Download Inspiration Rain - Dr. Ahmad Abanamy Hospital

Mayella Mercado - Montemar, M.D.
Dr. Ahmed Abanamy Hospital
Department of Obstetrics & Gynaecology
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Page 1
Objective:
• To present the management of
debilitated patient diagnosed to have
ovarian cancer
• To discuss the role of ancillary
procedures and tumour markers in
the diagnosis and management of
ovarian cancer
• To discuss the preventive measures
of ovarian cancer
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Page 2
General Data:
•
•
•
•
•
•
E.G.
53 years old
Married
Muslim
Riyadh, K.S.A.
May 23, 2013
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Chief complaint:
Abdominal
enlargement
x
6 months
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Page 4
HPI:
6 months PTA
Abdominal
discomfort &
distension
(-) early satiety,
DOB, abdominal
fullness,
dyspepsia, bowel
habit changes
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(+) Consult
Ranitidine
Mefenamic
acid
for whole
abdominal
CT scan
Page 5
Abdominal
enlargement
3 months
PTA
Loss of
appetite
Weight loss
of 20%
Abdominal
fullness
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4 weeks PTA
(+) persistence of
signs &
symptoms
(+) DOB
(+) Body malaise
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(+) Consult
Whole
abdominal
UTZ
(+)
Referred to
MOH
Page 7
Whole abdominal UTZ
• Ascites, seen in the perihepatic,
perispleenic, paracolic and pelvic
region
• Large pelvo-abdominal cystic
mass: a large multiloculated mass in
the midpelvic abdomen seen above
the urinary bladder which measured
8.6 x 9.0 x 8.7 cm
• Cholelithiasis with gallbladder wall
thickening
• None visualized right kidney maybe
due to
overlying
bowel gas
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1 week PTA
Persistence
of s/sx
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(+) consult
Whole
abdominal
CT scan
Page 9
Whole abdominal CT scan
• Absent uterus (s/p subtotal hysterectomy)
• Pelvo-abdominal mass t/c ovarian new
growth: huge multiloculated mass noted in
the midline extending to the left hemi
abdomen approximately measuring 18.39 x
11.31 x 16.08 cm. Some locules contain
anechoic fluid while some contain very fine
scattered echoes. Locule walls with solid
components and slightly thickened at 3-4
mm
• The peritoneum is outlined by anechoic
fluid
• Normal ovarian structures
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5 days PTA
severe weakness
noted by relatives
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- Government
hospital
- Hydrated
- CBC
- CA 125
- Advised
admission
Page 11
CBC
•
•
•
•
•
•
Hgb- 10.7 g/dL
Hct- 0.33
WBC- 9.72
Segmenters- 82.1
Lymphocytes- 13.1
Platelets- 471
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CA 125
143 U/mL (< 35 u/ml)
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Few hours
PTA
(+) Consult
Private GYN
OPD
Admission
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Menstrual history:
•
•
•
•
Menarche: 11 years old
Interval: 28-30 days
Duration: 3-4 days
Amount: moderately soaked,
2-3 pads/day
• (+) dysmenorrhoea
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OB history:
G4P3 (3103)
G1
1972
LSCS I
due to
CPD
LTBG
BW: 2.7
kg
CGH
(-) FMC
G2
1975
LSCS II
LTBG
BW: 2.7
kg
OM
(-) FMC
G3
1977
VBAC
stillbirth ? BW
JRRMMC
(?) FMC
G4
1978
LSCS III
LTBG
JRRMMC
PPH due
to
BW: 3.1
kg
intractable
uterine
atony
Subtotal
hysterectomy
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Gyne History:
• (-) history of contraceptive use
• (-) history of STD
• (-) history of dyspareunia
and post-coital bleeding
• Last pap smear was 1977
(normal), no further check-up
since then
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PMH:
• (+) HPN with poor medical
compliance
– HBP: 150/100 mmHg
– UBP: 120/80 mmHg
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Family History:
•
•
•
•
(+) HPN, paternal side
(-) DM
(-) Asthma
(-) Malignancy
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Personal, Sexual and
Social History:
•
•
•
•
•
•
•
Coitarche: 15 years old
Monogamous
Housewife
Unemployed
High fat and meat diet
Non- smoker
Non-alcoholic beverage drinker
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Review of Systems:
• Unremarkable
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P.E.
