early detection ovarian cancer.gps2010 dr yudi
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8/7/2019 Early Detection Ovarian Cancer.gps2010 Dr Yudi
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EARLY DETECTION INOVARIAN CANCER
Yudi Mulyana Hidayat
DEPT OF OBSTETRIC AND GYNECOLOGY
PADJADJARAN UNIVERSITY BANDUNG
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objectives
The fisiology of
ovarium
Statistic and fact
of ovarian cancer
Symtoms and
risk factor of
ovarian cancer
Screening
ovarian cancer is
still necessary?
Methode of
screening
ovarian cancer
summary
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Ovarian Physiology
The ovary has two mainfunctions:
1-Reproductive function:
produce gametes.
2-Endocrinal and metabolic function: produce hormones.
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Ovarian Physiology
The ovary is a complex metabolic organ
consisting of follicular and stromal
compartments.
1-Follicles: produce both androgens
and estrogen.2-Stromal tissue: synthesizes
androgens.
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Statistics The average age when ovarian cancer is
detected in women is 56.3 years.
Less than 1 out of 10 of the woman said had nosymptoms prior to diagnosis.
More than 25% of the women sought help from amental health professional.This suggested thatwomens concerns were not being fully
addressed and symptoms may have beenmistakenly attributed to stress or depression.
About 1 in every 70 women will develop ovarian
cancer in their lifetime.
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Symptoms
Abnormal vaginalbleeding and discharge
Fatigue and fever
Abdominal swellingand bloating
Infertility or changes in
menstruations
Gas
Nausea
Bowel disturbance Pelvic pain
Not all symptoms can be caused by cancer.Often there are no symptoms in the early stages and
the cancer has spread by the time it is found out.
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Risk factors
Family medical history- increased if closerelatives has it.
Use of infertility drugs
Not having children
Age- women over 50 are at risk and the riskincreases with age
Personal medical history- women with breastcancer are twice as like to get ovarian cancer
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Table : Score for Womens
History
History Score
Family history of ovarian carcinoma 2
Past or family history of genital, breast or
colon
1
Negative history of oral contraceptive 1
Nulligravida 1
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02/24/2003Epidemiology of ovarian c ance r 12
97.3
73.465.4
41.6
0 50 100 150
% survival
Ovary
Cervixc.uterus
Trophob
5 years survival rate of
gynecological cancer (FIGO, 1998)
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02/24/2003Epidemiology of ovarian cance r 13
72.8 %
46.30%
17.2 %
4.8 %
1
Stad I
Stad II
Stad III
Stad IV
Survival 5 tahun kanker
ovarium,FIGO,1998
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Tumor mark er
Ca 125 ( Carcinoma antigen )
Ca 72-4LAI ( Leucocyt e Adher enc e
inhi bition t est )
Transvaginal Ultrasound ind eks morfologik
Transvaginal Color D oppl er ( C D T )color flow doppl er
Cancer Ovarium Screening Strategies
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Ultrasound
Both transabdominal and transvaginaltechniques identify enlarged ovaries or abnormalmorphology;TVUS has better resolution
One large study of TVUS underway has reportedsensivity of 81% and specificity of 98.9%
Major limitations are poor PPV in asymptomaticwomen and inability to detect malignances when
ovaries are normal size Allows earlier stage detection
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Figure : (a) At US, ovarian mass shows fine, particulate, evenlydistributed echoes, consistent with an endometrioma.(b) Repeat scan of ovarian mass shows resolution of
particulate appearances, consistent with organization of anendometrioma.
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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
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Figure: ( a ) Color flow image of right adn ex a obtain ed with endovaginal t echn iqueshows a compl ex right adn ex al mass with contain ed, apparently sol id el ements .Not e that through t ransmiss ion is good, and the cont ents of this mass arecompl et ely avasc ular. Thes e appearanc es are cons ist ent with an endomet rioma.
(b) Color flow US scan of l eft adn ex a obtain ed with endovaginal t echn ique. Thereis a p art ially cyst ic and part ially sol id mass in the l eft adn ex a. Despit e good through t ransmiss ion in the cyst ic part of this mass, there is vasc ularizat ion in thesol id
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Figure : US s can of cystic and solid right ovarian mass w ith pe ak-systolic ve locitie s of 18.8 cm /se c and e nd-diastolic ve locitie s of 11 cm /se c. giving an RI of 0.41. S urge ry re ve ale d a stage I Carcinoma of ovary
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Appearance Score
Atro phic 0
Volume >8cm. 1
Sim ple anechoic <3cm 1Sim ple anechoic <5cm 2
Sim ple anechoic >5cm 3
Multilocular <5cm 2
Multilocular >5cm 3
Com plex, cyst with echoic shadows. 4
Solid cyst (solid areas >50%) 5
Table :Scoring for US appearance ofovaries
Professor Galal Lotfi Obstetrics & Gynecology Suez Canal
University.Egypt
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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-gynecologicmalignancies as well as benign conditions)
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CA-125
Malignant conditions
CervicalCA
Fallopian tubeCA
EndometrialCA
PancreaticCA
ColonCA
BreastCA
Lymphoma
Mesothelioma
Benign conditions
Endometriosis/Menses
Uterine fibroids
PID
Pregnancy
Diverticulitis
Pancreatitis
Liver disease Renal failure
Appendicitis
IBD
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Diagnosis of ovarian tumor
P rocedure Se Sp P pv Npv Acura
Color doppler 70 .0 84 .4 77 .8 83 .6 81.7
USG Morf 90 .0 6 5 .2 6 0 .0 91.8 74 .3
Ca 125 70 .0 6 0 .9 50 .9 77 .8 6 4 .2
Ca 72-4 40 .0 84 .1 59 .3 70 .7 6 7 .9
Ca 19-9 35 .0 6 8 .1 39 .9 6 1.4 59 .0
Kawai et al, 1994
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Current Screening Guidelines
Routine screening for ovarian cancer byultrasound, the measurement of serum tumormarkers, or pelvic examination is notrecommended. There is insufficient evidence torecommend for or against the screening of asymptomatic women at increased risk of developing ovarian cancer.
U.S.Preventive ServicesTaskforce, Guidelines from Guide to
Clinical Preventive Services, 2nd edition, 1996
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Screening Guidelines contd
NIHConsensusConference (1994)
women with presumed hereditary cancer syndromeshould undergo annual pelvic exams, CA-125
measurements, andTVUS until childbearing iscomplete or at age 35, at which time prophylactic
bilateral oopherectomy is recommended.
ACP
counsel high risk women about potential harms andbenefits of screening
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Pe lvic Exam (PE) + VST
VST (+) VST (-)
Re pe at VST4-6 minggu Re pe at PE and VSTEve ry ye ar
Positif Ne gatif
Ca 125 CDTS onografi-morfologiLaparotomy
Not e:Post me nopause > 50 yFamili (+) > 30 y (2 fam)
VST: USG transvCDT: Color dopple r transv
Schreening of ovarian tumor
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Post me nopausal w ome n ( > 5 0 ye ars)
Ge ne tic and familial ovarian cance rge ne tic and ch romosome abnormalityhe re ditary ovarian cance r syndrome
sit e spe cific familial ovarian cance rbre ast/ovarian familial cance r syndrLynch II syndr (k olon,ovarium,e ndome t ,bre ast)
Ge ne tic risk Family re lations I st ( OR 3 .6 )Family re lations 2 nd ( OR 2 .9 )
Az iz M F.S cree ning and e arly de t e ction in obvarian cance rKO GI,B ali,199 0
Kelompok resiko tinggi
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F amilial Ovarian Cancer Centre (F OCC)
E xam. cost: clinis, USG, Ca 125 ( $ 16 8 .00 )
New patiens : $ 54 6.00 Book patients : $ 471.00
Screening cost for post menopausal women (AS):
$ 2,700,000 per 1 cancer case
Biaya skrining
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Summary
Screening for ovarian cancer ?? Ov arian cancer incidence
Good 5 years sur v i v al rate early stage (
90 % ) Poor prognosis 5 years sur v i v al rate for
ad v ance stages( 5 % )
Screening cost expensi v e For limiting groups screening
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Summary, 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
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How about prophylactic
ovarectomy ???
Risks And Benefits of
Prophylactic Oophorectomy
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