1. Malignant Ovarian Tumor
A.Alsaadoun (2/12/2008)
Saturday, April 22, 2017
Malignant Ovarian Tumor
Dr. Mashael Shebaili
Assistant Prof. & Consultant
Department OF Ob & Gyn.
King Saud University

2. Objectives introduction History and examination Risk factor screening
Epidemiology
screening
Investigation
Treatment
Prevention

3. Introduction
Historically ovarian cancer has been called the silent killer because symptoms often become apparent too late in the processes that the chance of cure were poor

4. Ovarian cancer accounts for 3.3% of all new cases of cancer
Epidemology
The lifetime risk for developing ovarian cancer is 1.6% in the general population
Ovarian cancer accounts for 3.3% of all new cases of cancer
The fifth in cancer deaths among women and accounts for more deaths than any other cancer of the female reproduction system
only 19% of ovarian cancers discovered at early stage.
Most cases are diagnosed in the seventh decade of life.

5. symptoms Urinary urgency Abd/pelvic pain Abdominal distention
Vaginal bleeding
symptoms
Bloating
Change bowel habit
Irregular menses

6. Types of ovarian cancer
Germ cell tumor
Epithelial tumor
Stromal cell tumor

7. Physical finding Ascites Patient with advance disease
Ovarian or Pelvic mass
Pleural effusion
Ascites
Bowel
obstruction

8. Obesity
parity
HRT
OCP
Risk factors
Hereditary
Family
history

9. Multiple pregnancies offer an increasingly protective effect
A.Alsaadoun (2/12/2008)
Saturday, April 22, 2017
parity
Obesity
Women who have been pregnant have 50% decreasd risk for develoing ovarian cancer compared to nulliparous women
Multiple pregnancies offer an increasingly protective effect
HRT
OCP
Hereditary
Family
history 9

10. Its protective effect lasted to 2-3 decade after cessation of use
OCP
Obesity
The use of OCP more than one year reduce the risk of ovarian cancer by 30%-50%
Its protective effect lasted to 2-3 decade after cessation of use
Parity
HRT
Hereditary
Family
history

11. No evidence of hereditary pattern
Family
history
Obesity
No evidence of hereditary pattern
The risk in general popultion is 1.6%
The risk increased to 4-5% when 1st degree family member is affected ,rising to 7% when two relatives are affected
Parity
HRT
OCP
Hereditary

12. Hereditary
Obesity
Represent 5% of all ovarian cancer
2 syndrome are clearly identified:
Breast/ovarian cancer syndrome : Associated with early onset breast or ovarian cancer ,transmitted as AD and occur due to BRCA gene mutation
Parity
HRT
OCP
Family
history

13. Hereditary
Obesity
Lynch ll syndrome or hereditary non polyposis colorectal cancer : These families characterized by high risk of developing colorectal ,endometrial, stomach, small bowel, breast ,pancreas and ovarian cancer and it is due to mutation in mismatch repair gene .
Parity
HRT
OCP
Family
history

14. HRT
Obesity
A large study puplished in the journal of national cancer institute in October 2006 report that women who used hormonal therapy for 5 years or more face a significantly increase risk of ovarian cancer
Parity
OCP
Hereditary
Family
history

15. Obesity
Studies have suggested that women who are obese at age of 18 are at increased risk of developing ovarian cancer befor menopause
parity
HRT
OCP
Hereditary
Family
history

16. However, 95% of all ovarian cancers occur in women without risk factors.

17. Screening
Effective screening tests are available for several common cancers, including: mammography for breast cancer, the Pap test for cervical cancer but no standardized screening test exists to reliably detect ovarian cancer.
Researchers haven't yet found a screening tool that's sensitive enough to detect ovarian cancer in its early stages and specific enough to distinguish ovarian cancer from other, noncancerous conditions

18. Screening
Most experts feel that a screening protocol for ovarian cancer should have a positive predictive value of at least 10 percent (that is, no more than nine healthy women with false-positive screens would undergo unnecessary procedures for each case of ovarian cancer detected

