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Ovarian Cancer

What I would like to do this morning is to talk a little bit about ovarian cancer, how we approach it as a disease and to talk about a few other topics toward the end that you may asked by your patient’s and some of the other things you may see in the literature. Ovarian cancer, numbers are increasing, I first started giving this talk a few years ago, and there about 19,000 new cases a year, we are up to about 24,000 some of the other series even up closer to 26,000 cases a year. It causes 5% of all cancer deaths in women today, it causes more death in women than both cervix and endometrial cancers combined do.

Ovarian cancer, although it peaks ages around 50 to 60 years of age, we do see it in younger patient’s, the youngest patient I have had, and this talk only pretty much deals with epithelial ovarian cancer, was 19 years of age, she died when she was 21 and that was a very typical epithelial ovarian cancer, and we do have, unfortunately in my practice, I probably have 10 to 15 patient’s who are about 25 years of less than 30 years of age.

We look at things that increase the risk of ovarian cancer, most of these risk factors we have here are typical from a lot of cancers, the high fat diet, industrialized environment, advanced age, use of genital talc is an interesting one, and this is done mostly from pathologic slides looking with the polarized microscope and you can actually see some talc crystals in some ovarian cancers. Other things to look at have to do with the amount of ovulations that women may have during their life time, the move ovulation and easy way to remember pros and cons of ovarian cancer are risks and things that decrease the risk are how many ovulations.

Symptom are very vague usually, and I’m sure everyone has seen these, most of the time the symptoms are all related to more advanced stage cancers, at times we will get fortunate and someone will have a torsion, so someone just having a routine pelvic exam diagnosing in stage I disease. Ovarian cancer spreads two ways, one is intraperitoneally and this is an ovarian cancer here in probably the right ovary, you can see the peritoneal seating and spread, and if we remember inside the peritoneal cavity, there is a clockwise motion of the fluid, so very early on, we will find disease under the diaphragm on the right side.

II is confined to the pelvis, stage III is what we usually will see and that’s when disease is outside the pelvis in the peritoneal cavity and the omentum, or in the retroperitoneal lymph nodes, they always love putting inguinal lymph nodes which is part of the staging, actually still a stage IIIC, not a stage IV, the inguinal lymph nodes are included with the pelvics and periaortics.

Surgical staging is very important, and this is a very old trial now, this was out of the NCI, had a protocol for their patient’s who were referred in with "early stage ovarian cancer, so there were patient’s who had surgery by their gynecologist found in ovarian cancer, the gynecologist thought they were a stage I or stage II, referred them to the NCI for treatment.

The role of laparoscopy in ovarian cancer, we are still trying to determine, and the problem is, we really don’t always know what’s inside these large masses, I had one patient referred to me that had an 18 cm solid mass removed through a laparoscope, it was a granulosis cell tumor, proceeded to seat all of the ports. The evidence on the rupture of these cysts.

Important thing is the type of incision you make. Gynecologists are in love with Pfannenstiel incisions and I do have a slide I couldn’t find that showed a woman lying a beach sunning herself with a vertical incision in her bikini and the woman with the Pfannenstiel incision in the coffin, so you cannot stage ovarian cancer through a Pfannenstiel incision, it’s not possible back in that NCI study, they found that 80% of their incisions in that study, they felt were inadequate to stage the patient, you have to be able to get under the diaphragm. If you have a very thin patient, you can often times use a malard incision and get high enough.

Early stage disease, this again is an older trial, this is looking at stage IA or IB tumor, so either one or both ovaries are involved, they have no tumor on the surface, your washings were negative, you had no ascites, an early grade tumor, either a grade I or grade II tumor, these patient’s were randomized to either observation of six months of Alkeran and there was no difference in the survival rate, so out of this study, we essentially not treat these patient’s with early stage disease.

The other groups outside of this early stage disease, if we look at the stage IC or the stage II which are completely resected, we have never had a real trial that compares that group of patient’s with observation alone, it never was felt to be ethical to do that, so that group of patient’s pretty much is all treated now routinely with chemotherapy, we’ll talk about that in a little bit. We do pretty well in the large trials that are done in adequately staged patient’s, put the prognosis in our early staged patient’s at greater than 80% . Unfortunately, we see way too much of this in our practice.

Again, with some varied techniques, we can get rid of a large amount of tumor, and whenever we talk about tumor reductive surgery, it’s defined not by how much is removed, and often times I will get reports that say 90% was removed. That really doesn’t help us. What we’re looking for when we talk about tumor reductive surgery, is what is the largest diameter of the residual tumor. So if you have one mass that’s 2 cm and that’s all that’s left, that’s still considered a suboptimal resected patient. So it’s always the largest diameter, how much you take out, it really matters, nothing in the staging of out patient’s.

We look at why do we do all this, this is probably not seen real well, but essentially, this is an older trial, looking at 2 cm as the residual disease cut off. We can see our survival rates are about twice as long, or graphically with some of the data out of the GOG, we can see this line here, the lower line is the suboptimally resected patient’s, patient’s who had disease greater than 1 cm, the top line is microscopic residual disease, which is a about 55% survival rates.