Transcript 06. malig.ovar.tumor

Malignant Ovarian Tumor
Dr. Mashael Shebaili
Assistant Prof. & Consultant
Department OF Ob & Gyn.
King Saud University
Objectives
introduction
History and
Epidemiology examination Risk factor
screening
Investigation Treatment
Prevention
• Introduction
Historically ovarian cancer has
been called the silent killer
because symptoms often
become apparent too late in the
processes that the chance of
cure were poor
Epidemology
• The lifetime risk for developing ovarian
cancer is 1.6% in the general population
• Ovarian cancer accounts for 3.3% of all new
cases of cancer
• The fifth in cancer deaths among women and
accounts for more deaths than any other
cancer of the female reproduction system
• only 19% of ovarian cancers discovered at
early stage.
• Most cases are diagnosed in the seventh
decade of life.
Urinary
urgency
Abd/pelvic
pain
Abdominal
distention
Vaginal
bleeding
Bloating
Change
bowel habit
Irregular
menses
Types of ovarian cancer
Epithelia
l tumor
Germ
cell
tumor
Stromal
cell
tumor
Physical finding
Ovarian or
Pelvic
mass
Ascites
Patient with
advance disease
Pleural
effusion
Bowel
obstruction
Obesity
HRT
Hereditary
parity
OCP
Family
history
Risk factors
parity
Obesity
HRT
Hereditary
OCP
Family
history
•Women who have
been pregnant have
50% decreasd risk
for develoing
ovarian cancer
compared to
nulliparous women
•Multiple
pregnancies offer an
increasingly
protective effect
OCP
Obesity
Parity
HRT
Hereditary
Family
history
•The use of OCP
more than one year
reduce the risk of
ovarian cancer by
30%-50%
•Its protective
effect lasted to 2-3
decade after
cessation of use
Family
history
Obesity
•No evidence of
hereditary pattern
Parity
•The risk in general
popultion is 1.6%
HRT
Hereditary
OCP
•The risk increased
to 4-5% when 1st
degree family
member is affected
,rising to 7% when
two relatives are
affected
Hereditary
Obesity
HRT
•Represent 5% of all
ovarian cancer
Parity
•2 syndrome are clearly
identified:
OCP
Family
history
Breast/ovarian cancer
syndrome : Associated
with early onset breast
or ovarian cancer
,transmitted as AD and
occur due to BRCA gene
mutation
Hereditary
Obesity
HRT
Parity
OCP
Family
history
Lynch ll syndrome or
hereditary non polyposis
colorectal cancer :
These families
characterized by high
risk of developing
colorectal ,endometrial,
stomach, small bowel,
breast ,pancreas and
ovarian cancer and it is
due to mutation in
mismatch repair gene .
HRT
Obesity
Parity
OCP
Hereditary
Family
history
•A large study puplished
in the journal of
national cancer institute
in October 2006 report
that women who used
hormonal therapy for 5
years or more face a
significantly increase
risk of ovarian cancer
Obesity
parity
HRT
Hereditary
OCP
Family
history
•Studies have suggested
that women who are
obese at age of 18 are
at increased risk of
developing ovarian
cancer befor menopause
However, 95% of all
ovarian cancers
occur in women
without risk factors.
Effective screening tests are available for several
common cancers, including: mammography for
breast cancer, the Pap test for cervical cancer but
no standardized screening test exists to reliably
detect ovarian cancer.
Researchers haven't yet found a screening tool
that's sensitive enough to detect ovarian cancer
in its early stages and specific enough to
distinguish ovarian cancer from other,
noncancerous conditions
Most experts feel that a screening
protocol for ovarian cancer should have a
positive predictive value of at least 10
percent (that is, no more than nine healthy
women with false-positive screens would
undergo unnecessary procedures for
each case of ovarian cancer detected
LPA
Other tumor
markers
Screening
US
Ca 125
Screening
LPA
Other tumor
marker
Has a sensitivity of 70%-80%
And a specificity of 98.6% - 99.45%
US
Ca 125
LPA
Other tumor
marker
Screening
US
Ca 125
False positive :
Increase in other cancers (pancreas ,breast ,bladder ,liver ,lung) ,in benign
disease (diverticulitis , endometriosis, benign ovarian cyst ,tuboovarian
abscess, renal disease) and in physiological condition (pregnancy and
Menstruation )
LPA
Screening
Other tumor
marker
False negative :
Elevated in only 80% of ovarian cancer cases
US
Ca 125
LPA
Other tumor
marker
Screening
US
Ca 125
Positive predictive value:
Annual CA125 testing has low predictive value (3%) which does not meet
the level required for screening post meopausal women at average risk
LPA
Other tumor
marker
Screening
US
Ca 125
CA125 as a first line test followed by US as a second line test
for positive CA125 result has a shown to be very specific
and achieve positive predictive value of 20% or greater .
