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Ovarian cancer > BGCS > Flashcards

BGCS Flashcards

1
Q

how common is EOC in the UK?

A

6th most common cancer in women

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2
Q

how common is death from EOC in the UK?

A

6% of cancer deaths in women

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3
Q

what is the peak age of EOC

A

60-64

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4
Q

what percentage of EOC is advanced at diagnosis?

A

70%

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5
Q

What percentage of EOC presents as an emergency admission?

A

26%

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6
Q

When do we worry about bowel origin when interpreting tumour markers

A

When CA125/CEA ratio is less than 25, especially if there is a raised CA19-9

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7
Q

Drawbacks of cytology-based diagnosis

A

No genetics

Serous borderline may be falsely diagnosed as carcinoma

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8
Q

Histological features of HGSOC

A

moderate to marked nuclear atypia
greater than 12 mitoses per 10 high power fields
Necrosis and multinucleate cells

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9
Q

IHC features of HGSOC

A

CK7, WT1, PAX8, oestrogen receptor and CA125 positive

They do not stain for CK20, CEA and CDX2

P53 shows aberrant expression, characterized by either diffuse strong positive staining in greater than 75% of cells or by complete lack of staining

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10
Q

What percentage of women with a high grade serous or G3 endometrioid ovarian cancer have an underlying germline BRCA mutation?

What proportion of these have no family history?

A

18%

44%

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11
Q

Advantages of BRCA testing

A
  • Prognostics
  • Genetic testing and risk reduction/screening for family members
  • PARPi
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12
Q

what proportion of EOC is endometrioid ovarian cancer

A

10-15%

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13
Q

What is endometrioid ovary cancer associated with

A

Endometrioisis
or
10-15% chance of synchronous endometrial primary

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14
Q

How do you manage G3 endometrioid ovarian cancer

A

as per HGSOC

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15
Q

What ovary cancer is linked to endometriosis

A

Clear cell cancer

Endometrioid

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16
Q

What is clear cell carcinoma of the ovary linked to?

A

Endometriosis
Paraneoplastic hypercalcaemia
Venous thromboembolism

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17
Q

Clear cell histopathology

A

clear, or hobnail, cells arranged in papillary, glandular or solid patterns in a hyaline stroma

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18
Q

Clear cell IHC

A

typically WT1-/p53 wild type and show staining with napsin A. They mostly lack expression of oestrogen and progesterone receptors

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19
Q

What is unique in the management of clear cell cancer of the ovary

A

less chemoresponsive

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20
Q

What proportion of ovarian cancer is carcinosarcoma?

A

1-3%

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21
Q

What percentage of carcinosarcoma is advanced at presentation?

A

90%

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22
Q

what is the aim of surgery for early ovarian cancer?

A

complete macroscopic tumour resection and adequate surgical staging

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23
Q

Adequate surgical staging for ovarian cancer

A

peritoneal washings/ascitic sampling taken prior to manipulation of the tumour

bilateral salpingo-oophorectomy

total hysterectomy

multiple peritoneal biopsies from the para-colic spaces
and the sub-diaphragmatic spaces bilaterally

omentectomy

pelvic and bilateral para-aortic lymph node assessment up to the level of the insertion of the ovarian vessels in the absence of peritoneal dissemination

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24
Q

Staging difference in mucinous tumours

A

The rate of positive lymph nodes in mucinous tumours is very low and lymph node dissection is therefore not warranted. However, appendicetomy should be performed where a mucinous tumour is suspected.

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25
Q

What percentage of women with apparent early stage disease are upstaged by staging?

A

30%

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26
Q

What is the likelihood of high grade disease confined to the ovary having microscopic LN?

A

15%

Cass et al

Among these patients, 50% had positive pelvic nodes, 36% had positive para-aortic node and both were positive in 14% of the cases

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27
Q

What is fertility sparing surgery?

A

uterus/contra-lateral ovary preserving surgery, in combination with surgical staging of the remaining peritoneal surfaces +/- retroperitoneal lymph node chains

28
Q

Who is appropriate for fertility sparing surgery?

A

Patients with grade 1 or 2 mucinous, serous, endometrioid, or mixed histology and FIGO stage IA or stage IC with unilateral ovarian involvement may be eligible

29
Q

If unilateral disease, should we do unilateral or bilateral lymph node assessment?

A

Retrospective evidence reveals that 3.5%-11% of the women with unilateral disease will have contra-lateral pelvic lymph node metastases, despite negative ipsilateral nodes

30
Q

When to or when not to operate twice in the primary treatment of advanced ovarian cancer

A

Attempt complete cytoreduction once.

ie: if small procedure or diagnostic first, worth cytoreductive surgery.

Not for “second-look” cytoreductive surgery after previous maximum effort cytoreductive surgery

31
Q

Once a decision to operate has been made, when should it happen?

A

Within 2-4 weeks

32
Q

If unable to achieve complete cytoreduction, what is the aim?

What is the evidence?

A

Du Bois 2009

Overall survival:
complete cytoreduction vs <1cm: HR 2.12
1mm to 1cm disease vs >1cm: HR 1.2

PFS:
complete cytoreduction vs <1cm: HR 2.03
1mm to 1cm disease vs >1cm: HR 1.25

ie: time to progression/death
0mm ; 15.5 months
1mm to 10mm: 10.1 months
>10mm: 7.8 months

33
Q

Should we do systematic PLND or PALND in treatment of advanced ovarian cancer - what is the evidence?

