Ovarian Cancer - Gyn-Oncology Case Presentation

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Ovarian Cancer - Gyn-Oncology Case Presentation Powered By Docstoc
					Gyn-Oncology
Case Presentation

       David Engle MD
       Dept. of Ob/Gyn
  University of TN- Memphis
Case

• 62yo SEA Female G2P2
• Pt presented to PCP complaning
  of recent weight gain, and
  feeling of Abdominal Pressure.
• TVUSG showed a Complex R
  adnexal mass that measured
  16.7cm, with mixed solid and
  cystic components.
• CA125=Unk?
More

• In OR Pt had large Ovarian
  Mass, with a frozen section
  showing-Poorly Diff. Serous
  Tumor.
• At this time a TAH/BSO/Stagging
  was perfomed
• Staging: Pelvic & Periaortic
  LND; Diaphram Scrapping,
  Omentectomy, Bx of Bil
  Pericolic gutters, side walls,and
More Again

• Pt remained hospitalized x5
  days, and was finally ―out the
  door‖
• Pt had an NG tube placed in OR
  and left (or should have been) to
  low intermittent suction x24
  hrs. Why? Not for N&V.
Final Path

• Poorly Diff Serous Epithelial Ca
  In Both Ovaries. Node negative,
  Washings Negative.
 Ovarian Carcinoma -
 General Information
• Leading cause of death from
  gynecologic cancers
• Incidence (USA)
  • 27,000 new cases; 15,000 deaths
• Major types
  • epithelial carcinoma - most common
    (including borderline)
  • germ cell & sex cord - tumor markers
  • sarcoma - very rare
Ovarian Carcinoma -
Etiology
• Incessant ovulation theory
• 1 in 74 women
• Risk factors
  • high number of ovulatory cycles
    • protective effects of OCP, birth #, breast
      feeding
  • genetics
    • one family of 1st-degree relatives: 5% risk of
      ovarian cancer
  • unknown causes
  • Diseases of older patients
Origin of Ovarian CA
Ovarian Carcinoma -
Germ cells
• Benign germ cell mostly dermoid
  cyst
• Types
  • dysgerminoma
  • immature teratoma
  • endodermal
  • choriocarcinoma
  • embryonal
Ovarian Carcinoma - Sex
cord stromal tumors
• Most are benign (fibromas)
• Malignant types
  • Hormones producing (estrogen/
    testosterone)
  • Granulosa cell tumor
  • Sertoli, Leydig, steroid cell tumors,
    mixed, other
Ovarian Carcinoma -
Symptoms
•   Asymptomatic
•   Vague symptoms
•   Ascites/weight gain
•   80% present with metastatic
    disease
Typical Presentation
Ovarian Carcinoma -
Suspicious ovarian mass
• cyst characteristics :
    • complex, solid or mixed
      component
    • Simple cyst > 5 - 10 cm &
      persistent
•   very young & old
•   abnormal CA 125 (> 35)
•   Ascites
•   Omental metastases
Ovarian Carcinoma -
Diagnosis
• Radiographic: CT/ MRI/
  ultrasound
• Not paracentesis
• Tumor marker
  • epithelial carcinoma - CA 125
  • germ cell carcinoma - AFP, LDH,
    HCG
  • granulosa cell tumors - inhibin
Before Surgery
During Surgery
Ovarian Carcinoma -
Staging
• Stage I—confined to the ovaries
• Stage II—one or two ovaries with pelvic
  extension
• Stage III—tumor in pelvis but with
  metastases to abdomen
• Stage IV—distant metastases
Pattern of Spread

• Transcelomic-Exfoliation of Cells.
  Follows Circulatory path of
  Peritoneal Fluids.
• Lymphatic-Pelvic & Paraaortic
  • Stage III 78% with +Pelvic Nodes
  • +Para-Aortic Nodes: I 18%; II 20%; III
    42%; IV 67%
  • Hematogenous- Rare at time of Dx. Only
    2-3% spread to vital organs at initial Dx.
Ovarian Carcinoma -
Treatment
• Optimal debulking - residual < 1
  cm
• Chemotherapy
  • Stage IA/B, grade I/II : no adjuvant
    chemotherapy
  • More advanced stages : Platinum
    and Taxol
• Radiotherapy - little role
Guide Line
            Pelvic Mass


                 Work Up
            History & Physical
      CXR, abd/pelvic CT scan or USG
        Obtain family cancer history
        CA 125, CBC, Chem Profile
       BE/colonoscopy if symptomatic




         Surgical Candidate?
     Surgical Candidate              Non Surgical Candidate


 TAHBSO (USO if desires              FNA diagnoses, Chemo
 fertility & stg I) + staging         + interval debulking


Primary adjuvant Rx
Stg Ia/a gr 1 – observation
Stg Ia/b gr 2 – obs vs. chemo
Other stages - chemo


                                 Follow Up
                     Visit q 3 m x 2 y, then q 6 m x 3 y
                        Every visit: exam + Ca 125
                  If symptomatic: CT, CXR, CBC, Chem
                                  Follow Up




                 Cure                             Recurrent




            Clinical relapse                  Incr. Ca 125, no symptoms
   If < 6 m after chemo : 2nd line chemo              Observe
     If > 6 m after chemo : carboplatin             Restart chemo
if locally resectable, consider redebulking
       and followed with carboplatin
Five year survival
   90
   80
   70
   60
   50                                             Percents
   40
   30
   20
   10
    0
    Stage I I
       Stage    Stage II
                 Stage     Stage
                           Stage III   Stage
                                       Stage IV
        90%       II         III         IV
                 80%        20%          5%
Ovarian Cancer
Comparisons
          Ovarian Cancer              Breast Cancer
Stage   % at Dx   % 5 yr Survival   % at Dx % 5 yr Survival

  I       20         90               55         90+

 II       15         80               20         90

 III      50         20               15         30

 IV       15          5               10         10
Postmenomausal
Screening for Ovarian
Cancer
• Postmenopausal women (age >
  45 y)
• Control arm (10,977), study arm
  (10,958)
• Intervention: CA125, pelvic sono
  3x/year
• No difference in number of
  death from ovarian cancer
BRCA I & II Screen
• Most epithelial Ca is sporadic, only
  +family hx 5-10% of all Malignancy.
• BRCA I-Most hereditary Ovarian Ca.
  Located Ch 17.
• BRCA II-Small proportion on Ch 13.
• Both AD inheritance
• +BRCA I –Lifetime risk Ovarian
  ca=28-44% and BRCA II=27%
• Risk of Breast Ca with either =56-
  87%
BRCA I & II Screen

• Very Conflicting data
• NIH Consensus- Screening
  TVUSG and CA125 levels
• This data has not been clearly
  established.
BRCA I & II Screen
General Recommendations
• Genetic Consult and screen
• TVUSG q 6mo
• OCP’s
• Prophylactic BSO? Need
  +Genetic screen. Not 100%.
• +Fh Breast Ca- Mammogram age
  30.
After Surgery

				
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Description: ovarian cancer, Cancer cells, ovarian cancer symptoms, ovarian cancer treatment, ovarian cyst,