• General Survey: conscious, coherent,
weak and dry looking, ambulatory,
not in cardio-respiratory distress
• BP: 120/70 mmHg HR: 110
bpm
RR: 21 cpm Temp:
36.5 C BMI: 21.6 kg
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P.E.
HEENT: Pale palpebral
conjunctivae, anicteric sclera,
no naso-aural discharge, no
tonsillopharyngeal congestion
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• Neck: Supple, no neck vein
engorgement, no palpable
cervical LN
• Chest/Lungs: Symmetrical chest
expansion, no retractions,
decrease breath sounds, bibasal
• CVS: Adynamic precordium,
normal rate, regular rhythm, no
murmur
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• Abdomen: globular with
abdominal girth of 100.5 cm,
(+) fluid wave, (+) shifting
dullness, (+) fixed, palpable,
solid mass at the hypogastric
area, non tender,
approximately measuring 8.0 x
8.0 cm
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• Speculum examination: cervix
smooth with minimal mucoid
discharge, non foul smelling,
no bleeding
• Internal Examination: cervix
firm, closed
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Page 26
Initial Impression:
Gravida 4 Para 4 (3-1-0-3)
Pelvo-abdominal mass
probably Ovarian in origin, t/c
malignancy,
Anemia 2⁰,
HPN Stage II,
s/p Subtotal Hysterectomy
(1978)
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Course in the Ward
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Page 28
Date
Problem
Diagnosis
On
Pelvo-
Ovarian
admission
abdominal
New
Management
-
For Exploratory Laparotomy, PFC,
BSO, Frozen section, if malignant,
IO, BLND, Complete Surgical
mass
Growth
probably
probably
Referral to IM for CP clearance :
ovarian
malignant
-
Low salt low fat diet
-
PNSS 1L x 8 hours
-
For CBC, Na, K, TPAG, CEA, 12 L
Staging once CP cleared
ECG, CXR, CT Scan of whole
abdomen
-
Monitor VS Q 1 hour
-
Measure abdominal girth daily
-
Maintain on high back rest
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Page 29
Date
Problem
Diagnosis
CBC- Hgb: 8.5 g/dL
Na- 128 (135-147 meq/L)
admission K- 5.6 (3.5-5.0 meq/L)
Albumin- 3.15 (3.5-5.5
g/dL)
Globulin- 4.29 (2.3-3.5
g/dL)
A/G ratio- 0.7 (0.8-2.0)
CEA- 4.41 (< 2.5 ng/mL)
CXR- (+) layering of
fluid, left hemithorax
12 L ECG – NSR,
Intraventricular wall
possible anteroseptal wall
infarct
Whole abdominal CT
Scan- not done
On
t/c Ovarian
Management
-
IV once a day
Cancer,
followed by
Pleural effusion
left, probably
Furosemide 20 mg IV
-
malignant,
Ascites 2⁰,
Anemia 2⁰,
Hypertension
Albumin 25% 50 cc
Blood transfusion of 1
unit PRBC
-
Repeat CBC with
platelet count
6
hours post BT was
normal
Stage II
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Page 30
Date
Problem
Diagnosis
Management
On
(+) difficulty of
Pleural effusion left,
-
O2 at 2-3 LPM
admission
breathing
probably malignant
-
IVF x 16 hours
BP: 120-140/80-110
Ascites 2⁰
-
Amlodipine 5 mg
mmHg
Anemia 2⁰- corrected
CR: 90-102 bpm
Hypertension Stage
Cardiopulmonary
RR: 20-26 cpm
II
clearance:
tablet OD
-
Temp: afebrile
High risk for
contemplated procedure
C/L: (+) poor
inspiratory effort
(↓) breath sounds,
bibasal
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Page 31
Date
Hospital
day 1
Problem
(+) weak looking
HEENT: pale palpebral conjunctivae, there
were no palpable masses noted on the supra
and infraclavicular area, thyroid and breast
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Abdomen: globular, dull in
percussion, (+) fluid wave with
palpable irregular nodular pelvo-
abdominal mass enlarged to 6
months size since with a floater,
