Ovarian Cancer Screening and Diagnosis Nancy Wozniak, MD

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 metastatic disease from other primary cancers (e.g. breast, Krukenberg, and GI tract)

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 75 85 % of cases are advanced at the time of diagnosis

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

Physical examination
Palpation of an adnexal mass is usually what gets a work up started If the mass is irregular, and fixed it is more likely to be malignantbut remember to broaden your differential TOA endometrioma dermoid tumor If theres a mass and ascitesits really likely to be cancer

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.

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

Endometrioma Fibroid Functional cyst TOA Ectopic pregnancy Dermoid tumor (younger women)

You found a masswhat next

Pelvic ultrasound

You found a masswhat next

Pelvic ultrasound

You found a masswhat next

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 or otherwise patient should have surgery. The threshold is lower for post menopausal womensurgery if their cyst is > 3 cm.

Tumor Markers CA-125

The CA-125 is a glycoprotein (nl <35) Its elevated in 80% of women with EOC
Its elevated in 50% of women w/ stage I disease and 90% if stage II

The CA-125 is highest in women with serous histology (the most common type) and lowest in mucinous tumors.

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 in postmenopausal women (PPV = 97%)

Tumor Markers

LDH (lactate dehydrogenase)dysgerminoma HCG (human chorionic gonadotropin) choriocarcinoma. AFP (alpha fetal protein)-- endodermal sinus tumors

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 scan to find the possible extra ovarian primary tumor.

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

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 reported abdominal 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.

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)

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

Case.
A tumor is born

Case.
This is a mucinous cystadenoma of the ovary. Impressive, eh??

Mucinous tumor (neonatal size)

Cystic teratomas (dermoid): second most common

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)

Other categories
Borderline tumors: tumors of low malignant potential. They have atypical epithelial 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 ovarian involvment Predominantly serous histology Surface involvement less than 5 mm in depth

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

Patterns of spread
Intraperitoneally Hematogenously Lymphatics Most common means of spreadexfolation of cells that implant 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.

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 will be upstaged to Stage III. Histologic grade is an important predictor of this.

Staging

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 them surgically later. For patients with advanced disease, debulking should be done at the time of the initial surgery.