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Endometrial & Ovarian CancerEndometrial & Ovarian CancerOverviewOverview
EpidemiologyEpidemiology
Signs & symptomsSigns & symptoms
Management / outcomeManagement / outcome When to refer to a subWhen to refer to a sub--specialistspecialist
FollowFollow
--up surveillanceup surveillance
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Endometrial CancerEndometrial CancerEpidemiologyEpidemiology
36,000 cases/yr; 6,500 deaths36,000 cases/yr; 6,500 deaths
4th most common cancer in women4th most common cancer in women
(breast, lung, colon)(breast, lung, colon) 75% postmenopausal (avg. age 58 y.o.)75% postmenopausal (avg. age 58 y.o.)
5% cases: < 40 years old5% cases: < 40 years old
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Endometrial CancerEndometrial CancerRisk FactorsRisk Factors -- DeleteriousDeleterious
Relative RiskRelative RiskObesityObesity 22--1111Family historyFamily history 1.51.5--2.82.8NulliparityNulliparity 33Infertility (Infertility (>>3yrs)3yrs) 33Endogenous estrogensEndogenous estrogens 1.51.5 -- 44
EstrogenEstrogen--secreting tumorssecreting tumors
Unopposed exogenous estrogensUnopposed exogenous estrogens 22 -- 1212DiabetesDiabetes 22 -- 1010TamoxifenTamoxifen 22 -- 77
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Endometrial CancerEndometrial CancerRisk FactorsRisk Factors -- ProtectiveProtective
Oral contraceptives (1Oral contraceptives (1--5 years)5 years) 0.30.3--0.50.5
Cigarette smokingCigarette smoking 0.40.4--.08.08
ParityParity 0.30.3--0.50.5
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Endometrial CancerEndometrial Cancer----Risk FactorsRisk FactorsHereditaryHereditary NonpolyposisNonpolyposisColorectal CancerColorectal Cancer
5% of colorectal cancers5% of colorectal cancers
Mutations in DNA mismatch repair genesMutations in DNA mismatch repair genes
LifetimeLifetimerisk of developing:risk of developing:
Colorectal cancer 80%Colorectal cancer 80%
Endometrial cancer 40%Endometrial cancer 40%
Ovarian cancer 10%Ovarian cancer 10%Other GI cancer 20%Other GI cancer 20%
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Endometrial CancerEndometrial CancerCarcinogenesisCarcinogenesis Precancerous LesionsPrecancerous Lesions
HyperplasiaHyperplasia Progression to CancerProgression to CancerSimpleSimple 1%1%
ComplexComplex 3%3%
Simple, atypicalSimple, atypical 8%8%
Complex, atypicalComplex, atypical 29%29%
Kurman, 1985
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Endometrial CancerEndometrial CancerSymptomsSymptoms
Postmenopausal bleedingPostmenopausal bleeding Present in > 90% menopausal cases ofPresent in > 90% menopausal cases of
endometrial cancerendometrial cancer
20% patients with PMB20% patients with PMB malignancymalignancy
5% patients with PMB5% patients with PMB endoendo hyperplasiahyperplasia
PremenopausalPremenopausal patientspatients abnormal uterineabnormal uterine
bleedingbleeding
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Endometrial CancerEndometrial CancerSignsSigns
Most exams are normalMost exams are normal May have:May have:
enlarged uterusenlarged uterus
PeripheralPeripheral adenopathyadenopathy AscitesAscites
vaginalvaginal metsmets
adnexaladnexal massmass
culcul--dede--sacsac nodularitynodularity
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Endometrial CancerEndometrial CancerDiagnosisDiagnosis Pap SmearPap Smear
In patients with endometrial cancer:In patients with endometrial cancer:
4040--50% suspicious50% suspicious endoendo cells on Papcells on Pap
22--5% normal endometrial cells5% normal endometrial cells
Montz2001, Win 2001, Ashfag2001, Sarode2001
