Early Detection Ovarian Cancer.gps2010 Dr Yudi

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EARLY DETECTION INOVARIAN CANCER

Yudi Mulyana Hidayat

DEPT OF OBSTETRIC AND GYNECOLOGY

PADJADJARAN UNIVERSITY BANDUNG



objectives

The fisiology of

ovarium

Statistic and fact

of ovarian cancer

Symtoms and

risk factor of

ovarian cancer

Screening

ovarian cancer is

still necessary?

Methode of

screening

ovarian cancer

summary



Ovarian Physiology

The ovary has two mainfunctions:

1-Reproductive function:

produce gametes.

2-Endocrinal and metabolic function: produce hormones.



Ovarian Physiology

The ovary is a complex metabolic organ

consisting of follicular and stromal

compartments.

1-Follicles: produce both androgens

and estrogen.2-Stromal tissue: synthesizes

androgens.



Statistics The average age when ovarian cancer is

detected in women is 56.3 years.

Less than 1 out of 10 of the woman said had nosymptoms prior to diagnosis.

More than 25% of the women sought help from amental health professional.This suggested thatwomens concerns were not being fully

addressed and symptoms may have beenmistakenly attributed to stress or depression.

About 1 in every 70 women will develop ovarian

cancer in their lifetime.







Symptoms

Abnormal vaginalbleeding and discharge

Fatigue and fever

Abdominal swellingand bloating

Infertility or changes in

menstruations

Gas

Nausea

Bowel disturbance Pelvic pain

Not all symptoms can be caused by cancer.Often there are no symptoms in the early stages and

the cancer has spread by the time it is found out.



Risk factors

Family medical history- increased if closerelatives has it.

Use of infertility drugs

Not having children

Age- women over 50 are at risk and the riskincreases with age

Personal medical history- women with breastcancer are twice as like to get ovarian cancer



Table : Score for Womens

History

History Score

Family history of ovarian carcinoma 2

Past or family history of genital, breast or

colon

1

Negative history of oral contraceptive 1

Nulligravida 1





02/24/2003Epidemiology of ovarian c ance r 12

97.3

73.465.4

41.6

0 50 100 150

% survival

Ovary

Cervixc.uterus

Trophob

5 years survival rate of

gynecological cancer (FIGO, 1998)



02/24/2003Epidemiology of ovarian cance r 13

72.8 %

46.30%

17.2 %

4.8 %

1

Stad I

Stad II

Stad III

Stad IV

Survival 5 tahun kanker

ovarium,FIGO,1998



Tumor mark er

Ca 125 ( Carcinoma antigen )

Ca 72-4LAI ( Leucocyt e Adher enc e

inhi bition t est )

Transvaginal Ultrasound ind eks morfologik

Transvaginal Color D oppl er ( C D T )color flow doppl er

Cancer Ovarium Screening Strategies



Ultrasound

Both transabdominal and transvaginaltechniques identify enlarged ovaries or abnormalmorphology;TVUS has better resolution

One large study of TVUS underway has reportedsensivity of 81% and specificity of 98.9%

Major limitations are poor PPV in asymptomaticwomen and inability to detect malignances when

ovaries are normal size Allows earlier stage detection



Figure : (a) At US, ovarian mass shows fine, particulate, evenlydistributed echoes, consistent with an endometrioma.(b) Repeat scan of ovarian mass shows resolution of

particulate appearances, consistent with organization of anendometrioma.



Color-flow Doppler

Used in conjunction with TVUS

Measures resistance in blood vessels

supplying the ovaries May provide additional information to help

distinguish malignant from benign masses



Figure: ( a ) Color flow image of right adn ex a obtain ed with endovaginal t echn iqueshows a compl ex right adn ex al mass with contain ed, apparently sol id el ements .Not e that through t ransmiss ion is good, and the cont ents of this mass arecompl et ely avasc ular. Thes e appearanc es are cons ist ent with an endomet rioma.

