1 / 50

Reproductive Medicine and Urology: Week 3

Reproductive Medicine and Urology: Week 3. This week is a combination of benign gynecology and gynecologic malignancies. The PBL case raises several topics, including ovarian masses, abnormal pap smears and postmenopausal bleeding. Adnexal (Ovarian) masses. Dr. Valerie Capstick 2010.

joben
Download Presentation

Reproductive Medicine and Urology: Week 3

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Reproductive Medicine and Urology: Week 3 • This week is a combination of benign gynecology and gynecologic malignancies. • The PBL case raises several topics, including ovarian masses, abnormal pap smears and postmenopausal bleeding.

  2. Adnexal (Ovarian) masses Dr. Valerie Capstick 2010

  3. The Adnexa The tube and ovary

  4. What does every physician dealing with women need to know about ovarian/adnexal masses? • Common • Some are very, very serious • Most are not at all serious, requiring reassurance only • Need to be able to distinguish non serious from those requiring further managment.

  5. Objectives • 1. Describe a classification for both benign and malignant ovarian/adnexal tumors. • 2. Discuss the differential diagnosis for an adnexal mass in an adolescent (or young adult) and in a peri/post -menopausal woman. • 3. Describe how the investigation and surgical management would differ in these two women and explain why. • 4. Outline the staging system for carcinoma of the ovary. • 5. Describe the natural history/prognosis of epithelial ovarian cancer. • 6. Describe the symptoms and physical findings of Ovarian cancer • 7. List the risk factors for ovarian cancer • 8. Outline a plan for investigation/management for a suspicious ovarian mass.

  6. Introduction

  7. Ovarian Cancer (usually serious) • Worst Cure Rates of any Gynecologic Cancer Why? • Diagnosed in advanced stages in 75% of cases • No effective screening test • Symptoms are non specific- ‘Disease that whispers’ • 2,500 cases estimated in Canada for 2009 • 1700 deaths a year

  8. Trends in Incidence, Cancer, Canada, Females, 1971-2009Age Standardized per 100,000 women • Breast • Lung • Colorectal • Uterine • Ovary • Cervix 100 50 10 1971 2000

  9. Lung Breast Colorectal Ovary Uterus (endo) Cervix Trends in Mortality, Females, CanadaAge-Standardized Mortality Rates / 100,000,1971 - 2009 50 40 30 20 10 1971 1980 1990 2000

  10. Where do we start? Adnexal mass

  11. The Adnexal Mass • An enlargement of the ovary can be benign, malignant, borderline malignant or ‘functional’ • The ‘adnexa’ refers to the area either side of the uterus that holds the fallopian tube and ovary. • ‘Adnexal mass’ is any space occupying lesion that feels abnormal to the examiner. • Ovary • FallopianTube • Uterus (fibroid) • Bowel, Bladder, Appendix, Retroperitoneum, Kidney Bilateral ovarian masses

  12. Differential Diagnosis of an Adnexal Mass. (what else could it becoming from?) • GI: Stool, Bowel Cancer, Abscess (appendix or diverticular), • GU: pelvic kidney, full bladder • OBGYNE: • Uterus: Pregnant uterus, fibroids, • Fallopian tube: ectopic pregnancy, hydrosalpinx (dilated tube), paratubal cyst, cancer

  13. Differential diagnosis of an ovarian cyst or mass. • Functional ovarian cyst • Endometrioma (endometriosis) • Metastatic Cancer (GI, GU, Breast, Lymphoma) – 10% of them are from metastases • True tumors (benign or malignant) • Stromal tumors (most arise from granulosa or theca cells) • Germ Cell Tumors- arise from the egg • Dermoids (teratomas)-Benign • Germ cell cancers • Epithelial Tumors -arise from peritoneum on surface of ovary • Benign • Malignant (90% of all ovarian cancers are epithelial cancers) • Borderline malignant (low malignant potential)

  14. The Ovary-important structures • 1. Corpus luteum –(ovum) • 2. Epithelium (modified peritoneum) • 3. Ovarian Stroma-granulosa and theca cells 3 2 1

  15. Benign Ovarian masses/cysts

  16. Functional Ovarian cysts • Very Common • 6 cm or less (usually) • ‘cysts’ that form as a result of ovulation, perhaps related to ‘failure to launch’ the ovum • Always resolve spontaneously over 1-2 months • Vast majority are not detected- no symptoms and no examination to reveal presence • Occasionally may have symptoms, ie sudden pain due to rupture • NOTE: these can only appear in reproductive age women who are ovulating. • Management: observe suspected functional cysts (ultrasound is reasonable) and only refer to specialist if fail to resolve in 6-8 weeks.

