1. Ovarian Cancer

2. The Case of Olivia Carson
You are a generalist in the community.
You have a new patient.
She is a 65 year old with a large pelvic mass arising from the right adnexum.

3. The Case of Olivia Carson
What is the likelihood that she has ovarian cancer?

4. The Case of Olivia Carson
What is the likelihood that she has ovarian cancer?
Age
Menopausal status
Mass characteristics

5. Ovarian Neoplasms
90% benign
10% malignant

6. Incidence of Ovarian Cancer
Age Group
Incidence (per 100,000)
25-29
40-44
75-79

7. Incidence of Ovarian Cancer
Age Group
Incidence (per 100,000)
25-29 4
40-44 15
75-79 48

8. Predictive Value of Menopausal Status
Malignant
Premenopausal
7-13%
Postmenopausal
8-45%
Vasilev. Obstet Gynecol 1988

9. The Case of Olivia Carson
The only other data you have is that she underwent an imaging study.
Which study do you hope she has had?

10. Imaging of Ovarian Masses
Sensitivity
Specificity CT
MRI US
Scoutt. Clin Obstet Gynecol 1991

11. Imaging of Ovarian Masses
Sensitivity
Specificity CT
Poor
MRI
95%
88% US
75%
98%
Scoutt. Clin Obstet Gynecol 1991

12. Transvaginal Ultrasound
Cost effective
High frequency
Improved resolution

13. Ultrasound Evaluation of Adnexal Masses
Simple cyst
Complex cyst

14. Ultrasound Evaluation of Adnexal Masses
Simple cyst
Anechoic
Smooth walls
Complex cyst
Cystic and solid
Irregular outline
Septa
Papilla
Heterogeneous

15. Ultrasound Findings
Benign
Malignant

16. Ultrasound Findings Benign Malignant Unilateral Bilateral Cystic
Solid component
Unilocular
Multilocular
Stable over time
Growth
No ascites
Ascites

17. Ultrasound scoring system
Simple cyst. Smooth borders. 1
Clear cyst.
Either irregular border or low level echoes. 2
Clear cyst, postmenopausal.
Both irregular border and low level echoes. 3
Solid component. Irregular border and echoes.
4-6
Mult septations, irregular border, nodularity.
7-9
As above plus ascites. 10
1-3 = benign
4-6 = equivocal
7-10 = malig

18. Transvaginal ultrasound: predictive value
Pos predictive value
Neg predictive value
Premenopausal
82%
86%
Postmenopausal
93%
71%
Finkler. Obstet Gynecol 1988

19. The Case of Olivia Carson
Her ultrasound shows a solid mass.
If this were cancer, predict the histology.

20. Cancer Rule of Thumb
Oncology recapitulates ontogeny

21. Embryology of the Ovary
3 cell types

22. Embryology of the Ovary
Coelomic
epithelium
Mesenchyme
Germ cells

23. Embryology of the Ovary
Coelomic
epithelium
Mesenchyme
Germ cells
Epithelium
Stromal cells
Ova

24. Stromal Tumors: Histologic Subtypes
Fibroblasts
Granulosa cell tumors
Thecal cells
Sertoli-Leydig cells

25. Stromal tumors: Histologic subtypes
Fibroblasts Fibromas
Granulosa cells Granulosa cell tumor
Thecal cells Thecoma
Sertoli-Leydig cells Sertoli-Leydig cell tumor

26. The Case of Olivia Carson
65 year old with a large pelvic mass arising from the right adnexum.
Solid mass on TV US.
You do a careful history and determine that she has had new onset of vaginal bleeding.

27. Granulosa Cell Tumors
Hormonally active
Estrogen
Inhibin
MIS

28. The Case of Olivia Carson
65 year old with a HARD large pelvic mass arising from the right adnexum.
Solid mass on TV US.
Extensive ascites on TV US.
Right pleural effusion.

