Ovarian Cancer

Question 1

What do ovarian masses come to clinical attention?

Answer 1

When they are very large and cause distension, or when USS/laparoscopy/laparotomy is performed for unrelated reasons.
Clinically silent

Question 2

What are the acute presentations of an ovarian mass?

Answer 2

1. Torsion of pedicle - impairs blood supply, abdominal pain - infarction if not treated.
2. Rupture - releases contents, intense pain - associated with mature teratoma.
3. Haemorrhage - into itself or peritoneal cavity, pain, can cause hypovolaemic shock.

Question 3

What is the most common type of benign ovarian tumour and what are it’s two subtypes?

Answer 3

1. Benign epithelial cell tumour

2. Cystopapilloma or cystoadenoma

Question 4

What is this describing?
Pre-menopausal ovarian cyst, often asymptomatic and bilateral, lined by skin, underlying sebaceous glands and hair follicles.

Answer 4

Benign mature cystic teratoma (dermoid cyst)

Question 5

What is a teratoma?

Answer 5

Germ cell tumour which forms normal tissue structure, arises from the ova of the ovary.

Question 6

What is the most common malignant ovarian tumour and what are its two components?

Answer 6

1. High grade serous carcinoma

2. Solid and cystic components

Question 7

What type of cancer is ovarian cancer?

Answer 7

90% are carcinomas, most commonly high grade cysto-adenocarcinoma.

Question 8

What are the risk factors for developing ovarian cancer?

Answer 8

1. Number of ovulations - higher number, higher risk (pregnancy, breastfeeding and COCP are protective)
2. Early menarche and late menopause
3. Family history - BRCA1/BRCA2 and Lynch syndrome

Question 9

Why does ovarian cancer have a poor prognosis?

Answer 9

1. Asymptomatic, or diverse and non-specific symptoms.

2. Late presentation at high stage, worse prognosis.

Question 10

What are the signs and symptoms of ovarian cancer?

Answer 10

1. Abdominal distension, bloating, fullness, loss of appetite, ascites.
2. Pelvic/abdominal pain and mass
3. Urgency and frequency, change in bowel habit
4. Unexplained weight loss, fatigue
5. Pleural effusion
6. Rupture, peritonism

Question 11

How is ovarian cancer investigated?

Answer 11

1. FBC, U&Es, LFTs
2. CA125 - If <40 years AFP, LDH, bHCG (germ cell tumour)
3. TVUSS, CXR
4. Ascites and pleural effusion can be sampled and sent for cytology
5. Risk of malignancy (RMI) calculated

Question 12

How is RMI (risk of malignancy) calculated in ovarian cancer?

Answer 12

USS score (1 or 3) x menopausal score (1 or 3) x serum CA125 level

Question 13

What does an RMI score of >250 in suspected ovarian cancer indicate and what is the management?

Answer 13

1. 75% risk of having cancer
2. Refer to gynaecology oncology service
3. CT +/- MRI - peritoneal spread, ascites, liver metastases
4. Laparotomy - formal diagnosis and staging (FIGO)
5. Total abdominal hysterectomy and bilateral salpingo-oophrectomy