Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

year 4 CDM 2 > Case 17 cancer: ovarian > Flashcards

Case 17 cancer: ovarian Flashcards

1
Q

Ovarian tumours: metastatic

A
  • 5% of ovarian tumours
  • Krukenberg tumour- malignant, metastases from a gastrointestinal tumour resulting in a mucin secreting signet ring cell adenocarcinoma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Ovarian tumour: symptoms

A
  • Often asymptomatic
  • Bloating or indigestion
  • Gradually increasing abdominal distension
  • Difficulty eating and feeling full, fatigue, anorexia
  • Chronic abdominal, pelvic or back pain, urinary frequency/urgency, constipation/altered bowel habit/bowel obstruction, leg swelling and DVT/PE
  • Abnormal vaginal bleeding
  • Symptoms of metastatic disease i.e. pleural effusion, ascites, weight loss and fatigue
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Complications of ovarian cancer: not metastatic

A
  • Sudden torsion or rupture can present with acute abdominal or pelvic pain
  • VTE due to prothrombotic tendency
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Other organ involvement in ovarian cancer and symptoms

A
  • Bowel: abdominal bloating or distension, loss of appetite, nausea, vomiting, altered bowel habit, esp. constipation, abdominal pain, bowel obstruction
  • Kidney: hydronephrosis secondary to ureteric obstruction, haematuria, recurrent UTI, loin pain, renal failure
  • Pleural effusion: breathlessness, respiratory distress (rare) as a result of a large pleural effusion, which is more common on the right
  • Umbilical peritoneal deposits in stage 4 disease and Saint Mary Joseph nodules
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Symptoms of ovarian cancer due to local mass effect and lymph node involvement

A
  • bladder: urgency, frequency
  • para-aortic lymph nodes can be affected causing back ache
  • Inguinal or femoral nodes are not normally affected - suggestive of other gynae disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Differential diagnosis for ovarian cancer

A
  • Gastric cancer: abdo symptoms, early satiety and sometimes ascites
  • Bowel cancer: unlikely <50 unless strong family history
  • Colon cancer: can present with ascites
  • Hepatocellular carcinoma: normally due to alcohol or hepatitis B/C
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Clinical signs of ovarian cancer

A
  • general examination – cachexia, lymphadenopathy, signs of pleural effusion
  • abdominal examination – distension, ascites, palpable pelvic mass, “omental cake” metastasis
  • Cusco speculum examination – usually normal
  • bimanual palpation – palpable adnexal/pelvic mass which may be fixed and immobile
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Ovarian cancer epidemiology

A
  • Ovarian cancer kills more people than other gynaecological cancer
  • 50-75 Caucasian, higher rates in developed countries
  • 5-10% have genetic cause
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Ovarian cancer bloods and investigations

A

Bloods Ovarian cancer: FBC, serum biochemistry, LFT, Bone profile, CA-125, CEA. In younger women hCG, AFP, LDH

Investigations
- Pregnancy test
- AFP, beta-hCG: elevated in ovarian germ cell tumours
- Other tumour markers: CA19-9, beta-hcg, ALP (suggests liver mets), AFP, Inhibin and LDH, CA125
- Transabdominal +/- transvaginal ultrasound: first line
- Exploratory laparotomy with biopsy: to confirm diagnosis, for staging

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

CA-125

A
  • Is present in most cases of advanced ovarian cancer.
  • Raised suggests worse prognosis.
  • If doubles after remission suggests relapse
  • > 30 is suggestive of ovarian cancer
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Ovarian cancer: imaging

A
  • Imaging- CXR to check for pleural effusion or lung metastases
  • CT +/- MRI abdomen and pelvis to assess mass, pelvic nodes and any metastases in advanced disease
  • PET scan may in advanced disease
  • Invasive tests – pleural or ascitic tap with cytology
  • Laparoscopy and biopsy: to confirm diagnosis, staging
  • Preoperative endometrial sampling: women with abnormal vaginal bleeding
  • Preoperative cytological or histological evaluation of effusion or tumour mass
  • Genetic test: for BRCA
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

How is transvaginal US scored for ovarian cancer

A
  1. 1 point for each of:
  2. multilocular lump
  3. bilateral disease
  4. solid areas, ascites or mets
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Risk factors for ovarian cancer

