Work up of a Pelvic Mass

Transcription

1 Work up of a Pelvic Mass Considerations from the north where primary care and CON clinic / GPO work interface Dr. Shannon Douglas, GPO Vanderhoof with support by Dr Margaret Smith and Dr. Ursula Lee Nov 17, 2017

2 Disclosures Dr.Ursula Lee In compliance with accreditation, we require the following disclosures to the session audience: Research Support/P.I. Employee Consultant Major Stockholder Speakers Bureau Honoraria Scientific Advisory Board N/A N/A N/A N/A N/A LEO, Ipsen, Novartis, N/A Presentation includes discussion of the following off- label use of a drug or medical device: N/A

3 Dislosures for S. Douglas No conflict of interest or financial disclosures

4 Mrs. Debbie Savory* Age 72 Farmer from 30 km out of a very small town in northern BC Cattle, chickens, horses, donkeys and one very big pig Raised all her children on the farm and active in the community Lived with her elderly husband Daughter and son-in-law live at the bottom of the hill

5 The Story G6T3, 3 late miscarriages Hx of bladder sling procedure years ago and recurrent UTI Stress incontinence Urge incontinence On assortment of medications typical PRESENTING COMPLAINT: Med renewals Request for revision of sling procedure as feeling of prolapse, worsening stress incontinence for 3 months

6 Symptoms of Ovarian Cancer Often minimal in early stage. More common to present at later stage Presentations can be quite non-specific. Can include: Abdominal pain Bloating Ascites Shortness of breath Early satiety Pain Weight loss Nausea and / or vomiting Pelvic pressure and symptoms

7 Clinical Findings on examination Looked well and in no distress No abnormal lymph nodes, chest clear, heart sounds regular and normal with no SOA and no signs of DVT Lower abdominal mass, non-tender Felt like a week gestation Pelvic exam showed no real prolapse, small cystocele, normal vulva Couldn t really feel the mass in the pelvis but I could feel something pushing into the vagina with pushing down on the abdominal mass

8 What is our most likely diagnosis? Seemed like something bad DDX uterine enlargement benign or malignant Ovarian origin benign or malignant Colon Bladder or kidney Lymphoid Unlikely vascular Unlikely MSK What else would you have on your list? What do we do next?

9 What are considerations in your environment? Travel? Financial? Personal preference? Parking? Availability? Language? Cultural considerations? Other?

10 Imaging US showed 24 cm mass, mixed solid cystic, presumed ovarian origin Received phone call from radiologist to inform I phoned patient who was still traveling and we set up a CT scan for the following week CT scan confirmed a suspicious mass, 19 cm. Presumed ovarian mass. Presumed malignant. No evidence of metastasis. What next?

11 Ovarian Cancer 1/80 Lifetime risk for women, or 17.1/ women 90% epithelial, 70% of these are HGSC 5 th most common cancer in BC women 35% 5 year survival Stable incidence over last 30 years

12 Classification of Ovarian Cancer Epithelial (90%) Serous Tumors Mucinous Tumours, endocervical-like and intestinal-type Endometrioid tumours Transitional cell tumours Squamous Cell tumours Mixed epithelial Tumors (specify Types) Undifferentiated Carcinoma Non epithelial (10%) Germ Cell tumors Granulosa Cell tumours Sertoli-Leydig cell tumors others

13 How do we modify risk for ovarian cancer? SOGC completed a review and published new guidelines in 2017 For us in primary care: - No negative impact with hormonal treatment, before or after ovarian cancer diagnosis - No negative impact recognized with fertility treatment, though parity and nulliparity may impact risk June 2017 CMA published abstract from guidelines and links to complete review

14 SOGC 2017 Summary HGSC (high grade serous cancer) account for 70% of the epithelial cancers Fallopian tube cancers are HGSC 90% of the time. They have identified precursor STIC lesions (serous tubal intraepithelial carcinomas) Prophylactic BSO reduced high grade epithelial carcinomas by 80 90% in high risk breast cancer mutation carrying women

15 SOGC 2017 Summary Clear cell and endometrioid cancers are felt to originate in the endometrium and deposit outside the uterus Tubal ligation decreases the risk of clear cell and endometrioid cancers by about 50%. HGSC decreased by only 19% with tubal ligation OCP taken for 10 years confers a 50% reduction in ovarian cancer risk Premenopausal BSO decreases risk of ovarian cancer by 94%, but overall mortality increased by 12% felt to be due to cardiovascular risk

16 Back to Mrs. Savory Where should she go? Closest gyne is in Prince George 2 hr by road. Closest gyne-onc is Vancouver Now it s Christmas approaching, Vancouver will be at least a month away before opinion. Advice any different? Any value in biopsy, open or core? Any lab work that would be helpful? Any additional imaging to facilitate staging or treatment decision making?

17 Terrible 6 weeks We watched the tumor grow, appetite decrease, anxiety increase, nausea started, worsening urinary symptoms Surgery completed in late January First presentation just before Halloween Anything we could have done differently? Anything you would do differently? What is the relative value of gyne-onc vs. regular gyne vs. general surgeon in a case like this? Staging incomplete? Symptoms worsening?

18 Surgical Considerations in Ovarian Cancer Management Clinical judgement plays a large role Laparoscopic vs open technique may be considered with caution Goal is intact surgical removal or optimal debulking If optimal debulking felt to be unlikely, surgery may be delayed until after systemic therapy to permit more complete debulking Optimal debulking is to less than 1 cm of residual disease Consideration for placement of an IP port for IP chemotherapy - Stage III epithelial ovarian Cancer - Less than 1 cm residual disease post primary or delayed debulking - Fit for therapy, lack of contraindications

19 Pathology / Staging for Mrs. Savory Pathology mucinous adenocarcinoma of the ovary, grade 3, +LVI, adherent to pelvic side wall on left and ruptured with removal Positive peritoneal washes Lymph nodes negative Markers: Her2-, ER-, CK7+, CDX-, CK20 Omentum negative and no visual evidence of spread Stage 1c

20 Staging of Ovarian Cancer Stage I Growth limited to the ovaries Stage II Growth involving one or both ovaries with pelvic extension Stage III Tumor involving one or both ovaries with peritoneal implants outside the pelvis and / or positive retroperitoneal or inguinal nodes; superficial liver metastasis equals stage III Stage IV Growth involving one or both ovaries with distant metastasis; if pleural effusion is present, there must be positive cytology for Stage IV; parenchymal liver metastases equals stage IV

21 What should we look for on pathology? Type of cancer mucinous adenocarcinoma is fairly chemo-resistant STIC lesions serous tubal intraepithelial carcinomas often associated with BRCA mutations Grade Any value in biomarkers? What do you look for when reading the surgical report? What else do you look for on the pathology report?

22 Back to our patient CA pre op CA month post op CA year post op No further treatment recommended based on pathology with limited evidence of benefit Its now been 3 years and she has been symptoms free Reviewed every 3-4 months, shared care between gynecologist and myself

23 What does the future hold? My hopes from the north as a GPO and family doc 1. Increased use of telehealth / video-links to facilitate opinions 2. Enhance shared decision making between patient, family physician or GPO, local gyne / surgeon and gyne-oncologist Is this being done already? Yes to an extent. Certainly after diagnosis and surgery at the time of disposition / systemic therapy decisions. However, we could decrease the need for travel and help guide decision making prior to definitive therapy as well. BC has a diversity of people and challenges and optimal care may not look the same in every location