Transcript Case-report-for-CPC-07fri07

Clinico-pathological conference:
Gynae Oncology
Friday Dec 7th 2007
Alex Laios,
Orla Sheils,
John O’Leary
HISTORY
• 43 yr old, Irish lady, married, P0+0
• Consulted GP with a 3/12 Hx of:
– Abdominal distention (increasing abdominal girth)
– Intermittent abdominal pain, progressively worsening
(like tightness across the abdomen)
– Loss of appetite
– Weight loss associated with lower abdominal
discomfort of ~3/52 duration
– 1 recent episode of SOB and dry cough
– No change in urinary or bowel habits
Questions
• What are the possible causes of
increasing abdominal girth?
• What is the possible cause of weight loss
in this woman?
• Why does this woman have shortness of
breath and dry cough?
Questions
• What is the next step in managing this
patient?
• What investigations would be ordered in
this case?
Ultrasound examination of the
abdomen-pelvis [ordered by GP]
• Massive ascites
• 9 cm large complex cystic mass probably arising
from the pelvis, with multiple septations
• Left ovary could not be visualized
• Left hydronephrosis
Pelvis US scan
Referral to gynae oncology service
Physical examination
• Thin lady, previously healthy
• No lymphadenopathy
• Breast examination was normal
• Lung fields clear on auscultation
• Abdominal distention to 28 weeks size by a mass of poor
mobility arising from pelvis and upper abdominal
fullness, suggesting omental disease
• Clinical ascites
• Distended pouch of Douglas with thickening on rectovaginal examination
Medical and Gynaecologic History
Medical Hx:
– HTN, Ulcerative colitis (previously on long term steroids but no
evidence of DEXA osteopenia)
– Medications: Centyl, Lipitor
– Allergies: Penicillin
Surgical Hx: Arthroscopy, cholecystectomy
Family Hx: Bowel Ca (father), breast Ca (mother)
Gynae Hx:
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–
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–
Menarche at age 12y
Regular cycles, no dysmennorhea, LMP 2/52 ago
Last Cx smear 3 years ago
Never on OCP
Laboratory investigations
On admission
• FBC profile: Hb:13, WCC:9.8, PLTS:560
• Renal profile: urea:10.3, sodium:140, potassium:3.6,
creatinine:93 (marginally elevated)
• Liver profile: Albumin: 25 , LDH:385
• CA125: 534
• CA19.9: 3.9
Questions
• What is your provisional diagnosis?
• Can you identify any risk factors from her
medical history?
• What is your interpretation of her blood
results?
– Albumin
– urea, creatinine
– Hb, plts
Radiology investigations
• CXR:
– Lung fields appear clear
– No cardiomegaly
– No pleural effusion
• CT TAP (chest abdomen pelvis)
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–
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11 X 12.5cm complex pelvic mass arising from the left ovary
Massive ascites
Omental cake
No evidence of retroperitoneal lymphadenopathy
Left hydronephrosis
Splenic hilar and peritoneal nodes
• 3-D colour Doppler
• FDG-PET
CT- pelvis and abdomen
Omental cake
MRI scan -pelvis
3-D colour Doppler
FDG-PET
Laparotomy:Optimal debulking
Findings on laparotomy
TAH, BSO,Omentectomy, Appendicectomy
• Gross disease above pelvic brim
• 4 litres of ascites was removed
• Left ovary replaced by solid-cystic tumour at least 13 cm,
densely adherent to the left pelvic sidewall/peritoneum/POD
• Tumour deposits on splenic hilum, small deposits in
subdiaphragmatic and liver capsule (less than 0.5cm)
• Omental deposits
Describe the gross pathology findings
Peritoneal fluid
What does this show?
Histology
What does this show?
Immunocytochemistry: p53
Pathological diagnosis
• Papillary serous cystadenocarcinoma of
the left ovary
– TNM stage pT3, N1, Mx
– FIGO stage IIIC
HISTORY
• Uneventful recovery
• Histology available at day 9
• Referred to medical oncologists for adjuvant
chemotherapy
• Discharged on day 13
• Returned 6 weeks after surgery for initiation of
chemotherapy
HISTORY
• Received 6 cycles of Carboplatin and Taxol
– Question: what do these agents exactly do?
Actions of drugs
Mechanism of action of taxol
Mechanism of action of carboplatin
HISTORY
• Chemotherapy completed 3 months later
• Remained well and returned for combined
follow-up with Gynae-Oncologists and Medical
Oncologists
– Question: what is entailed in the medical follow-up?
Follow-up
• History
• Clinical examination
• CA-125
HISTORY
• Routine follow-up [3 months] for the first 2 years,
then every 6 months for the next 2 years, then
annually.
• 14 months after the original surgery she
complains of:
– Tiredness
– Intermittent low abdominal pain
– Vaginal bleeding
Questions
• Why does this patient have a vaginal
bleeding?
• What is the cause of the intermittent
abdominal pain?
HISTORY
• On clinical examination, two nodules are
identified close to the vaginal vault
• Raising CA125
• CT of thorax, abdomen and pelvis performed
– Two small soft tissue masses suspicious for disease
recurrence seen at the vaginal vault
• Biopsy performed of vaginal lesions
Vaginal vault biopsy
What does this show?
Relapse
• Will the patient benefit from the same
chemotherapy?
• Will she benefit from excision of the
nodules?
Recurrence in ovarian cancer
• 70% of ovarian cancer patients present
with advanced ovarian cancer [stage III/IV]
• 50%-70% of patients relapse
• Less than 20% long-term survivors
• Gene pathways for ovarian cancer
recurrence have just been defined
RECURRENCE
“The true Killer”
An integrative model for recurrence in
ovarian cancer
Management algorithm for patients
with ovarian cancer
Our opportunity for intervention
CHEMOPREVENTION
PROPHYLACTIC
OOPHORECTOMY
Ovulation
Environment
Family history
NORMAL
OVARY
PREMALIGNANT
CHANGE
TREATMENT
PRECLINICAL
DISEASE
SCREENING
CLINICAL
DISEASE
Life sciences
Image trait selection
Gene expression
data
Pre- processing
Disease traits
Image traits
Pathological
data
MRI
3-D colour
doppler
Proteomic
data
CT
FDG-PET
Expression data
Information sciences
Clustering
Classification
program learning
Module network
procedure
Life and Information sciences
Gene partition
Functional modules
Annotation
analysis
Post- processing
Independent Validation
Genes
Graphic presentation