19. US LPA Screening Other tumor Ca 125 markers A.Alsaadoun (2/12/2008)
Saturday, April 22, 2017
Screening US
LPA
Ca 125
Other tumor
markers 19

20. Has a sensitivity of 70%-80% And a specificity of 98.6% - 99.45%
Screening US
LPA
Ca 125
Other tumor
marker
Has a sensitivity of 70%-80%
And a specificity of 98.6% %

21. abscess, renal disease) and in physiological condition (pregnancy and
Screening US
LPA
Ca 125
Other tumor
marker
False positive :
Increase in other cancers (pancreas ,breast ,bladder ,liver ,lung) ,in benign
disease (diverticulitis , endometriosis, benign ovarian cyst ,tuboovarian
abscess, renal disease) and in physiological condition (pregnancy and
Menstruation )

22. Elevated in only 80% of ovarian cancer cases
Screening US
LPA
Ca 125
Other tumor
marker
False negative :
Elevated in only 80% of ovarian cancer cases

23. Positive predictive value:
Screening US
LPA
Ca 125
Other tumor
marker
Positive predictive value:
Annual CA125 testing has low predictive value (3%) which does not meet
the level required for screening post meopausal women at average risk

24. CA125 as a first line test followed by US as a second line test
Screening US
LPA
Ca 125
Other tumor
marker
CA125 as a first line test followed by US as a second line test
for positive CA125 result has a shown to be very specific
and achieve positive predictive value of 20% or greater .

25. Screening of 100,000 women over age of 45,would detect 40 cases of US
LPA
CA125
Other tumor
markers
Highly false positive :In one of the study it has been estimated that US
Screening of 100,000 women over age of 45,would detect 40 cases of
Ovarian cancer with 5,398 false positive result and more than 160
Complications from laproscopy .

26. In other screening studies in women at high risk of ovarian cancer ,US
LPA
CA125
Other tumor
markers
In other screening studies in women at high risk of ovarian cancer ,US
has performed poorly in detecting early stage epithelial ovarian cancer .

27. matrix in ovarian cancer . LPA concentration are elevated in 96% of
A.Alsaadoun (2/12/2008)
Saturday, April 22, 2017
Screening US
LPA
CA125
Other tumor
markers
The lipid lysophosphatidic acid is associated with invasion of the extracellular
matrix in ovarian cancer . LPA concentration are elevated in 96% of
women with ovarian cancer including 90% of those with stage 1 disease
Studies to evaluate the use of this biomarker are ongoing . 27

28. Screening US
LPA
CA125
Other tumor
marker
Studies on CA72-4,macrophage –colony stimulating factor (MCSF)Osbepontin
,inhibin and Kallikrein are going to evalute combination of tumor marker
complemantary to CA 125 that could offer greater sensitivity and specificity than
CA125 alone .

29. Benefit VS Harm
In one study of women at high risk of ovarian cancer, researchers
discovered that use of screening tests led to 20 operations on
Women only one of whom was found to have cancer — metastatic
breast cancer, not ovarian cancer.
The preliminary results from the Prostate, Lung, Colorectal and
Ovarian (PLCO) Cancer Screening Trial, appears in the November
15, American Journal of Obstetrics and Gynecology , Women
who had an abnormal test result in one or both screening tests
underwent a variety of diagnostic procedures to determine whether
cancer was present, including 570 women who underwent a
surgical procedure as follow-up. Thus, 541 women underwent
surgery but did not have cancer.
CD4

30. Point to remember
Screening for ovarian cancer is expensive because of low prevalence of disease, high rate of surgical intervention for noncancerous disease, and high costs of tests and follow-up.
Many experts suggest that the possible benefits of lowered mortality or years of life saved do not justify the costs of screening.
The low positive predictive value associated with currently available screening modalities suggests that more women without cancer will be subject to laparoscopy or laparotomy than will those with cancer.
Modeling studies of annual screening with CA 125, with or without a single screening with transvaginal ultrasound, found an increase in life expectancy of less than one day per woman screened .
No definitive large randomized controlled trials have been completed to show whether any screening strategy decreases mortality from ovarian cancer

