Malignant Ovarian Tumor

1
Malignant Ovarian Tumor

• Dr. Mashael Shebaili
• Assistant Prof. Consultant
• Department OF Ob Gyn.
• King Saud University

2
Objectives
Risk factor
History and examination
introduction
Epidemiology
Prevention
Investigation
Treatment
screening
3

• Introduction

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Epidemology

• The lifetime risk for developing ovarian cancer
  is 1.6 in the general population
• Ovarian cancer accounts for 3.3 of all new cases
  of cancer
• The fifth in cancer deaths among women and
  accounts for more deaths than any other cancer of
  the female reproduction system
• only 19 of ovarian cancers discovered at early
  stage.
• Most cases are diagnosed in the seventh decade of
  life.

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symptoms
6
Types of ovarian cancer
Stromal cell tumor
Epithelial tumor
7
Physical finding
8
parity
Obesity
HRT
OCP
Risk factors
Hereditary
Family history
9
parity

• Women who have been pregnant have 50 decreasd
  risk for develoing ovarian cancer compared to
  nulliparous women
• Multiple pregnancies offer an increasingly
  protective effect

Obesity
HRT
OCP
Hereditary
Family history
10
OCP

• The use of OCP more than one year reduce the risk
  of ovarian cancer by 30-50
• Its protective effect lasted to 2-3 decade after
  cessation of use

Obesity
Parity
HRT
Hereditary
Family history
11
Family history

• No evidence of hereditary pattern
• The risk in general popultion is 1.6
• The risk increased to 4-5 when 1st degree family
  member is affected ,rising to 7 when two
  relatives are affected

Obesity
Parity
HRT
OCP
Hereditary
12
Hereditary

• Represent 5 of all ovarian cancer
• 2 syndrome are clearly identified
• Breast/ovarian cancer syndrome Associated with
  early onset breast or ovarian cancer ,transmitted
  as AD and occur due to BRCA gene mutation

Obesity
Parity
HRT
OCP
Family history
13
Hereditary

• Lynch ll syndrome or hereditary non polyposis
  colorectal cancer These families characterized
  by high risk of developing colorectal
  ,endometrial, stomach, small bowel, breast
  ,pancreas and ovarian cancer and it is due to
  mutation in mismatch repair gene .

Obesity
Parity
HRT
OCP
Family history
14
HRT

• A large study puplished in the journal of
  national cancer institute in October 2006 report
  that women who used hormonal therapy for 5 years
  or more face a significantly increase risk of
  ovarian cancer

Obesity
Parity
OCP
Hereditary
Family history
15
Obesity

• Studies have suggested that women who are obese
  at age of 18 are at increased risk of developing
  ovarian cancer befor menopause

parity
HRT
OCP
Hereditary
Family history
16
However, 95 of all ovarian cancers occur in
women without risk factors.
17
Screening
Effective screening tests are available for
several common cancers, including mammography
for breast cancer, the Pap test for cervical
cancer but no standardized screening test exists
to reliably detect ovarian cancer. Researchers
haven't yet found a screening tool that's
sensitive enough to detect ovarian cancer in its
early stages and specific enough to distinguish
ovarian cancer from other, noncancerous
conditions
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Screening
Most experts feel that a screening protocol for
ovarian cancer should have a positive predictive
value of at least 10 percent (that is, no more
than nine healthy women with false-positive
screens would undergo unnecessary procedures for
each case of ovarian cancer detected
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US
LPA
Ca 125
Other tumor markers
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US
LPA
Ca 125
Other tumor marker
Has a sensitivity of 70-80 And a specificity of
98.6 - 99.45
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US
LPA
Ca 125
Other tumor marker
False positive Increase in other cancers
(pancreas ,breast ,bladder ,liver ,lung) ,in
benign disease (diverticulitis , endometriosis,
benign ovarian cyst ,tuboovarian abscess, renal
disease) and in physiological condition
(pregnancy and Menstruation )
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US
LPA
Ca 125
Other tumor marker
False negative Elevated in only 80 of ovarian
cancer cases
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US
LPA
Ca 125
Other tumor marker
Positive predictive value Annual CA125 testing
has low predictive value (3) which does not
meet the level required for screening post
meopausal women at average risk
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US
LPA
Ca 125
Other tumor marker
CA125 as a first line test followed by US as a
second line test for positive CA125 result has a
shown to be very specific and achieve positive
predictive value of 20 or greater .
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US
LPA
CA125
Other tumor markers

• Highly false positive In one of the study it has
  been estimated that US
• Screening of 100,000 women over age of 45,would
  detect 40 cases of
• Ovarian cancer with 5,398 false positive result
  and more than 160
• Complications from laproscopy .

