Ovarian cancer

Question 1

How do you calculate RMI?
What RMI level necessitates referral to gynae onc?

Answer 1

RMI = menopause status (1 or 3) x U (pts for BAMMS; 0, 1 or 3) x CA-125

U = Bilateral Ascites Multilocular Mets Solid

RMI >200

Question 2

Outline investigations and work up for a suspected ovarian malignancy

Answer 2

• Tumour markers: CA125, CA19-9, CEA
  
  • aFP, LDH, thCG
• Bloods: FBC, U&Es, LFTs, coags
• Imaging: TVUSS, CT CAP
  
  • Cystoscopy, colonoscopy
  • Mammogram
• Ascitic or pleural tap for cytology.

Question 3

Outline FIGO staging for ovarian cancer

Answer 3

Stage I: ovaries/tubes only

• IA: Ovary/tube only, no malignant cells in washings.
• IB: bilateral ovaries or tubes, no malignant cells in washings.
• IC: surgical spill, tumour on surface or malignant cells.

Stage II: spread to pelvis or peritoneum below pelvic brim.

Stage III: spread to retroperitoneal lymph nodes or above pelvic brim.

Stage IV: spread outside of abdomen

Question 4

Outline management of a post-menopausal woman with an asymptomatic simple, unilateral, unilocular ovarian cyst

Answer 4

<50 mm: CA125 + surveillance USS at 6 months and 1 year; D/C if CA125 normal and size stable or reduced.

50-70 mm: CA125 + yearly USS surveillance

>70 mm: MRI or surgery.

Question 4

Outline what fertility sparing surgery for ovarian cancer is and who is it appropriate for:

Answer 4

• Staging midline laparotomy, removal of affected ovary, biopsy of unaffected ovary, peritoneal washings, omenectomy, para-aortic node dissection.
• Indication: young and desiring fertility, stage IA, grade 1 and 2, no evidence of omental or peritoneal disease.

Question 5

Who should have adjuvant chemotherapy and outline drugs used and side-effects

Answer 5

• Indication: stage IC, stage II
• Carboplatin S/Es: change in taste, hair loss, mucositis, central neurotoxicity, ototoxicity
• Paclitaxel S/Es: pantocytopaenia, hair loss, joint and muscle pain, peripheral neuropathy, diarrhoea, mucositis

Question 6

What is the risk of endometrial and ovarian cancer in Lynch syndrome II?

Answer 6

• Risk of endometrial cancer 60%
• Risk of ovarian cancer 10%

Question 7

Outline management of BOT:

Answer 7

• Family complete: midline TAH, BSO, peritoneal and omentectomy, washings.
• Fertility sparing: midline USO, contralateral ovarian biopsy, peritoneal and omental biopies, washings.
  
  • If both affected or remaining ovary affected: perform partial oophorectomy or cystectomy on one side.
• Appendicectomy if mucinous BOT histology.

Question 8

Outline your investigations and management for a pregnant woman with suspected ovarian cancer

Answer 8

• TA/TVUSS
• MRI pelvis
• Tumour markers: CA125, AFP, tumour hCG, inhibin B, AMH, CA19-9, LDH.

Early-stage ovarian cancer can be treated in 2nd and 3rd trimester with open or laparoscopic USO, omentectomy, peritoneal biopsies and lymphadenectomy.

Can use paclitaxel and carboplatin-based chemotx in 2nd and 3rd trimester.

MoD: vaginal delivery.

Stage III/IV:

• Diagnosed in early pregnancy: complete debulking surgery, adjuvant chemo
• Diagnosed in late pregnancy: NACT until 35-36 weeks; then CS and cytoreductive therapy.

Risks: PTB, IUGR, SB.

Oncological outcomes are the same as for non-pregnant women.