary

Coelomic

epithelium

Mesenchyme

Germ cells

Epithelium

Stromal cells

Ova

stromal tumors histologic subtypes
Stromal Tumors: Histologic Subtypes
  • Fibroblasts
  • Granulosa cell tumors
  • Thecal cells
  • Sertoli-Leydig cells
stromal tumors histologic subtypes1
Stromal tumors: Histologic subtypes
  • Fibroblasts Fibromas
  • Granulosa cells Granulosa cell tumor
  • Thecal cells Thecoma
  • Sertoli-Leydig cells Sertoli-Leydig cell tumor
the case of olivia carson5
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
Granulosa Cell Tumors
  • Hormonally active
    • Estrogen
    • Inhibin
    • MIS
the case of olivia carson6
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
Meig’s syndrome
  • Fibroma
  • Ascites (>200 ml)
  • Hydrothorax
the case of olivia carson7
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
Gorlin’s Syndrome
  • Ovarian fibromas
  • Young women
  • Multiple basal cell nevi and carcinomas
  • Dental cysts
  • Skeletal abnormalities
  • Autosomal dominant
the case of olivia carson8
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
Management of Stromal Tumors
  • Washings
  • USO
  • Consider TAH BSO, nodes
    • Granulosa cell tumors
    • Sertoli-Leydig cell tumors
    • Suspicious for malignancy
the case of olivia carson9
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 tumors1
Histologic subtypes: germ cell tumors

Germ cell

Embryo

Fetus

Yolk sac

Placenta

histologic subtypes germ cell tumors2
Histologic subtypes: germ cell tumors

Germ cell

Dysgerminoma

Embryo

Embryonal ca

Fetus

Teratoma

Yolk sac

Placenta

Endodermal sinus tumor

Choriocarcinoma

the case of olivia carson10
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?
histologic subtypes germ cell tumors3
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 carson11
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
Germ Cell Tumors: Treatment
  • USO plus staging
  • Chemotherapy
the case of olivia carson12
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 carson13
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
CA-125: Predictive Value

Finkler. Obstet Gynecol 1988

the case of olivia carson14
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
Ovarian Masses: Surgical Management
  • Cyst aspiration
    • Ultrasound guided
    • Laparoscopic
  • Laparoscopy
  • Laparotomy
ovarian cyst aspiration
Ovarian Cyst Aspiration
  • Benign appearing cyst
ovarian cyst aspiration1
Ovarian Cyst Aspiration

Bret. Radiol 1992

cytology of ovarian aspirates
Cytology of Ovarian Aspirates
  • Cannot distinguish between primary and malignant disease
  • 10 - 66% false negative rate

Ganjei. Acta Cytol 1984

ovarian cyst aspiration2
Ovarian Cyst Aspiration
  • Limited value
  • High recurrence rate
  • Unreliable cytology
  • ? Upstaging a malignant tumor
effect of intraoperative rupture
Effect of Intraoperative Rupture

Sainz de la Cuesta. ObstetGynecol 1994

the case of olivia carson15
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
Apparent Stage I Disease

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

  • Peritoneal cytology 19%
  • Aortic nodes 12%
  • Peritoneum 10%
  • Pelvic nodes 9%
  • Diaphragm 8%
  • Omentum 7%
surgical staging procedures
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 carson16
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
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
Cytoreductive Surgery

Removal of the maximum amount of tumor possible.

basis of cytoreduction
Basis of Cytoreduction

Griffiths. Natl Cancer Inst Monogr 1975

surgical procedures
Surgical Procedures
  • Bowel resection
  • Ureteral/bladder resection
  • Pelvic/aortic node dissection
  • Peritoneal stripping
  • Diaphragm stripping
  • Liver/spleen/kidney/stomach resection
survival and aggressive surgery
Survival and Aggressive Surgery

N=163

Eisenkop. Gynecol Onc 1998

the case of olivia carson17
The Case of Olivia Carson
  • What is the likelihood that she has ovarian cancer?
    • Age
    • Menopausal status
    • Mass characteristics
    • CA-125
ovarian cyst aspiration3
Ovarian Cyst Aspiration
  • Limited value
  • High recurrence rate
  • Unreliable cytology
  • ? Upstaging a malignant tumor
summary stromal tumors
Summary: Stromal Tumors
  • Fibroblasts Fibromas
  • Granulosa cells Granulosa cell tumor
  • Thecal cells Thecoma
  • Sertoli-Leydig cells Sertoli-Leydig cell tumor
summary germ cell tumors
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
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