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Endometrial CancerEndometrial CancerDiagnosisDiagnosis Pap SmearPap Smear
Postmenopausal women with normalPostmenopausal women with normal endoendo cells oncells on
pap:pap:
2020--40% pathology40% pathology
PolypsPolyps Hyperplasia 10Hyperplasia 10--15%15%
Cancer 1Cancer 1--5%5%
22--5% asymptomatic5% asymptomatic pts with normal endometrialpts with normal endometrialcells:cells: cancercancer
Montz2001, Win 2001, Ashfag2001, Sarode2001
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Endometrial CancerEndometrial CancerDiagnosisDiagnosisBiopsyBiopsy
Inpatient (operative) dilation and curettageInpatient (operative) dilation and curettage(fractional)(fractional)
Outpatient endometrial biopsyOutpatient endometrial biopsy
PipellePipelle
VabraVabra, Novak, Novak
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Endometrial CancerEndometrial Cancer
DiagnosisDiagnosis Endometrial BiopsyEndometrial Biopsy
MetaanalysisMetaanalysis39 studies (5 prospect)39 studies (5 prospect) OfficeOfficebxbx compared to D&C,compared to D&C, hysthyst, or both, or both
Cancer:Cancer: SensitivitySensitivity 68 to 81%68 to 81%SpecificitySpecificity 99.6 to 99.9%99.6 to 99.9%
HyperplasiaHyperplasia SensitivitySensitivity 75%75%SpecificitySpecificity 99%99%
Dijkhuizenet al. Cancer 2000
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Endometrial CancerEndometrial CancerDiagnosisDiagnosis HysteroscopyHysteroscopy
Visual inspection vsbiopsy diagnosis of endometritis, polyp, hyperplasia, cancer
Overall sensitivity = 94%, spec 89% Most accurate: polyps sens95%, spec 95%
Worst: hyperplasia
sens70%, spec 92%, (PPV = 60%)
Garnti JAAGL 2001
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Endometrial CancerEndometrial Cancer
HysteroscopyHysteroscopy -- CAVEATCAVEATTranstubalTranstubal spread ofspread ofendoendo cellscells
ObermaierObermaier et alet al (Cancer 2000)(Cancer 2000) 113 pts113 ptsHSC/D&CHSC/D&C vsvs D&C aloneD&C alone
12%12% vsvs2.5% pos. peritoneal cytology (p
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Endometrial CancerEndometrial CancerDiagnosisDiagnosis TransvaginalTransvaginal UltrasoundUltrasound
MetaanalysisMetaanalysis TVUS & office biopsyTVUS & office biopsy
Endometrial thicknessEndometrial thickness
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Endometrial CancerEndometrial CancerDiagnosisDiagnosis -- SummarySummary
Office endometrial biopsyOffice endometrial biopsy preferredpreferredmethodmethod
Accurate, convenientAccurate, convenient
TV U/STV U/S can effectively r/o disease ifcan effectively r/o disease if
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Endometrial CancerEndometrial Cancer
SurgicalSurgical StagingStaging
Stage IStage I UterusUterus (75 to 80%)(75 to 80%)A.A. endometriumendometriumB.B. myometriummyometrium
Stage IIStage II CervixCervix (6 to 10%)(6 to 10%)
A.A. glandsglandsB.B. stromastroma
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Endometrial CancerEndometrial Cancer
SurgicalSurgical StagingStaging
Stage IIIStage III ExtrauterineExtrauterine (8%)(8%)A.A. serosaserosa,, adnexaadnexa, peritoneal cytology, peritoneal cytologyB.B. vagina, pelvic peritoneumvagina, pelvic peritoneum
C.C. lymph nodes (pelvic/abdominal)lymph nodes (pelvic/abdominal)
Stage IVStage IV DistantDistant (5%)(5%)
A.A. bowel/bladder mucosabowel/bladder mucosaB.B. intraabdominalintraabdominal, inguinal nodes, extra, inguinal nodes, extra
abdominalabdominal
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Endometrial CancerEndometrial CancerTreatmentTreatment----SurgerySurgery
Hysterectomy /Hysterectomy / salpingoophorectomysalpingoophorectomy (BSO)(BSO)