31. Screening recommendation
No organization currently recommends either ultrasound or cancer marker screening in asymptomatic women, and multiple organizations (including the American College of Physicians, the Canadian Task Force on the Periodic Health Examination, and the American College of Obstetricians and Gynecologists) recommend against it.
Regarding women at higher risk (e.g., hereditary cancer syndromes), the NIH consensus conference recommends annual CA 125 measurements, pelvic exam, and transvaginal ultrasound until childbearing is completed; at age 35, women should be referred for bilateral oophorectomy.

32. Investigation
Lab Studies
If ovarian cancer due to a pelvic or ovarian mass is suggested, minimize preoperative testing needed and staging laparotomy indicated .
Routine preoperative tests include CBC count, chemistry panel (including liver function tests), and a cancer antigen 125 assay (CA-125).

33. Investigation
Imaging Studies
Routine imaging is not required in all patients in whom ovarian cancer is highly suggested.
If diagnostic uncertainty is present, a pelvic ultrasound or CT scan of the abdomen and pelvis is warranted.

34. Investigation
Other Tests
In patients with diffuse carcinomatosis and GI symptoms, a GI tract workup may be indicated, including:
Upper and/or lower endoscopy
Barium enema
Upper GI series
Procedures
Biopsy
A fine-needle aspiration (FNA) or percutaneous biopsy of an adnexal mass is not routinely recommended. In most cases, taking this approach instead of performing a surgical staging laparotomy may only serve to delay appropriate diagnosis and treatment of ovarian cancer.
If a clinical suggestion of ovarian cancer is present, the patient should undergo a diagnostic and surgical procedure.
An FNA or diagnostic paracentesis should be performed in patients with diffuse carcinomatosis or ascites without an obvious ovarian mass.

35. staging
Ovarian cancer is staged using the International Federation of Gynecology and Obstetrics (FIGO) :
Stage I - Growth limited to the ovaries
Stage Ia - Growth limited to 1 ovary, no ascites, no tumor on external surface, capsule intact
Stage Ib - Growth limited to both ovaries, no ascites, no tumor on external surface, capsule intact
Stage Ic - Tumor either stage Ia or Ib but with tumor on surface of one or both ovaries, ruptured capsule, ascites with malignant cells or positive peritoneal washings
Stage II - Growth involving one or both ovaries, with pelvic extension
Stage IIa - Extension and/or metastases to the uterus or tubes
Stage IIb - Extension to other pelvic tissues
Stage IIc - Stage IIa or IIb but with tumor on surface of one or both ovaries, ruptured capsule, ascites with malignant cells or positive peritoneal washings
Stage III - Tumor involving one or both ovaries, with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes; superficial liver metastases equal stage III
Stage IIIa - Tumor grossly limited to pelvis, negative lymph nodes but histological proof of microscopic disease on abdominal peritoneal surfaces
Stage IIIb - Confirmed implants outside of pelvis in the abdominal peritoneal surface; no implant exceeds 2 cm in diameter and lymph nodes are negative
Stage IIIc - Abdominal implants larger than 2 cm in diameter and/or positive lymph nodes
Stage IV - Distant metastases; pleural effusion must have a positive cytology to be classified as stage IV; parenchymal liver metastases equals stage IV

36. except those patients with stage 1 and low risk characteristics
The standard treatment for ovarian cancer start with staging and cytoreductive surgery
For post operative treatment , chemotherapy is indicated in all patients with ovarian cancer
except those patients with stage 1 and low risk characteristics
Treatment

37. The 5-year survival rates are as follows:
Prognosis
The 5-year survival rates are as follows:
Stage I - 73%
Stage II - 45%
Stage III - 21%
Stage IV - Less than 5%