29. Meig’s syndrome
Fibroma
Ascites (>200 ml)
Hydrothorax

30. The Case of Olivia Carson
25 year old with acute pain and a HARD large pelvic mass arising from the right adnexum.
Solid mass on TV US.
Extensive ascites on TV US.
Right pleural effusion.
You note multiple skin lesions.

31. Gorlin’s Syndrome Ovarian fibromas Young women
Multiple basal cell nevi and carcinomas
Dental cysts
Skeletal abnormalities
Autosomal dominant

32. The Case of Olivia Carson
65 year old with a large pelvic mass arising from the right adnexum.
Solid mass on TV US.
What will you do to treat her?

33. Management of Stromal Tumors
Washings
USO
Consider TAH BSO, nodes
Granulosa cell tumors
Sertoli-Leydig cell tumors
Suspicious for malignancy

34. The Case of Olivia Carson
You are a generalist in the community.
You have a new patient.
She is a 15 year old with a large pelvic mass arising from the right adnexum.
What is the most likely tumor?

35. Histologic Subtypes: Germ Cell Tumors

36. Histologic subtypes: germ cell tumors
Embryo
Fetus
Yolk sac
Placenta

37. Histologic subtypes: germ cell tumors
Dysgerminoma
Embryo
Embryonal ca
Fetus
Teratoma
Yolk sac
Placenta
Endodermal sinus tumor
Choriocarcinoma

38. The Case of Olivia Carson
15 year old with a large pelvic mass arising from the right adnexum.
What pre-op labs do you want?

39. Tumor Markers: Germ Cell Tumors
LDH
AFP
hCG

40. Histologic Subtypes: Germ Cell Tumors
Dysgerminoma
LDH
Embryo
Embryonal ca
AFP/hCG
Fetus
Teratoma
AFP
Yolk sac
Placenta
Endodermal sinus tumor
Choriocarcinoma
hCG

41. The Case of Olivia Carson
15 year old with a large pelvic mass arising from the right adnexum.
What will you do to treat her?

42. Germ Cell Tumors: Treatment
USO plus staging
Chemotherapy

43. The Case of Olivia Carson
15 year old with a large pelvic mass arising from the right adnexum.
She underwent a USO at an outside hospital. A germ cell tumor was found on final path.
What do you recommend?

44. The Case of Olivia Carson
You are a generalist in the community.
You have a new patient.
She is a 65 year old with a TV US showing a 5 cm right ovarian cystic mass with one septation.
Her CA-125 is 40.
Do you refer her or keep her?

45. CA-125: Predictive Value 36% 82% 94% 80% Pos predictive value
Neg predictive value
Premenopausal
36%
82%
Postmenopausal
94%
80%
Finkler. Obstet Gynecol 1988

46. Combination US + CA-125: Positive Predictive Value
US alone
US + CA-125
Premenopausal
82%
71%
Postmenopausal
93%
100%
Finkler. Obstet Gynecol 1988

47. Combination US + CA-125: negative predictive value
US alone
US + CA-125
Premenopausal
85%
88%
Postmenopausal
71%
100%
Finkler. Obstet Gynecol 1988

48. The Case of Olivia Carson
65 year old with a TV US showing a 5 cm right ovarian cystic mass with one septation.
Her CA-125 is 40.
You explore her and find a smooth, benign-appearing cyst on the ovary.
There is no extra-ovarian disease.
What procedure do you do?