If clinical cervical involvement:If clinical cervical involvement:
RadicalRadical hysthyst vsvspreoppreopradiationradiation
StagingStaging selected patientsselected patients
Peritoneal cytologyPeritoneal cytology Lymph node dissectionLymph node dissection
OmentectomyOmentectomy (papillary serous/clear cell histology)(papillary serous/clear cell histology)
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Endometrial CancerEndometrial CancerTreatmentTreatmentSurgery 2005Surgery 2005
Increased role forIncreased role for laparoscopiclaparoscopic stagingstaging
LAVH/ BSO, staging if indicatedLAVH/ BSO, staging if indicated
Regardless of age, body mass indexRegardless of age, body mass index 75 to 95% have full staging by LSC75 to 95% have full staging by LSC
Conversion to open lap for obesity,Conversion to open lap for obesity,
intraperitonealintraperitoneal cancer, bleedingcancer, bleeding
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Endometrial CancerEndometrial CancerTreatmentTreatmentSurgery 2005Surgery 2005
LaparoscopicLaparoscopic hysthyst/ BSO/ staging/ BSO/ staging
Equal node countEqual node count
Equal survivalEqual survival Decreased length of stayDecreased length of stay
Longer OR time (230 minLonger OR time (230 minvsvs150 min)150 min)
Shorter delay for radiation (if indicated)Shorter delay for radiation (if indicated)
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Endometrial CancerEndometrial CancerStagingStaging Patient SelectionPatient Selection
Risk of pelvic lymph nodeRisk of pelvic lymph node
grade, depth ofgrade, depth ofinvasioninvasion
DepthDepth G1G1 G2G2 G3G3EndometriumEndometrium 00 33 00
Inner 1/3Inner 1/3 33 55 99
Middle 1/3Middle 1/3 00 99 44
Outer 1/3Outer 1/3 1111 1919 34%34%
Creasman1987
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Endometrial CancerEndometrial CancerStagingStaging Patient SelectionPatient Selection
Risk of lymph nodeRisk of lymph node tumor location
Pelvic LN Aortic LNFundus 8% 4%
Isthmus cervix 16% 14%
Creasman1987
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Endometrial CancerEndometrial Cancer -- StagingStagingPatient SelectionPatient Selection PrePre--op Prediction ?op Prediction ?
Grade 1 lesionGrade 1 lesion 1 in 31 in 3will require stagingwill require staging 10 to 15% : outer10 to 15% : outer invasioninvasion 10% : isthmus / cervix involvement10% : isthmus / cervix involvement
20% upgraded20% upgraded
intraopintraop
EndocervicalEndocervical curettagecurettage
10% false negative rate10% false negative rate High false positive (80High false positive (80--90%), unless90%), unless stromalstromalinvasion seeninvasion seen
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Endometrial CancerEndometrial Cancer -- StagingStagingPatient SelectionPatient Selection PrePre--op Prediction?op Prediction?
TransvaginalTransvaginal ultrasound/MRIultrasound/MRI
80% accurate:80% accurate: myometrialmyometrial invasioninvasion
33% accurate: cervix / isthmus involvement33% accurate: cervix / isthmus involvement
Therefore: no goodTherefore: no goodpreoppreoppredictor of needpredictor of need
for stagingfor staging
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Postoperative TreatmentPostoperative Treatment
Stage I ControversyStage I Controversy
Intermediate risk (5Intermediate risk (5--10% recur)10% recur)
Grade 1 or 2 with:Grade 1 or 2 with: Middle 1/3Middle 1/3myoinvasionmyoinvasion or cervix / isthmusor cervix / isthmus
High risk (>10% recur)High risk (>10% recur) Grade 3 or outer 1/3 invasionGrade 3 or outer 1/3 invasion
???? whole pelvis radiation vs.whole pelvis radiation vs.
vaginalvaginal brachytherapybrachytherapy vs.vs.
surgery alonesurgery alone????
