Endometrial Docu Cleaned
Transcript of Endometrial Docu Cleaned
-
7/28/2019 Endometrial Docu Cleaned
1/100
Endometrial &
Ovarian CancerEndometrial &Ovarian Cancer
Karen A. Zempolich, M.D.Karen A. Zempolich, M.D.Division of GynecologicOncology, Division of
Gynecologic Oncology,Dept. of Obstetrics &Gynecology Dept. ofObstetrics & GynecologyUniversity of Utah Universityof UtahHuntsman Cancer InstituteHuntsman Cancer Institute
-
7/28/2019 Endometrial Docu Cleaned
2/100
Endometrial &
Ovarian CancerEndometrial &Ovarian Cancer
Overview Overview EpidemiologyEpidemiology Signs & symptoms Signs
& symptoms Management / outcomeManagement / outcome When to refer to a sub
When to refer to a sub-specialist specialist
-
7/28/2019 Endometrial Docu Cleaned
3/100
Follow Follow-upsurveillance upsurveillance
EndometrialCancer
EndometrialCancerEpidemiology
Epidemiology 36,000 cases/yr; 6,500deaths 36,000 cases/yr;6,500 deaths
4th most commoncancer in women 4th mostcommon cancer in women
-
7/28/2019 Endometrial Docu Cleaned
4/100
(breast, lung, colon) (breast,lung, colon)
75% postmenopausal(avg. age 58 y.o.) 75%postmenopausal (avg. age58 y.o.)
5% cases: < 40 yearsold 5% cases: < 40 yearsold
EndometrialCancerEndometrialCancer
-
7/28/2019 Endometrial Docu Cleaned
5/100
Risk Factors Risk
Factors - DeleteriousDeleteriousRelative Risk Relative RiskObesity Obesity 2-11 11
Family history Familyhistory 1.5 1.5-2.8 2.8Nulliparity Nulliparity 3Infertility ( Infertility
(>3yrs) 3yrs) 3Endogenous estrogensEndogenous estrogens 1.51.5 - 4
Estrogen Estrogen-secretingtumors secreting tumors
-
7/28/2019 Endometrial Docu Cleaned
6/100
Unopposed exogenousestrogens Unopposedexogenous estrogens 2 -12 12Diabetes Diabetes 2 - 1010
TamoxifenTamoxifen 2 - 7
EndometrialCancer
EndometrialCancerRisk Factors Risk
Factors - ProtectiveProtective
-
7/28/2019 Endometrial Docu Cleaned
7/100
Oral contraceptives (1Oral contraceptives (1-5years) 5 years) 0.3 0.3-0.50.5 Cigarette smokingCigarette smoking 0.4
0.4-.08 .08 Parity Parity 0.3 0.3-0.50.5
EndometrialCancerEndometrialCancer-- --RiskFactors Risk Factors
-
7/28/2019 Endometrial Docu Cleaned
8/100
Hereditary HereditaryNonpolyposisNonpolyposis ColorectalCancer Colorectal Cancer 5% of colorectal cancers5% of colorectal cancers Mutations in DNAmismatch repair genesMutations in DNAmismatch repair genes
Lifetime Lifetime risk ofdeveloping: risk ofdeveloping: Colorectal cancer 80%
Colorectal cancer 80% Endometrial cancer 40%Endometrial cancer 40%
-
7/28/2019 Endometrial Docu Cleaned
9/100
Ovarian cancer 10%Ovarian cancer 10%
Other GI cancer 20%Other GI cancer 20%
Endometrial
CancerEndometrialCancerCarcinogenesisCarcinogenesis Precancerous LesionsPrecancerous Lesions
Hyperplasia HyperplasiaProgression to CancerProgression to Cancer
-
7/28/2019 Endometrial Docu Cleaned
10/100
Simple Simple 1% 1%Complex Complex 3% 3%Simple, atypical Simple,atypical 8% 8%Complex, atypicalComplex, atypical 29%
29%Kurman, 1985
EndometrialCancerEndometrialCancerSymptomsSymptoms
-
7/28/2019 Endometrial Docu Cleaned
11/100
Postmenopausalbleeding Postmenopausalbleeding Present in > 90%menopausal cases ofPresentin > 90% menopausal cases
ofendometrial cancerendometrial cancer 20% patients with PMB 20%patients with PMB
malignancy malignancy 5% patients with PMB 5%patients with PMB endoendo hyperplasia hyperplasia
PremenopausalPremenopausal patients
-
7/28/2019 Endometrial Docu Cleaned
12/100
patients abnormaluterine abnormal uterinebleeding bleeding
EndometrialCancer
EndometrialCancerSigns Signs
Most exams are normalMost exams are normal May have: May have: enlarged uterus enlarged
uterus Peripheral Peripheraladenopathy adenopathy Ascites Ascites
-
7/28/2019 Endometrial Docu Cleaned
13/100
vaginal vaginal mets mets adnexal adnexal mass mass
cul cul-de de-sac sacnodularity nodularity
EndometrialCancerEndometrialCancerDiagnosis Diagnosis Pap Smear PapSmearIn patients with
