Ovarian Cancer

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Ovarian Cancer

• District 1 ACOG Medical Student Teaching Module
  2009

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Differential Diagnosis of Adnexal Mass
Mature cystic teratoma
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Differential Diagnosis

• Young women
• Usually gynecologic
• Often functional cysts
• Postmenopausal
• Benign neoplasms
• Cystadenomas
• Higher risk of malignancy than premenopausal
• Metastatic cancers may first present as adnexal
  masses

Mucinous cystadenoma
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Ovarian Cancer

• Incidence/Morbidity/Mortality
• Lifetime risk approx 1/70

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Types of Ovarian Cancer

• Epithelial
• Germ Cell
• Dysgerminoma
• Immature teratoma
• Endodermal sinus tumor
• Embryonal carcinoma
• Polyembryonal
• Choriocarcinoma
• Mixed
• Sex Cord Stromal
• Granulosa cell
• Sertoli-Leydig
• Gynandroblastoma
• Unclassified
• Metastatic
• Breast
• Kruckenberg- Primary usually stomach, signet ring
  cells on pathology

Dysgerminoma
Signet ring pathology
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Ovarian Cancer Staging
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Ovarian Cancer Staging
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Ovarian Cancer Staging
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Ovarian Cancer Staging
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Ovarian Cancer Risks

• Increase Risk
• Age most important independent risk factor
• Family history
• BRCA1 (60x increased risk), BRCA2 (30x), HNPCC
  (13x)
• Nulliparity, infertility, endometriosis
• Decrease Risk
• Prophylactic oophorectomy
• Oral contraceptive pills

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Exam

• Physical
• Malignancy irregular, solid consistency, is
  fixed, nodular, or bilateral, is associated with
  ascites

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Exam

• Ultrasound
• Low positive predictive value for cancer
• Cancer excrescences, ascites, and mural nodules
• Benign unilocular, thin-walled sonolucent cysts
  with smooth, regular borders, regardless of
  menopausal status or cyst size

Ovarian cancer
Benign cyst
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Labs

• Tumor markers
• Epithelial CA 125, elevated in 80
• 35 U/mL is upper limit of normal
• Also elevated in many benign conditions
• Malignant germ cell tumors b-hCG, LDH, AFP
• Embryonal carcinoma AFP, BhCG
• Endodermal Sinus tumor AFP
• Granulosa cell tumors inhibin

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Work-up

• Premenopausal
• Symptomatic evaluate as appropriate for
  tuboovarian abcess, ectopic, torsion, ruptured
  ovarian cyst
• B-HCG, CBC, transvaginal USN, cervical cultures

Ectopic pregnancy
Tuboovarian abcess
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Work-up

• Postmenopausal
• Exclude common diagnoses endometriosis, cyst,
  abcess
• Higher index for suspicion transvaginal USN, CA
  125
• Unless simple cysts, most likely will need
  surgery
• Need breast exam, digital rectal, mammography

Ovarian Cancer
Ovarian Cancer
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Treatment of Epithelial Ovarian Cancer

• Chemotherapy
• Cytoreductive surgery (debulking)

CT of ovarian mass
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Treatment of Epithelial Ovarian Cancer

• Debulking

Removal of uterus, tubes, ovaries, omentum,
pelvic and paraaortic nodes, all visible
tumor Peritoneal washings Diaphragm biopsies
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Treatment of Epithelial Ovarian Cancer

• Carboplatin and Paclitaxel
• First line
• Mechanism of action
• Carbo binds and crosslinks DNA
• Taxol promotes formation and inhibits
  disassembly of stable microtubules, inhibiting
  mitosis
• Side effects
• Carbo thrombocytopenia, leukopenia, anemia,
  vomiting, hair loss
• Taxol neutropenia, leukopenia, anemia,
• hair loss, muscle pain, vomiting, diarrhea