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Endometrial CancerEndometrial Cancer
Stage I ControversyStage I Controversy----RadiationRadiation
GOG 99GOG 99 Stage IBStage IB--II, 390 ptsII, 390 pts
TAH/BSO/LNDTAH/BSO/LND pelvicpelvic radrad or noor no radrad
DecreasedDecreasedpelvic recurrence (12%pelvic recurrence (12% vsvs 1.7 %1.7 % ))
ImprovedImproved disease free survival (94%disease free survival (94% vsvs 85% )85% )
No differenceNo differencein overall survivalin overall survival
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Endometrial CancerEndometrial Cancer
Stage I ControversyStage I Controversy----RadiationRadiation
GOG 99GOG 99more controversy!more controversy! Final analysis only reported 2 yr survival dataFinal analysis only reported 2 yr survival data
Only 20% pts high risk (outer 1/3,Only 20% pts high risk (outer 1/3, GrGr 3)3)
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Endometrial CancerEndometrial CancerStage I ControversyStage I Controversy----RadiationRadiation
PORTEC:PORTEC: 715 pts715 pts Stage IBStage IB GrGr 2,3 , IC2,3 , IC GrGr 22
TAH / BSOTAH / BSO pelvicpelvic radrador noor no radrad
DecreasedDecreasedpelvic recurrence (14%pelvic recurrence (14% 4%)4%)
No differenceNo differencein survivalin survival
BUTBUT: Excluded IC,: Excluded IC, GrGr 33
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Endometrial CancerEndometrial CancerStage I ControversyStage I ControversyRadiationRadiation
VaginalVaginal BrachytherapyBrachytherapy (post op)(post op)
18 to 2218 to 22GyGy
Decreases vaginal recurrence 12% to 2%Decreases vaginal recurrence 12% to 2%
RT for local recurrenceRT for local recurrence
Vaginal recur:Vaginal recur: 68% 5 yr survival68% 5 yr survival
Pelvic recur:Pelvic recur: 20 to 50% 5 yr survival20 to 50% 5 yr survival Pelvic control of tumor: 50 to 65%Pelvic control of tumor: 50 to 65%
Ackerman 1996, Sears 1994, Morgan 1993, Wylie 2000Ackerman 1996, Sears 1994, Morgan 1993, Wylie 2000
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Endometrial CancerEndometrial CancerStage I TreatmentStage I Treatment U of U / LDSHU of U / LDSH
Patients: TAH/BSO and extended pelvic/aortic LNDPatients: TAH/BSO and extended pelvic/aortic LND
MyometrialMyometrial InvasionInvasion
NoneNone 50%
G1G1 00 00 VV
G2G2 00 VV VV
G3G3 VV VV VV++PP
(V = vaginal RT; P = pelvic RT)
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Endometrial CancerEndometrial CancerStage I TreatmentStage I Treatment U of U / LDSHU of U / LDSH
Patients:Patients: nono lymph node dissectionlymph node dissection
MyometrialMyometrial InvasionInvasion
NoneNone 50%
G1G1 00 00 VV++PP
G2G2 00 VV PP++VV
G3G3 VV VV++PP PP++VV
(V = vaginal RT; P = pelvic RT)
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Endometrial CancerEndometrial CancerSubspecialty ImpactSubspecialty Impact
Primary management:Primary management: GynGynonconc vsvs OB/GYNOB/GYN
207 cases, 49%207 cases, 49% GynGynonconc / 51% GYN/ 51% GYN
GynGynonconc pts:pts: Complete staging 2x more often (94Complete staging 2x more often (94vsvs45%)45%)
In hi risk Stage I, even more often (96In hi risk Stage I, even more often (96vsvs19%)19%)
HigherHigher avgavg#nodes (20#nodes (20vsvs8)8)
Roland 2004Roland 2004
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Endometrial CancerEndometrial CancerSubspecialty ImpactSubspecialty Impact
FewerFewer GynGynonconc pts received adjuvant radiationpts received adjuvant radiation
8.68.6vsvs21.7%21.7%
NoNo GynGynonconc pts with T1, N0 disease recpts with T1, N0 disease recddradiationradiation
18 GYN pts with T1, N0 or NX rec18 GYN pts with T1, N0 or NX recd radiationd radiation
Roland 2004Roland 2004
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Endometrial CancerEndometrial CancerTreatmentTreatment Stage IIIStage III
Survival, 5 yrSurvival, 5 yr
10 to 30% gross extra uterine disease10 to 30% gross extra uterine disease
40 to 80% microscopic40 to 80% microscopic
Treatment:Treatment: Nodes/Nodes/ serosaserosa// adnexaadnexa/ vagina/ vagina RTRT
Positive CytologyPositive Cytology
High doseHigh doseprogestinsprogestins if PR positiveif PR positive
Chemo vs. whole abdominal RTChemo vs. whole abdominal RT
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Endometrial CancerEndometrial CancerTreatmentTreatment Stage IVStage IV
Survival, 5 yearSurvival, 5 year 55 -- 10%10%
Treatment:Treatment:
Hormonal therapyHormonal therapy
ChemotherapyChemotherapy
Local radiationLocal radiation
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Endometrial CancerEndometrial CancerControversy: Estrogen ReplacementControversy: Estrogen Replacement
TherapyTherapy
Arguments against:Arguments against: Increase recurrenceIncrease recurrence??