endometrial cancer: Inpatients with endometrialcancer:
-
7/28/2019 Endometrial Docu Cleaned
14/100
40 40-50% suspicious50% suspicious endo endocells on Pap cells on Pap 2-5% normalendometrial cells 5%normal endometrial cellsMontz 2001, Win 2001, Ashfag 2001, Sarode2001
EndometrialCancer
EndometrialCancerDiagnosis Diagnosis
Pap Smear PapSmear
-
7/28/2019 Endometrial Docu Cleaned
15/100
Postmenopausal women withnormal Postmenopausal
women with normal endoendo cells on cells onpap: pap: 20 20-40% pathology 40%pathology Polyps Polyps Hyperplasia 10 Hyperplasia 10-15% 15% Cancer 1 Cancer 1-5% 5%
2-5% asymptomatic 5%
asymptomatic pts with normalendometrial pts with normalendometrialcells: cells: cancer cancerMontz 2001, Win 2001, Ashfag 2001, Sarode 2001
EndometrialCancer
-
7/28/2019 Endometrial Docu Cleaned
16/100
Endometrial
CancerDiagnosis DiagnosisBiopsy Biopsy Inpatient (operative)dilation and curettageInpatient (operative)dilation and curettage(fractional) (fractional) Outpatient endometrialbiopsy Outpatientendometrial biopsy Pipelle Pipelle
Vabra Vabra, Novak , Novak
-
7/28/2019 Endometrial Docu Cleaned
17/100
Endometrial
CancerEndometrialCancer
Diagnosis Diagnosis Endometrial BiopsyEndometrial Biopsy MetaanalysisMetaanalysis 39studies (5 prospect) 39studies (5 prospect)
Office Office bx bxcompared to D&C, comparedto D&C, hyst hyst, or both , orboth
-
7/28/2019 Endometrial Docu Cleaned
18/100
Cancer: Cancer:Sensitivity Sensitivity 68to 81% 68 to 81%Specificity Specificity 99.6to 99.9% 99.6 to 99.9% Hyperplasia HyperplasiaSensitivity Sensitivity 75%75%Specificity Specificity 99%99%Dijkhuizen et al. Cancer 2000
Garnti JAAGL 2001
Endometrial
Cancer
-
7/28/2019 Endometrial Docu Cleaned
19/100
Endometrial
CancerHysteroscopyHysteroscopy -
CAVEAT CAVEATTranstubalTranstubalspread ofspread ofendoendo cells cells
Obermaier Obermaier etal et al (Cancer 2000) (Cancer 2000) 113 pts 113 ptsHSC/D&C HSC/D&C vs vs D&Calone D&C alone
12% 12% vs vs 2.5% pos.peritoneal cytology (p
-
7/28/2019 Endometrial Docu Cleaned
20/100
2.5% pos. peritoneal cytology(p
-
7/28/2019 Endometrial Docu Cleaned
21/100
Endometrial
CancerEndometrialCancer
Diagnosis DiagnosisTransvaginal
Transvaginal
UltrasoundUltrasound MetaanalysisMetaanalysis TVUS &
office biopsyTVUS &office biopsy
-
7/28/2019 Endometrial Docu Cleaned
22/100
Endometrial thicknessEndometrial thickness
-
7/28/2019 Endometrial Docu Cleaned
23/100
High High negativepredictive value (99%)negative predictive value(99%)Smith-Bindman JAMA 1998Langer, NEJM 1997
EndometrialCancerEndometrial
CancerDiagnosis Diagnosis -Summary Summary Office endometrial
biopsy Office endometrialbiopsy preferredpreferred
-
7/28/2019 Endometrial Docu Cleaned
24/100
method method Accurate, convenient
Accurate, convenientTV U/STV U/S caneffectively r/o disease ifcan effectively r/o disease
if
-
7/28/2019 Endometrial Docu Cleaned
25/100
Endometrial
CancerEndometrialCancer
Surgical SurgicalStaging StagingStage I Stage I UterusUterus (75 to 80%) (75 to
80%)A. A. endometriumendometriumB. B. myometriummyometrium
-
7/28/2019 Endometrial Docu Cleaned
26/100
Stage II Stage II CervixCervix (6 to 10%) (6 to10%)A. A. glands glandsB. B. stroma stroma
EndometrialCancerEndometrial
CancerSurgical SurgicalStaging StagingStage III Stage III
Extrauterine Extrauterine(8%) (8%)
-
7/28/2019 Endometrial Docu Cleaned
27/100
A. A. serosa serosa, ,adnexa adnexa, peritonealcytology , peritonealcytologyB. B. vagina, pelvicperitoneum vagina, pelvic
peritoneumC. C. lymph nodes(pelvic/abdominal) lymphnodes (pelvic/abdominal)
Stage IV Stage IV DistantDistant (5%) (5%)A. A. bowel/bladdermucosa bowel/bladder
mucosaB. B. intraabdominalintraabdominal, inguinal
-
7/28/2019 Endometrial Docu Cleaned
28/100
nodes, extra , inguinalnodes, extraabdominal abdominal
EndometrialCancer
EndometrialCancer
Treatment
Treatment----Surgery Surgery Hysterectomy /Hysterectomy /
