Jennifer Erdrich, HMS III Gillian Lierberman, MD Two Women with Ovarian Cancer: Two Women with Ovarian Cancer: Mystery Metastasis vs. Primary Tumor Mystery Metastasis vs. Primary Tumor Jennifer Jennifer Erdrich Erdrich , HMS III , HMS III Gillian Lieberman, MD Gillian Lieberman, MD July 2006
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Jennifer Erdrich, HMS III
Gillian Lierberman, MD
Two Women with Ovarian Cancer:Two Women with Ovarian Cancer:Mystery Metastasis vs. Primary TumorMystery Metastasis vs. Primary Tumor
Jennifer Jennifer ErdrichErdrich, HMS III, HMS IIIGillian Lieberman, MDGillian Lieberman, MD
July 2006
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Ovarian CancerOvarian Cancer
55thth most common cause of female cancer death most common cause of female cancer death
5 year survival rate < 35%5 year survival rate < 35%
Mortality has only decreased slightly in 30 yrsMortality has only decreased slightly in 30 yrs
Most diagnosis made at advanced diseaseMost diagnosis made at advanced disease
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Ovarian TumorsOvarian Tumors
Majority derive from epithelial cellsMajority derive from epithelial cells
Benign ovarian tumors more common in Benign ovarian tumors more common in women ages 20women ages 20--4545
Malignant ovarian tumors more common in Malignant ovarian tumors more common in women ages 40women ages 40--6565
36 year old woman36 year old woman Increasing pelvic mass for last 2 months Increasing pelvic mass for last 2 months Abdominal distensionAbdominal distension Early satietyEarly satiety
Her age makes these more likely to be benign:Her age makes these more likely to be benign:benign: 20benign: 20--45 yrs45 yrsmalignant: 40malignant: 40--65 yrs65 yrs
However, the massive ascites on CT looks ominousHowever, the massive ascites on CT looks ominous
DdxDdx is extensive at this point as these images cannot is extensive at this point as these images cannot even determine benign vs. malignant status with any even determine benign vs. malignant status with any certainty certainty
Does the WHO Classification System help to further Does the WHO Classification System help to further characterize Ms. Xcharacterize Ms. X’’s condition?s condition?
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Ovarian Ovarian NeoplasmsNeoplasmsEpithelialEpithelial Germ CellGerm Cell Sex CordSex Cord MetsMets
Another look at the CT for Ms. XAnother look at the CT for Ms. X
This coronal CT shows This coronal CT shows gastric thickeninggastric thickening
It becomes apparent on It becomes apparent on a second look at the a second look at the axial images alsoaxial images also……
PACS, BIDMC
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Another look at the CT for Ms. XAnother look at the CT for Ms. X
PACS, BIDMC
The original axial CT image that demonstrated ascites also shows gastric thickening on a second look.
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Could this be a Could this be a KrukenbergKrukenberg Tumor?Tumor?
Profile of patients with Profile of patients with KrukenbergKrukenberg::–– Young, premenopausal womenYoung, premenopausal women–– Abdominal pain that is vague early in the disease, Abdominal pain that is vague early in the disease,
but more severe as the disease progressesbut more severe as the disease progresses–– Abdominal swellingAbdominal swelling–– Menstrual regularity still maintainedMenstrual regularity still maintained–– Ovarian tumors are large, bilateral and associated Ovarian tumors are large, bilateral and associated
with asciteswith ascites
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The next step for Ms. XThe next step for Ms. X
Endoscopy!Endoscopy!A single biopsy has 70% sensitivity for A single biopsy has 70% sensitivity for
diagnosing gastric cancerdiagnosing gastric cancer Seven biopsies increase the sensitivity to 98%Seven biopsies increase the sensitivity to 98%Ms. X undergoes endoscopy, which shows an Ms. X undergoes endoscopy, which shows an
ulcerated, ulcerated, fungatingfungating, infiltrative mass with , infiltrative mass with recent bleeding in the body and recent bleeding in the body and cardiacardia; ; duodenum determined to be normalduodenum determined to be normal
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Ms. X: EndoscopyMs. X: Endoscopy
DxDx: gastric : gastric adenocarcinomaadenocarcinoma, predominantly signet ring cell, predominantly signet ring cellPACS, BIDMC
cervix described as wrinkled but not cervix described as wrinkled but not erythematouserythematous–– normal colonoscopy 2 years agonormal colonoscopy 2 years ago
Her presentation is similar to Ms.XHer presentation is similar to Ms.XWhat does CT reveal?What does CT reveal?
