Gynecology
[OVARIAN CANCER ]
Introduction Ovarian cancer is the leading cause of reproductive-aged cancer death. This is because there’s no good screening tool for ovarian cancer; it often presents as Stage III or worse when trying to screen. Because it’s in the pelvi s there are no structures to bump against and plenty of room to grow before becoming symptomatic. However, it isn’t as simple as “ovarian cancer;” there are many subtypes. You need to be able to visualize the cross-section of an ovary, know which tumors come from which type of cell, and recognize the presentation of each. Epithelial Ovarian Cancer When we talk about the highest mortality and late presentation, what we really mean is epithelial ovarian cancer. With repeated trauma of ovulation comes inflammation. Inflammation leads to cancer. The more ovulations, the higher the risk. Therefore, it’s not surprising this shows up in an older ( post-menopausal ) patient. Likewise, states that increase ovulations (low parity, delayed child bearing, early menarche) increase risk. Other risk is genetic (HNPCC, BRCA1 > BRCA2), while having children and 5 year OCP is protective. Epithelial cancer spreads by peritoneal seeding and remains asymptomatic until it’s too late, presenting with renal failure, small bowel obstruction, and ascites . A workup begins with pelvic ultrasound and an MRI or CT scan confirms diagnosis and stages the cancer. Ca-125 levels should NOT be used for diagnosis, but can be used to track recurrence. Since it’s often Stage III or worse, the only option is debulking surgery (TAH+BSO) followed by chemo with a platinum-based drug such as paclitaxel and carboplatin . For
Germ Cell - Dysgerminoma – LDH, Chemo - Endodermal Sinus – AFP - Choriocarcinoma – B-HCG - Teratoma – Ø…or Struma Ovarii
Stromal Tumors - Sertoli-Leydig ! Testosterone - Granulosa-Theca ! Estrogen
Epithelial - Serous Cystadenocarcinoma - Mucinous Cystadenocarcinoma - Endometroid Cystadenocarcinoma - Brenner tumor
Presents in Stage III Post-menopausal CA-125 Transvaginal Ultrasound TAH+BSO ! Paclitaxel
Adnexal Mass
women at super-high super-high risk (BRCA1 ) screening screening can be done with annual Ca-125 and transvaginal ultrasound. After she’s done having kids a prophylactic BSO @ 35 will prevent the need for screening. Screening the general population doesn’t work since it detects cancer at Stage III or later. Germ Cell Cancer Unlike the malignant epithelial cancer that occurs in postmenopausal women, germ cell tumors occur in teenage reproductive girls and are often benign. These tumors usually get big before they get dangerous and are often found at Stage I. A mass may be palpated then confirmed on transvaginal ultrasound . Just as in testicular cancer, there are multiple types, with each followed by a given tumor marker. In girls a teratoma is usually benign and the chemoreceptive cancer is Dysgerminoma . Because they’re usually benign, Stage I, and present in a young girl, treatment is conservative (unilateral oophorectomy ) because we want her to grow and have kids! If there’s no need for fertility-sparing treatment, radical resection is preferred (TAH+BSO).
Presents in Stage I Pre-menopausal Markers as to the left Unilateral Oophorectomy Chemo
Transvaginal Ultrasound Smooth Balloon Small
Cystic Multiple Echoes Large
Simple Cyst
Complex Cyst
Conservative Age, Biopsy S m toms
Germ Cell Unilateral Oophorectomy
Epithelial Cell Aggressive TVH + BSO Paclitaxel
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