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Ovarian Tumors: Ovarian Tumors: Diagnosis or Diagnosis or Prognosis?Prognosis?

Professor Galal Lotfi. MD, MRCOG.

Suez Canal University. Egypt.

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IntroductionIntroduction

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Prognosis Has a Prognosis Has a Bleak Picture:Bleak Picture:

1. It presents late; 75% are stages III, IV. No change over past 10 ys.

2. 5 yr survival of late cases=10%.

3. So; It kills more than cx and endom both.

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To Improve Prognosis:To Improve Prognosis:

Early diagnosis:– Identifying women at risk.– Prompt investigation of suspicious symptoms.– Development of screening tests.

Prevention:– Prophylactic oophorectomy.

Improvement of use of existing therapeutics.Further development of experimental therapies.

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Early disgnosisEarly disgnosis

1. Identify woman at risk.2. Symptomatology.3. Screening tests.

1. Tumor markers.2. Imaging.3. Cytology.4. Pelvic examination.

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Who Are at Risk?Who Are at Risk?

Geography:– 5 times more in developed countries.– Highest in Sweden, Israel, least in Japan..– 15/100,000 in Sweden.– Residence is more important than race.

Race; White more susceptible.Age:

– Peri, postmenopausal, median age 60.

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Who are at risk?Who are at risk?

Sedentary life:– Sedentary behavior associated with higher

incidence of ovarian cancer (Am J Epidemiol; 163: 709-716.2006).

How:– Sedentary life leads to obesity, metabolic

abnorm, increased E, insulin that may promote cell proliferation.

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Who Are at Risk?Who Are at Risk?

Reproductive history:– Late age of 1st pregnancy (very important).– Nulligravida or small no. Of children.– No use OCP, protection of OCP proportional with

duration of use.– INCESSANT OVULATION HYPOTHESIS, (time from

menarche to cessation of ov – time of anovulation due to preg and lactation = index of ovarian cancer.

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Who Are at Risk?Who Are at Risk?

Family history:– If mother or sister have ov cancer, 18 fold risk.

Past history:– If she had primary BREAST, COLON,

ENDOMETRIUM, 4 times increased risk for primary ovarian.

Rubella at age 12-18, mumps antibody titre, has higher risk.

Talc, sanitary pads with talc, risk 3.

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To sum up: Who Are at Risk?To sum up: Who Are at Risk?

White. North Europe. >40ys. Nulliparous. Sedentary behavior. Late age 1st preg. No OCP. +ve family history.

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Symptomatology.Symptomatology.

Late diagnosis = poor prognosis; Public education for early seeking medical advice.

50% present to the wrong doctor.So: Not of great help

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Screening Tests:Screening Tests:

Rules for screening test:– The disease to be screened should have

significant morbidity and mortality.– The natural history of the disease is

understood and has revealed high prevalence of the preclinical disease in the population.

– The test comfortable and convenient, economic, easy to perform, least side effects.

– High specificity and sensitivity.

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Tumor MarkersTumor MarkersOncodevelopmental.(carcino embryonic

antigen CEA).Carcinoplacental. AFP, HCG.Metabolic: protein biomarkers, ovacheck

already in market; specificity and sensitivity of 97%. Not FDA approved yet.

Tumor specific or tumor associated (CA 125).– Could help in monitoring the prognosis.

– Poor sensitivity.

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CA-125CA-125

High in 80% of advanced cancer.High in only 50% of stage I; 50% have –ve

result.10% only positive predictive value.Should not be used for screening.Only for monitoring and follow up

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ImagingImagingUs: increased ov volume

twice the mean volume is suspicious.

Presence of cystic ov are suspicious.

CT? Impractical.MRI? Impractical.

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Let us look in USLet us look in US

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US…Screening ScoreUS…Screening Score Ovarian cancer screening tests are the subject

of endless debate. Some say it may progress to a late stage so quickly as to make screening impractical. This could be minimized by decreasing the time between follow up tests especially in women with family history of ovarian cancer. Again, this criticism could be said to any other screening programs.

