Transcript Ureteral Injuries in Gynecologic Surgery

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

What is the likelihood that she has ovarian
cancer?
The Case of Olivia Carson

What is the likelihood that she has ovarian
cancer?
 Age
 Menopausal
status
 Mass characteristics
Ovarian Neoplasms
90% benign
 10% malignant

Incidence of Ovarian Cancer
Age Group
25-29
40-44
75-79
Incidence (per 100,000)
Incidence of Ovarian Cancer
Age Group
Incidence (per 100,000)
25-29
4
40-44
15
75-79
48
Predictive Value of
Menopausal Status
Status
Malignant
Premenopausal
7-13%
Postmenopausal
8-45%
Vasilev. Obstet Gynecol 1988
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?
Imaging of Ovarian Masses
Sensitivity
Specificity
CT
MRI
US
Scoutt. Clin Obstet Gynecol 1991
Imaging of Ovarian Masses
Sensitivity
Specificity
CT
Poor
Poor
MRI
95%
88%
US
75%
98%
Scoutt. Clin Obstet Gynecol 1991
Transvaginal Ultrasound
 Cost
effective
 High
frequency
 Improved
resolution
Ultrasound Evaluation of
Adnexal Masses
Simple cyst
Complex cyst
Ultrasound Evaluation of
Adnexal Masses
Simple cyst
 Anechoic
 Smooth walls
Complex cyst
 Cystic and solid
 Irregular outline
 Septa
 Papilla
 Heterogeneous
Ultrasound Findings
Benign
Malignant
Ultrasound Findings
Benign
Malignant
Unilateral
Bilateral
Cystic
Solid component
Unilocular
Multilocular
Stable over time
Growth
No ascites
Ascites
Ultrasound scoring system
Simple cyst. Smooth borders.
1
Clear cyst.
Either irregular border or low level echoes.
Clear cyst, postmenopausal.
Both irregular border and low level echoes.
Solid component. Irregular border and echoes.
2
4-6
Mult septations, irregular border, nodularity.
7-9
As above plus ascites.
10
1-3 = benign
4-6 = equivocal
3
7-10 = malig
Transvaginal ultrasound:
predictive value
Pos predictive Neg predictive
value
value
Premenopausal
82%
86%
Postmenopausal
93%
71%
Finkler. Obstet Gynecol 1988
The Case of Olivia Carson

Her ultrasound shows a solid mass.

If this were cancer, predict the histology.
Cancer Rule of Thumb
Oncology recapitulates ontogeny
Embryology of the Ovary
3 cell types
Embryology of the Ovary
Coelomic
epithelium
Mesenchyme
Germ cells
Embryology of the Ovary
Coelomic
epithelium
Mesenchyme
Germ cells
Epithelium
Stromal cells
Ova
Stromal Tumors:
Histologic Subtypes
1.
Fibroblasts
2.
Granulosa cell tumors
3.
Thecal cells
4.
Sertoli-Leydig cells
Stromal tumors:
Histologic subtypes
1.
Fibroblasts
Fibromas
2.
Granulosa cells
Granulosa cell tumor
3.
Thecal cells
Thecoma
4.
Sertoli-Leydig cells
Sertoli-Leydig cell tumor
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.
Granulosa Cell Tumors

Hormonally active
1.
Estrogen
2.
Inhibin
3.
MIS
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.

Meig’s syndrome
Fibroma
 Ascites (>200 ml)
 Hydrothorax

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.

Gorlin’s Syndrome
Ovarian fibromas
 Young women
 Multiple basal cell nevi and carcinomas
 Dental cysts
 Skeletal abnormalities
 Autosomal dominant

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?
Management of Stromal Tumors
Washings
 USO


Consider TAH BSO, nodes
 Granulosa
cell tumors
 Sertoli-Leydig cell tumors
 Suspicious for malignancy
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?
Histologic Subtypes:
Germ Cell Tumors
Germ cell
Histologic subtypes:
germ cell tumors
Germ cell
Embryo
Fetus
Yolk sac
Placenta
Histologic subtypes:
germ cell tumors
Germ cell
Embryo
Dysgerminoma
Embryonal ca
Fetus
Yolk sac
Placenta
Teratoma
Endodermal sinus tumor
Choriocarcinoma
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?
Tumor Markers: Germ Cell
Tumors

LDH

AFP

hCG
Histologic Subtypes:
Germ Cell Tumors
Germ cell
Dysgerminoma
•LDH
Embryo
Embryonal ca
•AFP/hCG
Fetus
Yolk sac
Placenta
Teratoma
•AFP
Endodermal sinus tumor
Choriocarcinoma
•hCG
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?
Germ Cell Tumors: Treatment
USO plus staging
 Chemotherapy

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?
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?
CA-125: Predictive Value
Pos predictive Neg predictive
value
value
Premenopausal
36%
82%
Postmenopausal
94%
80%
Finkler. Obstet Gynecol 1988
Combination US + CA-125:
Positive Predictive Value
US alone
US + CA-125
Premenopausal
82%
71%
Postmenopausal
93%
100%
Finkler. Obstet Gynecol 1988
Combination US + CA-125:
negative predictive value
US alone
US + CA-125
Premenopausal
85%
88%
Postmenopausal
71%
100%
Finkler. Obstet Gynecol 1988
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, benignappearing cyst on the ovary.
There is no extra-ovarian disease.

What procedure do you do?



Ovarian Masses:
Surgical Management

Cyst aspiration
 Ultrasound
guided
 Laparoscopic
Laparoscopy
 Laparotomy

Ovarian Cyst Aspiration

Benign appearing cyst
Ovarian Cyst Aspiration
Status
Recurrence rate
Premenopausal
48%
Postmenopausal
80%
Bret. Radiol 1992
Cytology of Ovarian Aspirates
Cannot distinguish between primary and
malignant disease
 10 - 66% false negative rate

Ganjei. Acta Cytol 1984
Ovarian Cyst Aspiration
Limited value
 High recurrence rate
 Unreliable cytology
 ? Upstaging a malignant tumor

Ovarian cancer staging
IA
IB
IC
Involvement of one ovary
Intact capsule
Involvement of both ovaries
Intact capsule
Ovarian surface involvement
Capsule rupture
Effect of Intraoperative
Rupture
Stage
Death
Survival (mo)
IA
3%
97
IC
12%
94
Surgical IC
20%
73
Sainz de la Cuesta. Obstet Gynecol 1994
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 do an RSO. Frozen section shows serous
papillary carcinoma.
There is no extra-ovarian disease.

What do you do?

Apparent Stage I Disease
40% will have more advanced disease
due to occult metastases.
 Peritoneal
cytology
 Aortic nodes
 Peritoneum
 Pelvic nodes
 Diaphragm
 Omentum
19%
12%
10%
9%
8%
7%
Survival and Staging
5-year Survival
Apparent Stage I
60%
Surgical Stage I
90-100%
Surgical Staging Procedures
Pelvic washings
 Systematic exploration of all intraabdominal surfaces and viscera
 Peritoneal biopsies
 Diaphragmatic sampling
 Infracolic omentectomy
 Bilateral pelvic and para-aortic lymph
node dissection

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, benignappearing cyst on the ovary.
There is no extra-ovarian disease.

You do an RSO. Frozen section shows
borderline tumor.

What do you do?
Borderline Ovarian Cancer
Earlier age at presentation
 Fertility sparing surgery (USO or
cystectomy) is appropriate
 Avoid bivalving or wedge resection of
grossly normal ovary
 Ideal to surgically stage, however does
not change management
 Chemotherapy has no role

Cytoreductive Surgery
Removal of the maximum amount of
tumor possible.
Basis of Cytoreduction
Residual disease
Median survival
(months)
>1.5 cm
11
<1.5 cm
39
Griffiths. Natl Cancer Inst Monogr 1975
Surgical Procedures

Bowel resection

Ureteral/bladder resection

Pelvic/aortic node dissection

Peritoneal stripping

Diaphragm stripping

Liver/spleen/kidney/stomach resection
Survival and Aggressive
Surgery
Residual
disease
% patients
Median
survival (mo)
0
85
62
Any
14
20
N=163
Eisenkop. Gynecol Onc 1998
The Case of Olivia Carson

What is the likelihood that she has ovarian
cancer?
 Age
 Menopausal
status
 Mass characteristics
 CA-125
Ovarian Cyst Aspiration
Limited value
 High recurrence rate
 Unreliable cytology
 ? Upstaging a malignant tumor

Summary: Ovarian Cancer
Epithelial
Incidence
Age
Natural hx
Stromal
Germ cell
65-70%
5-10%
15-20%
50-60
All
<25
Fast growth
death
Slow growth Fast growth
benign
live
hormones
Tumor
CA-125
marker
Treatment Cytoreduction
Surgery
Chemo
LDH, AFP,
hCG
Surgery
 Chemo
Summary: Stromal Tumors
1.
Fibroblasts
Fibromas
2.
Granulosa cells
Granulosa cell tumor
3.
Thecal cells
Thecoma
4.
Sertoli-Leydig cells
Sertoli-Leydig cell tumor
Summary:
Germ Cell Tumors
Germ cell
Dysgerminoma
•LDH
Embryo
Embryonal ca
•AFP/hCG
Fetus
Yolk sac
Placenta
Teratoma
•AFP
Endodermal sinus tumor
Choriocarcinoma
•hCG
Summary:
Surgical Staging Procedures
Pelvic washings
 Systematic exploration of all intraabdominal surfaces and viscera
 Peritoneal biopsies
 Diaphragmatic sampling
 Infracolic omentectomy
 Bilateral pelvic and para-aortic lymph
node dissection
