Clinical Conference of the Ovary Flashcards
Why is the incidence of ovarian cancer decreasing?
Protective effect of the OCP
What is the 5ys of all stages of ovarian cancer?
30%
As most present with advanced disease and symptoms are really vague
In what age is ovarian cancer rare?
<30y
What is the most common ovarian malignancy?
Serous ovarian cancer (tends to affect older woman)
What are the risk factors for ovarian cancer?
Familial (5-10%) - HNPCC/Lynch type II familial cancer syndrome
BRCA 1/2
Incessant ovulation - no pregnancy & not on contraception, early menarche, late menopause
OCP PROTECTIVE!
What are the symptoms of ovarian cancer?
VAGUE Indigestion/early satiety/poor appetite Altered bowel habit/pain Bloating/discomfort/weight gain Pelvic mass (which may lead to pressure symptoms)
All v. similar to IBS
How do you diagnose ovarian cancer?
Surgical/pathological for definitive diagnosis
USS pelvis/abdomen to pick up mass
CT for staging
CA 125
What is CA125?
Glycoprotein antigen
Biomarker for ovarian cancer detection & monitoring of success of Rx
BUT low specificity - also raised in endometrial/fallopian tube/lung/breast cancer… and in benign conditions (menstruation, endometriosis, PID) - anything that leads to peritoneal irritation
What % of woman with ovarian cancer have a raised CA125?
80%
Can you make a diagnosis of ovarian cancer from a very elevated CA125?
No - but it is highly suggestive of ovarian cancer
What range of CA125 is considered to be normal?
1-35 (above = elevated)
What equation can you use to assess the likelihood of cancer?
Risk of malignancy index (RMI)
RMI = U (ultrasound features) x M (menopausal status) x CA125
U: 1 feature = 1 point, 2-5 features = 3 points:
Multilocular, solid areas, bilateral, ascites, intra-abdominal
M: premenopausal = 1 point, postmenopausal = 3 points
CA125 use actual level
>200 suggestive of malignancy
How do you stage ovarian cancer?
1 - limited to ovaries, intact capsule
2 - one or both ovaries with pelvic expansion
3 - one or borth ovaries with peritoneal implants outside pelvis (e.g. on capsule of abdominal organs) or + nodes
4 - distant mets (e.g. in parenchyma of liver/spleen)
How do you Rx ovarian cancer?
Surgery is gold standard: usually open due to tumour size
Stage 3 dx may req. extensive surgery (e.g. peritonectomy, diaphragm stripping, bowel resection etc)
Chemo - adjuvant/neoadjuvant
When should you do a midline laparotomy if high suspicion of ovarian cancer?
To obtain a tissue diagnosis, stage disease, disease clearance, debulk disease
What chemo is used for ovarian cancer?
First line platinum & taxane
Use within 8 weeks of surgery
Unlikely to cure (esp if stage 3/4)
What is the average response to chemo?
2 years
What is the cure rate of stage 1-4 ovarian cancer?
1 - 85%
2 - 47%
3 - 15%
4 - 10%
How do you manage recurrence of ovarian cancer?
Chemo Palliation (if systematic recurrence) Platinum if >6 months Surgery Tamoxifen - for those who cannot tolerate systemic chemo
How does tamoxifen work?
Blocks oestrogen
At what age do you get screened for ovarian cancer?
Population screening not proven as unable to pick up pre-cancer change
What is offered to woman who are at high risk of ovarian cancer?
Oophorectomy & salphingectomy
What is ascites?
Accumulation of fluid in peritoneal cavity
Either due to inflammation or tumour deposits
Define benign ovarian cyst
Any ovarian follicle >2cm
Usually unilocular/few locules, smooth, in tact surface, can become v. big
What is the benign version of a serous adenocarcinoma?
Serous benign cyst adenoma
What forms a serous adenoma?
Epithelial tissue similar to that of the fallopian tube lining
Where do mucinous cystadenomas arise from?
Mucinous epithelium
What is a borderline ovarian cyst?
Between malignant and benign
Can be serous/mucinous
Multilocular & may have papillary excrescence (cauliflower like growths) which line the cyst surface & can shed into the ascitic fluid
What is the prognosis with borderline ovarian cyst?
Some will be entirely benign others may come back as malignant (even several years later)
How do you investigate a borderline ovarian cyst?
Try to sample every 1cm as they may have very small focal points of malignancy
What is the appearance of an ovarian carcinoma?
Irregular outline, replaced by mixed solid and cystic tumour
Where do most cases of ovarian cancer arise from?
Fallopian tube
Fimbrial surface sheds into ovary, thought to become incorporated into the cortex of the ovary
Changes of fallopian tube mean these fimbrial cells are pre-malignant
If cancer arises will be high grade
Where is the second most common place ovarian cancer arises from?
Pre-existing benign ovarian cysts (often transform into lower grade malignancies)
What are the types of ovarian cancer?
Adenocarcinomas (cystadenocarcinoma/mucinous)
Germ cell tumours, e.g. teratoma
How are the BRCA genes inherited?
AD
What is the lifetime risk assoc. with BRCA genes and ovarian cancer?
15-45%
& will develop it at a younger age
What are the BRCA genes?
Tumour suppressor genes involved in DNA repair and cell cycle control