salpingoophorectomysalpingoophorectomy (BSO)(BSO)
-
7/28/2019 Endometrial Docu Cleaned
29/100
If clinical cervicalinvolvement: If clinical
cervical involvement: Radical Radical hyst hystvs vs preop preop radiationradiation
Staging Staging selectedpatients selected patients Peritoneal cytologyPeritoneal cytology Lymph node dissection
Lymph node dissection Omentectomy Omentectomy(papillary serous/clear cellhistology) (papillary
serous/clear cell histology)EndometrialCancer
-
7/28/2019 Endometrial Docu Cleaned
30/100
Endometrial
CancerTreatmentTreatmentSurgery
2005 Surgery 2005 Increased role forIncreased role forlaparoscopic laparoscopic
staging staging LAVH/ BSO, staging ifindicated LAVH/ BSO, stagingif indicated Regardless of age, body
mass index Regardless of age,body mass index
-
7/28/2019 Endometrial Docu Cleaned
31/100
75 to 95% have full stagingby LSC 75 to 95% have full
staging by LSC Conversion to open lap forobesity, Conversion to openlap for obesity,intraperitoneal intraperitonealcancer, bleeding cancer,bleeding
Endometrial
CancerEndometrialCancer
TreatmentTreatmentSurgery2005 Surgery 2005
-
7/28/2019 Endometrial Docu Cleaned
32/100
LaparoscopicLaparoscopic hyst hyst/BSO/ staging / BSO/staging Equal node count Equalnode count
Equal survival Equal survival Decreased length of stayDecreased length of stay Longer OR time (230 minLonger OR time (230 min vs
vs 150 min) 150 min) Shorter delay for radiation (ifindicated) Shorter delay forradiation (if indicated)
EndometrialCancer
-
7/28/2019 Endometrial Docu Cleaned
33/100
Endometrial
CancerStaging Staging Patient Selection
Patient SelectionRisk of pelvic lymph nodeRisk of pelvic lymph node grade, depth ofgrade,
depth ofinvasion invasionDepth Depth G1 G1 G2 G2G3 G3EndometriumEndometrium 03
-
7/28/2019 Endometrial Docu Cleaned
34/100
0Inner 1/3 Inner 1/3 3 5 9Middle 1/3 Middle 1/3 0 94Outer 1/3 Outer 1/3 11 1119 19 34% 34%Creasman 1987
EndometrialCancer
EndometrialCancerStaging Staging
Patient SelectionPatient Selection
-
7/28/2019 Endometrial Docu Cleaned
35/100
Risk of lymph node Risk oflymph node tumorlocationPelvic LN Aortic LNFundus 8% 4%Isthmus
cervix 16% 14%Creasman 1987
EndometrialCancerEndometrialCancer - StagingStagingPatient SelectionPatient Selection
-
7/28/2019 Endometrial Docu Cleaned
36/100
Pre Pre-op Prediction
? op Prediction ? Grade 1 lesion Grade 1lesion 1 in 3 1 in 3 willrequire staging will
require staging 10 to 15% : outer 10 to15% : outer invasioninvasion 10% : isthmus / cervix
involvement 10% : isthmus /cervix involvement 20% upgraded 20%upgraded intraop intraop
EndocervicalEndocervical curettagecurettage
-
7/28/2019 Endometrial Docu Cleaned
37/100
10% false negative rate 10%false negative rate
High false positive (80 Highfalse positive (80-90%), unless90%), unless stromal stromalinvasion seen invasion seen
EndometrialCancerEndometrial
Cancer - StagingStagingPatient Selection
Patient Selection Pre Pre-op
-
7/28/2019 Endometrial Docu Cleaned
38/100
Prediction? op
Prediction?TransvaginalTransvaginalultrasound/MRI
ultrasound/MRI 80% accurate: 80%accurate: myometrialmyometrial invasion invasion 33% accurate: cervix /
isthmus involvement 33%accurate: cervix / isthmusinvolvement
Therefore: no good
Therefore: no good preoppreop predictor of needpredictor of need
-
7/28/2019 Endometrial Docu Cleaned
39/100
for staging for staging
PostoperativeTreatmentPostoperative
Treatment
Stage I ControversyStage I Controversy Intermediate risk (5
Intermediate risk (5-10%recur) 10% recur) Grade 1 or 2 with: Grade 1or 2 with: Middle 1/3 Middle 1/3
myoinvasion myoinvasion orcervix / isthmus or cervix /isthmus
-
7/28/2019 Endometrial Docu Cleaned
40/100
High risk (>10% recur)High risk (>10% recur) Grade 3 or outer 1/3invasion Grade 3 or outer 1/3invasion
?? ?? whole pelvis
radiation vs. whole pelvisradiation vs.vaginal vaginalbrachytherapy
brachytherapy vs. vs.surgery alone surgeryalone ?? ??
