Clinical Conference of the Ovary

Question 1

Why is the incidence of ovarian cancer decreasing?

Answer 1

Protective effect of the OCP

Question 2

What is the 5ys of all stages of ovarian cancer?

Answer 2

30%

As most present with advanced disease and symptoms are really vague

Question 3

In what age is ovarian cancer rare?

Answer 3

<30y

Question 4

What is the most common ovarian malignancy?

Answer 4

Serous ovarian cancer (tends to affect older woman)

Question 5

What are the risk factors for ovarian cancer?

Answer 5

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!

Question 6

What are the symptoms of ovarian cancer?

Answer 6

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

Question 7

How do you diagnose ovarian cancer?

Answer 7

Surgical/pathological for definitive diagnosis
USS pelvis/abdomen to pick up mass
CT for staging
CA 125

Question 8

What is CA125?

Answer 8

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

Question 9

What % of woman with ovarian cancer have a raised CA125?

Answer 9

80%

Question 10

Can you make a diagnosis of ovarian cancer from a very elevated CA125?

Answer 10

No - but it is highly suggestive of ovarian cancer

Question 11

What range of CA125 is considered to be normal?

Answer 11

1-35 (above = elevated)

Question 12

What equation can you use to assess the likelihood of cancer?

Answer 12

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

Question 13

How do you stage ovarian cancer?

Answer 13

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)

Question 14

How do you Rx ovarian cancer?

Answer 14

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

Question 15

When should you do a midline laparotomy if high suspicion of ovarian cancer?

Answer 15

To obtain a tissue diagnosis, stage disease, disease clearance, debulk disease

Question 16

What chemo is used for ovarian cancer?

Answer 16

First line platinum & taxane
Use within 8 weeks of surgery
Unlikely to cure (esp if stage 3/4)

Question 17

What is the average response to chemo?

Answer 17

2 years

Question 18

What is the cure rate of stage 1-4 ovarian cancer?

Answer 18

1 - 85%
2 - 47%
3 - 15%
4 - 10%

Question 19

How do you manage recurrence of ovarian cancer?

Answer 19

Chemo 
Palliation (if systematic recurrence) 
Platinum if >6 months
Surgery 
Tamoxifen - for those who cannot tolerate systemic chemo

Question 20

How does tamoxifen work?

Answer 20

Blocks oestrogen

Question 21

At what age do you get screened for ovarian cancer?

Answer 21

Population screening not proven as unable to pick up pre-cancer change

Question 22

What is offered to woman who are at high risk of ovarian cancer?

Answer 22

Oophorectomy & salphingectomy

Question 23

What is ascites?

Answer 23

Accumulation of fluid in peritoneal cavity

Either due to inflammation or tumour deposits

Question 24

Define benign ovarian cyst

Answer 24

Any ovarian follicle >2cm

Usually unilocular/few locules, smooth, in tact surface, can become v. big

Question 25

What is the benign version of a serous adenocarcinoma?

Answer 25

Serous benign cyst adenoma

Question 26

What forms a serous adenoma?

Answer 26

Epithelial tissue similar to that of the fallopian tube lining

Question 27

Where do mucinous cystadenomas arise from?

Answer 27

Mucinous epithelium

Question 28

What is a borderline ovarian cyst?

Answer 28

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

Question 29

What is the prognosis with borderline ovarian cyst?

Answer 29

Some will be entirely benign others may come back as malignant (even several years later)

Question 30

How do you investigate a borderline ovarian cyst?

Answer 30

Try to sample every 1cm as they may have very small focal points of malignancy

Question 31

What is the appearance of an ovarian carcinoma?

Answer 31

Irregular outline, replaced by mixed solid and cystic tumour

Question 32

Where do most cases of ovarian cancer arise from?

Answer 32

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

Question 33

Where is the second most common place ovarian cancer arises from?

Answer 33

Pre-existing benign ovarian cysts (often transform into lower grade malignancies)

Question 34

What are the types of ovarian cancer?

Answer 34

Adenocarcinomas (cystadenocarcinoma/mucinous)

Germ cell tumours, e.g. teratoma

Question 35

How are the BRCA genes inherited?

Answer 35

AD

Question 36

What is the lifetime risk assoc. with BRCA genes and ovarian cancer?

Answer 36

15-45%

& will develop it at a younger age

Question 37

What are the BRCA genes?

Answer 37

Tumour suppressor genes involved in DNA repair and cell cycle control