LWBK1006-23 LWW-Govindan-Review December 12, 2011 19:10
Chapter 23•Gynecologic Cancers 311ANSWERS
Answer 23.1.1. The answer is C.
This woman should be referred for genetic counseling and possible genetic
testing. Some 40% to 60% of patients of Jewish descent who have epithe-
lial ovarian cancer carry one of the three founder BRCA1 or BRCA2 muta-
tions (irrespective of family history). These, like other BRCA mutations,
are inherited in an autosomal dominant manner, through either the pater-
nal or maternal side. If this woman carries a BRCA1 mutation, her lifetime
risk of ovarian cancer is 20% to 60%, and her risk of breast cancer is even
higher. Although transvaginal ultrasound and CA-125 screening are gen-
erally recommended for mutation carriers who have their ovaries in place,
there is no good evidence that such screening will decrease mortality. Oral
contraceptives have been suggested to decrease the risk of ovarian cancer
by up to 50%. Removal of the ovaries likely confers the best method for
reducing the risk of ovarian cancer; it remains controversial whether the
uterus should be removed as well.Answer 23.1.2. The answer is D.
Understaging is common, particularly when the preoperative diagnosis
is that of a benign process. Earlier laparoscopic surgical staging series
suggested that up to 30% to 40% of patients thought to have FIGO
stage I or II disease actually had disease in the upper abdomen. The
incidence of extraovarian spread will be lower with a grade 1 tumor.
Nonetheless, complete surgical staging, if possible, is advised in this case,
because the recommendation for a stage IA grade 1 mucinous tumor is no
chemotherapy. Although some data have suggested that advanced-stage
mucinous tumors may respond less well to chemotherapy than serous
tumors, a low-grade early-stage mucinous tumor does not have a poor
prognosis. However, chemotherapy would be recommended in the case of
any extraovarian spread. In the hands of an experienced surgeon, laparo-
scopic staging, including omentectomy and para-aortic lymph node exam-
ination, is an option. Preservation of the uterus and contralateral ovary
is reasonable if no further disease is found at the time of staging. CA-
125 is frequently normal in women with mucinous ovarian tumors, even
when of advanced stage. A PET scan will not detect microscopic disease,
may not be positive in low-grade malignancies, and is not likely to be
helpful.Answer 23.1.3. The answer is C.
CA-125 is not useful for screening because early-stage ovarian cancer has
an elevated CA-125 approximately 50% of the time. Furthermore, the
positive predictive value of an elevated CA-125 is very low because many
things cause an elevated CA-125 and the prevalence of the disease is quite
low. It is not particularly useful in the diagnosis of ovarian cancer for the
above reasons. It is useful in monitoring treatment.