Ovarian Tumors: How to improve prognosis?

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Ovarian Tumors How to improve prognosis?

• Professor Galal Lotfi. MD, MRCOG.
• Head Department Obstetrics Gynecology. Suez
  Canal University. Egypt.

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Introduction
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Prognosis Has a Bleak Picture

• 1. It presents late 75 are stages III, IV.
• 2. 5 yr survival of late cases10.
• 3. So It kills more than cx and endom both.

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Improve Prognosis

• Early diagnosis
• Identifying women at risk.
• Prompt investigation of suspicious symptoms.
• Development of screening tests.
• Prevention
• Prophylactic oophorectomy.
• Improvement of use of existing therapeutics.
• Further development of experimental therapies.

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Early diagnosis

• Identify woman at risk.
• Symptomatology.
• Screening tests.
• Tumor markers.
• Imaging.
• Cytology.
• Pelvic examination.

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Who Is at Risk?

• Geography
• 5 times more in developed countries.
• Highest in Sweden, Israel, least in Japan..
• 15/100,000 in Sweden.
• Residence is more important than race.
• Race White more susceptible.
• Age
• Peri, postmenopausal, median age 60.

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Who Is at Risk?

• Reproductive history
• Late age of 1st pregnancy (very important).
• Nulligravida or small no. Of children.
• Did not use OCP, protection of OCP proportional
  with duration of use.
• INCESSANT OVULATION HYPOTHESIS, (time from
  menarche to cessation of ov time of anovulation
  due to preg and lactation index of ovarian
  cancer.

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Who Is at Risk?

• Family history
• If mother or sister have ov cancer, 18 fold risk.
• Past history
• If she had primary BREAST, COLON, ENDOMETRIUM, 4
  times increased risk for primary ovarian.
• Rubella at age 12-18, mumps antibody titer, has
  higher risk.
• Talc, sanitary pads with talc, risk 3.

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Who Is at Risk?

• White.
• North Europe.
• gt40ys.
• Nulliparous.
• Late age 1st preg.
• No OCP.
• ve family history.

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Symptomatology.

• Late diagnosis poor prognosis Public education
  for early seeking medical advice.
• 50 present to the wrong doctor.

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Screening Tests

• Rules for screening test
• The disease to be screened should have
  significant morbidity and mortality.
• The natural history of the disease is understood
  and has revealed high prevalence of the
  preclinical disease in the population.
• The test comfortable and convenient, economic,
  easy to perform, least side effects.
• High specificity and sensitivity.

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Tumor Markers

• Oncodevelopmental.(carcino embryonic antigenCEA).
• Carcinoplacental. AFP, HCG.
• Metabolic.
• Tumor specific or tumor associated (CA 125).
• Could help in monitoring the prognosis.
• Poor sensitivity.

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Imaging

• Usincreased ov volume twice the mean volume is
  suspicious.
• Presence of cystic ov are suspicious.
• Cat? Impractical.
• MRI? Impractical.

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Cytology

• Pap, abnormal in only 10, unreliable.
• Pouch of Douglas peritoneal cytology,
  questionable and unreliable.

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Pelvic Examination.

• Vaginal examination is very important tool.
• Palpable ovaries in postmenopausal women is
  abnormal.

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Prevention Prophylactic oophorectomy

• Literature report of 30,000 patients with
  retained ovaries after hysterectomy for benign
  conditions, 0.2 got ovarian cancer. 500
  prophylactic oophorectomy has to be done during
  surgery for postmenopausal women to save one
  woman from cancer So if it is done in every case
  7 cancer can be prevented.
• For premenopausal woman, consider risk factors.
• If family history, oophorectomy after family
  compl.
• Grossly abnormal ov, remove it, irrespective of
  age.

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Improve Existing Treatment.

• Surgery (cornerstone of treatment).
• Staging.
• Surgical procedure.
• Postoperative treatment.
• Adjuvant therapy.
• Monitoring treatment.
• Us, cat.
• Laparoscopy.
• Markers.
• 2nd look.

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Staging

• Vertical incision.
• Aspirate, or saline washing.
• Careful assessment., Liver, rt hemidaphragm,
  (because lymph of peritoneal cavity drain to
  inferior surface of diaphragm before getting
  mediastinal LN. Diaphragmatic metastases 10
  stage I, 20 stage II.), All other organs as
  omentum, intestine,.
• Paraaortic LN sampling.
• Proper staging, for prognosis, selection of
  adjuvant therapy..

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Staging, (Surgical)

• I confined to 1 or 2 ov.
• Ia one ovary.
• Iai capsule intact.
• Iaii capsule perforated.
• Ib two ovary.
• IIbi, Iibii.
• Ic either one or two ov, with ve cytology.
• Ici, Icii.
• II extension tubes, uterus.
• III extension other pelvic.
• IV abdominal and general.
• V cases not staged.

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Surg Procedure.

• Maximum surgical effort leave no residue, or
  Cytoreductive surgery reduce residual tumor to
  minimum.
• TAH BSO Omentectomy appendectomy.
• Prognosis high if residue lt1.6cm.

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Postoperative Treatment.

• Prognostic indicators
• Residual mass.
• Tumor grade. Then..
• Stage , age, histology.

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Adjuvant Therapy.

• Chemotherapy.
• Single vs multiple agents.
• Radiotherapy.
• Combined.

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Monitoring

• To confirm complete response, stop chemo.
• To avoid premature discontinuation of TT.
• To confirm presence of residual mass requiring
  resection or modification of treatment.
• Research procedure to assess different modalities.

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Monitoring

• markers.
• II look CAT, unreliable.
• Laparoscopy.
• Tumor laparotomy.

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Experimental

• New cytotoxic agents, platinum analogues.
• Hormonal therapy, trials of antiestrogen,
  progestogen.
• Stem cell assay, a method of selecting drugs with
  specific action in individual patients to improve
  response rate and decrease side effects ( like C
  S).
• Immunotherapy, attempts to stimulate cell
  mediated immunity, Corynebacterium Parvum,
  interferon and use of heteroantisera.
• High dose chemotherapy,