  17. Endometrioma/Endometriosis • ‘chocolate cyst’ • Collection of blood in ovary due to cyclic bleeding from endometriosis in ovary • Ca 125 can be significantly elevated • Rare after menopause – because there is no longer estrogen Tissue that lines uterus starts to grow in other places (bleeds every month). CA 125 Is a tumour marker in the most common form of ovarian cancer – seen in endometriosis

  18. Dermoid/ MatureTeratoma • Dermoid- teeth and hair and sebaceous fluid- arises from an ovum • Will present as asymptomatic mass/torsion/rupture so they are removed • Ties with serous cystadenoma for most common ‘tumor’ in reproductive age women (but can occur at any age) (squamous cell cancer)

  19. Benign epithelial tumors • Serous cystadenoma • Ties with dermoid cyst for most frequently diagnosed ‘tumor’ in reproductive age women • Mucinous cystadenoma (can get huge)

  20. Ovarian cancer

  21. Ovarian Cancer

  22. Ovarian Cancer-Histology-3 main histologic categories • EpithelialOvarian Cancer • Serous papillary- (80%) (there is a thought that many started in the fallopian tube???) (tumor marker:Ca125) – mimicking fallopean tube • Mucinous (mimicking cervix or bowel) • Endometrioid/clear cell (mimicking pregnancy, uterus) • Mixed/undifferentiated • Germ cell Cancers • Immature Teratoma, Dysgerminoma, endodermal sinus tumor (alpha-fetoprotein, BHCG ). Don’t need to know the types…just that they do very well • Stromal tumors (low malignant potential) • Granulosa cell tumors (estrogen producing) – 5 year old can start to develop breasts, in post-menopausal it can provoke endometrial cancer • Sertoli-Leydig cell (testosterone producing)-really rare

  23. Median age: 56 1.4 % of women (1/70) 30%of epithelial neoplasms (masses) after the menopause are malignant 7%of epithelial neoplasms before the menopause are malignant Risk Factors for ovarian cancer Decrease risk: Oral Contraceptive Pill (cuts the amount in ½) Tubal ligation? (maybe tying it off prevents noxious stuff from getting up there) Increase risk: Lots of ovulations: early menarche, late menopause, infertility BRCA 1 and 2 mutation, or strong family history Epithelial Ovarian Cancer (?fallopian tube cancer):

  24. BRCA 1 30-40% chance ovarian/tubal ca 85% chance breast ca Autosomal dominant Younger age (30s & 40s) Prophylactic surgery best way to prevent ovarian/tubal cancer (at age 35) BRCA 2 20% chance ovarian/tubal ca 60% chance breast ca Autosomal dominant Prophylactic surgery around menopause best way to prevent ovarian/tubal cancer. Hereditary Ovarian Cancer – 10-15 % of Ovarian/fallopian tube Cancer Prophylactic surgery not 100% effective against cancer similar to ovarian cancer. ‘Primary peritoneal’ cancer still possible in later years. 6-11% chance of occult fallopian tube cancer being found at time of prophylactic surgery!

  25. Presenting Symptoms of Ovarian Cancer/Adnexal Mass • Often Non specific and vague !!! • Incidental finding (physical exam or ultrasound/ct for another reason) • Irregular menses, postmenopausal bleeding • Urinary frequency • Constipation • Abdominal distension, pressure, pain • Dyspareunia • Acute pain due to rupture or torsion • Bowel obstruction, pleural effusion

  26. Physical Findings • Palpable pelvic (abdominal) mass • Ascites (very common) • Omental mass • Inguinal nodes (not very common) • Pleural effusion (stage 4)

  27. Making the diagnosis Need to think of the possibility!!!!! Very nonspecific symptoms, very late appearing.

  28. Investigations • Ultrasound, pelvic + abdominal • CT scans are frequently used, MRI occasionally useful • CBC & differential, Creatinine (masses can obstruct ureters and can present with renal failure) • Ca 125 • (CEA, alpha fetoprotein, BHCG) for women under 30 • (19-9) British Colombia • Investigate bowel/stomach(gastroscopy and colonoscopy) if anemicas • primary cancers of these can spread to the ovaries and mimic ovarian cancer.

  29. Benign or functional ovarian masses tend to be Unilateral Cystic Less than 8 cm (to be functional she must be in reproductive years and ovulatory) Malignant ovarian masses tend to be Bilateral Solid and cystic Greater than 8 cm Highly assoc with cancer: Ascites Omental lesions Nodal metastasis Characteristic Ultrasound findings- (but not diagnostic) But:A unilateral cystic mass can be cancer!

  30. Confirming the diagnosis • Laparotomy (preferred), remove the mass, stage the cancer if confirmed • IF surgery not feasible (variety of reasons) then • Percutaneous biopsy and or paracentesis (removal of fluid) for cytology- often by radiology • Laparoscopy for direct biopsy

  31. Laparotomy for Ovarian Mass/ suspected cancer • Laparotomy-Frozen section of the ovarian mass • If Cancer, but no gross evidence of abdominal spread will need surgical staging (pelvic and paraaortic node dissection, omentectomy,) • If cancer and obvious gross spread, needs debulking of as much tumor as possible (Optimal is < 1cm nodules remaining). • Total Abdominal hysterectomy and removal of remaining tube and ovary is usually included. • Large or small bowel resection is possible if obstructed or tumor attached.