Epidemiologic studies:Epidemiologic studies:Unopposed estrogenUnopposed estrogen risk developingrisk developingendoendo caca
In vitro studies:In vitro studies:
growth of cultured cells with estrogen therapygrowth of cultured cells with estrogen therapy
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Endometrial CancerEndometrial CancerControversy: Estrogen ReplacementControversy: Estrogen Replacement
TherapyTherapy
Arguments in support:Arguments in support:
Benefits:Benefits: bone /bone / neuroneuro / symptoms/ symptoms
Likelihood of (Likelihood of (oncologiconcologic) harm:) harm: Early stage, low grade: ER positiveEarly stage, low grade: ER positive
LeastLeast recurrentrecurrent
High stage, high grade: higher recurrenceHigh stage, high grade: higher recurrence
mostmost ER negativeER negative
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Endometrial CancerEndometrial CancerEstrogen Replacement TherapyEstrogen Replacement Therapy
249 pts, stages I, II, III (cohort study)249 pts, stages I, II, III (cohort study)
130 pt130 pt ERT (50% with progesterone)ERT (50% with progesterone)
Age/stage matched controls (75 pairs)Age/stage matched controls (75 pairs)
Similar inSimilar in surgicopathologysurgicopathology, treatment, treatment
ERT usersERT users 1% recurrence1% recurrence
Non ERTNon ERT 14% recurrences14% recurrences
SurianoSuriano et al 2001et al 2001
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Endometrial CancerEndometrial CancerTreatmentTreatmentERT protocolERT protocol
GOG 137GOG 137 Stage I / occult stage II endometrial cancerStage I / occult stage II endometrial cancer
Premarin 0.625/ day vs. placeboPremarin 0.625/ day vs. placebo
Plan: 3 years treatment, 2yr fl/uPlan: 3 years treatment, 2yr fl/u
Closed prematurely due to accrualClosed prematurely due to accrual
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Endometrial CancerEndometrial CancerERT protocolERT protocolGOG 137GOG 137
Median f/u 30 mo, 1234 ptsMedian f/u 30 mo, 1234 pts ERT:ERT:
Recurrence 12 pts (1.9%)Recurrence 12 pts (1.9%)
Death due toDeath due to endomendomCa 3 pts (0.5%)Ca 3 pts (0.5%) Placebo:Placebo:
Recurrence 10 pts (1.6%)Recurrence 10 pts (1.6%)
Death due toDeath due to endomendomCa 4 pts (0.6%)Ca 4 pts (0.6%)
((NOT statistically valid)NOT statistically valid)
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Endometrial CancerEndometrial CancerSummarySummary
44thth
most common cancer in womenmost common cancer in women Caught early, excellent survivalCaught early, excellent survival
Abnormal bleeding merits evaluationAbnormal bleeding merits evaluation
Office biopsy, pursue diagnosis if persists!Office biopsy, pursue diagnosis if persists!
Family predispositionFamily predispositionendometrial, HNPCCendometrial, HNPCC
Family Cancer Assessment ClinicFamily Cancer Assessment Clinic
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Endometrial CancerEndometrial CancerSummarySummary
Full staging may forego radiationFull staging may forego radiation
Grade 1Grade 1preoppreopbiopsiesbiopsies33% need staging33% need staging
Laparoscopy is the new paradigm inLaparoscopy is the new paradigm inendometrial cancerendometrial cancer
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Ovarian CancerOvarian Cancer Second most common gynecologic cancerSecond most common gynecologic cancer
in the USin the US Responsible for 25,000 cases annuallyResponsible for 25,000 cases annually
14,500 deaths annually14,500 deaths annually
Most lethal gynecologic cancerMost lethal gynecologic cancer
70% of women are diagnosed present with70% of women are diagnosed present withadvanced diseaseadvanced disease
American Cancer Society2000
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Ovarian Cancer:Ovarian Cancer:
Stage Distribution and SurvivalStage Distribution and Survival
StageStage PercentPercent SurvivalSurvival
