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What will you look for on history and physical?

A 57 yo female presents to the emergency room with a large pelvic mass. Answer the following questions regarding her management. What will you look for on history and physical?. HISTORY (name Risk Factors) Age Ethnicity (Ashkenazi Jewish, white) LMP, menopause Status

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What will you look for on history and physical?

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  1. A 57 yo female presents to the emergency room with a large pelvic mass. Answer the following questions regarding her management.

  2. What will you look for on history and physical? HISTORY (name Risk Factors) • Age • Ethnicity (Ashkenazi Jewish, white) • LMP, menopause Status • PMH: Cancers: breast, uterine, ovarian, colon, lymphoma, DM, HTN, obesity, • PSH: TL, Ovarian cysts, OR/ pathology reports • FAMILY HX: breast, uterine, ovarian, Colon, lymphoma, endometriosis, fibroid • MEDICATIONS: no OCP, HRT • ALLERGIES: • HABITS: smoking ETOH, drugs • SOCIAL: occupation, marital status • POBS: GPTLA, nulliparity, infertility, IVF, did not breastfeed • PGYN: • early menarche, late menopause, regularity of cycles, PAP hx, STI’s/PID, PCOS, • Hx of pelvic radiation, last mamo/ colonoscopy) (BRCA, HNPCC, age of Dx) • benign gyn pathology (endometriosis, ov cysts, fibroids, adenomyosis), hot flushes, vag dryness, PM bleeding • HPI: • abd pain/bloating, N/V, urinary frequency / urgency/dysuria, constipation / diarrhea/dyschezia, bloody stool, early satiety / anorexia, vaginal bleeding, constitutional symptoms: fatigue, weight loss, weakness, anorexia. • Symptoms progression/duration • Activities of daily living/ functional status

  3. PHYSICAL EXAM • VITAL SIGNS, height weight BMI, general appearance • LYMPHADENOPATHY: supraclavicular, inguinal, pelvic • HEENT: thyroid, nodes • CVS • RESP: pleural effusion • BREAST EXAM • ABDOMINAL EXAM: ascites, masses, tenderness • PELVIC, RECTAL AND PV/PR (cul de sac nodules/masses)

  4. What work up you want to do? • CBC, T & S • Creatinine, BUN, lytes, LFT • CA-125, CEA, CA 19.9 (mucinous, pancreas), 15.3 (breast) • Pap test • Cultures, endometrial Bx if indicated • ULTRASOUND for RMI 2 score (TVUS and Abd) • CXR, ECG • r/o other primary as Hx indicates: Barium enema, colonoscopy, mammogram • UA, cytology, C&S if positive hx • BHCG • Paracentesis/ omental bx can be considered: often non diagnostic. Still need surgical staging • CT/ MRI/ bone scan/ PET not necessary pre-op if US and RMI score abnormal

  5. What is your differential diagnosis of a pelvic mass? Benign (Ovarian/ Other Gyn/ GI/ GU) • Endometrioma • Dermoid • Cystadenoma • Functional ovarian cyst • Ruptured / hemorrhagic ovarian cyst • Fibroid, adenomyosis • TOA, hyrdosalpinx, paratubal cyst • Ectopic (pre menopausal) • Diverticulosis • Pelvic kidney MALIGNANT • Primary Ovarian CA (epithelial)- borderline, cystadenocarcinoma • Sex cord / stromal tumor (Granulosa cell causes PMBleed, SertoliLeydig) • Metastatic Ovarian (breast, stomach etc) • Endometrial CA, • Cervical mass/ cancer • Uterine Sarcoma • Fallopian Tube Ca • Colon • Lymphoma/ Leukemia • Germ cell tumors usually NOT in this age group (different OSCE)

  6. What are the ultrasound criteria suggestive of an ovarian malignancy? • Multiloculated, complex mass • Solid echogenic components • Bilateral • Ascites • Peritoneal nodularities • > 5 cm • Thick septations • Papillary excrescences • Central vascularity on Doppler

  7. List the specific criteria and scoring system for the RMI II. What is the specificity of this index? • RMI II = ultrasound score x [CA-125 level] x menopause score • RMI II > 200 high risk of malignancy, Refer to gyn onc. • List the components of the RMI 2 • U/S score: Multilocular cyst, presence of solid areas, bilaterality, presence of ascites, presence of intra-abdominal mets • 1 = 0 or 1 abnormality, 4 = 2 or > abnormalities • Menopausal score: • Premenopausal = 1 and Postmenopausal = 4 • Specificity of RMI II: 90% ppv = 80%

  8. Your patient’s result show the following: • TVUS: bilateral ovarian masses, solid & cystic components and ascites • CA-125: 100 • How much is RMI score and how will you manage her?