  32. Simplistic Staging Ovarian Cancer • Stage 1-confined to ovary or ovaries • Stage 2- confined to pelvis • Stage 3- confined to abdomen (not including parenchyma of liver) – most are at this stage • Stage 4- parenchyma liver or beyond abdomen (typically pleural effusion)

  33. Treatment of Epithelial Ovarian Cancer • Stage 1, grade 1,(sometimes grade 2) Epithelial ovarian cancers can be watched after surgery (no chemotherapy). These are not common • All others require chemotherapy • Carboplatin & Taxol X 6 cycles is first line chemotherapy. • Regimens can include intraperitoneal chemotherapy

  34. 5 year Survival in Epithelial Ovarian Cancer • Stage 1 - 90 % • Stage 3 - 30 -40% (75% of women are this stage at diagnosis) • Stage 4 – 25% • Often they end up with a small bowel obstruction, get clots, and starve

  35. Causes of Death in Epithelial Ovarian Cancer • Cachexia • Bowel Obstruction • Pulmonary Emboli

  36. Germ Cell Cancers of the Ovary

  37. Germ Cell Cancers • Young women (children, adolescents) • Preserve fertility – this is the goal • Very high cure rates even with advanced metastatic disease. • Chemotherapy is same as testicular cancers, cisplatin, bleomycin and VP-16 • Tumor markers:Alpha-fetoprotein, BHCG • Histologic types:Dysgerminoma, Immature Teratoma, Endodermal Sinus Tumor

  38. Who needs to see a Specialist and Who doesn’t? It is very common to palpate an adnexal mass at a routine pelvic exam. You will need to be comfortable knowing who to watch and who to refer.

  39. Case one: • 29 year old G2P2 with an IUCD for the last 2 years sees her doctor for a pap smear. • She has no complaints. Bimanual exam shows a 5-6 cm left adnexal ‘mass’ that is slightly tender. Right side is normal. Last menstrual period was 3 weeks ago. It was normal. • What is the ‘mass’ most likely to be?

  40. A. Ovarian cancer • B. Endometriosis • C. Functional Ovarian Cyst • D. Dermoid cyst

  41. Functional Ovarian Cyst • Most likely reason for adnexal ‘mass’ or cyst in an asymptomatic reproductive age female who is ovulating. You only know that is the diagnosis when the cyst is gone in 6-8 weeks (80% will disappear). • This diagnosis only applies if the cyst is unilateral and less than 8 cm. and the woman is ovulating. • The rest (including non resolving) need referral to a gynecologist. Vast majority will be benign lesions. • Endometriomas, Serous cysts and Dermoids would be top three diagnosis if it does not go away. • Only 3 % will have cancer.

  42. Case 2 • A 30 year old G1 P1 presents with complaints of intermittent left lower abdominal pain. • Exam shows a large, palpable mass in her left adnexa. Ultrasound shows a complex (solid and cystic) 10 cm cyst. • What is the most likely diagnosis?

  43. What is the most appropriate next step in management?, between c and d, most likely c • A. ovarian cancer • B. functional ovarian cyst • C. dermoid cyst • D. Serous cystadenoma

  44. A. repeat ultrasound in 6-8 weeks, to see if it has resolved. • B. referral for surgery • C. tumor markers then refer for surgery – this is the right answer

  45. Laparoscopy/laparotomy-left ovarian dermoid, intermittent torsion on blood supply suspected. Cystectomy performed. Hair and teeth in specimen. • Diagnosis: Dermoid cyst ovary, (benign)

  46. Case 3 • 55 year old presents with a 2 month history of abdominal bloating and pain. • She saw your partner a month ago. • A Barium Enema done 2 weeks ago was negative. She feels even more uncomfortable now. • Exam reveals distention consistent with ascites. Pelvic exam shows bilateral ovarian masses posterior to the uterus and adherent in the pelvis.

  47. Case 3 continued • Abdominal and Pelvic ultrasound (or CT if you can get one quickly) shows bilateral large, complex ovarian masses, and a large amount of ascites (several liters). Ca125 is 2650 (Normal is < 35) • Refer to Gyne Oncology • Laparotomy for TAH BSO, omentectomy to debulk stage 3 ovarian cancer. Followed by 6 cycles of Carboplatin and Taxol chemotherapy. • Recurrence of cancer 2 years later, response to more chemotherapy. • Ultimately dies of bowel obstruction and cachexia 3.5 years after original diagnosis.

  48. Case 4 • 48 year old woman is diagnosed with advanced serous carcinoma ovary. Her mother and aunt had breast cancer in their forties • Genetic testing confirms the patient to be a carrier of a BRCA 1 mutation • Her 22 year old daughter is tested positive for the same mutation. • What advice would you give the daughter?

  49. Increased risk of breast and ovarian cancer at a younger age than usually seen. • Some women choose risk reducing mastectomy (+/-) reconstruction. • Risk reducing removal of tubes and ovaries significantly reduces risk ?age to do it? • Role of Hormone replacement therapy after oophorectomy

  50. Questions?

More Related