II ----ovaryovary 2424 95%95%
IIII ----pelvispelvis 66 65%65%
IIIII I ----
abdomenabdomen5555 1515--30%30%
IVIV----distantdistant 1515 00--20%20%
OverallOverall 50%50%American Cancer Society 2000American Cancer Society 2000
O i C Ri k F tO i C Ri k F t
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Ovarian Cancer: Risk FactorsOvarian Cancer: Risk Factors
IncreaseIncrease DecreaseDecrease
AgeAge Oral ContraceptivesOral Contraceptives(50% decrease)(50% decrease)
Family historyFamily history PregnancyPregnancy
andand
BreastfeedingBreastfeeding
Infertility/low parityInfertility/low parity
Personal cancerPersonal cancer
historyhistoryHysterectomy/RemovalHysterectomy/Removal
of Both Ovariesof Both Ovaries
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Ovarian Cancer: Hereditary RisksOvarian Cancer: Hereditary Risks
Family History of OvarianFamily History of Ovarian
CancerCancerLifetime RiskLifetime Risk
NoneNone 1.8%1.8%
1 first1 first--degree relativedegree relative 5%5%
2 first2 first--degree relativesdegree relatives 7%7%
Hereditary ovarian cancerHereditary ovarian cancer
syndromesyndrome 40%40%Known BRCA1 or BRCA2Known BRCA1 or BRCA2
inherited mutationinherited mutation3535--65%65%
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Ovarian Cancer:Ovarian Cancer:Hereditary SyndromesHereditary Syndromes
Account for only 10% of ovarian cancerAccount for only 10% of ovarian cancer
Inherited from either parentInherited from either parent
IncompleteIncompletepenetrancepenetrance
Associated with breast, colon, prostateAssociated with breast, colon, prostateand endometrial cancersand endometrial cancers
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Ovarian Cancer:Ovarian Cancer:How is Ovarian Cancer Diagnosed?How is Ovarian Cancer Diagnosed?
VaginalVaginal -- rectal examrectal exam
TransvaginalTransvaginal ultrasoundultrasound
CA 125 blood testCA 125 blood test
Surgical biopsy / resectionSurgical biopsy / resection
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Ovarian CarcinomaOvarian Carcinoma----SymptomsSymptoms 95% of women DO report symptoms95% of women DO report symptoms
80 to 90% of pts with Stage I/ II disease80 to 90% of pts with Stage I/ II disease More often, more acute onset ofMore often, more acute onset ofsxsx, more, more
severesevere
Vague and often nonVague and often non--gynecologicgynecologic abdominal bloating,abdominal bloating, incrincr girth, pressuregirth, pressure
FatigueFatigue
GI (nausea, gas, constipation, diarrhea)GI (nausea, gas, constipation, diarrhea) Urinary frequency/ incontinenceUrinary frequency/ incontinence
Abdominal/ pelvic painAbdominal/ pelvic pain
Weight loss/ gainWeight loss/ gain
Shortness of breathShortness of breath
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Ovarian CarcinomaOvarian CarcinomaPrimary ManagementPrimary Management
Initial surgeryInitial surgery
Thorough surgical stagingThorough surgical staging
Aggressive tumor resection (Aggressive tumor resection (debulkingdebulking,,
cytoreductioncytoreduction))
Combination chemotherapyCombination chemotherapy 6 cycles:6 cycles: carboplatincarboplatin && paclitaxelpaclitaxel
OvarianCarcinomaOvarianCarcinoma
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Ovarian CarcinomaOvarian Carcinoma
Primary ManagementPrimary ManagementInitial SurgeryInitial Surgery
Surgical StagingSurgical Staging
HystHyst / BSO // BSO / OmentectomyOmentectomy Washings, peritoneal biopsiesWashings, peritoneal biopsies
Pelvic/Pelvic/ ParaaorticParaaortic LymphadenectomyLymphadenectomy
80% of ovarian cancer pts receive inadequate80% of ovarian cancer pts receive inadequatestaging from nonstaging from non gyngyn--onconc surgeonsurgeon
May translate into choice between 2May translate into choice between 2ndnd surgery orsurgery orchemotherapychemotherapy
OvarianCarcinomaOvarianCarcinoma
