Ovarian cancer

Question 1

58-year-old woman presents with abdominal distension and discomfort. She has had significant weight loss over the last 3 months. She has a palpable adnexal mass on examination. How would you assess and manage?

Answer 1

Impression
With adnexal mass and weight loss, given woman’s age, am immediately concerned about a malignancy. There are a number of potential causes I would like to consider including;
- uterine: fibroids, adenomyosis, leimyosarcoma, endometrial carcinoma
- ovarian: physiological cyst (follicular, luteal, etc), neoplasia (endothelial, sex-chord/stromal, germ cell), endometrioma
- cervical, Fallopian tube: hydrosalpinx, ectopic
- GIT, genitourinary
- infectious: TOA,

Goals
- conduct targeted Hx/Ex, likely require imaging and tumour markers to inform diagnosis upon definitive management with surgical excision would likely be appropriate in the setting of ovarian cancer.

Question 2

Ovarian carcinoma - history

Answer 2

History

• sx: PV bleeding, pain, dyspareunia, bowel/urinary changes, bloating/ascites, confirm menopausal status, does mass change across menstrual cycle?
• RISKS: fam hx, age, early menarche/late menopause, nulliparous, BRCA, Lynch syndrome, smoking
• protective: PCOS, breastfeeding, multiparity, COCP
• Medications; HRT?
• Fam Hx, O&G Hx

Question 3

Ovarian carcinoma - examination

Answer 3

Examination

• General obs + vitals
• Abdo: ascites, mass
• Pelvic: adnexal mass, ?bleeding, tenderness,

Question 4

Ovarian carcinoma - investigations

Answer 4

Investigations
- Key/diagnostic: PV Ultrasound (solid/cystic, thickened capsule, increased vascularity, abdominal fluid, size >6cm, septations); Tumour markers (Ca125, CEA, AFP)

• bedside: urinary ß-HCG
• bloods: FBC, UEC, LFT, CRP/ESR, Ca125, CEA, AFP, CMP
• imaging: PV US, staging imaging
• calculate risk of malignancy index (RMI) menopausal status + US findings + Ca125

Biopsy not undertaken due to risk of peritoneal seeding, could confirm diagnosis histologically with excision of mass if deemed appropriate management pathway

Question 5

Ovarian carcinoma - management

Answer 5

Management
core principles
- MDT approach
- patient education, counselling, reassurance

Definitive
for ovarian cancer, most will have surgical excision +/- adjuvant chemotherapy (platinum-based)

Surgery:
- pelvic clearance

Additional

• genetic screening if strong family hx (BRCA, Lynch syndrome)
• post-therapy surveillance - monitor Ca125 for recurrence