Ovaries in post-menopause woman:

Ok, now let c. By some tools either it’s sono or CT , or even laparatomy , u r viewing ovaries in post-menopause woman . What do u c? well, almost nothing. It’s like telling u, u r looking at thymus of normal healthy 45 year old man! What do u c? Nothing! Years before there were 2 ovaries , but now they r not.

So now normal situation to understand disease.

65 y old woman comes to your office , U examine her pelvic and sense one large mass in her adnexa . It can’t be real ovary! With her age , big big consideration for malignancy.
Another case of cancer? Maybe! Not 100% but big chance of malignancy. If u think u r not sure about your examination, send her to sono, but if u r sure , no need for sono.
Write for her checking CA125, LDH, HCG, alpha feto, estro, testos
Why? We call these tumor markers . Not specific for disease not sensitive for disease but it will give u a “ clue “ about type of tumor u r encountering and also it gives u a baseline for follow up.

So let c what is the scenario : 65y woman, no sign no symp , u did pelvic exam, found andnexal mass , checked CA125, LDH, HCG, alpha feto, testos, estrog.

There is one subtype of ovarian cancer which is asso with ascites . let’s R/O this one first.
CT Abdomen and Pelvic will show u the tumor , the size of it , the presence of ascites or absence of it .

UR CT scan showed no presence of ascites. Ok ! that subtype is R/O . now what?
Do u think we can start treatment? Put her on chemo? Give her big radiation shot at pelvic? Or do you like to c this mass under microscope? Don’t u want a tissue of this mass for establishing diagnosis? Of course u want !

Ok. Operation Room. Pt in under general anesthesia , u open her abdomen, and cut her mass , which almost means u r doing “ unilateral salpingo oopherectomy “ remember? There is no ovary there ! so if u cut the mass, u r cutting every thing there.

U call pathologist and send him frozen section and want him to tell u ASAP is it benign or malignant? Better bet to go with malignancy in this age. So he reports for u the section taken out is malignant.

U r still in OR, pt in still under gen anesthesia and it’s better to deal with tumor here! And what a procedure we r going through! Consider Arnold in OR, taking out his BIG KNIFE and thinks about Cutting her abdomen right away ! u ask him , u beg him “ please please don’t do this. Please please …” and he tells u “ This mass is big, this mass is agrresive , this mass is in axis of evil , no chemo no radiation alone will work on it and soon it will kill pt . so we have to “ DEBULK” it. “ ok! U think he is right too.
So he begin Debulking process : first he gets rid of uterine “ Total Abd hysterectomy “ or TAH , then we cut both ovaries and there utitlies Bilateral Salpingo Oopherectomy “ BSO. Then we cut Omentum covering some part of uterine “ Omentectomy “ . let’s cut some part of bowel 2 . Bowel resection!
Oh Man!! We did TAH+ BSO + Omentectomy + Bowel Resection!

Ok, u send pt into GYN ward and then??? R u finished? Your pt is fine? Well at least right now she lost 4-5 kg ! “thanx Doc! For making me a model! “ come on doc! U r dealing with one of deadliest malignancy in women population! Don’t let her go ! u r not done! U have to prescribe her Post Operation Chemo with Carbo and Taxol.

Oooooooooooof! After that big surgery now here it comes chemo! After chemo what do u want to do? Let her go? NO ! PLEASE! Do not let cancer pt go away! Follow her . although u did what u can, but it’s ur duty to take care of her, to follow her. Tell her she has to vist u every 3 months for 2 years and then every 6 months for another 2 years and in each visit she has to bring her CA125 with herself.

Dealing with the pathologist report “ benign “ is much easier . Both for u and ur pt. is she is good candidate for surgery , she gives u consent about TAH+BSO. Do it and follow her in yearls basis. That’s it.

Remember! Dealing with Ovarian cancer is hard, for u as a physician , for her as a pt and for her family due to fear of losing good mother.

Armin