Gynae-Oncology

Question 1

What is a rapid access clinic?

Answer 1

Designed to provide a one stop service to help triage patients with pelvic masses into those that need onward referral to a gynae cancer centre and those that can be managed locally.

Question 2

When would you suspect ovarian cancer?

Answer 2

If USS shows ovarian cysts that are large, bilateral, appear ‘complex’ (i.e. have both solid and cystic areas) then suspect ovarian malignancy. Marker for ovarian cancer = Ca-125. Diagnosis usually via laparotomy.

Question 3

What is the treatment for ovarian cancer?

Answer 3

Choosing what is the best treatment for advanced ovarian cancer is complex. Overall, the aim of the treatment is to eradicate as much disease as possible, using a combination of chemo and surgery. There are 2 options: primary surgery followed by chemo or doing surgery halfway through chemo (neoadjuvant chemo).

Question 4

How do you prepare patients for surgery?

Answer 4

• Perioperative care: patient should consume protein rich meals (help with recovery and growth of healthy cells)
• Diabetes is hard to get under control quickly but HTN can quickly be rectified
• CPET devices can be used to determine the likelihood that patients will need high dependency support
• Review patient each day to identify problems

Question 5

What is cytoreductive surgery?

Answer 5

Surgical procedure to remove tumours from patients with peritoneal mesothelioma. Aims to remove all macroscopic disease - involves total hysterectomy, bilateral oophorectomy and omentectomy followed by removal of any other disease where possible. May also do bowel resection, with or without formation of a colostomy, stripping of peritoneal surfaces such as under surface of diaphragm and splenectomy.

Question 6

What is one of most commonest subtypes of ovarian cancer?

Answer 6

• High grade serous ovarian cancer (HSGC) is one of the most commonest subtypes of epithelial ovarian cancer - arises from the serous epithelial layer mainly found in the ovary.
• HSGCs make up most ovarian cancer cases and have the lowest survival rates.
• ~15% of HSGC are associated with a germline mutation in either BRCA1 or BRCA2. Carrying one of these makes it far more likely to develop ovarian and breast cancer than non-carriers.

Question 7

What is the function of testing patients with ovarian cancer for the mutation?

Answer 7

1. If a patient is a carrier - allows other family members to undergo testing to see if they are at risk too. Asymptomatic carriers may elect to undergo prophylactic surgery to reduce the risk of breast and ovarian cancer
2. Determining if ovarian cancer is related to a germline mutation also has direct benefits for the patient. It is clear that some treatments, including treatment with PARP inhibitors, work much better in BRCA-related tumours.

Question 8

What chemotherapy is available for ovarian cancer?

Answer 8

Standard platinum based chemo for all types of ovarian cancer - carboplatin and paclitaxel - IV (5hr infusion) every 3 weeks, 6 doses total.
SEs:
- Carboplatin: nausea, decreased blood count, allergy
- Paclitaxel: hair loss, nausea decreased blood count, nerve damage, allergy

Question 9

What other medications are available for ovarian cancer?

Answer 9

Restrict blood supply to cancer cells. Bevacizumab (Avastin) is an antibody that blocks VEGF and Cediranib blocks the VEGF receptor. SEs of VEGF blockers:

• HTN
• Proteinuria
• Bowel perforation
• Fistula
• Drugs that block receptors: similar SEs, diarrhoea, malaise

Question 10

What drugs are used to target faulty DNA repair?

Answer 10

Olaparib and other PARP inhibitors inhibit DNA repair within cancer cells particularly important in HGSC.

• HGSC: most common, often recurs, responds well to chemo, linked to faults in BRCA genes, cause reduced ability to repair DNA damage
• Olparib: capsule treatment, most effective after cancer reduced by chemo (maintenance treatment), maintain benefit for longer, SEs: fatigue, sickness, diarrhoea and low blood count

Question 11

How do you calculate the risk of malignancy index (RMI1)?

Answer 11

RMI combines 3 pre-surgical features: serum Ca-125 (IU/MI), menopausal status (M) and USS (U). RMI = UxMxCa125

• USS scored 1 point for each of: multiocular cysts, solid areas, metastases, ascites and bilateral lesions (scored out of 5)
• Menopausal scored as 1 = pre-menopausal, 3 = post-menopausal
• Post-menopausal = woman who’s had no period for >1yr in a woman >50 and >2yrs in women <50 or a woman >50 who’s had a hysterectomy
• Serum Ca-125 measured in IU/MI and can vary from 0 to hundreds/thousands of units

Question 12

What are common presentations of ovarian cancer?

Answer 12

• Abdominal distension
• Alteration in bladder habit
• No symptoms
• Vague lower abdominal pain

Question 13

What can decrease ovarian cancer risk?

Answer 13

COCP by reducing no. of ovulations.