CPC ovary Flashcards by Evie withington

epidemiology of ovarian cancer

600 cases p/a scotland
400 deaths p/a

5YS all stages 40-45%
most present with advanced disease

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how common is ovarian cancer

rare <30y/o

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who are the high risk families for ovarian cancer

5-10% of all cases
early onset presentation

HNPCC/Lynch type II familial cancer syndrome
BRCA1
BRCA2

incessant ovulation

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what can be protective for ovarian cancer

OCP
breast feeding
numerous pregnancies

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origins of ovarian cancer

most cases originate from the fimbrial end of fallopian tube
some derive from pre-existing benign ovarian cysts (often low grade cancers)

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ovarian cancer origins and pathogenesis - molecular alterations

P53
BRCA1 and 2
ARID1A
PIK3CA
PTEN
BRAF
KRAS
NRAS
ERBB2

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pathogenesis of ovarian cancer

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what mutation causes an aggressive ovarian cancer

p53 mutations

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role of pathology in ovarian cancer

type of tumour (epithelial, stromal, sex cord; benign, borderline, malignant), tumour grade and stage determines treatment and prognosis

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what type of tumour is this

how common

commonest epithelial tumour type

serous cystadenoma

benign

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describe the appearance of serous cystademonas

unilocular cyst

thin wall

flat epithelial lining

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what tumour type is shown here

borderline serous tumour

tree like area on left

atypical epithelium

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describe the features of borderline serous tumours

develop from benign cysts and mutate and proliferate

tree like papillary excrescences - overgrowth of epithelial lining of a cyst

can develop areas of invasive disease

concerning but not as aggressive as high grade carcinomas

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what is shown here

which is high grade and which is low grade

serous carcinoma

low - top
high - bottom

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features of high grade carcinomas

often serous carcinomas

more solid tumours
involvement of omentum - present at high stage disease

nuclearpleomorphism and prominent nucleoli

invasion into stroma

high mitotic rate

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in what grade carcinomas are psammoma bodies seen

low grade carcinomas

they are calcifications

ovarian cancer symptoms

vague
indigestion, early satiety, poor appetite
altered bowel habit/pain
bloating, discomfort, weight gain
pelvic mass - asymptomatic, pressure symptoms

be aware of these symptoms presenting for the first time, esp if 50-60y/o

ovarian cancer diagnosis

surgical/pathological
USS abdo and pelvis
CT scan - chest, abdo, pelvis - extent of disease
CA125
surgery - gold standard

what is CA 125

glyco-protein antigen

tumour marker

non-specific

what malignancies is CA125 associated with

ovary
colon/pancreas
breast

also lung

e.g. anything that causes disease in peritoneal cavity

what benign conditions is CA125 associated with

menstruation, endometriosis, PID

liver disease, recent surgery, effusions

how is CA125 used in the diagnosis of ovarian cancer

80% of women w/ ovarian ca have raised CA125

50% of women w/ stage 1 disease

used in detecting and monitoring epithelial ovarian tumours

ovarian cancer RMI

used in all women who present with ovarian masses

RMI = U x M x CA125

risk of malignancy index
U = US features
M = menopausal status (pre = 1, post = 3)
CA125 level

RMI >200 - suggestive of ovarian malignancy

US features for RMI

1 point for 1 feature, 3 points for >1: 
multi-locular
solid areas
bilateral 
ascites
intra-abdominal

stage 1 ovarian cancer

limited to ovaries w/ capsule intact/cytology

stage 2 ovarian cancer

one or both ovaries w/ pelvic extension

stage 3 ovarian cancer

one or both ovaries with peritoneal implants outside pelvis or +ve nodes

stage 4 ovarian cancer

distant mets or complications

ovarian cancer treatment

surgical chemotherapy - adjuvant, neoadjuvant gold standard = surgery followed by chemo

laparotomy for ovarian cancer

obtain tissue diagnosis stage disease disease clearance debulk disease - if not possible to remove all visible disease

chemotherapy for ovarian cancer

``` 1st line: platinum + taxane (Taxol) post-op: within 8wks of surgery complete/partial response cure unlikely - esp stage 3 avg response 2yrs (i.e. relapse in stage 3 disease following remission) ```

cure rates for ovarian cancer

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

management of recurring disease

``` chemotherapy palliation for symptomatic recurrence platinum if >6mths since last recurrence ?surgery if 1st recurrence and able to remove all disease tamoxifen - if unable to manage chemo ```

normal CA125

up to 35

ovarian cancer screening

population screening not proven high risk women (cancer gene mutation carriers, ≥2 relatives) - little positive evidence pelvic exam, USS ovaries, CA 125 difficult to detect women in precancerous stage no prognostic/survival benefit

what can be offered to high risk women to prevent ovarian cancer

prophylactic laparoscopic bilateral salpinogoophorectomy removal of tubes and ovaries following completion of families residual risk of 1y peritoneal cancer potential for risk reducing early salpingectomy and delayed oophorectomy

why is ovarian cancer screeening not recommended

limited sensitivity and specificity | FIGO stages of cancer detected rather than pre-cancerous change