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Ms. D: CT FindingsMs. D: CT Findings
CT shows bilaterally enlarged ovaries with cystic and solid components
PACS, BIDMC
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Ms. D: CT FindingsMs. D: CT Findings
CT shows omental caking, peritoneal studding, and free pelvic fluid
PACS, BIDMC
omental caking diffuse peritoneal studdingLight gray, soft tissue densities throughout
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Ms. D: CT FindingsMs. D: CT Findings
CT shows complications from the ovarian tumors: obstructive renal failure and large bowel dilatation
PACS, BIDMC
Nonuniform enhancing renal parenchyma; absence of contrast in collecting system
Dilatation of large bowel
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Ms. DMs. D
Exploratory surgery found studding of the Exploratory surgery found studding of the small and large bowel, small and large bowel, omentumomentum, and , and peritoneum. peritoneum.
It was determined that Ms. D had a primary It was determined that Ms. D had a primary mucinmucin producing tumor that had spread producing tumor that had spread throughout her abdomen. throughout her abdomen.
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Ms. X and Ms. DMs. X and Ms. D
These women illustrate two examples of ovarian These women illustrate two examples of ovarian tumorstumors–– Ms. X: stomachMs. X: stomachovary (Met)ovary (Met)–– Ms. D: ovary Ms. D: ovary abdomen (Primary)abdomen (Primary)
Their presenting symptoms and radiographic findings Their presenting symptoms and radiographic findings are similar. are similar.
The findings alone cannot establish whether the The findings alone cannot establish whether the malignancies are primary or metastatic.malignancies are primary or metastatic.
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Ms. X and Ms. DMs. X and Ms. D
Surgery and histology are critical in diagnosis, Surgery and histology are critical in diagnosis, staging and developing a treatment plan.staging and developing a treatment plan.
Both were advanced in their disease at diagnosis. Both were advanced in their disease at diagnosis. Could their tumors be detected earlier?Could their tumors be detected earlier?
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Could screening have Could screening have helped these women?helped these women?
Could screening have Could screening have helped these women?helped these women?
Possible screening testsPossible screening tests–– Pelvic ExamPelvic Exam
Early stage tumors rarely found due to deep anatomic Early stage tumors rarely found due to deep anatomic location of the ovarylocation of the ovary
–– Serum markers: CEA, CASerum markers: CEA, CA--125125Nonspecific Nonspecific –– these markers can be elevated in a these markers can be elevated in a
number of conditionsnumber of conditions
–– UltrasoundUltrasound–– CTCT
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Radiographic characteristics that help differentiate Radiographic characteristics that help differentiate benign and malignant benign and malignant adnexaladnexal massesmasses
BenignBenign MalignantMalignant
Simple cyst, < 10 cm Simple cyst, < 10 cm Solid, or solid and cysticSolid, or solid and cystic
–– CTCTMost useful for evaluating Most useful for evaluating metastaticmetastatic disease (M Stage)disease (M Stage)Cannot rely on it for T or N StagingCannot rely on it for T or N StagingCT is used to monitor recurrenceCT is used to monitor recurrence
Screening RisksScreening Risks–– Unnecessary surgery as followUnnecessary surgery as follow--up to positive testsup to positive tests
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SummarySummary
Case examples of metastatic and primary ovarian tumorsCase examples of metastatic and primary ovarian tumors
Pelvic and abdominal anatomyPelvic and abdominal anatomy
Radiographic imaging is essential in diagnosis.Radiographic imaging is essential in diagnosis.–– Menu of Tests for these patients: US, CT, endoscopy. Menu of Tests for these patients: US, CT, endoscopy.