solid which is palpable at the left
hypochondriac area
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IE: Cervix is 2.5 cm, firm, closed,
nontender and posteriorly directed,
anterior fornix is distended probably
due to ascitic fluid
RVE: There is a multinodular firm to
stony mass distending the posterior
fornix with very limited mobility
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Page 34
Date
Diagnosis
Management
Hospital
Ovarian New Growth
Gyne – Onco Notes:
day 1
highly suspicious of
-
malignancy with pelvic
Add Ensure 150 cc, 4 scoops + 120 cc water
every 4 hours
and peritoneal spread
-
Moriamin forte 1 tablet OD
(upon review of
-
For Paracentesis, Neoadjuvant
imaging test)
chemotherapy, 3 courses, 21 days apart with
Ascites Massive 2⁰,
Paclitaxel and Carboplatin followed by
Anemia 2⁰
Interval debulking Surgery 2 weeks after
the 3rd cycle. Then post-operative
chemotherapy, 3 cycles to complete 6 cycles
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Page 35
Date
Problem
Diagnosis
Hospital
(+) difficulty of
Pleural
day 1
breathing
effusion left,
Management
- Repeat CXR
showed
BP: 120-130/90-100 probably
progression of the
mmHg
malignant
left sided pleural
CR: 90-102 bpm
Hypertension
effusion and
RR: 20-23 cpm
Stage II
diminished lung
Temp: afebrile
volume bilaterally
C/L: crackles mid to
base, right lung field
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Page 36
Date
Problem
Diagnosis
Hospital
(+) shortness of breath
day 2
(+) speaks in short
t/c Malignant
Pleural
sentences
Effusion
BP: 120/70 mmHg
CR: 82 bpm
Management
Referral to Pulmonology
-
Strict aspiration precaution
-
Limit fluid intake to 4 L/day
-
O2 at 2-3 LPM
-
CXR (AP sitting view)
showed persistence of the
RR: 25 cpm
left sided pleural effusion
O2 Sat: 99%
with suggestive marginal
C/L: slight respiratory
progression, both lungs
distress, decrease breath
remain hypoaerated
sound, left mid to base,
-
Furosemide 20 mg IV with
BP precautions
crackles, right base
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Page 37
Date
Problem
Diagnosis
Hospital
(+) shortness
t/c Malignant
day 2
of breath
Pleural
Management
-
Ultrasound of the chest:
bilateral pleural effusion with
septations with approximate
(+) tachypnea Effusion
volume of 65 cc on the right and
BP: 110130/80-90
691 cc on the left
-
ABG:
mmHg
Mixed Respiratory Alkalosis &
CR: 80-90
Metabolic Acidosis with Mild
bpm
Hypoxemia
-
RR: 21-26
NaHCO3 600 mg/tablet, 1 tablet
TID
cpm
Temp: afebrile
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Page 38
Date
Problem
Diagnosis
Hospital
(+) uncontrolled BP HPN
day 2
BP: 130-140/100
mmHg
CR: 80-90 cpm
Stage II
Management
- Revised Anti-hypertensive
medications:
- Losartan 50 mg tablet OD
RR: 24 cpm
- Amlodipine 5 mg tablet OD
Temp: afebrile
- Metoprolol 50 mg tablet
BID
- Maintain systolic BP at
< 130 mmHg and diastolic
BP at < 100 mmHg
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Page 39
Date
Problem
Diagnosis
Management
Hospital
(+) coffee ground vomitus,
Upper GI bleed Referral to
day 2
300 cc
probably 2⁰ to
(+) on and off epigastric pain
for 1 year, burning in
stress ulcer,
character
Acute Peptic
(+) feeling of bloatedness
Disease
(+) constipation
Gastroenterology
-
For NGT insertion
but patient refused
-
Pantoloc 40 mg
OD
-
Motilium 10 mg/
BP: 120/90 mmHg
tablet, 1 tablet
CR: 96 bpm
TID before meals
RR: 23 cpm
-
Temp: afebrile
Maintain on high
back rest
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Page 40
Paracentesis:
-Post paracentesis – drained