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US
LPA
CA125
Other tumor markers

• In other screening studies in women at high risk
  of ovarian cancer ,US
• has performed poorly in detecting early stage
  epithelial ovarian cancer .

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US
LPA
CA125
Other tumor markers

• The lipid lysophosphatidic acid is associated
  with invasion of the extracellular
• matrix in ovarian cancer . LPA concentration
  are elevated in 96 of
• women with ovarian cancer including 90 of
  those with stage 1 disease
• Studies to evaluate the use of this biomarker are
  ongoing .

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US
LPA
CA125
Other tumor marker

• Studies on CA72-4,macrophage colony stimulating
  factor (MCSF)Osbepontin
• ,inhibin and Kallikrein are going to evalute
  combination of tumor marker
• complemantary to CA 125 that could offer greater
  sensitivity and specificity than
• CA125 alone .

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Benefit VS Harm

• In one study of women at high risk of ovarian
  cancer, researchers
• discovered that use of screening tests led to
  20 operations on
• Women only one of whom was found to have cancer
  metastatic
• breast cancer, not ovarian cancer.
• The preliminary results from the Prostate,
  Lung, Colorectal and
• Ovarian (PLCO) Cancer Screening Trial, appears
  in the November
• 15, 2005 American Journal of Obstetrics and
  Gynecology , Women
• who had an abnormal test result in one or both
  screening tests
• underwent a variety of diagnostic procedures to
  determine whether
• cancer was present, including 570 women who
  underwent a
• surgical procedure as follow-up. Thus, 541 women
  underwent
• surgery but did not have cancer.

CD4
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Point to remember

• Screening for ovarian cancer is expensive because
  of low prevalence of disease, high rate of
  surgical intervention for noncancerous disease,
  and high costs of tests and follow-up.
• Many experts suggest that the possible benefits
  of lowered mortality or years of life saved do
  not justify the costs of screening.
• The low positive predictive value associated with
  currently available screening modalities suggests
  that more women without cancer will be subject to
  laparoscopy or laparotomy than will those with
  cancer.
• Modeling studies of annual screening with CA 125,
  with or without a single screening with
  transvaginal ultrasound, found an increase in
  life expectancy of less than one day per woman
  screened .
• No definitive large randomized controlled trials
  have been completed to show whether any screening
  strategy decreases mortality from ovarian cancer

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Screening recommendation

• No organization currently recommends either
  ultrasound or cancer marker screening in
  asymptomatic women, and multiple organizations
  (including the American College of Physicians,
  the Canadian Task Force on the Periodic Health
  Examination, and the American College of
  Obstetricians and Gynecologists) recommend
  against it.
• Regarding women at higher risk (e.g., hereditary
  cancer syndromes), the NIH consensus conference
  recommends annual CA 125 measurements, pelvic
  exam, and transvaginal ultrasound until
  childbearing is completed at age 35, women
  should be referred for bilateral oophorectomy.

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Investigation

• Lab Studies
• If ovarian cancer due to a pelvic or ovarian mass
  is suggested, minimize preoperative testing
  needed and staging laparotomy indicated .
• Routine preoperative tests include CBC count,
  chemistry panel (including liver function tests),
  and a cancer antigen 125 assay (CA-125).

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Investigation

• Imaging Studies
• Routine imaging is not required in all patients
  in whom ovarian cancer is highly suggested.
• If diagnostic uncertainty is present, a pelvic
  ultrasound or CT scan of the abdomen and pelvis
  is warranted.

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Investigation

• Other Tests
• In patients with diffuse carcinomatosis and GI
  symptoms, a GI tract workup may be indicated,
  including
• Upper and/or lower endoscopy
• Barium enema
• Upper GI series
• Procedures
• Biopsy
• A fine-needle aspiration (FNA) or percutaneous
  biopsy of an adnexal mass is not routinely
  recommended. In most cases, taking this approach
  instead of performing a surgical staging
  laparotomy may only serve to delay appropriate
  diagnosis and treatment of ovarian cancer.
• If a clinical suggestion of ovarian cancer is
  present, the patient should undergo a diagnostic
  and surgical procedure.
• An FNA or diagnostic paracentesis should be
  performed in patients with diffuse carcinomatosis
  or ascites without an obvious ovarian mass.