(b) Color flow US scan of l eft adn ex a obtain ed with endovaginal t echn ique. Thereis a p art ially cyst ic and part ially sol id mass in the l eft adn ex a. Despit e good through t ransmiss ion in the cyst ic part of this mass, there is vasc ularizat ion in thesol id



Figure : US s can of cystic and solid right ovarian mass w ith pe ak-systolic ve locitie s of 18.8 cm /se c and e nd-diastolic ve locitie s of 11 cm /se c. giving an RI of 0.41. S urge ry re ve ale d a stage I Carcinoma of ovary





Appearance Score

Atro phic 0

Volume >8cm. 1

Sim ple anechoic <3cm 1Sim ple anechoic <5cm 2

Sim ple anechoic >5cm 3

Multilocular <5cm 2

Multilocular >5cm 3

Com plex, cyst with echoic shadows. 4

Solid cyst (solid areas >50%) 5

Table :Scoring for US appearance ofovaries

Professor Galal Lotfi Obstetrics & Gynecology Suez Canal

University.Egypt



CA-125

Sustained elevation in 82% of women with advanced ovarian cancer, but fewer than 1%of healthy women

Poor sensitivity (elevated in only 50% of women with Stage I disease)

Poor specificity (elevated in many

gynecologic and non-gynecologicmalignancies as well as benign conditions)



CA-125

Malignant conditions

CervicalCA

Fallopian tubeCA

EndometrialCA

PancreaticCA

ColonCA

BreastCA

Lymphoma

Mesothelioma

Benign conditions

Endometriosis/Menses

Uterine fibroids

PID

Pregnancy

Diverticulitis

Pancreatitis

Liver disease Renal failure

Appendicitis

IBD







Diagnosis of ovarian tumor

P rocedure Se Sp P pv Npv Acura

Color doppler 70 .0 84 .4 77 .8 83 .6 81.7

USG Morf 90 .0 6 5 .2 6 0 .0 91.8 74 .3

Ca 125 70 .0 6 0 .9 50 .9 77 .8 6 4 .2

Ca 72-4 40 .0 84 .1 59 .3 70 .7 6 7 .9

Ca 19-9 35 .0 6 8 .1 39 .9 6 1.4 59 .0

Kawai et al, 1994



Current Screening Guidelines

Routine screening for ovarian cancer byultrasound, the measurement of serum tumormarkers, or pelvic examination is notrecommended. There is insufficient evidence torecommend for or against the screening of asymptomatic women at increased risk of developing ovarian cancer.

U.S.Preventive ServicesTaskforce, Guidelines from Guide to

Clinical Preventive Services, 2nd edition, 1996



Screening Guidelines contd

NIHConsensusConference (1994)

women with presumed hereditary cancer syndromeshould undergo annual pelvic exams, CA-125

measurements, andTVUS until childbearing iscomplete or at age 35, at which time prophylactic

bilateral oopherectomy is recommended.

ACP

counsel high risk women about potential harms andbenefits of screening



Pe lvic Exam (PE) + VST

VST (+) VST (-)

Re pe at VST4-6 minggu Re pe at PE and VSTEve ry ye ar

Positif Ne gatif

Ca 125 CDTS onografi-morfologiLaparotomy

Not e:Post me nopause > 50 yFamili (+) > 30 y (2 fam)

VST: USG transvCDT: Color dopple r transv

Schreening of ovarian tumor



Post me nopausal w ome n ( > 5 0 ye ars)

Ge ne tic and familial ovarian cance rge ne tic and ch romosome abnormalityhe re ditary ovarian cance r syndrome

sit e spe cific familial ovarian cance rbre ast/ovarian familial cance r syndrLynch II syndr (k olon,ovarium,e ndome t ,bre ast)

Ge ne tic risk Family re lations I st ( OR 3 .6 )Family re lations 2 nd ( OR 2 .9 )

Az iz M F.S cree ning and e arly de t e ction in obvarian cance rKO GI,B ali,199 0

Kelompok resiko tinggi



F amilial Ovarian Cancer Centre (F OCC)

E xam. cost: clinis, USG, Ca 125 ( $ 16 8 .00 )

New patiens : $ 54 6.00 Book patients : $ 471.00

Screening cost for post menopausal women (AS):

$ 2,700,000 per 1 cancer case

Biaya skrining



Summary

Screening for ovarian cancer ?? Ov arian cancer incidence

Good 5 years sur v i v al rate early stage (

90 % ) Poor prognosis 5 years sur v i v al rate for

ad v ance stages( 5 % )

Screening cost expensi v e For limiting groups screening



Summary, take home points

Screening not indicated at this time

ASK about family history of cancers

LISTEN when women present with non-specific GI complaints; include OC in DDx

DO perform careful bimanual exam and rectal

exam as part of pelvic exam

Refer women with + Family Hx to GynOnc



How about prophylactic

ovarectomy ???

Risks And Benefits of

Prophylactic Oophorectomy





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