Gynecology Book

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Ovarian Cancer

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  1. Epidemiology
    1. Incidence: 26,800 new cases in U.S. in 1997
    2. Prevalence: 30 to 50 cases per 100,000
    3. Lifetime Risk: 1 in 70 (1.4%)
    4. Mortality: 14,200 deaths in U.S. in 1997
  2. Risk Factors
    1. Age over 40 years
    2. Nulliparity
    3. Family History (accounts for 5 to 10% of cases)
      1. Ovarian Cancer (2 to 20 fold increased risk)
        1. One affected first degree relative: 3 fold risk
        2. Two or more relatives affected: 40% risk
      2. Endometrial Cancer (Uterine Cancer)
      3. Colon Cancer
      4. Breast Cancer
        1. BRCA1 and BRCA2 account for 10% of ovarian cancers
        2. BRCA1 confers 44% lifetime risk of ovarian cancer
    4. Past Medical History
      1. Endometrial Cancer
      2. Colon Cancer
      3. Breast Cancer
  3. Risk Factors: Hereditary Ovarian Cancer Syndromes
    1. Breast-Ovarian Cancer Syndrome
    2. Site-specific Ovarian Cancer Syndrome
    3. Lynch II Syndrome
      1. Non-polyposis Colorectal Cancer
      2. Endometrial Cancer
      3. Ovarian Cancer
      4. Upper Gastrointestinal Tract Cancer
      5. Urinary Tract Cancer (Kidney pelvis and Ureter)
  4. Exam: Screening
    1. Bimanual rectovaginal examination
  5. Radiology
    1. Transvaginal Ultrasound
      1. High Test Sensitivity for small ovarian tumors
      2. Low Test Specificity for ovarian cancer
      3. Findings on ultrasound suggestive of ovarian cancer
        1. Increased cyst size
        2. Increased cyst wall thickness
        3. Intracystic papillary formations
        4. Intracystic solid areas
        5. Intracystic septation (complex cyst)
    2. CT Pelvis and CT Abdomen
  6. Labs
    1. CA-125 Radioimmunoassay
      1. Low Test Specificity and low Test Sensitivity
  7. Staging
    1. Stage I: Ovary only (25% of ovarian cancer diagnosis)
      1. Stage IA: One ovary involved
      2. Stage IB: Both ovaries involved
      3. Stage IC: Stage IA or IB with below:
        1. Tumor on surface of ovary or
        2. Ovarian capsule ruptured or
        3. Malignant Ascites or
        4. Peritoneal cytology positive
    2. Stage II: Pelvic Extension
      1. Stage IIA: Spread to Uterus or fallopian tubes
      2. Stage IIB: Spread to other pelvic tissues
      3. Stage IIC: Stage IIA or IIB with below
        1. Tumor on surface of ovary or
        2. Ovarian capsule ruptured or
        3. Malignant Ascites or
        4. Peritoneal cytology positive
    3. Stage III: Peritoneal implants
      1. Stage IIIA: Microscopic seeding to peritoneum
      2. Stage IIIB: Abdominal peritoneal implants <2 cm
      3. Stage IIIC: Abdominal implants >2cm or positive nodes
    4. Stage IV: Distant Metastasis
  8. Management
    1. Surgical resection
      1. Radical surgical resection improves survival
      2. Benefit most significant in carcinomatosis
      3. Cliby (2006) Obstet Gynecol 107:77
    2. Adjuvant Chemotherapy q3 weeks x6 cycles (70% respond)
      1. Medications: Protocols combine Platinum with Taxane
        1. Platinum Agents
          1. Cisplatin
            1. Significant Nausea and Vomiting
            2. Significant nephrotoxicity and neurotoxicity
            3. Administered over 24 hours with IV fluids
          2. Carboplatin
            1. Equivalent efficacy to Cisplatin
            2. Much less toxicity than with Cisplatin
            3. Can be administered outpatient over 3 hours
        2. Taxane Agents
          1. Paclitaxel (Taxol)
            1. Arthralgias and myalgias may be significant
            2. Risk of Peripheral Neuropathy
          2. Docetaxel
            1. Significant Neutropenia and nadir fever
            2. Less risk of adverse effects seen with Taxol
            3. May be preferred in pre-existing Neuropathy
      2. Intravenous (all 3 protocols with similar efficacy)
        1. Protocol 1: Cisplatin and Paclitaxel (Taxol)
        2. Protocol 2: Carboplatin and Paclitaxel
        3. Protocol 3: Carboplatin and Docetaxel
      3. Intraperitoneal (Regional) Chemotherapy
        1. Cisplatin is currently being used
        2. Carboplatin appears safe but efficacy not proven
      4. Current protocol recommended by NCI
        1. Cisplatin and Taxol Intraperitoneal and IV
        2. Armstrong (2006) NEJM 354:34
      5. References
        1. Markman (2003) Hematol Oncol Clin North Am 17:957
  9. Prognosis
    1. Median survival: 32 months
    2. Five year survival
      1. Overall five year survival: 40%
      2. Five year survival for advanced ovarian cancer: 20%
    3. Predictors of worse outcome
      1. Age >75 contrasted with age <45 (Hazard ratio 2.8)
      2. Residual tumor >1 cm (Hazard ratio 1.72)
      3. FIGO stage 4 versus stage 1 (Hazard ratio 11.75)
    4. References
      1. Tingulstad (2003) Obstet Gynecol 101:885
  10. Prevention: Factors against ovarian cancer development
    1. More than one full-term pregnancy
    2. Oral Contraceptive use (extended use beneficial)
  11. Prevention: Prophylactic oophorectomy
    1. Indicated for Hereditary Ovarian Cancer Syndromes
    2. Oophorectomy at age 35 or when childbearing complete
    3. Estrogen Replacement after oophorectomy
    4. Efficacy
      1. Reduces Ovarian Cancer risk
      2. Peritoneal Primary papillary serous tumors may occur
  12. References
    1. Nahhas (1997) Postgrad Med 102(3):112
    2. Teneriello (1995) CA Cancer J Clin 45(2):71

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