Ovarian and Fallopian Tube Cancer Flashcards by Mario Luna

Ovarian and Fallopian Tube Cancer

BONUS

Metastasis to the ovary from gastrointestinal malignancy.

Krukenberg tumors

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Ovarian and Fallopian Tube Cancer

What is the histology of the outer cortex of the ovary?

pseudocolumnar or cuboidal epithelium, termed the germinal epithelium of Waldeyer or ovarian surface epithelium (OSE)

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Ovarian and Fallopian Tube Cancer

The primary lymphatic drainage of the
ovary parallels the course of the ovarian arteries, with secondary lymphatic flow
passing through the inguinal canal and to the iliac nodal system.

TRUE or FALSE?

False.

it’s veins not arteries

read. 1 point is 1 point sa exam. Sayang.
Examiners are not always fair. hahaha

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Ovarian and Fallopian Tube Cancer

What is the arterial supply of the ovaries?

the fallopian tubes?

ovaries: ovarian artery

fallopian tubes: ovarian and uterine ateries.

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Ovarian and Fallopian Tube Cancer

The venous drainage of the fallopian tubes is through the Batson’s plexus to the ovarian vein and uterine plexus.

TRUE or FALSE?

False.

pampiniform not batson

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Ovarian and Fallopian Tube Cancer

The fallopian tubes consist of four separate histologic layers: the mucosa, submucosa, muscularis (external longitudinal and inner circular layers), and outer serosal layer, which is continuous with the visceral peritoneum of the uterus.

TRUE or FALSE?

True.

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Ovarian and Fallopian Tube Cancer

What is the most common histology of primary “fallopian tube” tumors?

high-grade serous carcinoma

papillary serous adenocarcinoma

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Ovarian and Fallopian Tube Cancer

What is the precursor lesion of primary fallopian tube tumors?

serous tubal intraepithelial carcinomas (STICs)

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Ovarian and Fallopian Tube Cancer

Two-pathway model.
Identify whether type 1 or 2.

High-grade serous carcinoma

Type 2

All müllerian subtypes (serous, endometrioid,
mucinous, clear cell, transitional) are type 1

In general, type 1 are low grades, type 2 are high grades

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Ovarian and Fallopian Tube Cancer

Two-pathway model.
Identify whether type 1 or 2.

activated MAPK pathway (KRAS or BRAF mutation)

Type 1

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Ovarian and Fallopian Tube Cancer

Two-pathway model.
Identify whether type 1 or 2.

activated PI3K pathway (PIK3CA or PTEN mutation)

Type 1

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Ovarian and Fallopian Tube Cancer

Two-pathway model.
Identify whether type 1 or 2.

loss of BAF250a expression (ARID1a mutation)

Type 1

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Ovarian and Fallopian Tube Cancer

Two-pathway model.
Identify whether type 1 or 2.

Inactivation of BRCA pathway

Type 2

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Ovarian and Fallopian Tube Cancer

Two-pathway model.
Identify whether type 1 or 2.

High frequency p53 mutation

Type 2

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Ovarian and Fallopian Tube Cancer

Two-pathway model.
Identify whether type 1 or 2.

Widespread DNA copy number change

Type 2

Type 1 is usually chromosomally stable

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Ovarian and Fallopian Tube Cancer

Two-pathway model.
Identify whether type 1 or 2.

Usually platinum sensitive

Type 2

Type 1 is usually insensitive

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Ovarian and Fallopian Tube Cancer

Main patient-related risk factor?

increased frequency of ovulation/incessant ovulation

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Ovarian and Fallopian Tube Cancer

OCP use reduces the risk of ovarian cancer.

TRUE or FALSE?

True

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Ovarian and Fallopian Tube Cancer

Estrogen (HRT) reduces the risk of ovarian cancer.

TRUE or FALSE?

False.

Exogenous estrogen increases the risk, as well as elevated androgens.

Progestins are protective.