Endometrial
Cancer
-
7/28/2019 Endometrial Docu Cleaned
41/100
Endometrial
CancerStage I ControversyStage I Controversy--
--RadiationRadiation GOG 99 GOG 99 Stage IB Stage IB-II, 390 pts
II, 390 ptsTAH/BSO/LNDTAH/BSO/LND pelvic pelvic rad rad or noor no rad rad Decreased Decreased pelvic
recurrence (12% pelvicrecurrence (12% vs vs 1.7 %1.7 % )
-
7/28/2019 Endometrial Docu Cleaned
42/100
Improved Improved diseasefree survival (94% disease
free survival (94% vs vs 85% )85% ) No difference No differencein overall survival in overallsurvival
EndometrialCancerEndometrialCancerStage I ControversyStage I Controversy--
--RadiationRadiation
-
7/28/2019 Endometrial Docu Cleaned
43/100
GOG 99 GOG 99morecontroversy! morecontroversy! Final analysis only reported2 yr survival data Finalanalysis only reported 2 yr
survival data Only 20% pts high risk(outer 1/3, Only 20% pts highrisk (outer 1/3, Gr Gr 3) 3)
EndometrialCancerEndometrial
CancerStage I ControversyStage I Controversy--
-
7/28/2019 Endometrial Docu Cleaned
44/100
--Radiation
Radiation PORTEC: PORTEC: 715pts 715 pts Stage IB Stage IB Gr Gr 2,3 ,
IC 2,3 , IC Gr Gr 2TAH / BSOTAH / BSO pelvic pelvic rad rad or no orno rad rad Decreased Decreased pelvicrecurrence (14% pelvicrecurrence (14% 4%) 4%) No difference No differencein survival in survival
BUT BUT: Excluded IC, :Excluded IC, Gr Gr 3
-
7/28/2019 Endometrial Docu Cleaned
45/100
Endometrial
CancerEndometrialCancer
Stage I ControversyStage I ControversyRadiation Radiation Vaginal Vaginal
Brachytherapy Brachytherapy(post op) (post op) 18 to 22 18 to 22 Gy Gy Decreases vaginalrecurrence 12% to 2%
Decreases vaginal recurrence12% to 2%
-
7/28/2019 Endometrial Docu Cleaned
46/100
RT for local recurrence RTfor local recurrence
Vaginal recur: Vaginal recur:68% 5 yr survival 68% 5 yrsurvival Pelvic recur: Pelvic recur: 20to 50% 5 yr survival 20 to50% 5 yr survival Pelvic control of tumor: 50 to65% Pelvic control of tumor:50 to 65%Ackerman 1996, Sears 1994, Morgan 1993, Wylie
2000 Ackerman 1996, Sears 1994, Morgan 1993,Wylie 2000
EndometrialCancer
EndometrialCancer
-
7/28/2019 Endometrial Docu Cleaned
47/100
Stage I Treatment
Stage I Treatment U of U / LDSH U of U /LDSHPatients: TAH/BSO andextended pelvic/aortic LNDPatients: TAH/BSO andextended pelvic/aortic LNDMyometrial MyometrialInvasion Invasion
None None 50%G1 G1 0 0 VG2 G2 0 V VG3 G3 V V V+P
(V = vaginal RT; P = pelvic RT)
-
7/28/2019 Endometrial Docu Cleaned
48/100
Endometrial
CancerEndometrialCancer
Stage I TreatmentStage I Treatment U of U / LDSH
U of U / LDSHPatients: Patients: no nolymph node dissection lymphnode dissectionMyometrial MyometrialInvasion InvasionNone None 50%
-
7/28/2019 Endometrial Docu Cleaned
49/100
G1 G1 0 0 V+PG2 G2 0 V P+V
G3 G3 V V+P P+V(V = vaginal RT; P = pelvic RT)
EndometrialCancerEndometrialCancerSubspecialty Impact
Subspecialty Impact Primary management:Primary management:Gyn Gyn onc onc vs vs
OB/GYN OB/GYN
-
7/28/2019 Endometrial Docu Cleaned
50/100
207 cases, 49% 207cases, 49% Gyn Gyn onconc / 51% GYN / 51% GYN Gyn Gyn onc onc pts:pts: Complete staging 2x more
often (94 Complete staging 2xmore often (94 vs vs 45%)45%) In hi risk Stage I, even moreoften (96 In hi risk Stage I,even more often (96 vs vs19%) 19%) Higher Higher avg avg #nodes (20 # nodes (20 vs vs
8) 8)Roland 2004 Roland 2004
-
7/28/2019 Endometrial Docu Cleaned
51/100
Endometrial
CancerEndometrialCancer
Subspecialty ImpactSubspecialty Impact Fewer Fewer Gyn Gynonc onc pts received
adjuvant radiation ptsreceived adjuvantradiation 8.6 8.6 vs vs 21.7% 21.7%
No No Gyn Gyn onc oncpts with T1, N0 disease
-
7/28/2019 Endometrial Docu Cleaned
52/100
rec pts with T1, N0disease recdradiation radiation 18 GYN pts with T1, N0or NX rec 18 GYN pts withT1, N0 or NX recd
radiation d radiationRoland 2004 Roland 2004