3.35 L serosangenous ascitic
fluid, abdominal girth of 96 cm
(from 103 cm)
-Ascitic fluid analysis was
suspicious for adenocarcinoma
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Page 41
Date
Hospital
day 3
Diagnosis
Problem
(+)Weak looking
Management
Ovarian New Growth -
CBC, platelet count,
highly suspicious of
urinalysis, SGPT,
malignancy with
SGOT, BUN, Crea,
BP: 100/60 mmHg
pelvic and peritoneal
Total Bilirubin,
CR: 100 bpm
spread (upon review
B1,B2 were all
of imaging test)
normal
(+) dyspnea
(+) DOB
(+) cyanosis
RR: 25-30 cpm
Temp: afebrile
(+) Pale palpebral conjunctivae
Anemia 2⁰
(+) pale nail beds
-
Ascites Massive 2⁰
CBC – anemia with Hgb of
-
1st cycle
chemotherapy was
rendered
8.5 g/dL from 108 hence
blood transfusion of 4 units
PRBC
-
Repeat Hgb & Hct post
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blood transfusion, improved
Page 42
Date
Problem
Diagnosis
Management
Hospital
(+) occasional difficulty of
day 4
breathing
Onco, Cardio, Pulmo,
Conscious, coherent,
and Gastro stand point
-
Discharge from Gyne-
BP: 110-120/80-90 mmHg
CR: 100 bpm
RR: 25-30 cpm
Temp: afebrile
C/L: (↓) breath sound, left lung
field and right mid to base lung
field
Abdomen: globular, soft, (+) fluid
wave, (+) palpable mass at the
hypogastric area
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Page 43
Final diagnosis:
Gravida 4 Para 4 (3-1-0-3)
Ovarian New Growth highly suspicious of
malignancy w/ pelvic and peritoneal
spread, t/c Malignant Pleural effusion,
Massive Ascites 2⁰, Anemia 2 ⁰corrected, Electrolyte derangementresolved, Upper GI Bleed probably 2⁰ to
Stress ulcer, Acute Peptic Diseaseresolved, Hypertension Stage IIresolved, Chemotherapy
(Carboplatin/Paclitaxel) x 1st cycle,
Blood transfusion, s/p Subtotal
Hysterectomy (1978)
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Clinical Discussion
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Page 45
E.G.
53 yo
G4P3
(3103)
Salient Feature:
ONG
Highly suspicious
of malignancy
Others
Malignant
Pleural
effusion
Electrolyte
derangement
Ascites 2⁰
HPN St II
Anemia 2⁰
Upper GI
bleed
APD
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Page 46
Increases the risk for developing ovarian cancer
1. A strong family history of either breast or ovarian CA
Level II-2, Grade B
2. Long term use of unopposed estrogen or estrogenprogestin
Level II-2, Grade B
3. Endometriosis
Level II-3, Grade B
4. PID
Level II-3, Grade C
5. PCOS
Level II-3, Grade C
6. Adult obesity and obesity in early adulthood
Level II-3, Grade C
7. Cigarette smoking increases the risk of development for
mucinous EOC
Level II-2, Grade B
8. High meat and fat intake
Level II-2, Grade B
2nd Edition of Clinical Practice Guidelines for the Obstetrician Gynecologists
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Page 47
(November 2010)
Lesser or no risk for developing ovarian cancer
1. Ages at menarche and menopause
Level II-3, Grade C
2. Use of fertility drugs
Level II-2, Grade B
3. Alcohol intake
Level II-2, Grade B
4. Perineal talc use
Level II-2, Grade B
2nd Edition of Clinical Practice Guidelines for the Obstetrician Gynecologists
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Page 48
(November 2010)
E.G.
53 yo
G4P3
(3103)
Clinical Manifestation
Symptoms
Early
stage
• asymptomatic
Late
stage
• Bowel obstruction due to
intra-abdominal masses
• DOB due to pleural
effusion
Toralba et. al., Ovarian Cancer: Diagnosis, Staging and Management, 2010 Annual
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Page 49
Postgraduate Course
E.G.
