Ovariancancer

Ovarian CancerOvarian Cancer

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Differential Diagnosis of Adnexal MassDifferential Diagnosis of Adnexal Mass

Mature cystic teratoma


Differential DiagnosisDifferential Diagnosis

Young womenYoung women– Usually gynecologicUsually gynecologic– Often functional cystsOften functional cysts

PostmenopausalPostmenopausal– Benign neoplasmsBenign neoplasms

CystadenomasCystadenomas

– Higher risk of malignancy than premenopausalHigher risk of malignancy than premenopausal Metastatic cancers may first present as adnexal massesMetastatic cancers may first present as adnexal masses


Ovarian CancerOvarian Cancer

Incidence/Morbidity/MortalityIncidence/Morbidity/Mortality– Lifetime risk: approx 1/70Lifetime risk: approx 1/70


Types of Ovarian CancerTypes of Ovarian Cancer EpithelialEpithelial Germ CellGerm Cell

– DysgerminomaDysgerminoma– Immature teratomaImmature teratoma– Endodermal sinus tumorEndodermal sinus tumor– Embryonal carcinomaEmbryonal carcinoma– PolyembryonalPolyembryonal– ChoriocarcinomaChoriocarcinoma– MixedMixed

Sex Cord StromalSex Cord Stromal– Granulosa cellGranulosa cell– Sertoli-LeydigSertoli-Leydig– GynandroblastomaGynandroblastoma– UnclassifiedUnclassified

MetastaticMetastatic– BreastBreast– Kruckenberg- Primary usually stomach, signet ring cells on pathologyKruckenberg- Primary usually stomach, signet ring cells on pathology


Ovarian Cancer Staging








Ovarian Cancer RisksOvarian Cancer Risks

Increase RiskIncrease Risk– Age most important independent risk factorAge most important independent risk factor– Family historyFamily history– BRCA1 (60x increased risk), BRCA2 (30x), BRCA1 (60x increased risk), BRCA2 (30x),

HNPCC (13x)HNPCC (13x)– Nulliparity, infertility, endometriosisNulliparity, infertility, endometriosis

Decrease RiskDecrease Risk– Prophylactic oophorectomyProphylactic oophorectomy– Oral contraceptive pillsOral contraceptive pills


ExamExam

PhysicalPhysical– Malignancy: irregular, Malignancy: irregular,

solid consistency, is solid consistency, is fixed, nodular, or fixed, nodular, or bilateral, is associated bilateral, is associated with ascites with ascites


ExamExam UltrasoundUltrasound

– Low positive predictive Low positive predictive value for cancervalue for cancer

– Cancer: excrescences, Cancer: excrescences, ascites, and mural ascites, and mural nodules nodules

– Benign: unilocular, thin-Benign: unilocular, thin-walled sonolucent cysts walled sonolucent cysts with smooth, regular with smooth, regular borders, regardless of borders, regardless of menopausal status or menopausal status or cyst size cyst size

Ovarian cancer

Benign cyst


LabsLabs

Tumor markersTumor markers– Epithelial: CA 125, elevated in 80% Epithelial: CA 125, elevated in 80%

35 U/mL is upper limit of normal35 U/mL is upper limit of normal Also elevated in many benign conditionsAlso elevated in many benign conditions

– Malignant germ cell tumors: b-hCG, LDH, AFP Malignant germ cell tumors: b-hCG, LDH, AFP – Embryonal carcinoma: AFP, BhCGEmbryonal carcinoma: AFP, BhCG– Endodermal Sinus tumor: AFPEndodermal Sinus tumor: AFP– Granulosa cell tumors: inhibinGranulosa cell tumors: inhibin


Work-upWork-up

PremenopausalPremenopausal– Symptomatic : evaluate as appropriate for Symptomatic : evaluate as appropriate for

tuboovarian abcess, ectopic, torsion, ruptured tuboovarian abcess, ectopic, torsion, ruptured ovarian cystovarian cyst

– B-HCG, CBC, transvaginal USN, cervical B-HCG, CBC, transvaginal USN, cervical culturesculturesTuboovarian abcess

Ectopic pregnancy


Work-upWork-up

PostmenopausalPostmenopausal– Exclude common diagnoses: endometriosis, cyst, Exclude common diagnoses: endometriosis, cyst,

abcessabcess– Higher index for suspicion: transvaginal USN, CA 125Higher index for suspicion: transvaginal USN, CA 125– Unless simple cysts, most likely will need surgeryUnless simple cysts, most likely will need surgery– Need breast exam, digital rectal, mammographyNeed breast exam, digital rectal, mammography

Ovarian Cancer

Ovarian Cancer


Treatment of Epithelial Ovarian Treatment of Epithelial Ovarian CancerCancer

ChemotherapyChemotherapy Cytoreductive surgery (debulking)Cytoreductive surgery (debulking)

CT of ovarian mass


http://radiographics.rsnajnls.org/cgi/content/full/23/3/687/F4A


DebulkingDebulking

Removal of: uterus, tubes, ovaries, omentum, pelvic and paraaortic nodes, all visible tumor

Peritoneal washings

Diaphragm biopsieswww.freelivedoctor.comwww.freelivedoctor.com


Carboplatin and PaclitaxelCarboplatin and Paclitaxel– First lineFirst line– Mechanism of actionMechanism of action

Carbo: binds and crosslinks DNACarbo: binds and crosslinks DNA Taxol: promotes formation and inhibits disassembly of stable Taxol: promotes formation and inhibits disassembly of stable

microtubules, inhibiting mitosismicrotubules, inhibiting mitosis

– Side effectsSide effects Carbo: thrombocytopenia, leukopenia, anemia, vomiting, hair Carbo: thrombocytopenia, leukopenia, anemia, vomiting, hair

lossloss Taxol: neutropenia, leukopenia, anemia, Taxol: neutropenia, leukopenia, anemia,

hair loss, muscle pain, vomiting, diarrheahair loss, muscle pain, vomiting, diarrhea


Ovariancancer

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