23Case 2: History Operation at 和信醫院: Total abdominal hysterectomy + bilateral salpingo-oophorectomy + pelvic LN dissection + Cul-de-sac & peritoneal tumor resection + omentectomy
24Case 2: History Patholgy: Bil. Ovary & fallopian tube: High grade papillary serous carcinomaR’t ovary: 2.5 x 2 x 1.5 cmL’t ovary : 2.5 x 1.1 x 0.5 cm
25Case 2: History Cul-de-sac, peritoneum, omentum: High grade papillary serous carcinomaSerosal surface of the uterus, pelvic LNs:metastatic adenocarcinoma (N1 stage StageIIIC at least)Uterus:four myoma (measuring up to 3.4 cm)
27Peritoneal Carcinomatosis Definition:Extensive, or very widespread, metastasis of cancerous tumors onto the inside surfaces (peritoneum) of the abdomen.
28Peritoneal Carcinomatosis Occurs commonly with abdominopelvic tumorsMost common tumors:Ovarian carcinoma (female)Gastric cancerPancreas cancerColon cancer
29Peritoneal Carcinomatosis AscitesSoft tissue masses or thickening of the parietal peritoneumOmental thickening (omental cake)Tumor nodules & enlarged LNs in the mesenteryThickening & nodularity of the bowel wall
45Normal-sized ovarian carcinoma syndrome Diffuse metastatic disease of the peritoneal cavity.Ovaries are macroscopically normal (<4cm) or only have fine nodularities on the external surface.Obstet Gynecol. 1989;73(5 Pt 1):
46Normal-sized ovarian carcinoma syndrome Including:MesotheliomaPrimary peritoneal carcinomaPrimary ovarian carcinoma ( Serous surface papillary carcinoma of ovary, Papillary serous carcinoma in ovaries of normal size )Metastatic tumor from another primary originObstet Gynecol. 1989;73(5 Pt 1):
47Serous surface papillary carcinoma of ovary Originating from the surface epithelium of the ovaryAbsence of involvement or only microscopic involvement of the ovarian parenchyma.A distinct subtype of serous papillary carcinoma of the ovaryExtensive peritoneal spreadActa Radiologica 38 (1997)
48Serous surface papillary carcinoma of ovary Imaging findings (CT, US, MRI):Diffuse nodularities along the serosal surface of the ovaries, uterus and peritoneum without ovarian mass.The nodular lesions obliterated the outer margin of uterus and ovaries.Acta Radiologica 38 (1997)
50Serous surface papillary carcinoma of ovary Elevated CA-125 in all pts (most > 200 U/ml)AJR 2004;183:1721–1724
51CA-125 & Ovarian CancerThe average reported sensitivities for ovarian cancer:50% for stage I90% for stage II or higher diseaseVaries according to histologySpecificity of CA 125 is limited.Rarely > 100~200 U/ml in benign conditions.From UpToDate; Epithelial ovarian cancer : Clinical manifestations, diagnostic evaluation, staging, and histopathology
53CA-125 & Ovarian CancerNot a useful diagnostic test in premenopausal women, especially at low positive levels (warning if > 200 U/ml).It is more useful in postmenopausal women, in whom the positive predictive value for malignancy is 97 %.
54CA-125 & Ovarian CancerHigh preoperative CA-125 levels correlate with:Advanced stage (III or IV)High grade diseaseSerous histologyThe presence of ascites
55CA-125 & Ovarian CancerNot a reliable predictor of the likelihood of optimal cytoreduction.Baseline measurement is useful in evaluating the success of subsequent treatment.
56CA 125 & Ovarian Cancer A pelvic mass suspicious for malignancy if: AscitesNodularity/fixationEvidence of metastasesA First degree relative with ovarian or brest cancerElevated CA-125 level (normal < 35)Any abnormal in the postmenopausalA level > 200 U/ml in the premenopausalAmerican College of Obstetricians and Gynecologists
57ConclusionPeritoneal carcinomatosis occurs commonly with abdominopelvic tumors.FDG-PET/CT has the potential to improve detection of peritoneal carcinomatosis. But there are limits.In normal-sized ovarian carcinoma syndrome, peritoneal carcinomatosis is noted, despite of normal size of ovaries.
58ConclusionElevation serum CA-125 ( any abnormal in the postmenopausal, and > 200 U/ml in the premenopausal) can help in the diagnosis of ovarian cancer.