Post on 26-Dec-2015
Clinico-pathological conference:Gynae Oncology
Friday Dec 7th 2007
Alex Laios,
Orla Sheils,
John O’Leary
HISTORY
• 43 yr old, Irish lady, married, P0+0
• Consulted GP with a 3/12 Hx of:– Abdominal distention (increasing abdominal girth)– Intermittent abdominal pain, progressively worsening
(like tightness across the abdomen)– Loss of appetite– Weight loss associated with lower abdominal
discomfort of ~3/52 duration– 1 recent episode of SOB and dry cough– No change in urinary or bowel habits
Questions
• What are the possible causes of increasing abdominal girth?
• What is the possible cause of weight loss in this woman?
• Why does this woman have shortness of breath and dry cough?
Questions
• What is the next step in managing this patient?
• What investigations would be ordered in this case?
Ultrasound examination of the abdomen-pelvis [ordered by GP]
• Massive ascites • 9 cm large complex cystic mass probably arising
from the pelvis, with multiple septations• Left ovary could not be visualized• Left hydronephrosis
Referral to gynae oncology service
Physical examination • Thin lady, previously healthy• No lymphadenopathy• Breast examination was normal• Lung fields clear on auscultation• Abdominal distention to 28 weeks size by a mass of poor
mobility arising from pelvis and upper abdominal fullness, suggesting omental disease
• Clinical ascites• Distended pouch of Douglas with thickening on recto-
vaginal examination
Medical and Gynaecologic History
Medical Hx:– HTN, Ulcerative colitis (previously on long term steroids but no
evidence of DEXA osteopenia)– Medications: Centyl, Lipitor– Allergies: Penicillin
Surgical Hx: Arthroscopy, cholecystectomy Family Hx: Bowel Ca (father), breast Ca (mother)Gynae Hx:
– Menarche at age 12y– Regular cycles, no dysmennorhea, LMP 2/52 ago– Last Cx smear 3 years ago– Never on OCP
Laboratory investigations
On admission• FBC profile: Hb:13, WCC:9.8, PLTS:560• Renal profile: urea:10.3, sodium:140, potassium:3.6,
creatinine:93 (marginally elevated)• Liver profile: Albumin: 25 , LDH:385• CA125: 534• CA19.9: 3.9
Questions
• What is your provisional diagnosis?
• Can you identify any risk factors from her medical history?
• What is your interpretation of her blood results?– Albumin– urea, creatinine– Hb, plts
Radiology investigations
• CXR: – Lung fields appear clear– No cardiomegaly – No pleural effusion
• CT TAP (chest abdomen pelvis) – 11 X 12.5cm complex pelvic mass arising from the left ovary– Massive ascites– Omental cake– No evidence of retroperitoneal lymphadenopathy– Left hydronephrosis– Splenic hilar and peritoneal nodes
• 3-D colour Doppler• FDG-PET
Laparotomy:Optimal debulking
Findings on laparotomy
TAH, BSO,Omentectomy, Appendicectomy• Gross disease above pelvic brim• 4 litres of ascites was removed• Left ovary replaced by solid-cystic tumour at least 13 cm,
densely adherent to the left pelvic sidewall/peritoneum/POD• Tumour deposits on splenic hilum, small deposits in
subdiaphragmatic and liver capsule (less than 0.5cm)• Omental deposits
Pathological diagnosis
• Papillary serous cystadenocarcinoma of the left ovary– TNM stage pT3, N1, Mx– FIGO stage IIIC
HISTORY
• Uneventful recovery• Histology available at day 9• Referred to medical oncologists for adjuvant
chemotherapy• Discharged on day 13• Returned 6 weeks after surgery for initiation of
chemotherapy
HISTORY
• Chemotherapy completed 3 months later• Remained well and returned for combined
follow-up with Gynae-Oncologists and Medical Oncologists– Question: what is entailed in the medical follow-up?
HISTORY
• Routine follow-up [3 months] for the first 2 years, then every 6 months for the next 2 years, then annually.
• 14 months after the original surgery she complains of:– Tiredness– Intermittent low abdominal pain– Vaginal bleeding
Questions
• Why does this patient have a vaginal bleeding?
• What is the cause of the intermittent abdominal pain?
HISTORY
• On clinical examination, two nodules are identified close to the vaginal vault
• Raising CA125• CT of thorax, abdomen and pelvis performed
– Two small soft tissue masses suspicious for disease recurrence seen at the vaginal vault
• Biopsy performed of vaginal lesions
Relapse
• Will the patient benefit from the same chemotherapy?
• Will she benefit from excision of the nodules?
Recurrence in ovarian cancer
• 70% of ovarian cancer patients present with advanced ovarian cancer [stage III/IV]
• 50%-70% of patients relapse
• Less than 20% long-term survivors
• Gene pathways for ovarian cancer recurrence have just been defined
“The true Killer”RECURRENCE
Our opportunity for intervention
CLINICAL DISEASE
CLINICAL DISEASE
NORMAL OVARY
PRE- MALIGNANT
CHANGE
PRE- CLINICAL DISEASE
Family history
CHEMO- PREVENTION
PROPHYLACTIC OOPHORECTOMY
SCREENING
TREATMENT
Environment
Ovulation
Module network procedure
Pre- processing
Image trait selection
Disease traits
Gene expression data
Image traits
Expression data
Clustering
Gene partition
Functional modules
Annotation analysis
Graphic presentation
Independent Validation
Classification program learning
Post- processing
Genes
Life sciences
Information sciences
Life and Information sciences
Pathological data
Proteomic data
MRI3-D colour doppler CT FDG-PET