Based on the clinical findings and investigations, the differential diagnoses in this case include: 1. Advanced ovarian malignancy 2. Tubo-ovarian abscess 3. Advanced uterine malignancy 4. Advanced gastrointestinal malignancy The investigations that should be advised include: 1. Tumor markers (CA 125, CEA, CA 19-9) 2. Abdominal and pelvic ultrasound/ CT scan to look for primary site and metastases 3. Chest X ray 4. Colonoscopy Considering the age of the patient, elevated tumor markers, splenomegaly on USG and restricted mobility of mass on examination, advanced ovarian malignancy seems to be the likely diagnosis

1. Panel moderators
Dr Kiran Pandey
Prof. & Head of department , dept of OBG,
GSVM medical college, kanpur.
Dr Pavika Lal
Assistant Professor,GSVM
OVARIAN CANCER
AN-ENIGMATIC
DISEASE

2. NAME : DR KIRAN PANDEY MD, FICOG, FIMSA, FICMCH, MAMS
DESIGNATION: Head of department , dept of OBG,
GSVM medical college, kanpur.
President 2016-18, kanpur obs & gynae society
Secretary upsc agoi 2017-2019
CITY: KANPUR
Organizing secretary : AGOI surgical video workshop & UPSC annual CME – Dec 2018
Organizing secretary : WWWCON – 2018(INTERNATIONAL CONFERENCE)
Organizing chairperson : adolescent workshop, emergency obstetrics workshop – oct 2018
Organizing chairperson : National Adolescent Conference Youth Summit And C.M.E 2017
Organising Secretary ,National Conf of Obs &Gynae 2015.
Organising Chairperson, Urogynaecology, NDVH, Pelvic Floor Repair Workshop, National
Conference 2015
AWARDS: 11 National, 8 State level & 8 District level Awards & >30 awards at IMA
Awarded “Certificate of Appreciation“ for excellent contribution in family welfare 2017-2018
Received “President Appreciation Award” from Adolescent Health Committee at AICOG.
Received “Matrashakti Samaan Award” on International Women’s day 2019
Honoured by Mr.Satyadev Pachauri Minister of Khadi and Village Industries
 Received Best women doctor in IMA UP State.
 Received WOMEN OF SUBSTANCE award on international women’s day 2009-10.
Working towards a new Innovation for early diagnosis of cervical cancer with IIT kanpur – ‘GYTI’
AWARD from NIF India at RASHTRAPATI BHAWAN
FOGSI AWARD for original research work ”Dr.Chitrathara and Dr.Gangadharan preventive &
research oncology award”
PUBLICATIONS: Published > 100 research Papers in National & International Journals
Contributed chapters in various books
SPECIAL INTRESTS: GYNAE-Oncology, Infertility, Adolescent health, Uro-gynaecology, High risk
pregnancy

3. Introduction
• Epithelial Ovarian cancer, a term which encompasses
ovarian, fallopian and peritoneal cancers, is the leading
cause of gynecological cancer mortality.
• 6th most common cancer among women (ASIR-6.6/100,000)
• 7th leading cause of cancer deaths globally (A S mortality rate being
4.0/100,00) -Basu P et al. Indian J Cancer. 2009;46:28-33
• Management includes
complete surgical staging
 optimal cytoreductive surgery
chemotherapy
Incidence of a symptomatic
ovarian cyst being malignant
(GTG No 62. 2011) is:
Premenopausal : 1 in 1000
Postmenopausal (50yr ): 3 in 1000

4. Case 1A 35 yr old P0+0 woman
 C/O decreased appetite, hiccups, flatulence, heaviness in
abdomen, lethargy for 6months.
 LMP- 3 wks back. Menstrual history -WNL
 No other positive personal/ family history.
 The patient consulted several physicians for her symptoms,
but there was no relief . Recently she had consulted to a
physician where she was adviced USG
 USG-A complex right adnexal cyst , No organomegaly
THE PATIENT WAS REFERRED TO GYNAECOLOGIST
THE PATIENT CAME TO OUR SIDE WITH THE REPORT OF USG