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Ovarian and Fallopian Tube Cancer

Ovarian cancers can arise from PCOS and endometriosis.
Those that arise from endometriosis are most often low-grade tumors with endometrioid or clear cell histology and are associated with a better prognosis.

TRUE or FALSE?

True.

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Ovarian and Fallopian Tube Cancer

I. BRCA-associated ovarian cancers are most frequently invasive serous adenocarcinomas and less likely borderline or mucinous tumors.

II. Mutation carriers are also more likely to present with advanced-stage disease and have poorly differentiated tumors.

III. BRCA1 or BRCA2 mutation carriers have a more unfavorable clinical course with a significantly shorter recurrence-free and overall survival compared to noncarriers.

Which statement is FALSE?

III.

favorable clinical course with a significantly longer recurrence-free and overall survival compared to noncarriers

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Ovarian and Fallopian Tube Cancer

Aside from BRCA mutations, what is the other syndrome accounting for the remaining 10% of hereditary ovarian cancers?

Ovarian cancer associated with this syndrome is more often diagnosed at an earlier stage with well- to moderately differentiated tumor grade in contrast to BRCA associated cancers.

HNPCC or Lynch II syndrome

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Ovarian and Fallopian Tube Cancer

What are the three procedures (lab/imaging/surgical procedure) that are used for screening (although the efficacy of screening has been disappointing in the high-risk population)?

CA-125
TVUS
laparotomy (surgical)

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Ovarian and Fallopian Tube Cancer

Most common type of ovarian tumor/malignancies?

epithelial
***
Most
ovarian malignancies (60% to 65%) are epithelial, with germ cell tumors (20%),
sex cord–stromal tumors (5%), and metastases to the ovary (5% to 10%)
accounting for the remainder.

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Ovarian and Fallopian Tube Cancer Most common type of ovarian "epithelial" tumor?

serous *** Serous tumors are most common, comprising 50% to 60% of epithelial tumors. Other subtypes include mucinous carcinoma in 10%; endometrioid carcinoma, 8%; clear cell carcinoma, 3% to 5%; transitional, 3% to 5%; and undifferentiated carcinoma, 1%.

Ovarian and Fallopian Tube Cancer Bilateral ovarian involvement, small multinodular ovaries, and surface and hilar spread likely represents a primary ovarian tumor. A large, cystic, unilateral tumor of low grade arising in a focus of endometriosis suggests metastatic involvement from an endometrial primary. TRUE or FALSE?

False. *** Bilateral ovarian involvement, small multinodular ovaries, and surface and hilar spread suggest metastatic involvement from an endometrial primary, particularly if the endometrial tumor is high grade, deeply invasive, and associated with lymphovascular invasion. A large, cystic, unilateral tumor of low grade arising in a focus of endometriosis likely represents a primary ovarian tumor.

Ovarian and Fallopian Tube Cancer Word association: Schiller-Duval bodies

Endodermal | sinus tumors, also known as yolk sac tumors

Ovarian and Fallopian Tube Cancer Word association: Call-Exner body

granulosa cell tumors | the most common sex cord–stromal tumor

Ovarian and Fallopian Tube Cancer What is the primary mode of spread of ovarian cancers?

Transperitoneal

Ovarian and Fallopian Tube Cancer What is the most common extrapelvic finding in stage IV disease?

Transdiaphragmatic spread occurs to the pleural cavity and is the most common finding in stage IV disease

Ovarian and Fallopian Tube Cancer FIGO Staging Pleural effusion with positive cytology

IVA IVB (is parenchymal metastasis including liver and spleen, and other extra-abdominal and distant organs)

Ovarian and Fallopian Tube Cancer FIGO Staging Inguinal nodal involvement

IVB | considered distant remember, the primary spread is transperitoneal

Ovarian and Fallopian Tube Cancer FIGO Staging Spleen or liver capsule involvement

IIIC

Ovarian and Fallopian Tube Cancer FIGO Staging Macroscopic peritoneal metastases (above pelvic brim) >2 cm

IIIB IIIA is microscopic IIIB

Ovarian and Fallopian Tube Cancer FIGO Staging Minimum stage if there is a positive retroperitoneal lymph node?