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Ovarian CarcinomaOvarian Carcinoma
Primary ManagementPrimary ManagementInitial SurgeryInitial Surgery ReoperationReoperation within 3 months forwithin 3 months for debulkingdebulking/ staging/ staging
Population based study, 3355 ptsPopulation based study, 3355 pts
PtsPts less likely to haveless likely to have reoperationreoperation ififdone:done:
In highIn high-- oror intermedintermed-- volume hospital (RR 0.24)volume hospital (RR 0.24) ByBy GynGyn OncOnc (RR 0.04)(RR 0.04)
By general Ob/By general Ob/ GynGyn (RR 0.37)(RR 0.37)
By high volume surgeon (RR 0.09)By high volume surgeon (RR 0.09)
(> 10 ovarian cancer cases/ yr)(> 10 ovarian cancer cases/ yr)
Elit et al, Gyn Oncol 20
OvarianCarcinomaOvarianCarcinoma
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Ovarian CarcinomaOvarian Carcinoma
Primary ManagementPrimary ManagementDebulkingDebulking
Residual DiseaseResidual Disease 5 yr survival5 yr survival
< 1 cm< 1 cm 50%50%
1 to 2 cm1 to 2 cm 20%20%
> 2 cm> 2 cm 13%13%
Baker et al, Cancer 1994
OvarianCarcinomaOvarianCarcinoma
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Ovarian CarcinomaOvarian Carcinoma
Primary ManagementPrimary ManagementDebulkingDebulking
Residual DiseaseResidual Disease Median survivalMedian survival
< 0.5cm< 0.5cm 40 months40 months
0.5 to 1.5 cm0.5 to 1.5 cm 18 months18 months
> 1.5 cm> 1.5 cm 6 months6 months
Hacker N, Ob & Gyn 1983
OvarianCarcinomaOvarianCarcinoma
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Ovarian CarcinomaOvarian Carcinoma
Primary ManagementPrimary ManagementInitial SurgeryInitial Surgery Survival advantage for advanced stage pts treatedSurvival advantage for advanced stage pts treated
byby gyngyn onconc 25% reduction in death at 3yrs, (25% reduction in death at 3yrs, (vsvs general Ob/general Ob/GynGyn))
J unorJ unor et al, Br Jet al, Br J Ob&GynOb&Gyn 19991999
Survival advantage for pts treated in highSurvival advantage for pts treated in high--volumevolume
hospitalhospital
55%55% vsvs 34% 5 yr survival for high34% 5 yr survival for high vsvs low volumelow volume
IokaIoka et al, Canceret al, Cancer SciSci 20042004
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Pelvic Mass: PreoperativePelvic Mass: PreoperativePrediction of MalignancyPrediction of Malignancy
5 to 25%5 to 25% premenopausalpremenopausal are malignantare malignant
1/31/3rdrd in pts < 21 y.o. (solid/ cystic)in pts < 21 y.o. (solid/ cystic)
> 50% in> 50% in premenarchalpremenarchal pts (solid/ cystic)pts (solid/ cystic)
35 to 63% postmenopausal are malignant35 to 63% postmenopausal are malignant
PreopPreop assessment of likelihood ofassessment of likelihood of
malignancy can allow appropriatemalignancy can allow appropriate
surgical planningsurgical planning
P ti P di ti f M li
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Preoperative Prediction of MalignancyPreoperative Prediction of Malignancy
Indicators (suspicious)Indicators (suspicious)
Pelvic examinationPelvic examinationfixed, nodular,fixed, nodular, ascitesascites
Tumor markersTumor markers
CA125 > 35U/CA125 > 35U/ mLmL AFP >10AFP >10 ngng// mLmL oror hCGhCG >15>15 mIUmIU// mLmL (non(non
pregnant)pregnant)
LDH > 350 U/ LLDH > 350 U/ L
UltrasonographicUltrasonographic findingsfindings solid, cystic withsolid, cystic with
mural nodulesmural nodules
Roman et al, Ob &Gyn 1997
Preoperative Prediction of MalignancyPreoperative Prediction of Malignancy
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Preoperative Prediction of MalignancyPreoperative Prediction of Malignancy
If all 3 indicatorsIf all 3 indicators nonsuspiciousnonsuspicious::
99% of pre99% of pre-- & postmenopausal masses& postmenopausal masses benignbenign
If all 3 indicatorsIf all 3 indicators suspicioussuspicious,,
77% of77% ofpremenopausalpremenopausal massesmasses malignantmalignant 1/31/3rdrd borderline, 2/3borderline, 2/3rdrd invasiveinvasive
