Meirowitz - Ovarian Cancer

Question 1

What are the types of tumors present in the ovaries? What percentage to they account for?

Answer 1

Metastasis: 5% of malignant ovarian tumors
Usually from GI tract and breasts
AKA Krukenberg tumor

Sex cord-stromal cells (2-3%)
Granumoa cell tumor- produces estrogen
Usually no metastasis
Treated surgically

Germ cell cancers (3-5%)
Usually no metastatic spread
Very sensitive to chemo

Surface Epithelial Cells
90%
Usually affect women over age 20

Question 2

What is the lifetime risk in the general population for ovarian cancer?

What if one first degree relative?

What if 2 or more first degree relatives?

What percent is hereditary?

What is the average age of onset in non-hereditary versus hereditary ovarian cancer?

What are ACOG recommendations for family with increased risk?

Answer 2

1.4% of general population

5% (3-4x higher if first degree)

7% if 2 or more

Affected relatives should be tested for mutation
Risk in BRCA1+ = up to 50%

10% hereditary

age of onset >60 (postmenopausal) normally
age 45 in hereditary cases

Before childbearing: reduce risk with oral contraceptives
After childbearing or after age 35 (whichever is later) perform risk-reducing oophorectomy (reduces by >90%)

Question 3

What factors increase risk for ovarian cancer?

Answer 3

BRCA mutations

Family history

More ovulation:

• Later menopause
• Induction of ovulation for infertility treatment
• Fewer term pregnancies
• Oral contraceptives are protective

Question 4

How are benign ovarian masses distinguished from ovarian cancer?

Answer 4

unilateral
cystic
mobile
smooth
no ascites
slow growth
young patient

Do ultrasound:
simple cyst (no solid pattern)
smooth borders
no ascites

Color Doppler to check blood flow:
Will be increased in malignancy d/t neovascularization

Check tumor markers:
CA 125
beta HCG
alpha fetoprotein

Question 5

In what conditions is CA-125 marker elevated and what is it indicative of?

Answer 5

healthy subjects ( 1 % )
endometriosis
P I D
leiomyomas
ectopic pregnancy
ovarian cystadenomas (benign)
liver disease
pancreatitis
peritonitis
renal failure
pregnancy
luteal phase of menstrual cycle
Heart failure resulting in ascites and pleural effusion

Normal values are up to 35 U/mL
Within clinical context useful
Most useful for follow-up

Question 6

What are the patterns of ovarian cancer spread? Which are most and least common?

Answer 6

Transcoelomic : most common and earliest-exfoliated cells implant along peritoneal cavity surfaces
Ex: to omentum

Lymphatic : to pelvic and paraaortic nodes-common, in advanced disease

Hematogenous : uncommon

Question 7

How is staging done for ovarian cancer and what is the treatment?

Answer 7

Contrary to clinical staging in cervical cancer, ovarian cancer staging is surgical

Must do surgery to diagnose and stage: remove omentum, lymph nodes, and affected ovary and fallopian tube
Peritoneal cytologic examination
Determine extent of disease in pelvis, peritoneal surfaces, diaphragm, liver, omentum and lymph nodes, omentectomy and lymph node removal
If older patient total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO)
20% of apparent stage I will be upstaged in surgery

In stage II and IV: debulking: removal of as much tumor as possible (<1cm), splenectomy, bowel resection, diaphragm removal, etc.

Neoadjuvant and adjuvant chemotherapy
Taxol (Paclitaxel) / Carboplatin (platinum) combination
-Good response but 80% relapse
Intraperitoneal chemotherapy: good results in combination with regular chemo but low tolerability (high toxicity and complications)

Question 8

What are the stages of ovarian cancer?

Answer 8

I: limited to ovaries

II: pelvic extension but not upper abdomen

III: extension to upper abdomen
IIIc: peritoneal implants >2cm
OR lymph metastasis
most common stage

IV: Distant metastasis outside abdominal cavity
(pleural effusion, liver parenchyma- more than surface)