EndometrialCancerEndometrialCancer
TreatmentTreatment Stage IIIStage III
-
7/28/2019 Endometrial Docu Cleaned
53/100
Survival, 5 yr Survival, 5yr 10 to 30% gross extrauterine disease 10 to 30%gross extra uterine disease 40 to 80% microscopic 40 to
80% microscopicTreatment:Treatment: Nodes/ Nodes/ serosaserosa/ / adnexa adnexa/
vagina / vagina RT RT Positive Cytology PositiveCytology High dose High dose progestinsprogestins if PR positive if PR
positive Chemo vs. whole abdominal RTChemo vs. whole abdominal RT
-
7/28/2019 Endometrial Docu Cleaned
54/100
Endometrial
CancerEndometrialCancer
TreatmentTreatment Stage IVStage IV Survival, 5 year Survival,5 year 5 - 10% 10%
Treatment:Treatment: Hormonal therapy Hormonal
therapy ChemotherapyChemotherapy
-
7/28/2019 Endometrial Docu Cleaned
55/100
Local radiation Localradiation
EndometrialCancerEndometrial
CancerControversy: EstrogenReplacement Controversy:Estrogen ReplacementTherapyTherapyArguments against:Arguments against:Increase recurrence
Increase recurrence ? Epidemiologic studies:Epidemiologic studies:
-
7/28/2019 Endometrial Docu Cleaned
56/100
Unopposed estrogenUnopposed estrogen risk
developing risk developingendo endo ca ca In vitro studies: In vitrostudies: growth of cultured cellswith estrogen therapy growthof cultured cells with estrogentherapy
EndometrialCancerEndometrialCancerControversy: EstrogenReplacement Controversy:Estrogen Replacement
-
7/28/2019 Endometrial Docu Cleaned
57/100
TherapyTherapyArguments in support:Arguments in support: Benefits: Benefits: bone /bone / neuro neuro /symptoms / symptoms
Likelihood of ( Likelihood of(oncologic oncologic) harm: )harm: Early stage, low grade: ERpositive Early stage, low grade: ER
positiveLeast Least recurrent recurrent High stage, high grade: higherrecurrence High stage, high grade:higher recurrencemost most ER negative ER negative
EndometrialCancer
-
7/28/2019 Endometrial Docu Cleaned
58/100
Endometrial
CancerEstrogen ReplacementTherapy EstrogenReplacement Therapy249 pts, stages I, II, III(cohort study) 249 pts,stages I, II, III (cohortstudy) 130 pt 130 pt ERT (50%with progesterone) ERT (50%with progesterone) Age/stage matched controls
(75 pairs) Age/stage matchedcontrols (75 pairs) Similar in Similar insurgicopathology
-
7/28/2019 Endometrial Docu Cleaned
59/100
surgicopathology, treatment ,treatment
ERT users ERT users 1%recurrence 1% recurrence Non ERT Non ERT 14%recurrences 14% recurrencesSuriano Suriano et al 2001 etal 2001
EndometrialCancer
EndometrialCancer
Treatment
TreatmentERTprotocol ERT protocol GOG 137 GOG 137
-
7/28/2019 Endometrial Docu Cleaned
60/100
Stage I / occult stage IIendometrial cancer Stage I /
occult stage II endometrialcancer Premarin 0.625/ day vs.placebo Premarin 0.625/ dayvs. placebo Plan: 3 years treatment, 2yrfl/u Plan: 3 years treatment,2yr fl/u Closed prematurely due to
accrual Closed prematurelydue to accrual
EndometrialCancer
EndometrialCancer
-
7/28/2019 Endometrial Docu Cleaned
61/100
ERT protocol ERT
protocolGOG 137GOG 137 Median f/u 30 mo, 1234pts Median f/u 30 mo,
1234 pts ERT: ERT: Recurrence 12 pts (1.9%)Recurrence 12 pts (1.9%) Death due to Death due toendom endom Ca 3 pts (0.5%)Ca 3 pts (0.5%)
Placebo: Placebo: Recurrence 10 pts (1.6%)
Recurrence 10 pts (1.6%)
-
7/28/2019 Endometrial Docu Cleaned
62/100
Death due to Death due toendom endom Ca 4 pts (0.6%)
Ca 4 pts (0.6%) (NOT statistically valid)NOT statistically valid)
Endometrial
CancerEndometrialCancerSummary Summary 4th th most commoncancer in women mostcommon cancer in women Caught early, excellentsurvival Caught early,excellent survival
-
7/28/2019 Endometrial Docu Cleaned
63/100
Abnormal bleedingmerits evaluationAbnormal bleeding meritsevaluation Office biopsy, pursuediagnosis if persists! Office
biopsy, pursue diagnosis ifpersists!