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staging

• Ovarian cancer is staged using the International
  Federation of Gynecology and Obstetrics (FIGO)
  
• Stage I - Growth limited to the ovaries
• Stage Ia - Growth limited to 1 ovary, no ascites,
  no tumor on external surface, capsule intact
• Stage Ib - Growth limited to both ovaries, no
  ascites, no tumor on external surface, capsule
  intact
• Stage Ic - Tumor either stage Ia or Ib but with
  tumor on surface of one or both ovaries, ruptured
  capsule, ascites with malignant cells or positive
  peritoneal washings
• Stage II - Growth involving one or both ovaries,
  with pelvic extension
• Stage IIa - Extension and/or metastases to the
  uterus or tubes
• Stage IIb - Extension to other pelvic tissues
• Stage IIc - Stage IIa or IIb but with tumor on
  surface of one or both ovaries, ruptured capsule,
  ascites with malignant cells or positive
  peritoneal washings
• Stage III - Tumor involving one or both ovaries,
  with peritoneal implants outside the pelvis
  and/or positive retroperitoneal or inguinal
  nodes superficial liver metastases equal stage
  III
• Stage IIIa - Tumor grossly limited to pelvis,
  negative lymph nodes but histological proof of
  microscopic disease on abdominal peritoneal
  surfaces
• Stage IIIb - Confirmed implants outside of pelvis
  in the abdominal peritoneal surface no implant
  exceeds 2 cm in diameter and lymph nodes are
  negative
• Stage IIIc - Abdominal implants larger than 2 cm
  in diameter and/or positive lymph nodes
• Stage IV - Distant metastases pleural effusion
  must have a positive cytology to be classified as
  stage IV parenchymal liver metastases equals
  stage IV

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• The standard treatment for ovarian cancer start
  with staging and cytoreductive surgery
• For post operative treatment , chemotherapy is
  indicated in all patients with ovarian cancer
• except those patients with stage 1 and low risk
  characteristics

Treatment
37
Prognosis

• The 5-year survival rates are as follows
• Stage I - 73
• Stage II - 45
• Stage III - 21
• Stage IV - Less than 5

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Prevention
1
OCP
2
Screening
3
Bilateral salpingo Oophrectomy
Pregnancy and Breast feeding
4
5
Tubal ligation and hystrectomy
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Prevention
1
OCP
2
Screening
3
Bilateral salpingo Oophrectomy
Pregnancy and Breast feeding
4
5
Tubal ligation and hystrectomy
40
Prevention
1
OCP
2
Screening
Bilateral salpingo Oophrectomy
3
Pregnancy and Breast feeding
4
5
Tubal ligation and hystrectomy
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1
OCP
2
Screening
3
Bilateral salpino Oophrectomy
4
Pregnancy and breast feeding
Tubal ligation and hystrectomy
5
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1
OCP
2
Screening
3
Bilateral salpigo Oophrectomy
4
Pregnancy and breast feeding
5
Tubal ligation and hystrectomy
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1
OCP
2
Screening
3
Bilateral salpigo Oophrectomy
4
Pregnancy and breast feeding
5
Tubal ligation and hystrectomy
44
1
OCP
2
Screening
3
Bilateral salpingo Oophrectomy
4
Pregnancy and Breast feeding
5
Tubal ligation And hystrectomy
45
1
OCP
2
Screening
3
Bilateral salpingo Oophrectomy
4
Pregnancy and Breast feeding
5
Tubal ligation And hystrectomy
46
1
OCP
2
Screening
3
Bilateral salpingo Oophrectomy
4
Pregnancy and Breast feeding
5
Tubal ligation And hystrectomy
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Take a home message
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• Ovarian cancer is the most common lethal
  gynecological malignancy and it represent the
  fifth cancer death in women in general
• It has many risk factor ,the most important one
  is the hereditary predisposition .
• No organization currently recommend the screening
  in asymptomatic women

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• 
  
  

Thank you