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Laura MRCOG Part 2 > 17) Gynae-oncology: Ovarian > Flashcards

17) Gynae-oncology: Ovarian Flashcards

1
Q

Percentage of women requiring surgery for ovarian mass in their lifetime

A

10%

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2
Q

Risk of ovarian malignancy in premenopausal woman/at age 50

A

Pre-menopausal: 1 in 1000

Age 50: 3 in 1000

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3
Q

What percentage of suspected ovarian masses are non-ovarian in origin?

A

10%

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4
Q

Investigations in premenopausal woman with ovarian mass

A
  • TV USS according to IOTA rules
  • If suspected malignancy, tumour markers including CA-125, and if age < 40 years - LDH, aFP, hCG.
  • Calculate RMI
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5
Q

How is RMI calculated?

A

RMI = menopause status x ca125 x ultrasound score

Menopause status: 1 = pre, 3 = post
Ultrasound score: 0= 0 features, 1=1 feature, 3=2-5 features.
Features include: solid component, multiloculated, ascites, metastases, bilateral lesions.

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6
Q

What are the IOTA “B” and “M” rules?

A

B rules:

  • Unilocular
  • Solid components < 7mm
  • Acoustic shadowing
  • Multilocular smooth < 100mm
  • No blood flow

M rules:

  • Irregular solid
  • Ascites
  • > 4 papillary structures
  • Multilocular irregular solid > 100mm
  • Very strong blood flow
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7
Q

Management of premenopausal ovarian mass

A
  • RMI > 200 or any M rules refer to gynae-oncology
  • If simple cyst <5cm no follow up required (physiological and likely to resolve within 3 cycles)
  • If simple cyst 5-7cm - annual follow up
  • If >7cm consider MRI/surgical intervention
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8
Q

Risk of chemical peritonitis with spillage of dermoid cyst

A

0.2%

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9
Q

Which port should cyst be removed from?

A

Umbilical

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10
Q

Incidence of ovarian masses in postmenopausal women

A

5-17%

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11
Q

Management of postmenopausal women with ovarian mass

A
  • Calculate RMI
  • If RMI >200 refer gynae-onc
  • If RMI <200 and cyst is asymptomatic, simple, <5cm, unilocular and unilateral can consider conservative management with repeat RMI in 4-6 months (95-99% benign and 70% will have resolved). If any of those criteria not met recommend BSO.
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12
Q

Ethnic variation in Ca-125

A

Higher in Caucasian than African/Asian

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13
Q

Risk of malignancy based on RMI score

A

<25: <3%
25-250: 20%
>250: 75%

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14
Q

Diagnostic accuracy of cyst aspiration in detecting malignancy

A

25%

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15
Q

Risk of recurrence if aspiration only treatment for cyst

A

25%

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16
Q

Lifetime risk of ovarian cancer

A

1:50

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17
Q

Peak incidence of ovarian cancer based on age

A

> 60 years (highest rate group 75-79 years)

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18
Q

Top 6 female cancers

A
  1. Breast
  2. Lung
  3. Bowel
  4. Uterus
  5. Melanoma
  6. Ovarian
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19
Q

Risk factors for ovarian cancer

A
  • 15% genetic component (BRCA 1 - 50% risk, BRCA 2 - 20% risk, HNPCC - 10% risk)
  • Nulliparity
  • Early menarche, late menopause
  • Inferility
  • Perineal talc
  • Obesity
  • HRT
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20
Q

Classification of ovarian cancers

A
  1. Epithelial (90%)
  2. Sex cord stromal (5%)
  3. Germ cell (5%)
  4. Metastatic
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21
Q

Most common type of epithelial ovarian cancer

A

Serous 60% (then endometrioid 10-15%)

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22
Q

Most common type of stromal ovarian cancer

A

Granulosa cell 70%

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23
Q

Most common type of germ cell tumour

A

Dysgerminoma

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24
Q

FIGO staging ovarian cancer

A

STAGE 1: OVARIES
A) 1 ovary, capsule intact
B) 2 ovaries, capsule intact
C) Capsule not intact

STAGE 2: TUBES/UTERUS
A) Tubes/uterus
B) Other pelvic intraperitoneal tissues

STAGE 3: PELVIC PERITONEUM (includes capsule of liver/spleen but not parenchyma)
A) Retroperitoneal LN +/- microscopic mets
B) Retroperitoneal LN +/- macroscopic mets <2cm
C) Retroperitoneal LN +/- macroscopic mets >2cm

STAGE 4: EVERYWHERE ELSE
A) Pleural effusion
B) Liver/spleen/extra-abdominal organs

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25
Q

Percentage of Granulosa cell tumours which secrete oestrogen

A

70%

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26
Q

Percentage of women with granulosa cell tumours who have endometrial cancer and endometrial hyperplasia

A

Hyperplasia - 1/3

Cancer - 10-15%

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27
Q

Feature of sertoli-leydig cell tumours

A

Masculinising due to testosterone production

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28
Q

Percentage of people with epithelial ovarian cancer diagnosed at stage 3 or 4

A

> 70%

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29
Q

Why should every woman with high grade serous adenocarcinoma or G3 endometriosis cancer be offered BRCA testing?

A

> 10% will have a mutation (and 44% of these did not have a family history)

30
Q

Associations with endometrioid ovarian cancer

A

Ovarian endometriosis

15% endometrial cancer

31
Q

Associations with clear cell ovarian cancer

A

Pelvic endometriosis
Paraneoplastic hypercalcemia
VTE

32
Q

Relevant fact for mucinous cancer

A

May be ovarian primary but if invasive more likely to be mets from GI. Need to consider upper and lower GI endoscopy and at surgery remove appendix.

