CPC ovary

Question 1

epidemiology of ovarian cancer

Answer 1

600 cases p/a scotland
400 deaths p/a

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

Question 2

how common is ovarian cancer

Answer 2

rare <30y/o

Question 3

who are the high risk families for ovarian cancer

Answer 3

5-10% of all cases
early onset presentation

HNPCC/Lynch type II familial cancer syndrome
BRCA1
BRCA2

incessant ovulation

Question 4

what can be protective for ovarian cancer

Answer 4

OCP
breast feeding
numerous pregnancies

Question 5

origins of ovarian cancer

Answer 5

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

Question 6

ovarian cancer origins and pathogenesis - molecular alterations

Answer 6

P53
BRCA1 and 2
ARID1A
PIK3CA
PTEN
BRAF
KRAS
NRAS
ERBB2

Question 7

pathogenesis of ovarian cancer

Answer 7

Question 8

what mutation causes an aggressive ovarian cancer

Answer 8

p53 mutations

Question 9

role of pathology in ovarian cancer

Answer 9

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

Question 10

what type of tumour is this

how common

Answer 10

commonest epithelial tumour type

serous cystadenoma

benign

Question 11

describe the appearance of serous cystademonas

Answer 11

unilocular cyst

thin wall

flat epithelial lining

Question 12

what tumour type is shown here

Answer 12

borderline serous tumour

tree like area on left

atypical epithelium

Question 13

describe the features of borderline serous tumours

Answer 13

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

Question 14

what is shown here

which is high grade and which is low grade

Answer 14

serous carcinoma

low - top
high - bottom

Question 15

features of high grade carcinomas

Answer 15

often serous carcinomas

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

nuclearpleomorphism and prominent nucleoli

invasion into stroma

high mitotic rate

Question 16

in what grade carcinomas are psammoma bodies seen

Answer 16

low grade carcinomas

they are calcifications

Question 17

ovarian cancer symptoms

Answer 17

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

Question 18

ovarian cancer diagnosis

Answer 18

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

Question 19

what is CA 125

Answer 19

glyco-protein antigen

tumour marker

non-specific

Question 20

what malignancies is CA125 associated with

Answer 20

ovary
colon/pancreas
breast

also lung

e.g. anything that causes disease in peritoneal cavity

Question 21

what benign conditions is CA125 associated with

Answer 21

menstruation, endometriosis, PID

liver disease, recent surgery, effusions

Question 22

how is CA125 used in the diagnosis of ovarian cancer

Answer 22

80% of women w/ ovarian ca have raised CA125

50% of women w/ stage 1 disease

used in detecting and monitoring epithelial ovarian tumours

Question 23

ovarian cancer RMI

Answer 23

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

Question 24

US features for RMI

Answer 24

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

Question 25

stage 1 ovarian cancer

Answer 25

limited to ovaries w/ capsule intact/cytology

Question 26

stage 2 ovarian cancer

Answer 26

one or both ovaries w/ pelvic extension

Question 27

stage 3 ovarian cancer

Answer 27

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

Question 28

stage 4 ovarian cancer

Answer 28

distant mets or complications

Question 29

ovarian cancer treatment

Answer 29

surgical
chemotherapy - adjuvant, neoadjuvant

gold standard = surgery followed by chemo

Question 30

laparotomy for ovarian cancer

Answer 30

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

Question 31

chemotherapy for ovarian cancer

Answer 31

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)

Question 32

cure rates for ovarian cancer

Answer 32

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

Question 33

management of recurring disease

Answer 33

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

Question 34

normal CA125

Answer 34

up to 35

Question 35

ovarian cancer screening

Answer 35

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

Question 36

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

Answer 36

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

Question 37

why is ovarian cancer screeening not recommended

Answer 37

limited sensitivity and specificity

FIGO stages of cancer detected rather than pre-cancerous change