  9. Your patient’s result show the following: • TVUS: bilateral ovarian masses, solid & cystic components and ascites • CA-125: 100 • How much is RMI score and how will you manage her? • 4x4x100 = 1600 • Refer to Gynecology Oncology

  10. What will be the proposed management by the GYN-ONC team for this 57 yo? • COMPREHENSIVE SURGICAL STAGING • Midline laparotomy • Peritoneal washings • Inspection/ palpation • Diaphragm, surface and parenchyma of liver, gallbladder, stomach, spleen, R+L kidney, R+L paracolic gutters, small bowel and mesentery, appendix, ascending, transverse, descending and rectosigmoid colon and mesentery, omentum, lesser sac • PALN and PLN, ovaries, tubes, uterus, bladder peritoneum and cul-de-sac. • TAH BSO frozen section • Retroperitoneal lymphadenectomy (pelvic, paraaorticnodes) • omentectomy • diaphragmatic scrapings / biopsies • Peritoneal biopsies of suspicious areas or adhesions • If no disease, multiple biopsies of peritoneum from cul-de-sac, paracolic gutters, bladder peritoneum, intestinal mesenteries

  11. Pathology of frozen section result shows Grade 2 papillary serous adenocarcinoma of the ovary. The patient’s pelvic lymph nodes are positive. No mets are seen. What is her surgical stage? • Stage IIIA1

  12. What will be the management for this patient? • Primary cytoreductive surgery Aiming for Optimal debulking (< 1cm macroscopic residual) • Chemotherapy: 6-9 cycles IV carboplatinum & paclitaxel • Or neoadjuvant chemo 3 cycles followed by interval debulking followed by adjuvant chemo for 3 cycles.

  13. Name 3 serious side effects of Carboplatin, Cisplatin and Paclitaxol • Carbo: myelosuppression(esp Platelets), hypersensitivity, less N&V and neuropathy • Cisplatin: nephrotoxic, neuropathy, severe N&V, metallic taste, anorexia, ototoxicity, hypersensitivity, less hematologic toxicity than carbo • Paclitaxol: myelosuppression, hypersensitivity, neurotoxic, alopecia

  14. Patient presented 15 months later with an evidence of recurrent disease and she asked you about surgerywhat is the role for secondary cytoreductive surgery? • No evidence of ascites or ascites less than 500 cc • Solitary site recurrence • Platinum sensitive disease • Prolonged disease free interval > 12 months

  15. What is the definition of Platinum sensitive/ resistant/ refractory? • Platinum sensitive = no recurrence more than 6 months after completion of primary platinum based chemo • Platinum resistance = less than 6 months before recurrence • Platinum refractory = progression while on primary platinum chemo

  16. what hereditary syndromes that you know can give rise to ovarian cancer ? • BRCA1, BRCA2 • HNPCC (LYNCH SYNDROME)

  17. What % of Ovarian cancers are hereditary? Name 3 genetic mutations. • 5 – 10% of all ovarian cancers: BRCA1, BRCA2, HNPCC • lifetime risk of ovarian ca BRCA1 – 40%, BRCA2 – 25% • lifetime risk of breast ca for BRCA1 or BRCA 2 – 56-87% • Occur 10 years earlier than non-hereditary ca

  18. What are the risks of ovarian and breast cancer in the general population and in BRCA patients? • Breast Ca: 12% vs 80% • Ovarian Ca: 1.3% vs 25% (BRCA2) vs 40% (BRCA1)

  19. Describe management of pts with BRCA mutations • Annual or biannual TVUS, CA 125 and pelvic exam • Mammography starting at age 30 if strong family hx of breast ca alternating with MRI every 6 months. • Prophylactic BSO done at age 40, post-op risk reduced to 0.8%, doesn’t protect against peritoneal ca (4%), decreases risk of breast ca significantly, consider TAH BSO (reduce FT ca) • OCP: Women with BRCA mutations can reduce ovarian cancer risk by 60% • TL: reduces risk by 39%, decreases blood supply to ovary and decreases carcinogens passing via tube into pelvis • If documented HNPCC, periodic mammography, colonoscopy and endometrial biopsy and urine cytology

  20. How is BRCA Prognosis different from other ovca patients • Improved overall survival for BRCA cancers • High grade • Papillary serous histology • More sensitive to radiation • More sensitive to chemotherapy • longer interval to recurrence

  21. What type of ovarian Ca can you get after TAH BSO? • Primary peritoneal carcinoma

  22. What is the risk of ovarian ca in HNPCC pts? & What % of hereditary ovca is due to HNPCC? • 3-fold increase risk in ovarian ca • 16% of hereditary ovarian ca

  23. What decreases a woman’s risk of Ov Ca? • Surgery: TL, BSO, Salpingectomy • Decreased estrogenic effect: Multiparity, breastfeeding, OCP

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