OVARIAN CARCINOMA Immune Therapy Antibodies to CA-125 (Ovarex) Vaccine therapy
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
Questions??
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
Ovarian Carcinoma Low Risk Premenopausal Unilateral, unilocular, cystic ovary. No family history of ovarian cancer. CA-125 <35 U/ML
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 (%) + 25 + 35 + + 51 + + 71 Frank et al, J Clin Onc 16:2417-2425, 1998
Ovarian Ca Age 85 MI Ca?Stomach Throat Ca Throat Ca Breast Ca Age 42 Bilat. Breast & Ovarian Ca MI Throat Ca SAB 1950 1951 Ovarian Ca 1954 Ovarian Ca 1961 Breast Ca 1964 D.H. 49 yo G0P0
Hemorrhagic corpus luteum
Multiseptated cyst
Ovarian cancer
Ovarian Carcinoma Intermediate Risk Who Knows??
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
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
OVARIAN CANCER HISTOLOGY OVARY EPITHELIAL GERM CELLS STROMA
OVARIAN CANCER HISTOLOGY (W.H.O.) SEROUS MUCINOUS ENDOMETRIOD CLEAR CELL TRANSITIONAL CELL MIXED EPITHELIAL UNDIFFERENTIATED UNCLASSIFIED
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
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
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
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
Can any imaging technique discern malignancy?
Solid & cystic mass in an elderly patient with ascites & pleural effusion- Is it malignant??
Sometimes the diagnosis is obvious
First operation for ovarian cancer apparent stage I disease Obligatory search for occult pelvic metastasis
First Operation for ovarian cancer Obligatory search for occult abdominal metastasis Apparent stage I disease
Ovarian cancer is primarily a peritoneal disease Technique of peritoneal biopsy
Surgical technique for Ovarian Cancer Access to aortic nodes
Surgical technique for ovarian cancer Access to aortic nodes
Surgical technique for ovarian cancer Access to aortic nodes
Surgical technique for ovarian cancer Diaphragmatic biopsy
Ovarian cancer surgery technical features Exploit peritoneal surface spread pattern
Ovarian cancer surgery technical features Peritoneum over the paravesicle space is mobile
Ovarian cancer surgery technical features Reflect the ureter off the peritoneum laterally
Ovarian cancer surgery Retroperitoneal approach Posterior Cul-de-sac tumor Cervix Anterior Cul-de-sac Peritoneal tumor
Ovarian cancer surgery technical features Psoas Psoas tendon Ureter Sciatic roots Ext art Ext vein Hypogas Obt nrv
Ovarian cancer surgery extended resection Terminal ileum Transmural metastasis
Ovarian cancer surgery extended resection spleen omentum lienocolic ligament