A.

Narendra

Incidence, Morbidity, Mortality Risk Factors Signs/Symptoms The Adnexal Mass Types of Ovarian Cancer Tumor Markers Treatment (Surgery and Chemotherapy) Survival

1:70 lifetime risk of developing ovarian cancer for all women 2nd most common GYN cancer in developed world (after uterine cancer) 22,430 new cases diagnosed annually in US 15,280 deaths annually in US Only ~ 20% cancers detected at Stage I Most present at advanced stages Median Age @ diagnosis: 63 yrs

Increase Risk
Age most important independent risk factor Family history BRCA1 (60x increased risk), BRCA2 (30x), HNPCC (13x) Nulliparity, infertility, endometriosis

Decrease Risk

Prophylactic oophorectomy Oral contraceptive pills

Nonspecific Symptoms

Bloating Increased abdominal girth Pelvic Pain Urinary symptoms Back/Leg pain Diarrhea, nausea, constipation, gas, early satiety, indigestion Dyspareunia Abnormal vaginal bleeding

Abdominal/Pelvic Exam

Ascites Adenexal Lesion: irregular, solid, fixed, nodular or bilateral

Young women Usually benign Often functional cysts

Postmenopausal More likely to be malignant than pre-menopausal women Many benign neoplasms
Cystadenomas
Mucinous cystadenoma

Mature cystic teratoma

Premenopausal
Often benign cyst: ie. Functional/follicular, endometrioma, hemorrhagic, dermoid Rule out other benign etiologies: ie. tuboovarian abcess, ectopic pregnancy If highly symptomatic rule out: ovarian torsion, ruptured ovarian cyst Testing should always include: BHCG, CBC, transvaginal ultrasound, cervical cultures

Tuboovarian abcess

Ectopic pregnancy

Postmenopausal
Exclude common diagnoses: endometriosis, cyst, abcess Higher index for suspicion: transvaginal US, CA 125 Unless simple cysts, most likely will need surgery Need breast exam, digital rectal, mammography

Ovarian Cancer

Ultrasound
Low positive predictive value for cancer Cancer: excrescences, ascites, and mural nodules Benign: unilocular, thinwalled sonolucent cysts with smooth, regular borders, regardless of menopausal status or cyst size

Ovarian cancer

Benign cyst

Other

MRI, CT, PET CT

Epithelial Germ Cell

Dysgerminoma Immature teratoma Endodermal sinus tumor Embryonal carcinoma Polyembryonal Choriocarcinoma Mixed Granulosa cell Sertoli-Leydig Gynandroblastoma Unclassified Breast, Colon Cancers Kruckenberg

Dysgerminoma

Sex Cord Stromal

Metastatic

Signet ring pathology

Primary usually stomach, signet ring cells on pathology

Epithelial: CA 125, elevated in 80%

35 U/mL is upper limit of normal Also elevated in many benign conditions

Malignant germ cell tumors: b-hCG, LDH, AFP Embryonal carcinoma: AFP, b-hCG Endodermal Sinus tumor: AFP Granulosa cell tumors: inhibin

Cytoreductive surgery (debulking)

Optimal cytoreducion = <1cm residual disease

Chemotherapy

CT of ovarian mass

Cytoreductive Surgery

Removal of: uterus, tubes, ovaries, omentum, pelvic and paraaortic nodes, all visible tumor Peritoneal washings Diaphragm biopsies

Ovarian Cancer Staging

Ovarian Cancer Staging

Ovarian Cancer Staging

Ovarian Cancer Staging

Up-front Cytoreductive Surgery IV Carboplatin and Paclitaxel

First line Mechanism of action

Carbo: binds and crosslinks DNA prevents DNA synthesis Taxol: binds stable microtubules inhibiting cell division

Side effects
Carbo
thrombocytopenia, leukopenia, anemia, vomiting, hair loss

Taxol
neutropenia, leukopenia, anemia, hair loss, muscle pain, vomiting, diarrhea

Intraperitoneal (IP) Chemotherapy

For optimally cytoreduced patients (<1cm residual disease after initial surgery) Usually given as combination IV/IP Chemotherapy

platinum-based (cisplatin or carboplatin) & taxol chemo agents

For very advanced disease at presentation

IV chemotherapy Followed by Interval Cytoreductive Surgery Chemotherapy (IV or IV/IP)

Percent percentage of patients who present at that stage Survival 5 year survival estimates