Ovarian Cancer. The Case of Olivia Carson l You are a generalist in the community. l You have a new patient. l She is a 65 year old with a large pelvic

Ovarian Cancer

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.


What is the likelihood that she has ovarian cancer?


What is the likelihood that she has ovarian cancer? Age Menopausal status Mass characteristics

Ovarian Neoplasms

90% benign 10% malignant

Incidence of Ovarian Cancer

Age Group

Incidence (per 100,000)

25-29

40-44

75-79

Incidence of Ovarian Cancer

Age Group

Incidence (per 100,000)

25-29 4

40-44 15

75-79 48

Predictive Value of Menopausal Status

Vasilev. Obstet Gynecol 1988

Status Malignant

Premenopausal 7-13%

Postmenopausal 8-45%


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 Obstet Gynecol 1991

Sensitivity Specificity

CT

MRI

US

Imaging of Ovarian Masses

Scoutt. Clin Obstet Gynecol 1991

Sensitivity Specificity

CT Poor Poor

MRI 95% 88%

US 75% 98%

Transvaginal Ultrasound

Cost effective

High frequency

Improved resolution

Ultrasound Evaluation of Adnexal Masses

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 Findings

Benign Malignant

Ultrasound Findings

Benign Malignant

Unilateral Bilateral

Cystic Solid component

Unilocular Multilocular

Stable over time Growth

No ascites Ascites

Ultrasound scoring system

1-3 = benign 4-6 = equivocal 7-10 = malig

Simple cyst. Smooth borders. 1Clear cyst. Either irregular border or low level echoes.

2

Clear cyst, postmenopausal. Both irregular border and low level echoes.

3

Solid component. Irregular border and echoes.

4-6

Mult septations, irregular border, nodularity.

7-9

As above plus ascites. 10

Transvaginal ultrasound: predictive value

Finkler. Obstet Gynecol 1988

Pos predictive

value

Neg predictive

valuePremenopausal 82% 86%

Postmenopausal 93% 71%


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


Coelomic epithelium

Mesenchyme

Germ cells


Coelomic epithelium

Mesenchyme

Germ cells

EpitheliumStromal cells

Ova

Stromal Tumors: Histologic Subtypes

1. Fibroblasts

2. Granulosa cell tumors

3. Thecal cells

4. Sertoli-Leydig cells

Stromal tumors: Histologic subtypes

1. Fibroblasts Fibromas

2. Granulosa cells Granulosa cell tumor

3. Thecal cells Thecoma

4. Sertoli-Leydig cells Sertoli-Leydig cell tumor


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

1. Estrogen

2. Inhibin

3. MIS


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


Extensive ascites on TV US. Right pleural effusion.

Meig’s syndrome

Fibroma Ascites (>200 ml) Hydrothorax


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


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




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


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 sacPlacenta

Histologic subtypes: germ cell tumors

Germ cell

Embryo

Fetus

Yolk sacPlacenta

Dysgerminoma

Embryonal ca

Teratoma

Endodermal sinus tumorChoriocarcinoma



What pre-op labs do you want?

Tumor Markers: Germ Cell Tumors

LDH AFP hCG

Histologic Subtypes: Germ Cell Tumors

Germ cell

Embryo

Fetus

Yolk sacPlacenta

Dysgerminoma•LDH

Embryonal ca•AFP/hCG

Teratoma•AFP


•hCG



What will you do to treat her?

Germ Cell Tumors: Treatment

USO plus staging Chemotherapy



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

What do you recommend?


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


Pos predictive

value

Neg predictive

valuePremenopausal 36% 82%


Combination US + CA-125: Positive Predictive Value


US aloneUS + CA-

125

Premenopausal 82% 71%


Combination US + CA-125: negative predictive value


US aloneUS + CA-

125

Premenopausal 85% 88%



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


Bret. Radiol 1992

Status Recurrence rate

Premenopausal 48%

Postmenopausal 80%

Cytology of Ovarian Aspirates

Cannot distinguish between primary and malignant disease

10 - 66% false negative rate

Ganjei. Acta Cytol 1984


Limited value High recurrence rate Unreliable cytology ? Upstaging a malignant tumor

Ovarian cancer staging

IA Involvement of one ovaryIntact capsule

IB Involvement of both ovariesIntact capsule

IC Ovarian surface involvementCapsule rupture

Effect of Intraoperative Rupture

Sainz de la Cuesta. Obstet Gynecol 1994

Stage DeathSurvival

(mo)

IA 3% 97

IC 12% 94

Surgical IC 20% 73



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 cytology 19% Aortic nodes 12% Peritoneum 10% Pelvic nodes 9% Diaphragm 8% Omentum 7%

Survival and Staging

5-year Survival

Apparent Stage I 60%

Surgical Stage I 90-100%

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



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

Residual diseaseMedian survival

(months)

>1.5 cm 11

<1.5 cm 39

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=163Eisenkop. Gynecol Onc 1998

Residual disease

% patientsMedian

survival (mo)

0 85 62

Any 14 20


What is the likelihood that she has ovarian cancer? Age Menopausal status Mass characteristics CA-125


Limited value High recurrence rate Unreliable cytology ? Upstaging a malignant tumor

Summary: Ovarian Cancer

Epithelial Stromal Germ cell

Incidence 65-70% 5-10% 15-20%

Age 50-60 All <25

Natural hx

Fast growth death

Slow growth

benign

Fast growth live

Tumor marker

CA-125 hormones

LDH, AFP, hCG

Treatment

Cytoreduction

Chemo

Surgery Surgery Chemo

Summary: Stromal Tumors

1. Fibroblasts Fibromas

2. Granulosa cells Granulosa cell tumor

3. Thecal cells Thecoma

4. Sertoli-Leydig cells Sertoli-Leydig cell tumor

Summary: Germ Cell Tumors

Germ cell

Embryo

Fetus

Yolk sacPlacenta

Dysgerminoma•LDH

Embryonal ca•AFP/hCG

Teratoma•AFP


•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

Documents

Ovarian Cancer. The Case of Olivia Carson l You are a generalist in the community. l You have a new patient. l She is a 65 year old with a large pelvic