53 yo
G4P3
(3103)
Clinical Manifestation
Signs
Pelvic mass
• Most important sign of ovarian
cancer
• Irregular, solid features & nodularity
Abdominal distension • Ascites
Abdominal masses • Omental caking
Pleural
effusion
Nodal
metastasis
• Difficulty of breathing
• Inguinal and supraclavicular nodes
Toralba et. al., Ovarian Cancer: Diagnosis, Staging and Management, 2010 Annual
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Page 50
Postgraduate Course
What ancillary procedure
will we request ?
•
•
•
•
•
Transvaginal ultrasound
Whole abdominal ultrasound
Doppler studies
Whole abdominal CT scan
MRI
De los Reyes, et. al. Pelvo-abdominal Mass: Diagnosis and Management, JRRMMC
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Page 51
2010 Annual Postgraduate Course , July 2010
Ultrasound in Ovarian
Neoplasm
• Useful in discriminating benign
from malignant adnexal masses
• Detects earliest possible
architectural changes in the
ovary
• Assessment include both ovarian
volume and morphology
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Page 52
Role of UTZ in
Ovarian Neoplasm
– Morphological parameters used:
•
•
•
•
•
•
•
Complex cysts
Septations
Loculations
Papillary projections
Irregular cyst walls
Echogenicity
Ascites
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Page 53
E.G.
53 yo
G4P3
(3103)
Whole abdominal UTZ
• Ascites, seen in the perihepatic,
perispleenic, paracolic and pelvic
region
• Large pelvo-abdominal cystic
mass: a large multiloculated mass
in the midpelvic abdomen seen
above the urinary bladder which
measures 8.6 x 9.0 x 8.7 cm
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Page 54
Color flow Doppler
• Uses altered blood flow patterns
to differentiate malignant from
physiologic and benign lesions
• Neovascularization: an obligate
early event in tumor growth and
neoplasia
• Malignancy = RI <0.4 or 0.6
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Page 55
CT scan in Ovarian
Cancer Suspect
• Helpful in identifying the extent of
clinical disease
» Togashi K. Eur, 2008
• 70-90% accurate in pre-operative
staging of ovarian cancer
» Brislow et.al Cancer
• Preferably w/ contrast
» Togashi K. Eur, 2008
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Page 56
CT scan in Ovarian
Cancer Suspect
• Currently:
– Detect recurrent or persistent
ovarian cancer
– Monitor tumor response to
subsequent therapy
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Page 57
E.G.
53 yo
G4P3
(3103)
Whole abdominal CT
scan
• Pelvo-abdominal mass t/c ovarian new
growth: huge multiloculated mass noted in the
midline extending to the left hemiabdomen
approximately measuring 18.39 x 11.31 x
16.08 cm. Some locules contain anechoic
fluid while some contain very fine scattered
echoes. Locule walls with solid components
but slightly thickened at 3-4 cm
• The peritoneum outlined by anechoic fluid
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Page 58
MRI in Ovarian
Cancer
• Distinguish benign from
malignant ovarian
masses
• Overall accuracy rate =
93%
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Page 59
What tumor markers will
we request ?
•
•
•
•
•
•
CA 125
HE 4
CEA
AFP
hCG
CA 19-9
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Page 60
E.G.
53 yo
G4P3
(3103)
CA
125
CEA
•143 U/mL
•(<35 U/mL)
•4.41 ng/mL
•(2.5 ng/mL)
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Page 61
CA 125
• Is expressed in approximately 80% of
ovarian epithelial cancers but less
frequently by mucinous types
• Postmenopausal patients w/ an
adnexal mass and high serum CA
125 level (>95 U/mL) there is a 96%
positive predictive value for
malignancy
Templates
Di Saia PJ, Creasman WT, Clin Powerpoint
Gynecol Onco,
7th ed, 2007
Page 62
CEA
• Negative in all normal ovarian
tissue
• Most frequently positive in
mucinous cancer (70-80 %)
• In serous tumor, CEA is much
less frequent positive (20 %)
• Endometriod Ca, Brenner tumor
are also frequently CEA positive
• Clear cell carcinoma is less
frequently CEA positive
Powerpoint Templates
5th Edition of Clinical Practice Guidelines , SGOP (August 2008)
Page 63
Other ancillary procedure?
• CXR
• Colonoscopy
• Routine hematologic and
chemical assessments
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Page 64
What is the role of
paracentesis?