A
  • Age (peaks age 60): postmenopausal
  • BRCA1 and BRCA2 genes (family history)- most associated with serous
  • Other conditions: Peuz-Jeghers syndrome, Lynch type II
  • Obesity, Smoking
  • Diet: fat, lactose, coffee
  • Recurrent use of clomifene
  • Increased number of ovulations: early onset periods, late menopause, no pregnancies, infertility, ovulation inducing drugs
  • Other factors: Talc, radiation, viruses (mumps, rubella, influenza)
  • Protective: pregnancy, prolonged breast feeding, COCP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

RMI: risk of malignancy index

A

Estimates the risk of an ovarian mass being malignant, taking account of three things:

  • Menopausal status: 1 if premenopausal, 3 if postmenopausal
  • Ultrasound findings: up to max score of 3. Get 1 point for following: Multilocular, Solid areas, Bilateral, Ascites, Metastases
  • CA125 level
  • RMI: U x M x serum CA-125
  • RMI >200 warrants referral to gynae
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Ovarian cancer: further investigations in secondary care

A
  • CT scan to establish the diagnosis and stage the cancer
  • Histology (tissue sample) using a CT guided biopsy, laparoscopy or laparotomy
  • Paracentesis (ascitic tap) can be used to test the ascitic fluid for cancer cells
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Women under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour:

A
  • Alpha-fetoprotein (α-FP)
  • Human chorionic gonadotropin (HCG)
17
Q

Staging ovarian cancer

A
  • Stage 1: Confined to the ovary
  • Stage 2: Spread past the ovary but inside the pelvis
  • Stage 3: Spread past the pelvis but inside the abdomen (microscopic peritoneal mets, superficial liver, regional nodes)
  • Stage 4: Spread outside the abdomen (distant metastasis), parenchymal liver metastasis
18
Q

BRCA mutations ovarian cancer

A

Most commonly associated with serous cancers of the ovary and occasionally endometrial cancer of the ovary. Autosomal dominant

19
Q

Other mutations in ovarian cancer

A

PARP1 mutations in ovarian cancer: PARP inhibitors (Olaparib, Rucaparib, Niraparib) are used following chemo in BRCA mutation carriers

Somatic gene mutation: present in the cancer cells only

20
Q

Ovarian cancer: management

A
  • Surgery: to remove tumour. Involves laparotomy, total hysterectomy, bilateral salpingo-oopherectomy with omenectomy and lymph node resection
  • Adjuvant chemotherapy: with carboplatin and paclitaxel, add bevaclizumab in high risk disease.
  • Neoadjuvant chemo in extensive disease or if surgery not initially possible i.e. due to fitness
  • Non epithelial ovarian cancer: surgery followed by chemo
  • Relapse: offer second line chemo
  • Serum CA125 can predict relapse
  • Aromatase inhibitors and Tamoxifen
  • PARP inhibitor: if BRCA mutation, take for 2 years start within 8 weeks of chemo
21
Q

Ovarian cancer complications

A
  • Local invasion: Lymphoedema, vaginal discharge, bowel obstruction, ascites, pleural effusion, hydronephrosis (due to ureteric obstruction)
  • Distant metastasis: liver, lung, bone, brain
  • Non metastatic: PE, dermatomyositis
  • Stage 1 have 90% survival rate, whereas stage 4 it is <25%
22
Q

Management of ascites in cancer

A
  • US, MRI or CT can help guide drainage
  • Treatment with paracentesis including indwelling (Pleurx catheters)
  • Diuretics and salt restriction aren’t helpful
23
Q

Summary of ovarian cancer treatment

A
  • surgery with intra-operative histology for staging and to decide extent of procedure
  • Minimum surgery: bilateral hystero-salpingo-oophorectomy and appendectomy
  • usually also systematic retroperitoneal lymphadenectomy unless stage 1
  • adjuvant chemo for 6 months unless low risk stage 1
24
Q

Investigations for metastatic disease of unknown primary

A
  • FBC, U&E, LFT, calcium, urinalysis, LDH
  • Chest X-ray
  • CT of chest, abdomen and pelvis
  • AFP and hCG
25
Q

Specific investigations for metastatic disease of unknown primary

A
  • Myeloma screen (if lytic bone lesions)
  • Endoscopy (directed towards symptoms)
  • PSA (men)
  • CA 125 (women with peritoneal malignancy or ascites)
  • Testicular US (in men with germ cell tumours)
  • Mammography (in women with clinical or pathological features compatible with breast cancer)
26
Q

Cachexia

A

reduction in weight, primary cause is cancer. Involves anorexia, weight loss, muscle wasting, anaemia and lack of energy.