A

LION trial 2019

If normal appearance of LN on imaging and at the time of surgery for advanced ovarian cancer and complete cytoreduction achieved..

No difference in PFS or OS with an increased risk of complications if undergoing systematic LNDs.

34
Q

PDS vs NAC/IDS - evidence

A

Vergote 2010
CHORUS 2015

IDS is non-inferior to PDS with respect to outcomes

35
Q

Chemotherapy response score - the evidence

A

Cohen 2019

CRS 3 is associated with improved PFS and OS and those with BRCA mutation more likely to achieve CRS 3

36
Q

Intraperitoneal chemotherapy - evidence

A

Jaaback 2016 (cochrane)

Improves OS and PFS but greater toxicity:

Toxicity: gastrointestinal effects, pain, fever and infection

37
Q

ICON 8

A

Carboplatin/Paclitaxel

No benefit to weekly chemotherapy vs 3 weekly

38
Q

Third chemotherapy agent?

A

No benefit

Bookman et al 2009

39
Q

More than six cycles of chemotherapy?

A

No benefit to more than 5 cycles of carboplatin

Lambert et al 1997

40
Q

ICON 7

A

First line treatment - use of BEV
During and 12 months post
Prolongs PFS but no change in OS

41
Q

CA 125 monitoring for follow up and evidence

A

Rustin 2010

No benefit for diagnosing relapse earlier and treating according to CA125

42
Q

DESKTOP III

A

Secondary cytoreductive surgery appropriate for:

First relapse
Platinum-sensitive - 6+ months
Positive AGO-Score (good performance status (ECOG 0), complete resection at first surgery, and ascites ≤500 mL)

significant increase of OS, PFS and TFST with acceptable morbidity

43
Q

SOC-1

A

Secondary cytoreduction followed by chemotherapy was associated with significantly longer progression-free survival than was chemotherapy alone in patients with platinum-sensitive relapsed ovarian cancer.

(iMODEL) score and PET-CT imaging to predict resectability

  • FIGO stage
  • residual disease after primary surgery
  • platinum-free interval
  • ECOG performance status
  • CA-125 at recurrence
  • presence of ascites at recurrence
44
Q

Platinum Sensitive

A

Progress with an interval of > 12 months after completion of chemotherapy

45
Q

Partially Plantinum Senstitive

A

Progress with an interval of between 6-12 months after completion of chemotherapy

46
Q

Platinum Resistant

A

Progress with an interval of less than 6 months after completion of chemotherapy

47
Q

Platinum Refractory

A

Progress during, or within 4 weeks after completion of chemotherapy

48
Q

Treatment of LGSOC

A

Surgical management as low chemotherapy response

49
Q

What is the chemotherapy response rate of LGSOC

A

25%

50
Q

What proportion of serous OC is LGSOC

A

5%

51
Q

Histological findings of LGSOC

A

Neither necrosis nor P53 mutation are features of LGSOC.

52
Q

Treatment of LGSOC relapse

A

Surgical management can be reconsidered

53
Q

What proportion of OC is mucinous

A

3-5%

54
Q

What histological finding is associated with GI met

A

Infiltrative pattern

55
Q

Infiltrative vs expansile mucinous carcinomas

A

Invasive mucinous carcinoma with an infiltrative pattern has a more aggressive course than mucinous carcinoma with an expansile pattern.

56
Q

IHC of mucinous tumours

A

CK7+
CK20-
CDX2-

57
Q

Origin of advanced stage mucinous tumours

A

Usually GI origin - appendiceal

Rarely - from teratoma

58
Q

Investigations when mucinous tumour thought to arise from GI tract

A

bidirectional GI endoscopy and consideration of referral to GI MDT

59
Q

What is a Wolffian tumour

A

Usually benign and composed of cysts of varying size with sieve like areas admixed with solid and spindled areas

60
Q

Small cell carcinoma of the ovary - types

A
  1. hypercalcaemic (SCCOHT)
  2. pulmonary ( SCCOPT)
  3. large cell variant
  4. classical carcinoid
61
Q

Small cell carcinoma of the ovary - advanced disease at presentation

A

75%

62
Q

Site of origin of origin of ovarian metastasis

A

colorectal
gastric
pancreaticobiliary
appendicular adenocarcinomas

63
Q

Characteristics of Krukenberg tumours

A

Bilateral solid ovarian masses, microscopically demonstrating replacement of the ovarian stroma by signet ring, mucinous cells.

64
Q

Primary site of Krukenberg tumours

A

The primary site is most often gastric or breast, where similar signet ring mucinous cells are seen.

65
Q

Treatment of borderline tumours

A

Complete surgical resection and adequate surgical staging

Pelvic and para-aortic lymph node sampling to stage cases of BOT is not recommended in the absence of bulky lymph nodes

Appendicectomy for mucinous BOT

No evidence for chemotherapy

66
Q

Risk of malignancy in borderline ovarian tumours

who is at lower risk?

A

2% of those with BOT had malignant transformation

but

in those who did relapse - 30% had malignant transformation

lower risk if aged less than 40 at diagnosis

Ovarian cancer (4 decks)

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