Ovarian and Fallopian Tube Cancer Flashcards
Ovarian and Fallopian Tube Cancer
BONUS
Metastasis to the ovary from gastrointestinal malignancy.
Krukenberg tumors
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)
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
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.
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
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.
Ovarian and Fallopian Tube Cancer
What is the most common histology of primary “fallopian tube” tumors?
high-grade serous carcinoma
papillary serous adenocarcinoma
Ovarian and Fallopian Tube Cancer
What is the precursor lesion of primary fallopian tube tumors?
serous tubal intraepithelial carcinomas (STICs)
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
Ovarian and Fallopian Tube Cancer
Two-pathway model.
Identify whether type 1 or 2.
activated MAPK pathway (KRAS or BRAF mutation)
Type 1
Ovarian and Fallopian Tube Cancer
Two-pathway model.
Identify whether type 1 or 2.
activated PI3K pathway (PIK3CA or PTEN mutation)
Type 1
Ovarian and Fallopian Tube Cancer
Two-pathway model.
Identify whether type 1 or 2.
loss of BAF250a expression (ARID1a mutation)
Type 1
Ovarian and Fallopian Tube Cancer
Two-pathway model.
Identify whether type 1 or 2.
Inactivation of BRCA pathway
Type 2
Ovarian and Fallopian Tube Cancer
Two-pathway model.
Identify whether type 1 or 2.
High frequency p53 mutation
Type 2
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
Ovarian and Fallopian Tube Cancer
Two-pathway model.
Identify whether type 1 or 2.
Usually platinum sensitive
Type 2
Type 1 is usually insensitive
Ovarian and Fallopian Tube Cancer
Main patient-related risk factor?
increased frequency of ovulation/incessant ovulation
Ovarian and Fallopian Tube Cancer
OCP use reduces the risk of ovarian cancer.
TRUE or FALSE?
True
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.
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.
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
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
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)
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.
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)