LPA
Other tumor
markers
Screening
US
CA125
•Highly false positive :In one of the study it has been estimated that US
Screening of 100,000 women over age of 45,would detect 40 cases of
Ovarian cancer with 5,398 false positive result and more than 160
Complications from laproscopy .
LPA
Other tumor
markers
Screening
US
CA125
•In other screening studies in women at high risk of ovarian cancer ,US
has performed poorly in detecting early stage epithelial ovarian cancer .
LPA
Other tumor
markers
Screening
US
CA125
• The lipid lysophosphatidic acid is associated with invasion of the extracellular
matrix in ovarian cancer . LPA concentration are elevated in 96% of
women with ovarian cancer including 90% of those with stage 1 disease
•Studies to evaluate the use of this biomarker are ongoing .
US
LPA
Screening
Other tumor
marker
CA125
•Studies on CA72-4,macrophage –colony stimulating factor (MCSF)Osbepontin
,inhibin and Kallikrein are going to evalute combination of tumor marker
complemantary to CA 125 that could offer greater sensitivity and specificity than
CA125 alone .
Benefit VS Harm
• In one study of women at high risk of ovarian cancer, researchers
discovered that use of screening tests led to 20 operations on
Women only one of whom was found to have cancer — metastatic
breast cancer, not ovarian cancer.
• The preliminary results from the Prostate, Lung, Colorectal and
Ovarian (PLCO) Cancer Screening Trial, appears in the November
15, 2005 American Journal of Obstetrics and Gynecology , Women
who had an abnormal test result in one or both screening tests
underwent a variety of diagnostic procedures to determine whether
cancer was present, including 570 women who underwent a
surgical procedure as follow-up. Thus, 541 women underwent
surgery but did not have cancer.
CD4
Point to remember
• Screening for ovarian cancer is expensive because
of low prevalence of disease, high rate of surgical
intervention for noncancerous disease, and high
costs of tests and follow-up.
• Many experts suggest that the possible benefits of
lowered mortality or years of life saved do not justify
the costs of screening.
• The low positive predictive value associated with
currently available screening modalities suggests
that more women without cancer will be subject to
laparoscopy or laparotomy than will those with
cancer.
• Modeling studies of annual screening with CA 125,
with or without a single screening with transvaginal
ultrasound, found an increase in life expectancy of
less than one day per woman screened .
• No definitive large randomized controlled trials have
been completed to show whether any screening
strategy decreases mortality from ovarian cancer
Screening recommendation

No organization currently recommends either
ultrasound or cancer marker screening in
asymptomatic women, and multiple
organizations (including the American College of
Physicians, the Canadian Task Force on the
Periodic Health Examination, and the American
College of Obstetricians and Gynecologists)
recommend against it.
 Regarding women at higher risk (e.g., hereditary
cancer syndromes), the NIH consensus
conference recommends annual CA 125
measurements, pelvic exam, and transvaginal
ultrasound until childbearing is completed; at
age 35, women should be referred for bilateral
oophorectomy.
Investigation
Lab Studies
• If ovarian cancer due to a pelvic or ovarian
mass is suggested, minimize preoperative
testing needed and staging laparotomy
indicated .
• Routine preoperative tests include CBC
count, chemistry panel (including liver
function tests), and a cancer antigen 125
assay (CA-125).
Investigation
Imaging Studies
• Routine imaging is not required in all patients
in whom ovarian cancer is highly suggested.
• If diagnostic uncertainty is present, a pelvic
ultrasound or CT scan of the abdomen and
pelvis is warranted.
Investigation
Other Tests
• In patients with diffuse carcinomatosis and GI symptoms, a GI
tract workup may be indicated, including:
– Upper and/or lower endoscopy
– Barium enema
– Upper GI series
Procedures
• Biopsy
– A fine-needle aspiration (FNA) or percutaneous biopsy of an
adnexal mass is not routinely recommended. In most cases, taking
this approach instead of performing a surgical staging laparotomy
may only serve to delay appropriate diagnosis and treatment of
ovarian cancer.
– If a clinical suggestion of ovarian cancer is present, the patient
should undergo a diagnostic and surgical procedure.
– An FNA or diagnostic paracentesis should be performed in
patients with diffuse carcinomatosis or ascites without an obvious
ovarian mass.