38. Prevention 1 OCP 2 Screening 3 4 5 Tubal ligation and hystrectomy
Women who use ocp for three years or more reduce their risk of ovarian cancer by 30%-50% 1
OCP 2
Screening 3
Bilateral salpingo
Oophrectomy
For each year that women take ocp ,her risk of ovarian cancer is reduced by about 5% on average 4
Pregnancy and
Breast feeding 5
Tubal ligation
and hystrectomy

39. Prevention 1 OCP 2 Screening 3 4 5 Tubal ligation and hystrectomy
Average women who used ocp for more than one year ,the protective effect lasted 2-3 decades after cessation of use 1
OCP 2
Screening 3
Bilateral salpingo
Oophrectomy
One analysis estimated that after 5 years of ocp ,nulliparous womwn can reduce their risk to the level seen in parous women who never used ocp 4
Pregnancy and
Breast feeding 5
Tubal ligation
and hystrectomy

40. Prevention 1 OCP 2 Screening 3 4 5 Tubal ligation and hystrectomy
Another study show that 10 years of ocp use by women with positive family history can reduce their risk to a level below that for women with no family history who never used ocp 1
OCP 2
Screening 3
Bilateral salpingo
Oophrectomy 4
Pregnancy and
Breast feeding 5
Tubal ligation
and hystrectomy

41. 1
OCP
The periodic use of trasvaginal ultrasonography and CA125 tumor marker is recommended in high risk women 2
Screening 3
Bilateral salpino
Oophrectomy 4
Pregnancy and
breast feeding 5
Tubal ligation
and hystrectomy

42. 1 2 3 4 5 Pregnancy and breast feeding OCP Surgical prophylaxis
decrease the risk by at
Least 90% but dose not
Completely eliminate the
risk WHY?
Because ovarian cancer
can be develop in the thin
lining of the abdominal
cavity that cover the
ovaries . women who have
had their ovaries removed
can still get a similar but
less common form of
cancer called primary
Peritoneal cancer
OCP 2
Screening 3
Bilateral salpigo
Oophrectomy 4
Pregnancy and
breast feeding 5
Tubal ligation
and hystrectomy

43. 1 2 3 4 5 Pregnancy and breast feeding OCP Who is prophylaxis
Oophrectomy recommended
For?
Patients with inherited
mutation in the BRCA
gene ,older than 35 year
who have completed their
families are the best
Candidates
Patients with family
history of breast or
ovarian cancer but no
known genetic mutation 2
Screening 3
Bilateral salpigo
Oophrectomy 4
Pregnancy and
breast feeding 5
Tubal ligation
and hystrectomy

44. Having at least one child lower the1
OCP
Having at least one child lower the
Risk of developing
Ovarian cancer
Breast feeding for
a year or longer
Also reduce the risk
of ovarian cancer 2
Screening 3
Bilateral salpingo
Oophrectomy 4
Pregnancy and
Breast feeding 5
Tubal ligation
And hystrectomy

45. The nurses health study which followed 1000
OCP
The nurses health study which followed 1000
Women for 20 years found asubstatial reduction in ovarian cancer risk in women who had tubal ligation and hystrectomy but it was more with the tubal ligation 2
Screening 3
Bilateral salpingo
Oophrectomy 4
Pregnancy and
Breast feeding 5
Tubal ligation
And hystrectomy

46. The suggested mechanism of protection:1
OCP
The suggested mechanism of protection:
By prevention of possible upward migration of carcinogens through the vagina, the cervix and fallopian tube into the peritoneal cavity 2
Screening 3
Bilateral salpingo
Oophrectomy 4
Pregnancy and
Breast feeding 5
Tubal ligation
And hystrectomy

47. Take a home message

48. Ovarian cancer is the most common lethal gynecological malignancy and it represent the fifth cancer death in women in general
It has many risk factor ,the most important one is the hereditary predisposition .
No organization currently recommend the screening in asymptomatic women

49. Thank you