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  • Half of all ovarian cancers are diagnosed in women > 65yo
  • Stage I: confined to ovary or ovaries IA: unilateral, capsule intact, no tumor on ext surface. No ascites. IB: bilateral, same as above IC: 1 or both ovaries with ruptured capsule, surface tumor, + ascites or + peritoneal washing
  • Stage II: Pelvic extension IIA: involvement of uterus or fallopian tubes, (-) peritoneal washings IIB: involvement of other pelvic tissues (bladder, sigmoid colon, rectum), (-) peritoneal washings IIC: IIA or IIB with ruptured capsule, surface tumor, + peritoneal washings or ascites
  • Stage III: Peritoneal implants outside pelvis or + retroperitoneal or inguinal LN IIIA: grossly limited to true pelvis with microscopic seeding of abdom peritoneum IIIB: Implants on abdom peritoneum < or = 2cm diam IIIC: Implants on abdom peritoneum > 2cm or + retroperitoneal or inguinal LN
  • Stage IV: distant mets (liver, lungs), + pleural fluid
  • CA-125 elevated in: Malignant conditions Ovarian CA of various types Cervical CA Fallopian tube CA Endometrial CA Pancreatic CA Colon CA Breast CA Lymphoma Mesothelioma Benign conditions: Endometriosis Uterine fibroids PID Pregnancy Diverticulitis Pancreatitis Liver disease Renal failure Menstruation Appendicitis Inflammatory bowel disease

mati mati Presentation Transcript

  • Ovarian Cancer Screening Mati Zolti M.D. Department of Obstetrics & Gynaecology Sheba Medical Center Tel Hashomer, Israel
  • Ovarian Cancer: Burden of suffering
    • 4 th leading cause of cancer death in women in the U.S. (after lung, breast and colon)
    • Overall 5-year survival rate is 35%
    • The “silent killer”: asymptomatic in early stages
    • 75% diagnosed with advanced stage disease; 5-year survival only 10-28%
    • Woman’s lifetime risk of dying from ovarian cancer is 1.1%
  • Ovarian Cancer in Israel
    • New Cases : 220
    • Death : 95
    • Median age : 51
    • (2XXX)
  • Ovarian Cancer
    • Symptoms of ovarian cancer :
    • asymptomatic
    • Lower abdominal pain/pressure
    • mass
    • Abdominal enlargement
    • Vaginal bleeding
    • Urinary/bowel symptoms
  • Types of Ovarian Tumors
      • Functional
        • Follicle cyst
        • Corpus luteum cyst
        • Theca lutein cyst
      • Inflammatory
        • Tubo-ovarian abscess
      • Benign tumors/cysts *
        • Endometriotic cyst
        • Brenner tumor
        • Benign teratoma (dermoid cyst)
        • Fibroma
        • *Rare or very rare potential for malignancy
    • Malignant (or malignant potential)
      • Malignant teratoma
      • Endometrioid carcinoma
      • Dygerminoma
      • Secondary ovarian tumor
      • Cystadenoma, cystadenocarcinoma (>50% for serous, ~5% for mucinous)
      • Granulosa cell tumor (15-20%)
      • Arrhenoblastoma (<20%)
      • Theca cell tumor (<1%)
  • Epithelial Ovarian Cancer
    • Overall 5-year survival rate is 75-95% if cancer confined to ovaries; decreases to 10-17% if distant metastases
    • Survival improved when cancer detected in early stage
    • Only 25% diagnosed in Stage I
  • Early Detection and Mortality
    • No direct evidence that women with early stage cancer found on screening have lower mortality than women with more advanced disease
    • Indirect evidence supports benefits of early detection:
      • Most important prognostic factor in patients with advanced ovarian cancer is tumor burden after initial debulking
      • Surgical debulking and chemo more effective when cancer detected early
  • The challenge
    • Natural history of ovarian cancer not well understood
      • No well-defined precursor lesion
      • Length of time from localized tumor to dissemination is unknown
    • Multiple efforts underway to develop effective screening method for early detection
  • Risk factors
    • The majority of women with ovarian cancer have no known risk factors
    • Most significant risk factor is genetic predisposition
  • Risk factors: Heredity
    • Up to 10% of epithelial ovarian cancer cases are familial
    • 3 familial syndromes
      • familial breast-ovarian cancer syndrome
      • site-specific ovarian cancer
      • cancer family syndrome (Lynch type II)
    • Familial breast-ovarian cancer and site-specific ovarian cancer syndromes both associated with mutations of the BRCA1 suppressor gene; account for 90% of familial ovarian cancers
            • Rollins,G. Ann Int Med 2000;133:1021-1024
  • Additional Risk Factors
    • Age
      • Women over age 50 account for ~80% of all cases (ave. age at dx is 61)
    • Reproductive history
      • early menarche, nulliparity or age >30 at first child-bearing, and late menopause
    • Fertility drugs
      • prolonged use of Clomid, especially without achieving pregnancy
    • Personal history of breast cancer
    • Hormone replacement therapy > 10 years
      • May be associated with 30% increased risk
    • Talcum powder
      • Some studies have shown slightly increased risk in women who use talc powder on genital area
      • American Cancer Society, 2001