staging
Ovarian cancer is staged using the International Federation of Gynecology and
Obstetrics (FIGO) :
•
Stage I - Growth limited to the ovaries
–
–
–
•
Stage II - Growth involving one or both ovaries, with pelvic extension
–
–
–
•
Stage IIa - Extension and/or metastases to the uterus or tubes
Stage IIb - Extension to other pelvic tissues
Stage IIc - Stage IIa or IIb but with tumor on surface of one or both ovaries, ruptured capsule,
ascites with malignant cells or positive peritoneal washings
Stage III - Tumor involving one or both ovaries, with peritoneal implants outside the
pelvis and/or positive retroperitoneal or inguinal nodes; superficial liver metastases
equal stage III
–
–
–
•
Stage Ia - Growth limited to 1 ovary, no ascites, no tumor on external surface, capsule intact
Stage Ib - Growth limited to both ovaries, no ascites, no tumor on external surface, capsule
intact
Stage Ic - Tumor either stage Ia or Ib but with tumor on surface of one or both ovaries,
ruptured capsule, ascites with malignant cells or positive peritoneal washings
Stage IIIa - Tumor grossly limited to pelvis, negative lymph nodes but histological proof of
microscopic disease on abdominal peritoneal surfaces
Stage IIIb - Confirmed implants outside of pelvis in the abdominal peritoneal surface; no
implant exceeds 2 cm in diameter and lymph nodes are negative
Stage IIIc - Abdominal implants larger than 2 cm in diameter and/or positive lymph nodes
Stage IV - Distant metastases; pleural effusion must have a positive cytology to be
classified as stage IV; parenchymal liver metastases equals stage IV
oThe standard treatment for ovarian cancer start
with staging and cytoreductive surgery
oFor post operative treatment , chemotherapy is
indicated in all patients with ovarian cancer
except those patients with stage 1 and low risk
characteristics
Prognosis
• The 5-year survival rates are as follows:
–
–
–
–
Stage I - 73%
Stage II - 45%
Stage III - 21%
Stage IV - Less than 5%
Prevention
1
2
OCP
Screening
3
Bilateral salpingo
Oophrectomy
4
Pregnancy and
Breast feeding
Tubal ligation
5 and hystrectomy
Women who use
ocp for three years
or more reduce
their risk of ovarian
cancer by 30%50%
For each year that
women take ocp
,her risk of ovarian
cancer is reduced
by about 5% on
average
Prevention
1
2
OCP
Screening
3
Bilateral salpingo
Oophrectomy
4
Pregnancy and
Breast feeding
Tubal ligation
5 and hystrectomy
Average women
who used ocp for
more than one year
,the protective
effect lasted 2-3
decades after
cessation of use
One analysis
estimated that
after 5 years of ocp
,nulliparous
womwn can reduce
their risk to the
level seen in
parous women who
never used ocp
Prevention
1
2
OCP
Screening
3
Bilateral salpingo
Oophrectomy
4
Pregnancy and
Breast feeding
Tubal ligation
5 and hystrectomy
Another study
show that 10
years of ocp use
by women with
positive family
history can
reduce their risk
to a level below
that for women
with no family
history who
never used ocp
1
OCP
2
Screening
3
Bilateral salpino
Oophrectomy
4
Pregnancy and
breast feeding
5
Tubal ligation
and hystrectomy
The periodic use of
trasvaginal
ultrasonography
and CA125 tumor
marker is
recommended in
high risk women
1
OCP
2
Screening
3
Bilateral salpigo
Oophrectomy
4
5
Pregnancy and
breast feeding
Tubal ligation
and hystrectomy
Surgical prophylaxis
decrease the risk by at
Least 90% but dose not
Completely eliminate the
risk WHY?
Because ovarian cancer
can be develop in the thin
lining of the abdominal
cavity that cover the
ovaries . women who have
had their ovaries removed
can still get a similar but
less common form of
cancer called primary
Peritoneal cancer
1
OCP
2
Screening
3
Bilateral salpigo
Oophrectomy
4
5
Pregnancy and
breast feeding
Tubal ligation
and hystrectomy
Who is prophylaxis
Oophrectomy recommended
For?
Patients with inherited
mutation in the BRCA
gene ,older than 35 year
who have completed their
families are the best
Candidates
Patients with family
history of breast or
ovarian cancer but no
known genetic mutation
1
OCP
2
Screening
3
Bilateral salpingo
Oophrectomy
4
Pregnancy and
Breast feeding
5
Tubal ligation
And hystrectomy
•Having at least
one child lower the
Risk of developing
Ovarian cancer
•Breast feeding for
a year or longer
Also reduce the risk
of ovarian cancer
1
OCP
2
Screening
3
Bilateral salpingo
Oophrectomy
4
Pregnancy and
Breast feeding
5
Tubal ligation
And hystrectomy
The nurses health
study which
followed 1000
Women for 20
years found
asubstatial
reduction in
ovarian cancer risk
in women who had
tubal ligation and
hystrectomy but it
was more with the
tubal ligation
1
OCP
2
Screening
3
Bilateral salpingo
Oophrectomy
4
Pregnancy and
Breast feeding
5
Tubal ligation
And hystrectomy
The suggested
mechanism of
protection:
By prevention of
possible upward
migration of
carcinogens
through the vagina,
the cervix and
fallopian tube into
the peritoneal
cavity
•Ovarian cancer is the most common lethal
gynecological malignancy and it represent
the fifth cancer death in women in general
•It has many risk factor ,the most important
one is the hereditary predisposition .
•No organization currently recommend the
screening in asymptomatic women
•