5. What relevant points do
you enquire in the history
of a patient suspicious of
ovarian tumour?

6. 1. Menstrual history:
 Early menarche, late menopause
2.Obstetric history:
 Parity is inversely related to risk of ovarian cancer,having
atleast one child is protective of the disease,with the risk
reduction of 0.3-0.4.
 Breast feeding lowers the risk further
3. Contraceptive history:
 11% risk reduction after 1st yr of use
 50% risk reduction after 5yrs of use
About 30% of ovarian neoplasms in postmenopausal woman are malignant,
where as only about 7% of ovarian epithelial tumors in premenopausal
patients are frankly malignant.- Berek JS, Ovarian and fallopian tube cancer.
Berek & Novak’s gynecology.14th ed.

7. 4. Past surgery:
 Tubal ligation reduces risk by 67%
 Prophylactical salpingo-oophorectomy reduces the risk of
BRCA related gynaecologic cancer by 96%.
 Hysterectomy (w/o BSO) reduces by 1/3rd.
5. Past history:
 Breast cancer-With mutation in BRCA 1 lifetime risk is 28-
44% and that with BRCA 2-,Risk is as high as 27%of
developing Ovarian cancer
 Ovulation inducing drugs-women who use oral
contraceptives have 50% reduction in development of
ovarian cancer.

8. 6. Family History
 H/o female breast cancer
Women with breast cancer who carry the mutation of BRCA
are at increased risk of developing ovarian cancer as well as
second breast cancer.
 H/o ovarian , endometrial tumor-
• Endometriod carcinoma of ovary is associated in 15-20%
of cases with carcinoma of endometrium.
• Patients with disease metastatic from uterus to ovaries
have 30% to 40% ,5 year survival,whereas those with
synchronous multifocal disease have a 75% to 80%
survival.
A WOMAN’’S RISK AT BIRTH OF HAVING
OVARIAN CANCER ,SOMETIME IN HER LIFE IS
1-1.5% AND THAT OF DYING FROM IT IS 0.5%

9.  H/o colon cancer
HNPCC includes multiple adenocarcinomas, involves
combination of familial colon cancer,a high rate of
ovarian,endometrial and breast cancers and other
malignancies of GIT and Genitourinary tract.

10. How do we assess the significance of
symptoms in ovarian cancer?

11. Symptom index is positive , if
any of the following occurred
>12 times per month and
present for < 1 yr :
 Pelvic/abdominal pain
 abdominal bloating
Feeling full/difficulty eating
In the confirmatory
sample in this study,
the index had
 56.7% sensitivity
for early disease
and specificity was
90% for women> 50
years.
“Ovarian cancer symptom
index”- Goff et al (2007)
WHAT INVESTIGATIONS SHOULD BE
DONE?

12. A pelvic ultrasound is the single most
effective way of evaluating an ovarian
mass with TVS being preferable due to
its increased sensitivity over TAS.
BIOMARKERS
TRANS VAGINAL
SONOGRAPHY
TVS

13. USG – right solid cystic
adnexal mass,
Of around 8cm*5cm
Doppler study - flow within
the papillary projections,
confirming that they
represent solid neoplastic
elements.
No ascites.
CA-125: 125U/ml
WHAT NEXT?

14. HOW CAN WE DIFFERENTIATE
BETWEEN BENIGN AND MALIGNANT
TUMOR ON THE BASIS OF TVS?
• INTERNATIONAL OVARIAN TUMOR ANALYSIS (IOTA)
has laid simple rules
B-rules M-rules
Unilocular cysts Irregular solid tumor
Presence of solid components where
the largest solid component <7mm
Atleast 4 papillary structures
Presence of acoustic shadowing Presence of ascites
Smooth multilocular tumor with a
largest diameter <100 mm
Irregular multilocular tumor with a
largest diameter >100 mm
No blood flow (colour score 1) Very strong blood flow (colour
score 4)