Family predispositionFamily predisposition
endometrial, HNPCCendometrial, HNPCC Family Cancer AssessmentClinic Family CancerAssessment Clinic
EndometrialCancer
-
7/28/2019 Endometrial Docu Cleaned
64/100
Endometrial
CancerSummary Summary Full staging may foregoradiation Full staging may
forego radiation Grade 1 Grade 1 preoppreop biopsies biopsies33% need staging 33%
need staging Laparoscopy is the newparadigm in Laparoscopyis the new paradigm in
endometrial cancerendometrial cancer
-
7/28/2019 Endometrial Docu Cleaned
65/100
Ovarian Cancer
Ovarian Cancer Second most commongynecologic cancerSecond most common
gynecologic cancerin the US in the US Responsible for 25,000cases annuallyResponsible for 25,000cases annually 14,500 deaths annually14,500 deaths annually Most lethal gynecologic
cancer Most lethalgynecologic cancer
-
7/28/2019 Endometrial Docu Cleaned
66/100
70% of women arediagnosed present with
70% of women arediagnosed present withadvanced diseaseadvanced diseaseAmerican Cancer Society
2000
Ovarian Cancer:Ovarian Cancer:Stage Distribution and
Survival StageDistribution andSurvival
Stage Stage Percent
Percent SurvivalSurvival
-
7/28/2019 Endometrial Docu Cleaned
67/100
I-- --ovary ovary 2424 95% 95%II II-- --pelvis pelvis 665% 65%III III-- --
abdomen abdomen55 55 15 15-30% 30%IV IV-- --distantdistant 15 15 0-20%
20%Overall Overall 50%50%American Cancer Society 2000 AmericanCancer Society 2000
Ovarian Cancer:Risk Factors
-
7/28/2019 Endometrial Docu Cleaned
68/100
Ovarian Cancer:
Risk FactorsIncrease IncreaseDecrease DecreaseAge Age Oral
Contraceptives OralContraceptives(50% decrease) (50%decrease)
Family history Familyhistory PregnancyPregnancy and andBreastfeeding
BreastfeedingInfertility/low parityInfertility/low parity
-
7/28/2019 Endometrial Docu Cleaned
69/100
Personal cancerPersonal cancerhistory historyHysterectomy/RemovalHysterectomy/Removalof Both Ovaries of Both
OvariesOvarian Cancer:Hereditary RisksOvarian Cancer:Hereditary RisksFamily History ofOvarian Family History
of OvarianCancer Cancer LifetimeRiskLifetime Risk
-
7/28/2019 Endometrial Docu Cleaned
70/100
None None 1.8% 1.8%1 first 1 first-degreerelative degree relative5% 5%2 first 2 first-degreerelatives degree
relatives 7% 7%Hereditary ovariancancer Hereditaryovarian cancer
syndrome syndrome40% 40%Known BRCA1 orBRCA2 Known BRCA1
or BRCA2
-
7/28/2019 Endometrial Docu Cleaned
71/100
inherited mutationinherited mutation 3535-65% 65%
Ovarian Cancer:Ovarian Cancer:
HereditarySyndromesHereditarySyndromes
Account for only 10%of ovarian cancerAccount for only 10% ofovarian cancer
Inherited from eitherparent Inherited fromeither parent
-
7/28/2019 Endometrial Docu Cleaned
72/100
IncompleteIncomplete penetrancepenetrance Associated withbreast, colon, prostateAssociated with breast,
colon, prostateand endometrialcancers andendometrial cancers
Ovarian Cancer:Ovarian Cancer:How is Ovarian
Cancer Diagnosed?How is OvarianCancer Diagnosed?
-
7/28/2019 Endometrial Docu Cleaned
73/100
Vaginal Vaginal -rectal exam rectalexam TransvaginalTransvaginalultrasound ultrasound
CA 125 blood test CA125 blood test Surgical biopsy /resection Surgical
biopsy / resectionOvarian CarcinomaOvarian Carcinoma--
--SymptomsSymptoms
-
7/28/2019 Endometrial Docu Cleaned
74/100
95% of women DO reportsymptoms 95% of women DO
report symptoms80 to 90% of pts with Stage
I/ II disease 80 to 90% of ptswith Stage I/ II disease
More often, more acuteonset ofMore often, moreacute onset ofsx sx, more ,moresevere severe
Vague and often non Vagueand often non-gynecologicgynecologic
abdominal bloating, abdominalbloating, incr incr girth, pressure
girth, pressureFatigue Fatigue
-
7/28/2019 Endometrial Docu Cleaned
75/100
GI (nausea, gas, constipation,diarrhea) GI (nausea, gas,
constipation, diarrhea)Urinary frequency/ incontinenceUrinary frequency/ incontinence
Abdominal/ pelvic painAbdominal/ pelvic pain
Weight loss/ gain Weight loss/
gainShortness of breath Shortness of
breath
Ovarian Carcinoma
Ovarian CarcinomaPrimary ManagementPrimary Management
Initial surgery Initial
surgery
-
7/28/2019 Endometrial Docu Cleaned
76/100
Thorough surgicalstagingThorough surgicalstaging
Aggressive tumorresection ( Aggressivetumor resection
(debulking debulking, ,cytoreductioncytoreduction)
Combination