  • Protective factors
    • Multiparity: First pregnancy before age 30
    • Oral contraceptives: 5 years of use cuts risk nearly in half
    • Tubal ligation
    • Hysterectomy
    • Lactation
    • Bilateral oopherectomy
  • Delays in Diagnosis
    • Lack of severity and specificity of early symptoms
      • Early signs/symptoms may include bloating, gas, indigestion, abdominal fullness or discomfort, constipation, pelvic pressure, urinary frequency, abnormal vaginal bleeding, fatigue, back pain, leg pain
    • Early stage tumors difficult to detect on pelvic exam
  • Diagnostic tools
    • History
    • Pelvic Exam (including rectal)
    • Transvaginal Ultrasound – detection of masses and mass characteristics
    • Tumor markers – CA-125, LPA (plasma lysophosphatidic acid)
    • CT – assess spread to LN, pelvic and abdominal structures
    • MRI – best for distinguishing malignant from benign tumors
  • Work-up of Adnexal Mass
    • Age
    • Size of mass
    • Unilateral vs. bilateral
    • CA-125 levels
    • Ultrasound configuration
    • Color-flow Doppler flow
    • Presence of symptoms
    • Must first categorize as functional, benign neoplastic or potentially malignant
    • Diagnostic approach depends on:
  • Diagnostic approach
    • If premenopausal and asymptomatic, with unilateral, mobile, simple cystic mass <8-10cm and no family history, can observe for 4-6 weeks and then repeat TVUS and pelvic exam.
      • If resolved, no further work-up necessary
      • If larger or unchanged, or if character of mass has changed on TVUS, surgical evaluation required
  • Diagnostic Approach
    • If postmenopausal and asymptomatic, with unilateral simple cyst <5cm AND normal CA-125, can follow closely with repeat TVUS
    • All other postmenopausal women with ovarian mass require surgical evaluation
  • Surgical Evaluation
    • Refer to Gyn-Onc specialist
    • Exploratory laparotomy has been the gold standard and includes:
      • Peritoneal washings for cytology
      • Evaluation of frozen section
      • Complete staging procedure if borderline or malignant tumor on frozen section
  • Surgical Evaluation
    • Laparoscopy can be considered in premenopausal woman with ovarian mass small enough to remove via laparoscopic approach; not recommended if high suspicion for malignancy
  • Stages Ia, Ib, Ic
  • Stages IIa, IIb, IIc
  • Stages IIIa, IIIb, IIIc
  • Stage IV
  • Treatment
    • Depends on staging, tumor type, age, desire for future fertility
    • Can include surgery, chemotherapy and/or radiation therapy
    • Clinical trials are ongoing
  • Surgical treatment
    • Primary debulking and cytoreduction; may include:
      • Bilateral salpingo-oopherectomy
      • Hysterectomy
      • Lymphadenectomy (para-aortic, inguinal)
      • Omentectomy
      • “brushing” of diaphragm, examination of liver
  • Chemotherapy and Radiation
    • Usually 6 cycles of chemotherapy
    • Cisplatin (or Carboplatin) plus Paclitaxel most commonly used combination therapy
    • XRT
  • Why screening for ovarian cancer is so difficult?
    • Anatomic location of the ovary, not easily accesible
    • Lack well defined precursor lesion and has poorly defined natural history
    • Low prevalence, need exquisite specificity to avoid unnecessary intervention
    • Lack of a good method
  • Screening Strategies
    • Ultrasound (transvaginal vs transabdominal)
    • Color-flow doppler
    • CA-125
    • Other tumor markers
  • Ultrasound
    • Both tranabdominal and transvaginal techniques identify enlarged ovaries or abnormal morphology; TVUS has better resolution
    • One large study of TVUS underway has reported sensivity of 81% and specificity of 98.9%
    • Major limitations are poor PPV in asymptomatic women and inability to detect malignances when ovaries are normal size
    • Allows earlier stage detection
  • 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
  • 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-gynecologic malignancies as well as benign conditions)
  • CA-125
    • Malignant conditions
    • Cervical CA
    • Fallopian tube CA
    • Endometrial CA
    • Pancreatic CA
    • Colon CA
    • Breast CA
    • Lymphoma
    • Mesothelioma
    • Benign conditions
    • Endometriosis/Menses
    • Uterine fibroids
    • PID
    • Pregnancy
    • Diverticulitis
    • Pancreatitis
    • Liver disease
    • Renal failure
    • Appendicitis
    • IBD
  • Lysophosphatidic acid (LPA)
    • Tumor marker being investigated for screening
    • Phospholipid with mitogenic and growth factor-like actions
    • In 1 small study LPA was detected in 9 of 10 patients with Stage I ovarian CA, 24/24 with advanced cancer, and 14/14 with recurrent cancer. Only 28 of 47 pts had elevated CA-125, including 2 of 9 with Stage I disease
  • Current Screening Guidelines
    • “ Routine screening for ovarian cancer by ultrasound, the measurement of serum tumor markers, or pelvic examination is not recommended. There is insufficient evidence to recommend for or against the screening of asymptomatic women at increased risk of developing ovarian cancer.”