15. • ≥1 M-features + 0 B-features:
malignantRule 1:
• ≥2 B-features + 0 M-feature:
BenignRule 2:
• if both M- and B-features are
present, or if no M- or B- features
are present, result is inconclusive.
Rule 3:

16. WHAT IS RMI SCORE IN THIS
PATIENT??
4*1*125*2=1000

17. USG
FINDINGS
MENOPAUSAL
STATUS
s. CA 125
WhatisRMI?
Riskof Malignancy
Index
RMI -IV
Yamamoto et al
(2009)
TUMOUR
SIZE
RMI=
UxMxSx
CA-125
• Ultrasound features:
– 1= none or one abnormality
– 4= two or more abnormality
• Menstrual status:
– 1= premenopausal
– 4= postmenopausal
• CA-125 levels (U/ml)
• Tumor size (single greatest diameter):
– 1= <7cm
– 2= ≥7 cm
RMI -II

18. • To date only RMI I and RMI II have been
sufficiently validated
• RMI II
Highest level of accuracy/diagnostic
performance.
Used for differentiation of malignant from
benign pelvic masses , is a reliable method
with USG finding.

19. How can we assess the risk of
malignancy in this patient?

20. SHOULD THIS
PATIENT BE TAKEN
FOR EXPLORATORY
LAPOROTOMY????
YES

21. Outcome
 Per operative findings:
Uterus normal in size, No abnormality seen
Right sided mass of size of around 10*12cm,intact capsule,with solid
and cystic components
Left sided ovary normal.
No evidence of any other peritoneal or abdominal disease.
Omentum grossly normal
Peritoneal washings taken.
 PROCEDURE DONE-exploratory laparotomy , TAH
+BSO,Peritoneal cytology With Pelvic lymphadenectomy and
Infracolic Omentectomy done.

22. WHAT IS THE STAGE OF
THIS PATIENT???
Her surgical staging
revealed a low risk
stage 1 disease.

23. What is the Management of
this patient?
Stage 1 cancer is characterized into high
and low risk disease.
Low Risk High Risk
Low grade High grade
Intact capsule Tumor growth through
capsule
No surface excrescences Surface excrescences
No ascites Ascites
Negative peritoneal
cytological findings
Malignant cells in fluid
Unruptured or intra-
operative rupture
Pre-operative rupture
No dense adherence Dense adherence
Diploid tumor Aneuploid tumor
Berek & Hacker’s Gynaecologic Oncology 2010

24. Stage 1 disease
Low risk
Chemoradiotherapy
is not required
Fertility Preservation
desired:
Uterus and C/L
ovary can be saved
Fertility Not desired:
TAH+BSO
High risk
TH+BSO
+ complete thorough
surgical staging
± chemotherapy

25. WHAT IS THE POST
OPERATIVE
MANAGEMENT
IS THERE ANY
ROLE OF
ADJUVANT
CHEMOTHERAPY
??

26. What is the preferred
chemotherapy in stage 1 cancer?
• adjuvant
chemotherapy
unnecessary
A) Early
stage,
Low Risk:
• Chemotherapy must be prescribed,
according to pt.
• T/t with carboplatin and paclitaxel
for 3-6 cycles
• Single agent carboplatin preferred
in older woman with medical co-
morbidities
B) Early
stage,
High risk

27. Should paracentesis be done in
ovarian carcinoma?
A woman with a pelvic mass and ascites can be assumed to
have ovarian cancer until proven otherwise surgically. -William’s
Gynaecology 3rd edition .
This procedure is avoided diagnostically
as cytologic results are nonspecific, and
abdominal wall metastases may form at
the needle entry site (Kruitwagen, 1996).
William’s Gynaecology 2nd edition 2008.

28. IS THERE ANY ROLE
OF CT AND USG
GUIDED FNAC IN
OVARIAN CANCER??
Diagnostic cytology - poor sensitivity to detect
malignancy.
Aspiration of a malignant mass induce spillage and
seeding of cancer cells into the peritoneal cavity ,
thereby changing the stage and prognosis.
Accuracy of CT scan - poor for differentiating a
benign from a malignant tumour when the disease is
limited to the pelvis.