IIIA1 ``` IIIA1i (≤10 mm) IIIA1ii if (10 mm) ``` can be IIIB, C, depending on other parameters not related to retroperitoneal lymph nodes.

Ovarian and Fallopian Tube Cancer FIGO Staging Uterine involvement

IIA (including FT and ovaries) | IIB if other intraperitoneal pelvic tissues, below the pelvic brim

Ovarian and Fallopian Tube Cancer FIGO Staging Surgical spill of ovarian or fallopian tube contents

IC1

Ovarian and Fallopian Tube Cancer FIGO Staging Ovarian capsule rupture prior to surgery

IC2

Ovarian and Fallopian Tube Cancer FIGO Staging Positive peritoneal washings

IC3

Ovarian and Fallopian Tube Cancer What are the criteria for pre-menopausal women who can undergo fertility sparing surgery?

stage I (stage 1A or 1C, but not 1B) because IB is bilateral and/or low-risk tumors (early-stage, low-grade invasive tumors, LMP/borderline lesions, or malignant stromal or germ cell tumors).

Ovarian and Fallopian Tube Cancer What are the most important determinants of survival?

stage grade histology optimal cytoreduction

Ovarian and Fallopian Tube Cancer Regarding cytoreduction, what is the GOG definition of: optimal complete suboptimal?

complete: no gross visible disease optimal - residual tumor ≤ 1 cm suboptimal - residual tumor nodules greater than 1 cm

Ovarian and Fallopian Tube Cancer Optimal cytoreduction confers improvement in median survival compared to suboptimal cytoreduction. TRUE or FALSE?

True

Ovarian and Fallopian Tube Cancer Preoperative CA-125 measurement is independently prognostic, as it likely reflects disease burden TRUE or FALSE?

False. Preoperative CA-125 measurement is not independently prognostic, as it likely reflects disease burden. In contrast, the half-life and nadir of CA-125 during induction chemotherapy are associated with improved outcome in ovarian and fallopian tube cancers

Ovarian and Fallopian Tube Cancer Management of Epithelial Ovarian Cancer Stage IA/B grade 1

Observation

Ovarian and Fallopian Tube Cancer Management of Epithelial Ovarian Cancer Stage IA/B grade 2

Observation or IV taxane/carboplatin for 3–6 cycles

Ovarian and Fallopian Tube Cancer Management of Epithelial Ovarian Cancer Stage IA/B grade 3

IV taxane/carboplatin for 3–6 cycles

Ovarian and Fallopian Tube Cancer Management of Epithelial Ovarian Cancer Stage IA/B grade 3

IV taxane/carboplatin for 3–6 cycles

Ovarian and Fallopian Tube Cancer Management of Epithelial Ovarian Cancer Stage II grade II

IV taxane/carboplatin for 6 cycles or IP chemotherapy in optimally cytoreduced patients

Ovarian and Fallopian Tube Cancer Management of Epithelial Ovarian Cancer Stage III optimally cytoreduced

``` IP chemotherapy or IV taxane/carboplatin for 6 cycles or clinical trial ```

Ovarian and Fallopian Tube Cancer Management of Epithelial Ovarian Cancer Stage III suboptimally cytoreduced Stage IV

``` IV taxane/carboplatin for 6 cycles or clinical trial or interval cytoreduction if indicated by tumor response and resectability ```

Ovarian and Fallopian Tube Cancer What are the two trials that showed a benefit to platinum-based chemotherapy for early stage cancer? What are the stages included in their treatment arms?

ICON1 (I/II) and ACTION (IA, IB, grades 2-3, IC-IIA all grades, clear cell)

Ovarian and Fallopian Tube Cancer What group conducted trial that compared 3 vs 6 cycles of chemotherapy (carboplatin and taxol) in early stage cancer which showed no survival difference? What group had the greatest benefit?

GOG serous tumors

Ovarian and Fallopian Tube Cancer In the study from PMH, the greatest benefit to the addition of WAI is seen on what subgroup of patients?

