Endo and Ovarian CA

7/28/2019 Endo and Ovarian CA

1/69


2/69

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


3/69

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


4/69

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


5/69

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


6/69

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%


7/69

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


8/69

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


9/69

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


10/69

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


11/69

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


12/69

Endometrial CancerEndometrial CancerDiagnosisDiagnosisBiopsyBiopsy

Inpatient (operative) dilation and curettageInpatient (operative) dilation and curettage(fractional)(fractional)

Outpatient endometrial biopsyOutpatient endometrial biopsy

PipellePipelle

VabraVabra, Novak, Novak


13/69

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


14/69

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


15/69


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


16/69

Endometrial CancerEndometrial CancerDiagnosisDiagnosis TransvaginalTransvaginal UltrasoundUltrasound

MetaanalysisMetaanalysis TVUS & office biopsyTVUS & office biopsy

Endometrial thicknessEndometrial thickness


17/69

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


18/69


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


19/69


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


20/69

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)


21/69

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


22/69

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)


23/69

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


24/69

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


25/69

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


26/69

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


27/69

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????


28/69


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


29/69


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)


30/69

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


31/69

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


32/69

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)


33/69

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)


34/69

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


35/69

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


36/69

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


37/69

Endometrial CancerEndometrial CancerTreatmentTreatment Stage IVStage IV

Survival, 5 yearSurvival, 5 year 55 -- 10%10%

Treatment:Treatment:

Hormonal therapyHormonal therapy

ChemotherapyChemotherapy

Local radiationLocal radiation


38/69

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


39/69

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


40/69

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


41/69

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


42/69

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)


43/69

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


44/69

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


45/69

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


46/69

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


47/69

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


48/69

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%


49/69

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


50/69

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


51/69

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


52/69

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


53/69

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



54/69


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



55/69


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



56/69


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



57/69


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


58/69

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


59/69

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



60/69


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


61/69

//

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


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


62/69

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


63/69


Predictive ValuePredictive Value----PrePremenopausalmenopausal

Criteria PPV (%) NPV (%)

CA125 70 85

Ascites 58 89

Mets 64 89

Family Hx 19 82

Overall 34 92



64/69


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



65/69


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


66/69

Modified Referral GuidelinesModified Referral Guidelines

PremenopausalPremenopausal ( 50 U/ ml

ascitesascites


Postmenopausal (>50)Postmenopausal (>50)

CA125 > 35 U/ mlCA125 > 35 U/ ml

ascitesascites





67/69


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%


68/69

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


69/69

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)

Endo and Ovarian CA

Documents

Transcript of Endo and Ovarian CA