29. USG guided FNAC can be done in
patients with advanced disease
(Presence of omental cake
,Metastasis to liver and other
organs) when considering the need
of neoadjuvant chemotherapy ,for
histopathological confirmation of
cancer.

30. Case 2
• 20 year old Unmarried female presented with C/O-
1. Lump in abdomen which progressively increased in size
since 3 months
2. History of irregular menstrual bleeding since 3 months
3. Pain abdomen since 1month
• ON EXAMINATION:
General examination-WNL
P/A- large abdominopelvic lump felt,filling the whole of
lower abdomen,Lower margins could not be palpated.
No oraganomegaly
P/R-Same lump felt and rectal mucosa free
WHAT IS THE DIFFERENTIAL DIAGNOSIS
WITH THIS PRESENTATION?

31. TAS :
Shows a Well defined heterogeneously enhancing cystic lesion of
14.6*11.7*9.7 cm extending from Right Adnexa upto umbilical
raphe,Uterus not seen separately from mass.
BIOMARKERS:
CA125-183.2IU/ml
LDH-324 U/L
AFP,HCG,PLAP adviced –but not done
MRI-
Mild hepatomegaly with right ovarian mass ,solid and cystic
components seen.KUB Region –WNL
HOW TO PROCEED FURTHER?
BIOMARKERS
TRANS ABDOMINAL
SONOGRAHY
MRI

32. She underwent Exploratory laparotomy with Right sided
oophorectomy ,pelvic lymphadenectomy,infracolic omentectomy
and biopsy taken from contralateral ovary .
INTRAOPERATIVELY :
Uterus was found to be normal in size
There was huge mass arising from right
sided ovary with preoperative rupture of
the capsule.
Left sided ovary found to be normal.
No free fluid in abdominal cavity.
On clockwise palpation of the intra
abdominal organs ,no abnormality seen
DOES THE RUPTURE OF CAPSULE CHANGE THE
STAGE OF THE DISEASE?
SHOULD THE OTHER OVARY BE REMOVED?
YES
NO

33. HPE Report-
• Large Right ovarian mass –yolk sac tumor,
ovary with mixed germ cell (Embryonal
carcinoma and dysgerminoma )
• Left ovarian cyst –haemorrhagic corpus luteal
cyst
• Omentum-chronic non specific omentitis with
focal haemorrhagic area.
What is the stage of the
disease?
IAC2

34. SHOULD THE UTERUS BE
REMOVED?
WHAT IS THE INCIDENCE OF
BILATERALITY IN GERM CELL
MALIGNANCY
NO
10-15%
• In the first two decades of life ,almost 70% of ovarian tumors
are of germ cell origin and 1/3 rd of these are malignant..
• Dysgerminomas is the only germ cell tumour that has high
rate of bilaterality.

35. Frozen section,if possible should be done to
determine the radicality of the surgical treatment
while still aiming for conservative treatment.
WHAT IS YOUR OPINION ABOUT FERTILITY
SPARING SURGERY?
ROLE OF FROZEN SECTION IN SUCH
CASES?
Malignant germ cell tumors are highly aggressive
neoplasm but chemo sensitive and early
intervention and fertility sparing surgery is required
for any adolescent girl presenting with rapidly
enlarging pelvic mass

36. Case 3
A 42 year old P2+0 presented with C/O –
lump felt in abdomen and menstrual irregularity since 3 months,
ON EXAMINATION:
• P/A-
*18-20 wk size abdominopelvic lump felt,
*firm to hard in consistency,
*restricted mobility present.
• P/V/R- same mass felt ,uterus could not be felt separately,Rectal
mucosa free
HOW TO PROCEED NEXT??

