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Ovarian Cancer

Ovarian Cancer. Annette Chen, MD Division Gynecologic Oncology UMass Memorial Medical Center. 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. The Case of Olivia Carson.

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Ovarian Cancer

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  1. Ovarian Cancer Annette Chen, MD Division Gynecologic Oncology UMass Memorial Medical Center

  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

  7. Incidence of Ovarian Cancer

  8. Predictive Value of Menopausal Status 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 Scoutt. Clin ObstetGynecol 1991

  11. Imaging of Ovarian Masses Scoutt. Clin ObstetGynecol 1991

  12. Transvaginal Ultrasound • Cost effective • High frequency • Improved resolution

  13. Simple cyst Complex cyst Ultrasound Evaluation of Adnexal Masses

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

  15. Ultrasound Findings

  16. Ultrasound Findings

  17. Ultrasound scoring system 1-3 = benign 4-6 = equivocal 7-10 = malig

  18. Transvaginal ultrasound: predictive value 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 Germ cell

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

  37. Histologic subtypes: germ cell tumors Germ cell 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 Germ cell • 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 Finkler. Obstet Gynecol 1988

  46. Combination US + CA-125: Positive Predictive Value Finkler. Obstet Gynecol 1988

  47. Combination US + CA-125: negative predictive value 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

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