• to relieve abdominal pressure from
ascites
• to diagnose spontaneous bacterial
peritonitis and other infections (e.g.
abdominal TB)
• to diagnose metastatic cancer
• to diagnose blood in peritoneal
space in trauma
McVay PA, Toy PT (1991). "Lack of increased bleeding after paracentesis and thoracentesis in patients with mild
coagulation abnormalities". Transfusion 31 (2): 164–71. doi:10.1046/j.1537-2995.1991.31291142949.x.
PMID 1996485.
Powerpoint
Templates
Page
65
Ginès P, Cárdenas A, Arroyo V, Rodés J (2004).
"Management
of cirrhosis and ascites". N. Engl. J. Med.
350 (16):
1646–54. doi:10.1056/NEJMra035021. PMID 15084697.
E.G.
53 yo
G4P3
(3103)
Ascitic fluid analysis
Chemical
Analysis
Albumin
5.317
mg/dL
RBC Count
204/cu.mm
Fresh RBC
61%
Cell Count
Crenated RBC 39%
WBC Count
56/cu.mm
Diff count:
Segmenters
15%
Lymphocytes
73%
Monocytes
12%
Powerpoint Templates
Cytology – Ascitic
fluid smears
show many
lymphocytes,
macrophages
and mesothelial
cells with few
cultures of
atypical cells
suspicious for
adenocarcinoma
Page 66
Surgery-Specific Risk
High risk: cardiac risk often > 5%
Aortic repair (aneurysmal, dissection)
Noncarotid major vascular (infrainguinal and intraabdominal)
Peripheral vascular surgery
Anticipated prolonged surgical procedures with large fluid shifts and/or blood
loss
Major emergency procedures, particularly in the elderly
Intermediate risk: cardiac risk generally < 5%
Major intraabdominal (nonvascular)
Intrathoracic (nonendoscopic)
Major orthopedic
Carotid endarterectomy
Major head and neck
Radical prostatectomy
Low risk: cardiac risk generally < 1%
Opthalmologic (excluding prolonged retinal)
Minor head and neck
Minor prostate (such as cystoscopy or TURP)
Biopsies and superficial procedures
ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery—Executive
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Page 67
Summary A Report of the American CollegePowerpoint
of Cardiology/American
Heart Association Task Force on Practice
Guidelines, 2002; 105: 1257-1267
Clinical criteria for high-risk surgical patients used by Shoemaker and
colleagues and adapted by Boyd and colleagues
Previous severe cardiorespiratory illness- MI, COPD, Stroke
Late stage vascular disease involving aorta
Age > 70 years with limited physiological reserve in one or more vital organs
Extensive surgery for carcinoma
Acute abdominal catastrophe with haemodynamic instability (e.g. peritonitis, perforated
viscus, pancreatitis)
Acute massive blood loss > 8 units
Septicaemia
Positive blood culture or septic focus
Respiratory failure: PaO2 < 8.0 kPa on FIO2 > 0.4 or mechanical ventilation > 48 hours
Acute renal failure: urea > 20 mmol/l or creatinine > 260 mmol/l
O Boyd et.al. The General Intensive Care Unit, The Royal Sussex County Hospital, Crit Care. 2005; 9(4): 390–
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Page 68
396., Brighton, UK
Tote S P , Grounds R M Br. J. Anaesth. 2006;97:4-11
• Primary cytoreductive
surgery
– When performing surgery in
women with ovarian cancer,
whether before chemotherapy or
after neoadjuvant chemotherapy,
the objective should be complete
resection of all macroscopic
disease
[Based on limited, contradictory evidence from two Cochrane systematic
reviews and two small randomised controlled trials]
Page
C. Redman et. Al. Recognition and initialPowerpoint
management Templates
of ovarian cancer: summary of NICE guidance
BMJ 2011; 342:d2073 doi: 10.1136/bmj.d2073 (Published 21 April 2011)
69
• The aim of surgery in earlier
years was optimal debulking with
residual disease up to 1 cm after
surgery
– Meta-analysis involving 3 prospective
RCT w/ > 3,000 patients showed that
there is still significant benefit for
residuals up to 1 cm compared w/ larger
remaining tumor masses, but the largest
benefit could be reached by complete
resection
Toralba et. al., Ovarian Cancer: Diagnosis, Staging and Management, 2010 Annual
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Page 70
Postgraduate Course
Amount of
Residual
Median
Survival
95%