37. WHAT INVESTIGATIONS
SHOULD BE ADVICED??
AFP-220 ng/ml
CA125 -417.8 IU/ml
USG-Splenomegaly,Right sided tubo ovarian
masses seen,Uterus slightly bulky,ET -15
mm,endometrial hyperplasia present.
MRI-Right sided malignant multiloculated,solid
,cystic mass of approx. 10*12 cm in size,left
sided adnexal mass of 6*7 cm in
size.?Malignancy.
No paraaortic and pelvic lymphadenopathy,
No omental caking,
Rest -WNL
BIOCHEMICAL
RADIOLOGICAL

38. • WHAT IS YOUR PROVISIONAL
DIAGNOSIS?

39. INTRAOPERATIVE FINDINGS:
• On intraabdominal palpation ,liver,spleen,mesentery found to be normal
• Right ovary enlarged 12*15cm ,
• Left ovary 7*8 cm,
• Capsule intact of both ovaries
• No peritoneal deposits
• No palpable lymphadenopathy
• On Cut section of uterus- Myohyperplasia present ,no other abnormality seen.
• Here ,Her Exploratory Laparotomy with TAH +BSO , infracolic
omentectomy + Peritoneal fluid cytology performed +Pelvic LN Sampling
done.
• WHAT IS THE STAGE OF THE
DISEASE?1B

40. HPE REPORT OF SAMPLE-
RIGHT OVARY CYST –MATURE TERATOMA
LEFT OVARY CYST-CYSTIC TERATOMA HOWEVER ONE AREA
SHOWS SMALL NEUROEPITHELIUM LIKE ISLANDS IN GLIAL
AREA.
OMENTUM FREE OF DISEASE
UTERUS FREE OF DISEASE
• WILL CHEMOTHERAPY
BE REQUIRED IN THIS
CASE?
NO

41. Case 4
• A 55 Year old,P3+0 Was referred to our setup for interval
debulking,the patient gives history of receiving 3 cycles
of chemotherapy at a private hospital in lucknow.
HOW TO PROCEED IN SUCH
CASES?
ON EXAMINATION-
P/A-Tense shiny skin
Tense ascites present
Abdominopelvic mass of 28 wks size
P/V-Size of mass could not be assessed , fullness in fornices and
pouch of douglas.

42. • CECT Abdomen-
Post chemotherapy ,residual cystic mass lesion of
size 20*17.5*15.5 cm with thick internal septations in
pelvic region.
Interface between mass and adjacent bowel loop is
ill defined s/o Adhesion.
Mass is abutting anterior wall of rectum ,ill defined
interface.
Mass is abutting B/L iliac vessels,Bowel loops
displaced and omental caking present.
CA 125=172.7 IU/ml
COMPLETE EVALUATION DONE WITH
DOPPLER IMAGING,CT Evaluation AND
MARKERS -CA125
Chest Xray

43. Intraoperatively :
• Ascitic fluid -6 litres
• Left ovarian mass (25*20cm)with cystic component and
preoperative rupture of capsule
• Right ovary 10*15 cm with capsule intact.
• Bladder densely adhered to anterior aspect of uterus .
• Pelvic peritoneum was studded with multiple small deposits <2
cm
• Bowel adhered to the mass on left side ,omentum on superior
aspect of uterus.
• Omental caking present.
• On clockwise palpation Small intestine,large
intestine,mesentery was found to be normal.
• No palpable pelvic lymph nodes
• The Patient was taken for INTERVAL CYTOREDUCTIVE
SURGERY-
WHAT IS THE STAGE OF
CANCER IN THIS PATIENT? IIIC

44. WHAT IS THE STAGE WISE
PROGNOSIS OF THE DISEASE?
I 94%
II 73%
III A
B
C
41%
25%
23%
IV 11%
5 YEAR SURVIVAL

45. Patient was referred to JKCI for further
chemotherapy.

46. Case 5
• A 56 yr old pt came to our OPD:
C/O lower abdominal pain and
H/O Primary cytoreductive surgery followed by 6
cycles of carboplatin and paclitaxel.
Patient was completely asymptomatic for 1 year
after the last chemotherapy .
After 1 year during her follow up -CA-125 level -
576 U/mL and Liver enzymes were raised.
WHAT ARE YOU SUSPECTING? RECURRENCE

47. How do we follow up a case
of ovarian cancer after
completion of
chemotherapy?
FOLLOW UP VISITS
First 2 years – every 2-4 months
Next 3 years- every 3-6 months
After 5 years- once a year
FOLLOW UP TESTS-
Physical and pelvic examination
CA 125
Chest X ray
CT,MRI,PET as needed or directed by the symptoms..