chemotherapyCombinationchemotherapy
6 cycles: 6 cycles:
carboplatin carboplatin &paclitaxel paclitaxel
-
7/28/2019 Endometrial Docu Cleaned
77/100
Ovarian Carcinoma
Ovarian CarcinomaPrimary ManagementPrimary ManagementInitial SurgeryInitial Surgery
Surgical Staging SurgicalStaging
Hyst Hyst / BSO / / BSO /
Omentectomy OmentectomyWashings, peritoneal biopsies
Washings, peritoneal biopsiesPelvic/ Pelvic/ Paraaortic Paraaortic
LymphadenectomyLymphadenectomy
80% of ovarian cancer ptsreceive inadequate 80% of
-
7/28/2019 Endometrial Docu Cleaned
78/100
ovarian cancer pts receiveinadequate
staging from non staging fromnon gyn gyn-onc onc surgeonsurgeon
May translate into choicebetween 2 May translate intochoice between 2nd nd surgeryor surgery orchemotherapy chemotherapy
Ovarian Carcinoma
Ovarian CarcinomaPrimary ManagementPrimary Management
Initial SurgeryInitial Surgery
-
7/28/2019 Endometrial Docu Cleaned
79/100
Reoperation Reoperationwithin 3 months for within 3
months for debulkingdebulking/ staging / staging
Population based study, 3355pts Population based study, 3355pts
Pts Pts less likely to have lesslikely to have reoperationreoperation ififdone: done:
In high In high- or or intermedintermed- volume hospital (RR0.24) volume hospital (RR 0.24)
By By Gyn Gyn Onc Onc (RR0.04) (RR 0.04)
By general Ob/ By general Ob/Gyn Gyn (RR 0.37) (RR 0.37)
By high volume surgeon (RR
0.09) By high volume surgeon (RR0.09)(> 10 ovarian cancer cases/ yr) (>10 ovarian cancer cases/ yr)
-
7/28/2019 Endometrial Docu Cleaned
80/100
Elit et al, Gyn Oncol 200
Ovarian CarcinomaOvarian CarcinomaPrimary ManagementPrimary Management
DebulkingDebulkingResidual Disease ResidualDisease 5 yr survival 5 yr
survival< 1 cm < 1 cm 50% 50%1 to 2 cm 1 to 2 cm 20% 20%> 2 cm > 2 cm 13% 13%Baker et al, Cancer 1994
Ovarian CarcinomaOvarian Carcinoma
-
7/28/2019 Endometrial Docu Cleaned
81/100
Primary Management
Primary ManagementDebulkingDebulkingResidual Disease Residual
Disease Median survivalMedian survival< 0.5cm < 0.5cm 40 months40 months0.5 to 1.5 cm 0.5 to 1.5 cm 18months 18 months> 1.5 cm > 1.5 cm 6 months6 monthsHacker N, Ob & Gyn 1983
Ovarian CarcinomaOvarian Carcinoma
-
7/28/2019 Endometrial Docu Cleaned
82/100
Primary Management
Primary ManagementInitial SurgeryInitial Surgery
Survival advantage for
advanced stage pts treatedSurvival advantage foradvanced stage pts treatedby by gyn gyn onc onc
25% reduction in death at 3yrs, (
25% reduction in death at 3yrs, (vsvs general Ob/ general Ob/GynGyn)
JunorJunor et al, Br J et al, Br J Ob&GynOb&Gyn 1999 1999
Survival advantage for ptstreated in high Survivaladvantage for pts treated inhigh-volume volume
-
7/28/2019 Endometrial Docu Cleaned
83/100
hospital hospital55% 55% vs vs 34% 5 yr survival
for high 34% 5 yr survival for highvs vs low volume low volumeIoka Ioka et al, Cancer et al, Cancer Sci Sci2004 2004
Pelvic Mass:
Preoperative PelvicMass: PreoperativePrediction of
MalignancyPrediction ofMalignancy
5 to 25% 5 to 25%
premenopausalpremenopausal aremalignant are malignant
-
7/28/2019 Endometrial Docu Cleaned
84/100
1/3 1/3rd rd in pts < 21 y.o.(solid/ cystic) in pts < 21 y.o.
(solid/ cystic)> 50% in > 50% in
premenarchal premenarchalpts (solid/ cystic) pts (solid/cystic)
35 to 63%postmenopausal aremalignant 35 to 63%postmenopausal are
malignantPreop Preop
assessment of likelihoodofassessment of
likelihood of
-
7/28/2019 Endometrial Docu Cleaned
85/100
malignancy can allowappropriate malignancycan allow appropriatesurgical planning surgicalplanning
PreoperativePrediction ofMalignancyPreoperative
Prediction ofMalignancy
Indicators (suspicious)Indicators (suspicious)
Pelvic examination Pelvicexaminationfixed, nodular,fixed, nodular, ascites ascites
-
7/28/2019 Endometrial Docu Cleaned
86/100
Tumor markersTumormarkers
CA125 > 35U/ CA125 > 35U/ mLmL
AFP >10 AFP >10 ng ng/ / mLmL or or hCG hCG >15 >15 mIUmIU/ / mL mL (non (nonpregnant) pregnant)
LDH > 350 U/ L LDH > 350 U/ L
UltrasonographicUltrasonographic findingsfindings solid, cystic with
solid, cystic withmural nodules mural nodulesRoman et al, Ob &Gyn 1997
Preoperative
Prediction ofMalignancy
-
7/28/2019 Endometrial Docu Cleaned
87/100
Preoperative
Prediction ofMalignancyIf all 3 indicators If all 3
indicators nonsuspicious
nonsuspicious::99% of pre 99% of pre- &