33
Q

Treatment for ovarian cancer

A

Early stage:
- Complete resection + platinum based chemo post-op

Late stage:
Cytoreduction of all macroscopic disease with chemo post-op (or neo-adjuvant chemo and then interval debulking if thought not to be possible as primary debulking)

34
Q

Prognosis for ovarian cancer

A 
5 year survival based on stage:
I - 90%
II - 45%
III - 18%
IV - 4%

Average 1 year survival 72%
Average 5 year survival 46%
Average 10 year survival 35%

35
Q

Side effects carboplatin

A 
Hypersensitivity
Nausea and vomiting
Nephrotoxicity
Neutropenia
Thrombocytopenia
Hypersensitivity
36
Q

Side effects paclitaxel

A 
Hypersensitivity
Nausea and vomiting
Nephrotoxicity
Neutropenia
Alopecia
Neurotoxicity
Arthralgia/myalgia
37
Q

Percentage of epithelial tumours which are borderline

A

15%

38
Q

Explanation of borderline ovarian tumours

A

No invasive characteristics (don’t grow into ovarian stroma, grow slowly and in more controlled way) but can break away e.g. into peritoneum and become invasive.

39
Q

Risk of recurrence in borderline ovarian tumour in contralateral ovary if only one removed

A

5%

40
Q

Cure rate for germ cell tumours

A

85%

41
Q

Percentage of dysgerminomas which are bilateral

A

15%

42
Q

What percentage of women with germ cell tumours present at early stage?

A

60-70%

43
Q

Management of germ cell tumours

A

Unilateral oophorectomy
Peritoneal washing
Omental biopsy
Selective removal of enlarged LN

If stage 1c or higher - Bleomycin/etoposide/cisplatin chemo.
If 1a/b can do surveillance - recurrence rate 20% the majority of which will then be cured by chemo.

44
Q

What percentage of recurrences of germ cell tumours occur in the first year?

A

75%

45
Q

Follow up of patients with germ cell tumours

A

Tumour markers and CXR every 2 months for 2 years and then 3-6m for next 3 years.

46
Q

What percentage of residual mature teratoma progresses as mature teratoma growing syndrome?

A

30%

47
Q

Percentage of women who regain menstrual function and fertility within 1 year of competing chemo

A

87-100% (3% have premature menopause)

48
Q

When is a family history considered significant when assessing ovarian cancer risk?

A
  • Known carrier of cancer gene mutation
  • Untested 1st degree relative of someone with known cancer gene
  • Untested 2nd degree relative (via unaffected male) of someone with known cancer gene

First degree relative in a family with:

  • > 2 ovarian cancers (first deg of each other)
  • 1 ovarian cancer (any age) and 1 breast cancer <50
  • 1 ovarian cancer (any age) and 2 breast cancer <60
  • 3 colon cancers or 2 colon and 1 stomach/ovarian/endometrial/urinary/small bowel (one <50)
  • one individual with both breast and ovarian cancer.
49
Q

What is the conventional chemotherapy used for ovarian cancer?

A

Carboplatin + paclitaxel - 6 cycles at 3 weekly intervals.

50
Q

What is the benefit of intraperitoneal chemo?

A

In women with optimally resected disease, it reduces risk of recurrence and prolongs survival.

51
Q

What is meant by, and what is the benefit of, dose-dense schedules?

A

Weekly carboplatin + paclitaxel.

Clinical benefit and reduced toxicity.

52
Q

What is bevacizumab?

A

A monoclonal antibody targeting VEGF under investigation.

53
Q

What are the types of relapsed disease?

A

Platinum refractory disease: Recurrence whilst receiving chemo.
Platinum resistant disease: Recurrence within 6m of finishing chemo.
Platinum sensitive disease: Recurrence >6m after finishing chemo (partially sensitive if 6-12m)

54
Q

Response rate to chemo in relapsed disease

A

Platinum sensitive - 40-75%
Partially sensitive - 25-30%
Resistant - 10-20%
Refractory <10%

55
Q

What may be of benefit in BRCA mutation patients?

A

PARP inhibitors

56
Q

Complications of mucinous tumour rupture?

A

Pseudomyxoma peritonei and small bowel obstruction

57
Q

Raised tumour markers in serous ovarian tumour

A

Ca 125

58
Q

Raised tumour markers in mucinous ovarian cancer

A

CEA and CA-125

59
Q

What percentage of clear cell cancers are bilateral?

A

10%

60
Q

Prognosis of clear cell cancers

A

Poor. Highly malignant.

61
Q

Proportion of clear cell cancers associated with a primary in the uterus

A

15%

62
Q

Feature of Brenner tumours

A

Transitional epithelium. Usually benign. If malignant may be associated with bladder tumour.

63
Q

Sertoli cell tumours

A

Usually benign

64
Q

Hormones secreted by Sertoli cell tumours

A

70% oestrogen, 20% androgenic, 10% no secretion

65
Q

What proportion of germ cell tumours are malignant?

A

2-3%

66
Q

What do dysgerminomas secrete?

A

LDH, placental ALP.

3% - bhCG.

67
Q

What percentage of mature cystic teratomas (dermoid) are bilateral?

A

15%

68
Q

What percentage of mature cystic teratomas (dermoid) undergo malignant change?

A

1%

69
Q

What can be secreted by immature teratomas?

A 
Thyroid hormones (struma ovaria)
Serotonin (Carcinoid)
70
Q

What is secreted by embryonal carcinoma?

A

bhCG and AFP

71
Q

What is secreted by yolk sac or endodermal sinus tumour

A

AFP

Laura MRCOG Part 2 (56 decks)

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