<2 cm residual.

Ovarian and Fallopian Tube Cancer WAI was proven comparable to chemotherapy in the adjuvant setting (MDA/Italian study) and was shown to have OS benefit by the PMH experience. Why is adjuvant WAI not routinely adapted in practice?

toxicity. also no level I evidence

Ovarian and Fallopian Tube Cancer Usual Dose: WAI

45 Gy to the pelvis, 22.5 to the whole abdomen (up to 30 with boost to paraaortic nodes up t 45-50 Gy)

Ovarian and Fallopian Tube Cancer What histologies of early-stage ovarian cancer usually benefit from consolidative RT?

clear-cell, mucinous, and endometrioid | not in serous

Ovarian and Fallopian Tube Cancer What type of chemotherapy drug was found out to be the most active class in ovarian cancer treatment as was proven by the meta-analysis of 49 trials from the Advanced Ovarian Cancer Trialists’ Group?

platinum-based

Ovarian and Fallopian Tube Cancer What radiocolloid is used in intraperitoneally in the treatment of ovarian cancers?

32P

Ovarian and Fallopian Tube Cancer What was approved as maintenance therapy was recently granted FDA approval based on the results of the SOLO-2 trial, which showed a significant improvement in progression-free survival in patients with germline BRCA-mutated, platinum-sensitive recurrent ovarian cancer when compared to placebo.

Olaparib

Ovarian and Fallopian Tube Cancer This agent was approved by FDA for patients with recurrent germline BRCA-mutated ovarian cancer who have received three or more prior lines of chemotherapy or as maintenance therapy following response to platinum therapy for those with platinum-sensitive recurrence.

Olaparib

Ovarian and Fallopian Tube Cancer This agent was approved by FDA for patients with with BRCA-mutated ovarian cancer (either deleterious tumor or germline mutation) who have received at least two prior lines of chemotherapy.

Rucaparib

Ovarian and Fallopian Tube Cancer This agent was approved by FDA for platinum-sensitive recurrent ovarian cancer patients as maintenance therapy following response to platinum-based chemotherapy, regardless of BRCA or tumor homologous recombination status.

Niraparib

Ovarian and Fallopian Tube Cancer Response to palliative RT is dependent on the recurrent tumor's sensitivity to platinum second-line chemotherapy. TRUE or FALSE?

Duh! | Of course not.

Ovarian and Fallopian Tube Cancer What is the most common ovarian germ cell tumor?

mature cystic teratoma

Ovarian and Fallopian Tube Cancer What is the most common ovarian neoplasm?

mature cystic teratoma

Ovarian and Fallopian Tube Cancer What is the most common malignant ovarian germ cell tumor?

dysgerminoma

Ovarian and Fallopian Tube Cancer Dysgerminoma Postoperative management for stage I dysgerminoma

observation.

Ovarian and Fallopian Tube Cancer Dysgerminoma Postoperative management for advanced-stage disease?

four cycles of BEP chemotherapy (bleomycin, etoposide, cisplatin)

Ovarian and Fallopian Tube Cancer Dysgerminoma adjuvant RT dose?

25 Gy in 12 to 14 fx (1.8)

Ovarian and Fallopian Tube Cancer Dysgerminoma has the highest bilaterality rate among germ cell tumors of the ovary. TRUE or FALSE?

True

Ovarian and Fallopian Tube Cancer What is the NCCN recommended treatment for well-staged patients with resected ovarian nondysgerminoma GCTs?

3-4 cycles of BEP

Ovarian and Fallopian Tube Cancer What is the NCCN recommended treatment for resected ovarian nondysgerminoma GCTs with gross residual or stage IV disease?

6 cycles of chemotherapy

Ovarian and Fallopian Tube Cancer Most common presenation of juvenile granulosa cell tumor

abdominal mass

Ovarian and Fallopian Tube Cancer Surgical treatment in premenopausal women with early stage granulosa cell tumors?

unilateral SO (USO)