Confidence
interval
No visible
residual
tumor
99.1 months
83.5
Residual
tumor 110mm
36.2 months
34.6-39.4
Larger than
10 mm
29.6 months
27.4-32.2
Toralba et. al., Ovarian Cancer: Diagnosis, Staging and Management, 2010 Annual
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Page 71
Postgraduate Course
• Neoadjuvant chemoptherapy
– Indications:
• All Stage IV except patients with
minimal pleural effusion or
supraclavicular node involvement
• Gross upper abdominal tumour on
imaging
• Clinically non-resectable pelvic
disease
• Significant and non-resectable
retroperitoneal lymphadenopathy
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Evidence Based Guidelines for the Powerpoint
ManagementTemplates
of Epithelial Ovarian Cancer – A WHO
Initiative
– Protocol
• 3 cycles of platinum-based
combination chemotherapy
(CAP or Platinum-Taxane)
• Interval cytoreductive surgery
w/in 3-4 weeks of completing
the 3rd treatment cycle
• The aim is to remove all
macroscopic tumor
• 3 further post-operative
treatment cycles
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WHO Evidence Based Guidelines for the Management of Epithelial Ovarian Cancer
– European Organization Research &
Treatment for Cancer (EORTC) trial:
• 3 cycles of neoadjuvant chemotherapy
followed by surgery and further 3
postoperative cycles in Stage IIC-IV ovarian
cancer were 719 patients were randomized
• Rate of optimal debulking was low at initial
surgery (48%) and was increased to (83%)
after interval debulking
• Lower rate of peri-operative complications
in the interval debulking arm and better
overall performance
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Toralba et. al., Ovarian Cancer: Diagnosis,
Staging
and Management, 2010 Annual Page 74
Postgraduate Course
• First-line chemotherapy consist
of platinum (cisplatin or
carboplatin) in combination w/
paclitaxel
• The combination are generally
well tolerated even at full doses
of both drugs. Shorter infusion of
paclitaxel (< 3 hours) is better
tolerated hematologically but w/
increased risk of arthralgiamyalgia & neuropathy
Bookman MA. Trials with Impact on Clinical Management First Line. Int J Gynecol Cancer 2009; 19:
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S55-S65
• Phase III trial by GOG-158
– Carboplatin/paclitaxel treatment
offered efficacy comparable w/
that of cisplatin/paclitaxel but did
not exhibit the cumulative
nephrotoxicity associated with
cisplatin therapy
Dunton et. al. Management of Treatment related Toxicity in Advanced Ovarian Cancer, The
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Oncologist, 2002
• International Collaborative
Ovarian Neoplasm Group
studies
– Use of Carboplatin as a single
agent was an acceptable
alternative first-line therapy for
patients w/ advanced ovarian
cancer
Dunton et. al. Management of Treatment related Toxicity in Advanced Ovarian Cancer, The
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Oncologist, 2002
• Myelosuppression is the main toxicity
associated with carboplatin, there is
also a significant risk of neurotoxicity
and hypersensitivity reactions
• Cleveland Clinic Cancer Center
– reported that hypersensitivity to
carboplatin developed in 12% of
carboplatin-treated patients
Markman M, Kennedy A, Webster K et al. Clinical features of hypersensitivity reactions
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to carboplatin. J Clin Oncol 1999;17:1141, The Oncologist 2002
• Paclitaxel exhibits high antitumor activity when used in
combination w/ carboplatin
• The use maybe limited by
cumulative peripheral
neuropathy
• The acute dose-limiting toxicity
is granulocytopenia
• Others: alopecia, nausea,
vomiting, diarrhea, mucositis,
and hypersensitivity
Muggia FM, Braly PS, Brady MF et al. Phase III randomized study of cisplatin versus paclitaxel versus cisplatin
and paclitaxel in patients with suboptimal stage
III or IV ovarian
cancer: a Gynecologic Oncology Group
study.79
J
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Clin Oncol 2000;18:106–115.