Nodules >2cm, size>10cm most predictiveNodules >2cm, size>10cm most predictive
83% of postmenopausal masses83% of postmenopausal masses malignantmalignant borderline,borderline, invasiveinvasive
CA125 > 100, suspicious U/S most predictiveCA125 > 100, suspicious U/S most predictiveRoman 199
ACOG / SGO Referral GuidelinesACOG / SGO Referral Guidelines
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//
Newly Diagnosed Pelvic MassNewly Diagnosed Pelvic Mass
PremenopausalPremenopausal ( 200 U/ ml
ascitesascites
abdabd/ distant/ distant metsmets
FamilyFamily HxHx Breast/Breast/
Ovarian cancer (1stOvarian cancer (1st
degree)degree)
Postmenopausal (>50)Postmenopausal (>50)
CA125 > 35 U/ mlCA125 > 35 U/ ml
ascitesascites
abdabd/ distant/ distant metsmets
FamilyFamily HxHx Breast/Breast/
Ovarian cancer (1stOvarian cancer (1st
degree)degree)
nodular/ fixed massnodular/ fixed mass
ACOG Committee Opinion 2002
ACOG / SGO Referral GuidelinesACOG / SGO Referral Guidelines
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Imet al, Ob &Gyn 2005
/
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
chart / path reviewchart / path review CA125CA125
preoppreoppelvic exampelvic exam
imaging studiesimaging studies path reportpath report
Referral GuidelinesReferral Guidelines
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Imet al, Ob &Gyn 2005
Predictive ValuePredictive Value----PrePremenopausalmenopausal
Criteria PPV (%) NPV (%)
CA125 70 85
Ascites 58 89
Mets 64 89
Family Hx 19 82
Overall 34 92
Referral GuidelinesReferral Guidelines
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Imet al, Ob &Gyn 2005
Predictive ValuePredictive Value----PostPostmenopausalmenopausal
Criteria PPV (%) NPV (%)
CA125 74 85
Ascites 79 72
Pelvic exam 66 61
Mets 84 77
Family Hx 42 56
Overall 60 91
Referral GuidelinesReferral Guidelines
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Imet al, Ob &Gyn 2005
Patient DistributionPatient Distribution
Specialty Ovarian Cancer Benign MassPremenopausal
Gyn Onc 70% 31%
OB/ Gyn 30% 69%Postmenopausal
Gyn Onc 94% 42%
OB/ Gyn 6% 58%
ModifiedReferral Guidelines
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Modified Referral GuidelinesModified Referral Guidelines
PremenopausalPremenopausal ( 50 U/ ml
ascitesascites
abdabd/ distant/ distant metsmets
Postmenopausal (>50)Postmenopausal (>50)
CA125 > 35 U/ mlCA125 > 35 U/ ml
ascitesascites
abdabd/ distant/ distant metsmets
Imet al, Ob &Gyn 2005
Referral GuidelinesReferral Guidelines
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Imet al, Ob &Gyn 2005
Patient DistributionPatient Distribution
Specialty Ovarian Cancer Benign MassPremenopausal
Gyn Onc 85% 27%
OB/ Gyn 15% 73%
Postmenopausal
Gyn Onc 90% 24%
OB/ Gyn 10% 76%
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Ovarian & Endometrial CancerOvarian & Endometrial CancerSurveillanceSurveillanceFrequency:Frequency:
Q 3 months x 2 yrsQ 3 months x 2 yrs
Q 4 months x 1 yrQ 4 months x 1 yr
Q 6 months until year 5,Q 6 months until year 5,then, annuallythen, annually
(roughly 75 to 90% recur(roughly 75 to 90% recurin 1st 3 years)in 1st 3 years)
Each visit:Each visit:
Physical /Physical / Pelvic examPelvic exam
Pap smearPap smear
Tumor markers (CA125,Tumor markers (CA125,CEA)CEA)
Annual:Annual:Chest XrayChest Xray
CBC, metabolic panelCBC, metabolic panel
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Endometrial & Ovarian CancerEndometrial & Ovarian Cancer
Early detectionEarly detection----improveimproves survivals survival Heighten awareness of symptoHeighten awareness of symptoms!ms!
Staging & completeStaging & completedebulkingdebulking decreasesdecreases
morbidity and increases survivalmorbidity and increases survival Consider consultation with gynecologicConsider consultation with gynecologic
oncologist (801oncologist (801--585585--2477)2477)