49. Ovarian Masses: Surgical Management
Cyst aspiration
Ultrasound guided
Laparoscopic
Laparoscopy
Laparotomy

50. Ovarian Cyst Aspiration
Benign appearing cyst

51. Ovarian Cyst Aspiration
Status
Recurrence rate
Premenopausal
48%
Postmenopausal
80%
Bret. Radiol 1992

52. Cytology of Ovarian Aspirates
Cannot distinguish between primary and malignant disease
% false negative rate
Ganjei. Acta Cytol 1984

53. Ovarian Cyst Aspiration
Limited value
High recurrence rate
Unreliable cytology
? Upstaging a malignant tumor

54. Ovarian cancer staging

55. Effect of Intraoperative Rupture
Stage
Death
Survival (mo) IA 3% 97 IC
12% 94
Surgical IC
20% 73
Sainz de la Cuesta. Obstet Gynecol 1994

56. The Case of Olivia Carson
65 year old with a TV US showing a 5 cm right ovarian cystic mass with one septation.
Her CA-125 is 40.
You do an RSO. Frozen section shows serous papillary carcinoma.
There is no extra-ovarian disease.
What do you do?

57. Apparent Stage I Disease
40% will have more advanced disease due to occult metastases.
Peritoneal cytology 19%
Aortic nodes 12%
Peritoneum 10%
Pelvic nodes 9%
Diaphragm 8%
Omentum 7%

58. Survival and Staging 5-year Survival Apparent Stage I 60%
Surgical Stage I
90-100%

59. Surgical Staging Procedures
Pelvic washings
Systematic exploration of all intra-abdominal surfaces and viscera
Peritoneal biopsies
Diaphragmatic sampling
Infracolic omentectomy
Bilateral pelvic and para-aortic lymph node dissection

60. The Case of Olivia Carson
65 year old with a TV US showing a 5 cm right ovarian cystic mass with one septation.
Her CA-125 is 40.
You explore her and find a smooth, benign-appearing cyst on the ovary.
There is no extra-ovarian disease.
You do an RSO. Frozen section shows borderline tumor.
What do you do?

61. Borderline Ovarian Cancer
Earlier age at presentation
Fertility sparing surgery (USO or cystectomy) is appropriate
Avoid bivalving or wedge resection of grossly normal ovary
Ideal to surgically stage, however does not change management
Chemotherapy has no role

62. Cytoreductive Surgery
Removal of the maximum amount of tumor possible.

63. Basis of Cytoreduction
Residual disease
Median survival (months)
>1.5 cm 11
<1.5 cm 39
Griffiths. Natl Cancer Inst Monogr 1975

64. Surgical Procedures Bowel resection Ureteral/bladder resection
Pelvic/aortic node dissection
Peritoneal stripping
Diaphragm stripping
Liver/spleen/kidney/stomach resection

65. Survival and Aggressive Surgery
Residual disease
% patients
Median survival (mo) 85 62
Any 14 20
N=163
Eisenkop. Gynecol Onc 1998

66. The Case of Olivia Carson
What is the likelihood that she has ovarian cancer?
Age
Menopausal status
Mass characteristics
CA-125

67. Ovarian Cyst Aspiration
Limited value
High recurrence rate
Unreliable cytology
? Upstaging a malignant tumor

68. Summary: Ovarian Cancer
Epithelial
Stromal
Germ cell
Incidence
65-70%
5-10%
15-20%
Age
50-60
All
<25
Natural hx
Fast growth death
Slow growth benign
Fast growth live
Tumor marker
CA-125
hormones
LDH, AFP, hCG
Treatment
Cytoreduction
Chemo
Surgery
 Chemo

69. Summary: Stromal Tumors
Fibroblasts Fibromas
Granulosa cells Granulosa cell tumor
Thecal cells Thecoma
Sertoli-Leydig cells Sertoli-Leydig cell tumor

70. Summary: Germ Cell Tumors
Dysgerminoma
LDH
Embryo
Embryonal ca
AFP/hCG
Fetus
Teratoma
AFP
Yolk sac
Placenta
Endodermal sinus tumor
Choriocarcinoma
hCG

71. Summary: Surgical Staging Procedures
Pelvic washings
Systematic exploration of all intra-abdominal surfaces and viscera
Peritoneal biopsies
Diaphragmatic sampling
Infracolic omentectomy
Bilateral pelvic and para-aortic lymph node dissection