postmenopausal masses &postmenopausal massesbenign benign
If all 3 indicators If all 3indicators suspicioussuspicious, ,
77% of77% of
premenopausalpremenopausal massesmasses malignant malignant
-
7/28/2019 Endometrial Docu Cleaned
88/100
1/3 1/3rd rd borderline, 2/3borderline, 2/3rd rd invasive invasive
Nodules >2cm, size>10cm mostpredictive Nodules >2cm,size>10cm most predictive
83% of postmenopausalmasses 83% of
postmenopausal massesmalignant malignantborderline, borderline, invasive invasive
CA125 > 100, suspicious U/Smost predictive CA125 > 100,suspicious U/S most predictiveRoman 1997
ACOG / SGOReferral Guidelines
-
7/28/2019 Endometrial Docu Cleaned
89/100
ACOG / SGO
Referral GuidelinesNewly DiagnosedPelvic Mass Newly
Diagnosed PelvicMass
PremenopausalPremenopausal (200 U/ mlascites ascites abd abd/ distant / distant
mets metsFamily Family Hx Hx Breast/Breast/
-
7/28/2019 Endometrial Docu Cleaned
90/100
Ovarian cancer (1st Ovariancancer (1st
degree) degree)Postmenopausal (>50)Postmenopausal (>50) CA125 > 35 U/ ml CA125 > 35U/ mlascites ascites abd abd/ distant / distantmets metsFamily Family Hx Hx Breast/
Breast/Ovarian cancer (1st Ovariancancer (1stdegree) degree) nodular/ fixed mass nodular/
fixed massACOG Committee Opinion 2002Im et al, Ob &Gyn 2005
-
7/28/2019 Endometrial Docu Cleaned
91/100
ACOG / SGO
Referral GuidelinesACOG / SGOReferral Guidelines
Predictive ValuePredictive Value
1,035 pts, 7 hospitals1,035 pts, 7 hospitals
30% ovarian cancer30% ovarian cancer
25% of cancer cases25% of cancer cases-- --
premenopausalpremenopausal
-
7/28/2019 Endometrial Docu Cleaned
92/100
chart / path reviewchart / path reviewCA125 CA125
preop preop pelvic exampelvic exam
imaging studies imagingstudiespath report path report
Im et al, Ob &Gyn 2005
Referral Guidelines
Referral GuidelinesPredictive ValuePredictive Value--
--Pre PremenopausalmenopausalCriteria PPV (%) NPV (%)
-
7/28/2019 Endometrial Docu Cleaned
93/100
CA125 70 85Ascites 58 89Mets 64 89Family Hx 19 82Overall 34 92Im et al, Ob &Gyn 2005
Referral GuidelinesReferral GuidelinesPredictive Value
Predictive Value----PostPostmenopausalmenopausalCriteria PPV (%) NPV (%)CA125 74 85
-
7/28/2019 Endometrial Docu Cleaned
94/100
Ascites 79 72Pelvic exam 66 61Mets 84 77Family Hx 42 56Overall 60 91Im et al, Ob &Gyn 2005
Referral GuidelinesReferral GuidelinesPatient Distribution
Patient DistributionSpecialty Ovarian CancerBenign MassPremenopausalGyn Onc 70% 31%
OB/ Gyn 30% 69%PostmenopausalGyn Onc 94% 42%
-
7/28/2019 Endometrial Docu Cleaned
95/100
OB/ Gyn 6% 58%
Modified ReferralGuidelinesModified Referral
GuidelinesPremenopausalPremenopausal ( 50 U/ mlascites ascites abd abd/ distant /
distant mets metsPostmenopausal (>50)Postmenopausal (>50)
-
7/28/2019 Endometrial Docu Cleaned
96/100
CA125 > 35 U/ ml CA125> 35 U/ ml
ascites ascites abd abd/ distant /distant mets metsIm et al, Ob &
Gyn 2005Im et al, Ob &Gyn 2005
Referral GuidelinesReferral Guidelines
Patient DistributionPatient DistributionSpecialty Ovarian Cancer BenignMass
PremenopausalGyn Onc 85% 27%OB/ Gyn 15% 73%Postmenopausal
-
7/28/2019 Endometrial Docu Cleaned
97/100
Gyn Onc 90% 24%OB/ Gyn 10% 76%
Ovarian &EndometrialCancer Ovarian &
EndometrialCancerSurveillance
SurveillanceFrequency: Frequency:Q 3 months x 2 yrs Q 3months x 2 yrs
Q 4 months x 1 yr Q 4 monthsx 1 yrQ 6 months until year 5, Q 6months until year 5,
-
7/28/2019 Endometrial Docu Cleaned
98/100
then, annually then, annually(roughly 75 to 90% recur
(roughly 75 to 90% recurin 1st 3 years) in 1st 3 years)Each visit: Each visit:Physical / Physical / Pelvicexam Pelvic examPap smear Pap smear
Tumor markers (CA125,Tumor markers (CA125,CEA) CEA)
Annual: Annual:Chest Xray Chest XrayCBC, metabolic panel CBC,metabolic panel
Endometrial &Ovarian Cancer
-
7/28/2019 Endometrial Docu Cleaned
99/100
Endometrial &
Ovarian Cancer Early detection Earlydetection-- --improveimproves survival s
survival Heighten awareness ofsympto Heighten awarenessof symptoms! ms!
Staging & completeStaging & completedebulking debulkingdecreases decreasesmorbidity and increasessurvival morbidity andincreases survival
-
7/28/2019 Endometrial Docu Cleaned
100/100
Consider consultationwith gynecologic Considerconsultation withgynecologiconcologist (801 oncologist(801-585 585-2477) 2477)