OVARIAN CARCINOMA Immune Therapy. Antibodies to CA-125 (Ovarex) Vaccine therapy

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1 OVARIAN CARCINOMA Immune Therapy Antibodies to CA-125 (Ovarex) Vaccine therapy

2 OVARIAN CARCINOMA Targeted Therapy Bevacizumab (Avastin): GOG- 218 Anti-VEGF, angiogenesis inhibitor TLK 286 (Telcyta): Glutathione s-transferase binding. Reduces chemo resistance and initiates apoptosis. Trabectedin, ET743 (Yondelis) Sea Squirt Inhibits DNA repair and initiates apoptosis

3 Questions??

4 Objectives To identify the patient at risk for developing ovarian cancer Evaluation of the patient with a pelvic mass To review current surgical and post-op therapy of ovarian cancer

5 Ovarian Carcinoma Low Risk Premenopausal Unilateral, unilocular, cystic ovary. No family history of ovarian cancer. CA-125 <35 U/ML

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9 Probability of BRCA1 or BRCA2 Mutation in a Woman w/breast Ca <50 Any relative with Br Ca,<50? Any relative with ovarian cancer? Proband w/bilateral Br or Ov Ca? Probability (%) Frank et al, J Clin Onc 16: , 1998

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11 Ovarian Ca Age 85 MI Ca?Stomach Throat Ca Throat Ca Breast Ca Age 42 Bilat. Breast & Ovarian Ca MI Throat Ca SAB Ovarian Ca 1954 Ovarian Ca 1961 Breast Ca 1964 D.H. 49 yo G0P0

12 Hemorrhagic corpus luteum

13 Multiseptated cyst

14 Ovarian cancer

15 Ovarian Carcinoma Intermediate Risk Who Knows??

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19 Ovarian Cancer Treatment Options Staging is surgical TAH/BSO, Tumor reduction Post-operative chemotherapy Pre-operative chemotherapy in selected cases Conservative surgery for germ cell tumors

20 Ovarian Cancer / Pelvic Mass Pre-treatment Evaluation Physical exam Cytological evaluation of pleural effusion if present Abd./Pelvic sono to characterize mass if no ascites present CT scan if ascites present

21 OVARIAN CANCER HISTOLOGY OVARY EPITHELIAL GERM CELLS STROMA

22 OVARIAN CANCER HISTOLOGY (W.H.O.) SEROUS MUCINOUS ENDOMETRIOD CLEAR CELL TRANSITIONAL CELL MIXED EPITHELIAL UNDIFFERENTIATED UNCLASSIFIED

23 OVARIAN CARCINOMA SCREENING TVS SONOGRAPHY 3220 ASYMPTOMATIC, POST- MENOPAUSAL WOMEN 44/3220 (1.4%) OVARIAN MASSES 44 EXPLORATORY LAPAROTOMY 3/44 CARCINOMA STAGE IA GRANULOSA CELL STAGE IA Gr III ADENO CA. STAGE IIIB Gr III ADENO CA. DePRIEST et al, GYN ONC, 1993

24 OVARIAN CANCER SCREENING 597 WOMEN SCREENED IN 12 MONTHS 449 PREMENOPAUSAL 148 POSTMENOPAUSAL ELIGIBILITY AGE > 35 YEARS FIRST DEGREE RELATIVE WITH BREAST CANCER COLON CANCER OVARIAN CANCER, OR OTHER GYN MALIG. SECOND DEGREE RELATIVE WITH OVARIAN CA KARLAN et al, Am J Obstet Gynecol, 1993 #1

25 OVARIAN CANCER SCREENING ASYMPTOMATIC WOMEN, (+) FAMILY HX METHOD OF SCREENING TVS FOR MORPHOLOGY PULSATILE INDEX RESISTANCE INDEX TUMOR MARKERS CA-125 LIPID-ASSOCIATED SIALIC ACID DM/7OK HER-2neu URINARY GONADOPROTEIN (UGP) GENETIC HISTORY & COUNSELLING IDENTIFIED 1 PT STAGE IA OVARIAN LMP TUMOR 1 PT STAGE IB Gr II ENDOMETRIAL CA 1/597 KARLAN et al, Am J Obstet Gynecol, 1993 #2

26 Ovarian Cancer / Pelvic Mass Pre-treatment Evaluation CBC, Comprehensive metabolic panel CA-125 CXR / EKG Nutritional and pulmonary evaluation Pre-op bowel preparation Surgical staging

27 Can any imaging technique discern malignancy?

28 Solid & cystic mass in an elderly patient with ascites & pleural effusion- Is it malignant??

29 Sometimes the diagnosis is obvious

30 First operation for ovarian cancer apparent stage I disease Obligatory search for occult pelvic metastasis

31 First Operation for ovarian cancer Obligatory search for occult abdominal metastasis Apparent stage I disease

32 Ovarian cancer is primarily a peritoneal disease Technique of peritoneal biopsy

33 Surgical technique for Ovarian Cancer Access to aortic nodes

34 Surgical technique for ovarian cancer Access to aortic nodes

35 Surgical technique for ovarian cancer Access to aortic nodes

36 Surgical technique for ovarian cancer Diaphragmatic biopsy

37 Ovarian cancer surgery technical features Exploit peritoneal surface spread pattern

38 Ovarian cancer surgery technical features Peritoneum over the paravesicle space is mobile

39 Ovarian cancer surgery technical features Reflect the ureter off the peritoneum laterally

40 Ovarian cancer surgery Retroperitoneal approach Posterior Cul-de-sac tumor Cervix Anterior Cul-de-sac Peritoneal tumor

41 Ovarian cancer surgery technical features Psoas Psoas tendon Ureter Sciatic roots Ext art Ext vein Hypogas Obt nrv

42 Ovarian cancer surgery extended resection Terminal ileum Transmural metastasis

43 Ovarian cancer surgery extended resection spleen omentum lienocolic ligament