Ultrasound CT Endoscopy
PACS, BIDMC
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SummarySummary
Ovarian tumor classificationOvarian tumor classification–– System organized by cell of origin: System organized by cell of origin:
Radiographic features can help differentiate Radiographic features can help differentiate benign vs. malignant:benign vs. malignant:–– evaluation of cystic/solid componentsevaluation of cystic/solid components–– unilateral/bilateralunilateral/bilateral–– septationsseptations, number and thickness, number and thickness
OVARIANTUMORS
EPITHELIALSerous
MucinousEndometroid
GERM CELLTeratoma
Yolk Sac TumorDysgerminoma
Mixed
SEX CORDGranulosa Cell
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SummarySummary
Ovarian cancerOvarian cancer–– 55thth most common cause of female cancer deathmost common cause of female cancer death–– Low survival rateLow survival rate
Current screening ineffective at detecting malignancies earlyCurrent screening ineffective at detecting malignancies early
Screening could pose risk of unnecessary proceduresScreening could pose risk of unnecessary procedures
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ReferencesReferences
Carlson, Karen J. Screening for ovarian cancer. UpCarlson, Karen J. Screening for ovarian cancer. Up--toto--Date, March 2006.Date, March 2006.
Chen, LeeChen, Lee--may, Jonathan S. may, Jonathan S. BerekBerek. Epithelial ovarian cancer: clinical manifestations, . Epithelial ovarian cancer: clinical manifestations, diagnositcdiagnositc evaluation, staging, and evaluation, staging, and histopathology. Uphistopathology. Up--toto--Date, May 2006. Date, May 2006.
Chen, LeeChen, Lee--may, Jonathan S. may, Jonathan S. BerekBerek. Epithelial ovarian cancer: pathogenesis, epidemiology, and ris. Epithelial ovarian cancer: pathogenesis, epidemiology, and risk factors. Upk factors. Up--toto--Date, May Date, May 2006. 2006.
FerrazziFerrazzi, E, , E, ZanettaZanetta, G, , G, DordoniDordoni, D, et al. , D, et al. TransvaginalTransvaginal ultrasonographicultrasonographic characterization of ovarian masses: comparison of characterization of ovarian masses: comparison of five scoring systems in a multicenter study. Ultrasound five scoring systems in a multicenter study. Ultrasound ObstetObstet GynecolGynecol 1997; 10:192.1997; 10:192.
HainsworthHainsworth, John D, F Anthony Greco. Adenocarcinoma of unknown primary sit, John D, F Anthony Greco. Adenocarcinoma of unknown primary site. Upe. Up--toto--date, December 2005. date, December 2005.
KinkelKinkel, K, , K, HricakHricak, H, Lu, Y, et al. US characterization of ovarian masses: A meta, H, Lu, Y, et al. US characterization of ovarian masses: A meta--analysis. Radiology 2000; 217:803.analysis. Radiology 2000; 217:803.
Kumar, Kumar, VinayVinay, , AbulAbul AbbasAbbas, Nelson , Nelson FaustoFausto. Pathologic Basis of Disease. The Female Genital Tract: 1092. Pathologic Basis of Disease. The Female Genital Tract: 1092--1117, The 1117, The Gastrointestinal Tract, 826. 2005Gastrointestinal Tract, 826. 2005
McGraw Hill Company. Gynecologic Oncology: Evaluation of the patMcGraw Hill Company. Gynecologic Oncology: Evaluation of the patient with a suspected ovarian neoplasm, Radiographic ient with a suspected ovarian neoplasm, Radiographic Evaluation, 2006. Evaluation, 2006.
Schneider, Arthur S, Philip A Schneider, Arthur S, Philip A SzantoSzanto. Pathology. Ovaries, 295. Pathology. Ovaries, 295--297,2006. 297,2006.
SchroySchroy, Paul C. Clinical features and diagnosis of gastric cancer. Up, Paul C. Clinical features and diagnosis of gastric cancer. Up--toto--Date, April 2006.Date, April 2006.
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AcknowledgementsAcknowledgements
Melissa Melissa GerlachGerlach, MD, MDAlice Fisher, MDAlice Fisher, MDGillian Lieberman, MDGillian Lieberman, MD Pamela LepkowskiPamela Lepkowski Larry Larry BarbarasBarbaras