 The screening tests tried for ovarian cancer included variety of techniques. Clinical examination, culdocentesis, immunoscintigraphy, tumor marker but all are insensitive.

We implemented US screening score.

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Appearance Score

Atrophic 0

Volume >8cm. 1

Simple anechoic <3cm 1

Simple anechoic <5cm 2

Simple anechoic >5cm 3

Multilocular <5cm 2

Multilocular >5cm 3

Complex, cyst with echoic shadows. 4

Solid cyst (solid areas >50%) 5

Table (1) Scoring for US appearance of ovaries

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Table (2), Score for WomenTable (2), Score for Women’’s Historys History

History Score

Family history of ovarian carcinoma 2

Past or family history of genital, breast or colon

1

Negative history of oral contraceptive

1

Nulligravida 1

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Table(3), Scoring of women, 1st Scan Result

TVS finding TVS score

Other Ovary

Family History

Malignant History

OCP History

Total Score

Simple cyst < 3cm (Persistent)

1$ 0 2 0 1 4

Simple cyst < 5cm

1 1 0 1 0 3

Simple cyst =>5cm

1 0 0 0 0 1

Multiloc < 5cm 1 1 0 0 1 3

Multiloc =>5cm 2$ 2 2 0 1 7

Complex 2$ 0 0 1 0 3

Solid 2 0 0 0 0 2

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Table (4): Surgical Results of Cases Table (4): Surgical Results of Cases Operated Upon After the First Examination Operated Upon After the First Examination (N=198(N=198).).

TVS result No. Result

Volume > 8Cm3 1 Not operated

Simple cyst < 3cm (persistent)

4 1 Malignant 3 Benign

Simple cyst < 5cm 5 2 Malignant 1 inflammatory 2Benign

Simple cyst =>5cm 3 3 simple serous

Multilocucyst < 5cm 1 Inflammatory

Multilocular cyst =>5cm 2 1 malignant 1 inflammatory

Complex cyst 1 Malignant

Solid cyst 1 Malignant

Total 18

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Table (5): cases with proved Table (5): cases with proved

malignancy.malignancy. TVS Surgic

al stage

Path. Grade

Pathology

Simple cyst < 3cm

1ai I Cystadenocarcinoma

Simple <5cm 1ai I Mucinous carcinoma

Simple <5cm 1aii I Cystadenocarcinoma

Multiloc. >5cm

1bi II Endometroid

Complex 1ai I Cystadenocarcinoma

Solid cyst 1c I Endometroid

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Table (6): Surgical results after one year (N 185)

TVS Result No. Surgical result

Volume >8cm3 1

Not operated

Simple Cyst < 3cm (persistent)

2 Simple serous

Simple < 5cm 2 Simple serous

Simple cyst => 5cm 0

Multilocular cyst <5cm 0

Multilocular cyst =>5cm 0

Complex cyst 0

Solid cyst 0

Total 5

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Table(7), Scoring of women after one year, N (185)

TVS finding TVS score

Other Ovary

Family History

Malignant History

OCP History

Total Score

Simple cyst < 3cm (Persistent)

1 0 2 0 1 4

Simple cyst < 5cm

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00

00

00

11

3

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Table (8): Comparison Between Cases Table (8): Comparison Between Cases With Proved Malignancy and Cases With Proved Malignancy and Cases With Benign Lesions (first Scan).With Benign Lesions (first Scan).

Lesion No. Min Score

Max score

Mean SD

Malignant

6 3 12 6.33 3.1

Benign 15 1 4 2.93 0.88

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Mean and SD of total score of Benign and malignant lesions (first scan)

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Detection of abnormal, benign and malignant lesion (first Scan) in 1st scan

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Detection of Abnormal, Benign and malignant lesion in 2nd scan.

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CytologyCytology

Pap, abnormal in only 10%, unreliable.

Pouch of Douglas peritoneal cytology, questionable and unreliable.

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Pelvic Examination.Pelvic Examination.

Vaginal examination is very important tool.

Palpable ovaries in postmenopausal women is abnormal.