  • Screening Guidelines– cont’d
    • NIH Consensus Conference (1994)
      • women with presumed hereditary cancer syndrome should undergo annual pelvic exams, CA-125 measurements, and TVUS until childbearing is complete or at age 35, at which time prophylactic bilateral oopherectomy is recommended.
    • ACP
      • counsel high risk women about potential harms and benefits of screening
  • Screening, cont’d
    • American Cancer Society, AAFP and ACOG do not recommend screening for ovarian cancer in the general population
    • Canadian Task Force on Periodic Health Examination
      • “insufficient evidence to recommend for or against screening in high-risk women”
  • Where do we go from here?
    • Several strategies for screening currently under investigation
      • TVUS as primary screening method
      • Multimodal strategy using CA-125 as initial indicator and if elevated, TVUS used for secondary testing
      • LPA (phospholipid with mitogenic and GF-like actions) may be more sensitive than CA-125 in detecting early stage cancers
  • Ovarian Cancer Screening Trials
    • The United Kingdom Collaborative Trial of Ovarian Cancer Screening: will compare TVUS and multimodal screening to control
    • The European Study: RCT to screen women with TVUS at 18-month or 3-year intervals
    • The NIH Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial: 10-year study using multimodal strategy
  • 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
  • Marker Updates - Ca 125 • Approved marker to test for recurrence • Remains the single most sensitive and specific marker for ovarian cancer to date • Addition of other markers might improve sensitivity and specificity • Longitudinal assessment may also improve sensitivity and specificity
  • ROCA: Risk of Ovarian Cancer Algorithm
  • Marker Updates—OvaCheck
    • In 2002, a paper in Lancet described an approach to ovarian cancer screening using mass spectrometry to create protein patterns from blood and computer software to find patterns associated with disease.
    • In 2003, the software developer announced it would market a test called OvaCheck for screening high risk populations. The test would be offered as a “homebrew” diagnostic circumventing the need for premarket review.
    • In July 2004, the FDA ruled that the computer software was, in fact, a medical device and would require review.
    • In 2004 and 2005, the developer announces partnerships with several hospitals to further validate the assay and patents “A process for distinguishing between biological states based upon hidden patterns from biological data.”
  • Marker Updates—Ciphergen Panel
    • Collaborating with several academic centers, Ciphergen has sought to combine mass spectrometry with Protein Chip arrays including some antibody-based chips
    • In 2004, a paper in Cancer Research identified three biomarkers:Apoliporotein A1 and transthyretin (both downregulated), and a fragment of inter-α-trypsin (up-regulated) in ovarian cancer. The three markers plus CA 125 had a sensitivity of 74% for early stage disease and specificity of 97%. An update in 2006 CEBP, found somewhat lower sensitivity and specificity when benign disease included. Testing is underway on a panel of 7 markers.
  • Marker Updates - Yale’s Panel
    • In a paper in PNAS in 2004, a group led by Yale investigators used antibody microarrays to identify four proteins that distinguished ovarian cancer: leptin, prolactin, osteopontin, and insulin-like growth factor II.
    • The combination had a sensitivity of 95% and specificityof 95% for distinguishing ovarian cancer, all stages.
    • In 2006, Yale announced it would partner with a Chinese diagnostics company to develop this panel as a screening test for ovarian cancer.
  • Marker Updates - Luminex Panel
    • In an AACR abstract, Lokshin et al from the Univ. of Pittsburgh used the “bead-based” Luminex system for multiplexing many antibody-based assays to distinguish ovarian cancer cases from controls.
    • Eight biomarkers had the highest diagnostic power including: CA 125, CA 19-9, EGFR, G-CSF, Eotaxin, IL-2r, cVCAM, and MIF.
    • For postmenopausal ovarian cancer the sensitivity was 100% at a specificity of 98.6%.
    • Has partnered with Pittsburgh biostatisticians to develop an algorithm to combine the markers.