27
Q

Jaundice in malignancy

A

obstructive jaundice, uraemia, Hodgkin’s disease, allergy, dermatitis, neuropathy or drug reaction (often with opiates). an be caused by widespread parenchymal liver metastases, solitary parenchymal liver metastasis near the porta hepatis, a lymph node mass at the porta hepatis, a drug reaction or viral infection

28
Q

Hypercalcaemia in malignancy

A
  • The most common metabolic complication of malignancy indicates poor prognosis
  • Common in multiple myeloma, breast, lung, kidney, head and neck cancer, lymphoma
  • Non specific presentation, can just cause deterioration
  • In any patient with confusion consider: Hypercalcaemia, Brain metastasis, Metabolic disturbance
29
Q

Calcium homeostasis

A
  • If Ca+2 is too high the thyroid releases Calcitonin to increase excretion and decrease uptake
  • If Ca+2 is too low, PTH is released increasing uptake
  • Tests on ascitic fluid: albumin,amylase, cytology, glucose, lactate dehydrogenase
30
Q

Causes of hypercalcaemia in malignancy

A
  • Common issue, mainly due to bone metastasis. True paraneoplastic hypercalcaemia is due to tumour production of parathyroid hormone related protein
  • Cancer types: NSLC, Head and neck, Renal, SCC of oesophagus
  • Clinical presentation: rapid onset nausea, poluria, polydipsia, dehydration, cardiac arrhythmias
  • Diagnosis: Serum Ca2+ > 2.7 mmol/l, serum chloride low, hypercalcuria, high urinary phosphate, low or undetectable plasma parathyroid hormone
  • Treatment: saline hydration, IV bisphosphonates
31
Q

Malignancy: bowel obstruction

A
  • When sub-acute: give medications IV, insert an NG tube and steroids (reduce inflammation)
  • Avoid Metoclopramide and give Haloperidol instead
32
Q

Carcinoma of unknown primary

A
  • Malignant tumour arising from the epithelial system of the body
  • Where the primary site is able to metastasis before the primary site is large enough to be identified
  • Difference to primary tumours: early dissemination, clinical absence of primary tumour, unpredictable metastatic pattern, more aggressive, absence of symptoms due to primary tumour
  • Common causes: multiple site involvement, liver, bone, lung, lymph node
33
Q

Poor prognostic factors for unknown primary cancers

A
  • Median survival 6-9 months
  • Poor prognosis: poorly differentiated carcinoma, neuroendocrine carcinoma, lymph node envolvement, number of metastatic sites, male, poor fitness, increased weight loss
  • Serum markers: alk phos, LDH, CEA
34
Q

Approach to carcinoma of unknown primary

A

Step 1: Search for a primary site

Step 2: Rule out potentially treatable or curable tumours

Step 3: Characterise the specific clinicopathological entity. Treat the patient if favourable sub sets with curative intent if unfavourable with palliative intent

35
Q

How would a primary peritoneal or ovarian cancer present

A

Predominantly nodal metastasis of poorly differentiated carcinomas and females with peritoneal carcinomatosis of a high grade serous histological type adenocarcinoma

36
Q

Common causes of transudate vs exudate

A
  • Transudate: heart failure, liver failure, kidney failure, thyroid failure, respiratory failure, Meig’s syndrome
  • Exudate: cancer, pneumonia, PE
37
Q

Causes of raised CA-125

A

Cervical adenocarcinoma, Endometrial carcinoma, Fallopian tube cancer, Heart failure, Hypothyroidim, Liver cirrhosis with severe necrosis, Non-Hodgkins lymphoma, Pleural effusion

38
Q

Investigations for cancer of unknown primary

A
  • Bloods: CEA, CA-125, TTF-1
  • CT TAP, CXR, Laproscopy with biopsies
39
Q

End of life care

A
  • Recognition of approach of death: by clinicians, patient and family
  • Assess psychological state: ability to communicate capacity, screen for depression with HAD (hospital anxiety and depression) score
  • Manage physical symptoms: pain, N+V, respiratory secretions, agitation
  • Spiritual support: for patient and family
  • Rationalising prescribing: routes of administration (subcut morphine), discontinue non essential drugs
  • Communicating with other professionals
  • MDT involvement in decision making
  • In final hours may withdraw nutrients and hydration

year 4 CDM 2 (39 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions