20. Ovarian Carcinoma Flashcards
Why do more women die from ovarian cancer than any other gynecological cancer?
Due to its vague symptomatology, leading to late-stage diagnosis
How does the incidence of ovarian cancer vary globally?
Higher in industrialized countries, except Japan (3/100,000). Highest in Scandinavia, Eastern Europe, and Canada (22-24/100,000). Lower in developing countries.
How are ovarian cancers classified?
They can be primary or secondary (metastatic).
What are common sources of secondary ovarian cancers?
Metastases from the gastrointestinal tract (Krukenberg tumours) or breast cancer.
What are the three most important types of primary ovarian cancers?
Epithelial cancers, germ cell tumours (GCTs), and sex cord-stromal tumours.
What percentage of ovarian cancers are epithelial?
About 90%.
From which tissue do epithelial ovarian cancers arise?
The surface epithelium of the ovary.
What are the subtypes of epithelial ovarian cancer?
Serous, mucinous, endometrioid, transitional, and undifferentiated subtypes
Which age group is most commonly affected by epithelial ovarian cancers?
Older postmenopausal women.
What is the 5-year survival rate for stage I epithelial ovarian cancer?
More than 90%.
What percentage of epithelial ovarian cancers are diagnosed at late stages (II-IV)?
About 75-80%.
What percentage of ovarian cancers are germ cell tumours?
Approximately 5%.
What is the origin of germ cell tumours?
Primordial germ cells of the ovary
What percentage of GCTs are diagnosed in women under 30 years old?
About 80%.
What is the most common type of germ cell tumour?
Dysgerminoma
Name other types of germ cell tumours besides dysgerminomas.
Yolk sac (endodermal sinus) tumours, immature teratomas, embryonal carcinomas, and non-gestational choriocarcinomas.
Do germ cell tumours often contain more than one histological type?
Yes
What percentage of ovarian cancers are sex cord-stromal tumours?
About 8%.
What is the origin of sex cord-stromal tumours?
The stromal connective tissue of the ovary.
Do sex cord-stromal tumours affect all age groups?
Yes
What are the most common types of sex cord-stromal tumours?
Juvenile granulosa cell tumours, adult granulosa cell tumours, and Sertoli-Leydig cell tumours.
What hormones can sex cord-stromal tumours produce?
Oestrogen, inhibin, progesterone, and testosterone.
What symptoms may patients with hormone-secreting sex cord-stromal tumours present with?
Abnormal uterine bleeding, pseudoprecocious puberty, endometrial hyperplasia (oestrogen effect), or virilization.
What is the lifetime risk of developing ovarian cancer in the general population?
About 1 in 70
What percentage of ovarian cancers are hereditary?
About 10%.
When should hereditary ovarian cancer be considered?
In cases of:
- Personal or family history of breast, ovarian, endometrial, prostate, or colon cancer
- A first-degree relative carrying a BRCA1 or BRCA2 mutation
- Epithelial ovarian cancer diagnosed in a younger woman
What is the lifetime risk of developing ovarian cancer in women with a BRCA1 or BRCA2 mutation?
About 20-50%.
How does uninterrupted ovulation affect ovarian cancer risk?
It increases the risk.
Is there a possible link between ovarian cancer and artificial ovulation induction?
Yes, but it remains controversial.
How does low parity affect ovarian cancer risk?
It increases the risk.
How does the use of combined oral contraceptives affect ovarian cancer risk?
Non-use increases the risk, as combined oral contraceptives provide a protective effect.
How does age influence ovarian cancer risk?
Increasing age is a significant risk factor.
How does diet influence ovarian cancer risk?
Diet, particularly in industrialized countries, is a contributing risk factor.
Risk factors for ovarian carcinoma
- Uninterrupted ovulation
- Possible increase in ovarian cancer in women undergo multiple artificial ovulation inductions, although this is controversial
- Low parity
- Non-use of combined oral contraception
- Increasing age
- Diet (particularly in industrialized countries)
Why do ovarian cancers often present late?
The ovaries are true intra-peritoneal organs, allowing tumors to grow significantly before becoming clinically evident. The disease also spreads in a creeping fashion rather than directly invading structures.
Why are ovarian cancer symptoms referred to as “whispers”?
They are vague and non-specific, often mistaken for gastrointestinal or urinary issues.
What are some early symptoms of ovarian cancer?
- Unexplained change in bowel or bladder habits
- Mild dyspepsia
- Feeling of fullness after meals
- Abdominal distension
- Unexplained slow weight loss
What are some common late symptoms of ovarian cancer?
- Pelvic pain or discomfort
- Fatigue
- Postmenopausal bleeding (in 10% of cases)
- Abnormal menstrual bleeding in younger women
What aspects of history and examination are crucial in diagnosing ovarian cancer?
A thorough history and examination focusing on lymph nodes, pleural effusion, ascites, and abdominal/pelvic masses.
What lymph node should be palpated in suspected ovarian cancer?
The left supraclavicular node (Virchow’s node).
Why is it important to check for pleural effusion in suspected ovarian cancer?
Ovarian cancer can spread to the pleura, causing malignant effusions.
What abdominal findings suggest advanced ovarian cancer?
- Ascites (fluid thrill or shifting dullness)
- Peri-umbilical nodule (Sister Mary Joseph nodule)
- Palpable abdominal or pelvic masses
Why is a pelvic-rectal examination important in ovarian cancer diagnosis?
It helps detect advanced cancers that may not be palpable on abdominal examination alone.
Routine investigations for ovarian cancer
- Haemoglobin
- Pregnancy test in women of reproductive age
- Urine dipstix
- Pap smear in all cases of suspected ovarian cancer
- Endometrial sampling if patient complains of abnormal vaginal bleeding
What are the routine blood investigations for suspected ovarian cancer?
Haemoglobin levels and a pregnancy test in women of reproductive age.
Why is a urine dipstick test performed in suspected ovarian cancer cases?
To check for proteinuria, haematuria, or infection that may suggest other differential diagnoses.
What gynecological screening tests should be done in suspected ovarian cancer cases?
A Pap smear and endometrial sampling if abnormal vaginal bleeding is present.
What imaging tests are useful in the metastatic and diagnostic workup of ovarian cancer?
- Chest X-ray
- Ultrasound and/or CT scan of the abdomen and pelvis
- Mammogram if indicated
Why is an ascitic or pleural tap performed in suspected ovarian cancer
For cytology, chemistry (including ADA to rule out abdominal TB), and microbiology.
When should bowel investigations like gastroscopy or colonoscopy be performed?
If the patient has significant bowel symptoms.
What is the significance of CA-125 in ovarian cancer?
It is raised in many benign conditions but, if >500/ml, strongly suggests ovarian cancer. It is elevated in over 80% of serous epithelial cancers but only 50% of mucinous carcinomas.
Which tumor marker is useful for diagnosing yolk sac (endodermal sinus) tumors?
Alpha-fetoprotein (AFP).
What tumor marker is commonly elevated in dysgerminomas?
Lactate dehydrogenase (LDH).
Which tumor marker is raised in non-gestational choriocarcinomas of the ovary?
Beta-hCG.
How is carcinoembryonic antigen (CEA) useful in distinguishing ovarian cancer from primary bowel cancer?
CEA is raised in gastrointestinal tract cancers, helping differentiate them from primary ovarian cancer.
What defines Stage I ovarian cancer?
The tumor is confined to one or both ovaries
What defines Stage II ovarian cancer?
The tumor involves one or both ovaries and has extended to other pelvic organs.
What defines Stage III ovarian cancer?
The tumor has spread to the bowel lining, abdominal peritoneum, or lymph nodes.
What defines Stage IV ovarian cancer?
The tumor has distant metastases, such as to the liver or chest.
What is the gold-standard treatment for ovarian cancer?
Surgery
What are the three primary goals of surgery in ovarian cancer management?
- To make the diagnosis
- To stage the disease
- To remove as much tumor as possible (debulking)
Why is a vertical incision preferred in ovarian cancer surgery?
It allows for thorough exploration of the entire abdomen.
What procedures are involved in staging ovarian cancer if it is confined to the ovaries?
- Peritoneal washings (peritoneal gutters, pouch of Douglas)
- Diaphragmatic wipes to check for microscopic disease
- Exploratory laparotomy
What are the key surgical components of ovarian cancer treatment?
- Total abdominal hysterectomy (TAH)
- Bilateral salpingo-oophorectomy (BSO)
- Infracolic omentectomy
- Debulking of all macroscopically visible tumors
What is the role of surgery in the management of GCTs?
Surgery is primarily diagnostic due to the need for fertility preservation and high chemosensitivity.
What is the mainstay of treatment for GCTs?
Multiple-agent chemotherapy.
What is the main treatment for SCSTs (Sex Cord Stromal Tumors) ?
Surgery is the primary treatment, with a limited role for chemotherapy.
Do most women with EOC (Epithelial Ovarian Cancer) require post-operative chemotherapy?
Yes, over 70% of women with EOC require chemotherapy after surgery.
What is the 5-year survival rate for early-stage ovarian cancer?
Over 90%.
What is the 5-year survival rate for Stage III ovarian cancer?
Less than 30%.
