Ovarian CancerScreening and Diagnosis

7/29/2019 Ovarian Cancer Screening and Diagnosis

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Ovarian Cancer

Screening and Diagnosis

Nancy Wozniak, MD


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Stats

Ovarian Ca. is the 2nd most common gyne

cancer.

It is the 5th most common cancer in women in

the U.S.

90% are of ovarian epithelial cells in origin.

The ovary is a common site of metastaticdisease from other primary cancers (e.g.

breast, Krukenberg, and GI tract)


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Clinical Manifestations

Most ovarian tumors are diagnosed between ages 40

and 65

Often have vague symptoms that are not very severe.

However, Ovarian ca. is not a silent killer

patients tend to be in denial and maybe so do

physicians.

Torsion is rare 7585 % of cases are advanced at the time of

diagnosis


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Symptoms that should make you take

notice

Ovarian cancer patients may have vague

symptoms but they are generally of shorter

duration (e.g. a few months rather than a year

or more)

Look for multiple symptoms such as bloating

and increased abdominal girth

Greater frequency and severity of symptoms


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Physical examination

Palpation of an adnexal mass is usually what gets awork up started

If the mass is irregular, and fixed it is more likely to

be malignantbut remember to broaden yourdifferential

TOA

endometrioma

dermoid tumorIf theres a mass andascitesits really likely to be

cancer


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Physical examination

Sad but truewe hardly ever find an early

ovarian cancer on exam

In menstruating women only 5-18% of adnexal

masses will prove malignant vs. postmenopausal

women 30-60% of masses will be malignant.


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So if you find a masswhat else can it be???

Endometrioma

Fibroid

Functional cyst TOA

Ectopic pregnancy

Dermoid tumor (younger women)


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You found a masswhat next

Pelvic ultrasound


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Pelvic ultrasound


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Its reasonable to follow a mass IF

- The mass is not suspicious on ultrasound

- (ie the mass is mobile, looks like a simple cyst, is less than 8-10cm)

- The mass should resolve over 2 mos orotherwise patient should have surgery.

- The threshold is lower for post menopausalwomensurgery if their cyst is > 3 cm.


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Tumor Markers

CA-125

The CA-125 is a glycoprotein (nl


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Tumor Markers

Its important to remember other causes of an elevated CA-125!

Other malignancies

Pregnancy

Endometriosis

Endometrial cancer

Certain pancreatic cancers

Uterine leiomyoma

PID

For the above reasons, a CA-125 is more useful inpostmenopausal women (PPV = 97%)


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Tumor Markers

LDH (lactate dehydrogenase)dysgerminoma

HCG (human chorionic gonadotropin)

choriocarcinoma.

AFP (alpha fetal protein)-- endodermal sinus

tumors


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Other imaging

CT scans are NOT used in staging or in

making the diagnosis, but

They are helping in finding mets, and in helping plan the

surgery.

Patients with ascites but NO mass, should have CT scanto find the possible extra ovarian primary tumor.


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Broad Categories of Ovarian Cancers

Epithelial Ovarian Cancer (75% of ovarian cancers)

Serousendosalpingeal (fallopian tubes)

Mucinous...endocervical

Endometriod..endometrial

Clear cellmullerian

Transitional (aka Brenner tumor) transitional

Also squamous and mixed tumors


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Case.

60 y.o. female

Psych patient

Was admitted to the hospital w/ a 3 month history of wt loss,

anorexia, and difficulty breathing. Relatives reportedabdominal distension during the last 8 mos.

Lab tests were normal

The above case and following pictures are from the European Association of

Radiology. Radiology and Surgery Department of Thriassio General Hospital.

Athens, Greece. V. Bizimi et. al.


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Case.

Transabdominal U.S.

Huge multilocualted mass filling the whole pelvis and left side of

the abdomen. The mass combined thick irregular walls,

multiple septations and low level internal echos with a larger

echogenic watery component (turned out to be exudate)


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Case.

Big mass!! 33.5 cm. Compressing other abdominal organs.


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Case.

A tumor is born


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Case.

This is a mucinous cystadenoma of the ovary.

Impressive, eh??


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Mucinous tumor (neonatal size)


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Figure 24-44 A, Brenner tumor ( right) associated with a benign cystic teratoma (left).B, Histologic detail of characteristic epithelial nests within the ovarian

stroma.(right)

Cystic teratomas (dermoid):

second most common


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Other categories

Borderline tumors: tumors of low malignant potential. They have atypicalepithelial proliferation without stromal invasion.

Primary Peritoneal tumors: aka papillary serous carcinoma of the peritoneum.This is associated with but distinct from Epithelial Ovarian Cancer.Histologically it looks the same as papillary serous ovarian carcinoma.

Ovaries are normal in size

Extaovarian involvement is greater than ovarianinvolvment

Predominantly serous histology

Surface involvement less than 5 mm in depth

Sometimes these get classified as an adenocarcinoma of anunknown primary site.


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Patterns of spread

Intraperitoneally

Hematogenously

Lymphatics

Most common means of spreadexfolation of cells thatimplant along the peritoneum

Tends to follow the circulatory path of respiration ie. Up the pericolic

gutters, along the intestinal mesentery to the right hemidiaphragm.

The colon is seldom invaded! However, the most common cause of

death is bowel obstruction.


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Staging

Thorough staging is important for prognosis and treatment.

Occult mets are common at the time of diagnosis even for stage I

and II cancers.

Overall, of patients thought to have Stage I-II disease willbe upstaged to Stage III. Histologic grade is an importantpredictor of this.


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Staging


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Staging

For patients who are incompletely staged,

they can be staged at a second procedure combined

with tumor resection.

They can be offered chemotherapy and reassess themsurgically later.

For patients with advanced disease, debulking shouldbe done at the time of the initial surgery.

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Ovarian CancerScreening and Diagnosis