48. How do we decide the
management of
recurrent ovarian
cancer?

49. If the remission occurs after
6 months of treatment,the
cancer is considered as
PLATINUM SENSITIVE,that
means platinum based
chemo worked well against
the cancer
If the remission occurs
before 6 months of
treatment, the cancer is
considered as PLATINUM
RESISTANT
PLATINUM SENSITIVE PLATINUM RESISTANT
-Carboplatin&
Gemcitabine
-Carboplatin,
Gemcitabine&
Bevacizumab
-Carboplatin &
Paclitaxel
Second line drugs:
-Cyclophosphamide
& Bevacizumab
-Liposomal
doxorubicin &
Bevacizumab
-Topotecan

50. IS RADIATION THERAPY
EFFECTIVE IN RECURRENT
OVARIAN CANCER?
• Whole abdominal radiation therapy given
as a t/t for recurrent or persistent disease
is associated with a high morbidity and is
not used.
• It is only palliative.
• Principal problem that develops with
radiotherapy is acute and chronic
intestinal morbidity (about 30%).

51. CASE 6
• 36 year ,P2+0 underwent B/L
oophorectomy at some private hospital
(Histopathology showed
Adenocarcinoma), and was referred to
JKCI for chemotherapy for 6 cycles.She
was then referred to our set up for
completion surgery.
HOW TO PROCEED FURTHER?

52. WHAT SHOULD BE THE
PROPER
MANAGEMENT IN
SUCH CASES?
IDEALLY WHEN THE FINDINGS ARE SUGGESTIVE FOR
ADENOCARCINOMA ,THE PATIENT SHOULD HAVE BEEN TAKEN
FOR CYTOREDUCTIVE SURGERY AND THEN FOR
CHEMOTHERAPY.

53. Case 7
A 62 yr old post-menopausal female :
• C/O frequent micturition, flank pain,loss of appetite.
ON EXAMINATION-
• P/A- soft and nontender
• P/V- A vague mass felt more on the right side ,Uterus
atrophic,Retroverted
TAS - simple, unilocular, right ovarian cyst of size 5cmx4cm
CA 125- wnl
Should surgery be done in this patient?
If yes then which surgery?

54. RCOG GTG no 34 for management
of post-menopausal ovarian cyst
Recommended
that , in normal
CA 125 levels ,
be managed
conservatively.
A ‘risk of malignancy
index’ is used to select
women who require
primary surgery.
No routine role for
Doppler, MRI, CT or PET.
Ovarian cysts in
postmenopausal
women
assessed using
CA125 andTVS.
Simple,
unilateral,
unilocular
ovarian cysts, <
8 cm in diameter
- low risk of
malignancy.
Aspiration is
not
recommended.

55. Outcome
• The patient and attendants were
counselled for the expectant
management/surgery,they opted for
expectant management.
• The patient is under regular follow up with
no symptom/sign suggestive of malignant
changes.

56. Take home messages
•Early diagnosis and treatment are the key to fighting
ovarian cancer.
•No sensitive screening test is present, so awareness
among high risk population is the best option available.
•Ca-125 levels along with TVS are the preferred
diagnostic modality.
• Staging laparotomy along with TAH+BSO +
omentectomy remains the mainstay of the treatment.
•Chemotherapy has an important role to play in the
management of ovarian cancer.
•Newer targeted therapies have increased our hopes and
deserve a fair trial.
•Patients need extensive follow-up.

57. Thank you panellists and audience!