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Prevention; Prophylactic Prevention; Prophylactic oophorectomyoophorectomy

Literature report: of 30,000 patients with retained ovaries after hysterectomy for benign conditions, 0.2% got ovarian cancer. 500 prophylactic oophorectomy has to be done during surgery for postmenopausal women to save one woman from cancer; So if it is done in every case 7% cancer can be prevented.

For premenopausal woman, consider risk factors. If family history, oophorectomy after family

compl. Grossly abnormal ov, remove it, irrespective of

age.

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Improve Existing Treatment.Improve Existing Treatment.Surgery (cornerstone of

treatment).– Staging.– Surgical procedure.

Postoperative treatment.Adjuvant therapy.Monitoring treatment.

– US, CT.– Laparoscopy.– Markers.– 2nd look.

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Staging:Staging:Vertical incision.Aspirate, or saline washing.Careful assessment., Liver, rt

hemidaphragm, (because lymph of peritoneal cavity drain to inferior surface of diaphragm before getting mediastinal LN. Diaphragmatic metastases 10% stage I, 20% stage II.), All other organs as omentum, intestine,….

Paraaortic LN sampling.Proper staging, for prognosis, selection

of adjuvant therapy…..

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Staging, (Surgical)Staging, (Surgical) I: confined to 1 or 2 ov.

– Ia: one ovary.Iai: capsule intact.Iaii: capsule perforated.

– Ib: two ovary.IIbi, Iibii.

– Ic: either one or two ov, with +ve cytology.Ici, Icii.

II: extension tubes, uterus. III: extension other pelvic. IV: abdominal and general. V: cases not staged.

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Surg Procedure.Surg Procedure.

Maximum surgical effort = leave no residue, or Cytoreductive surgery =reduce residual tumor to minimum.

TAH+ BSO+ Omentectomy + appendectomy.

Prognosis high if residue <1.6cm.

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Postoperative Postoperative Treatment.Treatment.

Prognostic indicators:–Residual mass.–Tumor grade. Then..–Stage , age, histology.

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Adjuvant Therapy.Adjuvant Therapy.

Chemotherapy.–Single vs multiple agents.

Radiotherapy.Combined.

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MonitoringMonitoringTo confirm complete response, stop

chemo.To avoid premature discontinuation

of TT.To confirm presence of residual mass

requiring resection or modification of treatment.

Research procedure to assess different modalities.

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MonitoringMonitoring

markers.II look CT, unreliable.Laparoscopy.Laparotomy.

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FutureFutureNew cytotoxic agents, platinum analogues.Hormonal therapy, trials of antiestrogen,

progestogen.Stem cell assay, a method of selecting

drugs with specific action in individual patients to improve response rate and decrease side effects ( like C &S).

Immunotherapy, attempts to stimulate cell mediated immunity, Corynebacterium Parvum, interferon and use of heteroantisera.

High dose chemotherapy,

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ConclusionConclusion

Vaginal examination and TVS every year.

Abnormal ovarian conditions detection rate by TVS was 9. 1% and 2.2% of cases in initial examination and subsequent year follow up.

Malignant detection rate by TVS was 3%.

No evidence based tests available with the sensitivity of Pap smear for Cx cancer.

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ConclusionConclusion

Andolf & Jorgensen (1989) found no malignancy in 58 anechoic lesions less than 5cm as detected by ultrasound.

Rodrigenz et al (1988) reported 3 cancers detected in simple cystic lesions with a diameter greater than 5cm.

In the present study, small cysts were found to be not immune for malignancy, 3 cases with cyst diameter less than 3cmwere found to be malignant.

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Epilog.Epilog.

With small cyst and in situations where we are in doubt, the implemented score could help in deciding up. For big, multilocular, complex or solid cysts, the answer is straight forward, surgical intervention.

TVS, cheap compared to other imaging techniques, non invasive, seems to provide a simple screening technique for early ovarian cancer.

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If you think PrognosisIf you think Prognosis

Think Early Diagnosis.

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If you think Survival or MortalityIf you think Survival or Mortality

Think improving surgical, imaging and chemotherapeutic.

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Thank you