• Prophylactic treatment with steroids
and antihistamines and a slow
infusion rate may minimize this risk,
although fatal anaphylaxis has still
been reported despite these
precautions
• As a consequence, patients should
be closely monitored during all
courses of cisplatin or carboplatin/
paclitaxel therapy
Zweizig S, Roman LD, Muderspach LI. Death from anaphylaxis to cisplatin: a case report. Gynecol Oncol
1994;53:121–122.
Onoyama Y, Umezu T, Kuriaki Y et al. Hypersensitivity
reactions
to cisplatin following multiple uncomplicated
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courses: a report on two cases. J Obstet Gynaecol Res 1997;23:347–352.
80
• The odds of achieving a complete
response following first line treatment
are only about 5%.
• The duration of this complete
response is usually less than 6
months.
• The possibility of cure is unknown,
but is probably only a percentage
point at most.
• The odds of cure if the second line
treatment does not work are too low
to calculate.
William M. Rich, M.D., Clinical Professor of Obstetrics and Gynecology, University of California, San Francisco,
Director of Gynecologic Oncology, University
Medical Center
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Fresno, California
• Laparoscopic assesment is
ideal/optional approach to all
suspicious adnexal mass
identified as:
– has complex morphology on
imaging
– Associated w/ normal or mildly
elevated CA 125
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WHO Evidence Based Guidelines for the Management of Epithelial Ovarian Cancer
• Progress in laparoscopy for
ovarian cancer has been
considerably slow
– Rare chance of early diagnosis for
ovarian cancer
– Concern for overall oncological
safety including the risk of tumor
seeding
– Higher rate of capsular rupture
Ghezzi F, Cromi A, Siesto G, et al. Laparoscopy
Staging
of Early Ovarian Cancer Our Experience
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and Review of the Literature. Int Gynecol Cancer 2009; 19:S7-S13
Follow-up
• Every 3 months for 4 visits, every 4
months for 3 visits, every 6 months
for 6 visits, then annually
• Determination of appropriate tumor
markers every visit
• TVS +/- Doppler studies every 4-6
months
De los Reyes, et. al. Pelvo-abdominal Mass: Diagnosis and Management, JRRMMC
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2010 Annual Postgraduate Course , July 2010
Follow-up
• CXR if indicated by signs and
symptoms
• Annual MRI or CT scan for the
first 3 years post-treatment is
recommended or when indicated
De los Reyes, et. al. Pelvo-abdominal Mass: Diagnosis and Management, JRRMMC
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2010 Annual Postgraduate Course , July 2010
Summary
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1⁰ Preventive measures:
1. BSO is the preventive measure of
choice for women w/ known germline
mutation in BRCA 1 or BRCA 2
2. OCP confers long-term protection
against ovarian CA
3. Analgesics such as aspirin, NSAIDS,
acetaminophen are potential
chemopreventive agents for ovarian CA
4. Increasing parity reduces the risk of
EOC
5. Lactation confers protection against
ovarian cancer risk most significant
with duration of 18 months or more
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CPG for the OB-GYN, SGOP, Nov. 2010
Page 87
1⁰ Preventive measures:
6. Tubal ligation confers a reduction in the
risk for ovarian cancer
7. Carotenoids significantly protect against
ovarian CA, either as food or as
supplements
8. The consumption of tea may reduce the
risk of EOC
9. Recreational physical activity confers at
best a week to modest protection
against EOC
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CPG for the OB-GYN, SGOP, Nov. 2010
Page 88
2⁰ Preventive measures:
1. For the general population, there is no
evidence yet to support routine
screening for ovarian cancer using
pelvic exam, CA-125, TVS
2. Although there is the lack of evidence
for routine screening among BRCA
mutation carriers who have not
undergone risk-reducing BSO, carriers
are advised semi-annual screening
using pelvic exam, CA-125, TVS
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CPG for the OB-GYN, SGOP, Nov. 2010
Page 89
Conclusion
• The outcome for women with ovarian
cancer is generally poor
• Most women have had symptoms for
months before presentation, and as
these are frequently non-specific,
delays often occur between
presentation and referral to a
specialist.
• Greater awareness of the disease
and appropriate initial investigations
are needed to enable earlier referral
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and optimum
treatment.
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