Ovarian Cancer

Question 1

What are the types of ovarian cancer

Answer 1

Primary
Epithelial carcinomas (90% primary cancers)
- Serous most common (70-80%)
- other types: mucinous, endometrioid, clear cell, transitional cell, squamous cell

Non-epithelial cancers (10%): germ cell, ovarian carcinoma, sex cord and stromal, small cell and neuroendocrine, squamous cell, struma ovarii malignum

Secondary
Often from endometrium, breast, GI tract

Question 2

Risk factors for ovarian cancer

Answer 2

Older age (peaks in 80s)
Genetic factors: BRCA 1 or 2
FHx ovarian cancer or other cancers
Lynch syndrome
Nulliparity
Early menarche
Late menopause
IVF
HRT (oestrogen-only AND combined)
PMHx cancer or endometriosis
Smoking, obesity, asbestos exposure, perineal use of talc-based body powder

Question 3

What are protective factors against ovarian cancer

Answer 3

Multiparity
Breastfeeding
COCP use
Early menopause

Question 4

Symptoms of ovarian cancer

Answer 4

Bloating / abdominal distension
Early satiety
Loss of appetite
Pelvic or abdominal pain
Increased urinary urgency or frequency
Weight loss
Malaise or fatigue
Change in bowel habit
Abnormal/postmenopausal bleeding
GI symptoms e.g. dyspepsia, nausea, bowel obstructions
SOB (pleural effusion)

Question 5

Differentials for ovarian cancer

Answer 5

Cancer of the cervix/uterus/rectum/bladder
Fibroids
Ascites from liver cirrhosis/HF
Adenomyosis
Gastric cancer
UTI
IBS or IBD
Constipation
Coeliac disease

Question 6

Signs of ovarian cancer

Answer 6

Abdominal exam
- Abdominal mass → refer for 2ww gynae
- Ascites

Pelvic exam
- Palpable adnexal mass or fixed pelvic mass with nodularity along the recto-vaginal septum → refer for 2ww gynae

(Resp exam)
- Diminished breath sounds or rales that are consistent with a pleural effusion

Question 7

Investigations for ovarian cancer

Answer 7

Symptoms frequent, >12x a month, → 2ww referral
Any mass felt on palpation → 2ww referral

First line: Ca-125
Gold standard: Surgical removal and histopathology

Bloods
Ca-125: >35IU/mL

Imaging
TVUSS: solid, complex, septated, multi-loculated mass with high blood flow
PET/PET-CT/MRI: staging
Surgical removal and histopathology

Question 8

Management for ovarian cancer

Answer 8

Usually surgical removal and histology
Pre-menopausal patients with a mass detected on TVUSS: surgery deferred for 2 to 3 menstrual cycles - ?functional or physiological mass

May require debulking surgery
± adjuvant chemotherapy (usually platinum-based) depending on stage

Early-stage low-risk disease + preserving fertility → uterus, contralateral ovary and fallopian tube preservation

Question 9

Complications of treatment for ovarian cancer

Answer 9

Chemotherapy: Intraperitoneal toxicity, plantar-palmar erythrodysaesthesia (PPE) secondary to liposomal doxorubicin, alopecia, N&V, infections, blood loss, GI disease, neutropenic fever/sepsis, bone marrow suppression

Bevacizumab: Bowel perforation, fistula, proteinuria, hypertension, wound-healing complications

Surgery: damage to surrounding bowel structures e.g. ileum, VTE

Question 10

Complications of ovarian cancer

Answer 10

Ovarian cancer may spread to
* Intraperitoneal structures and organs, causing intestinal obstruction and cachexia.
* The liver.
* Para-aortic lymph nodes.
* The lung, causing pleural effusions.

Question 11

Prognosis of ovarian cancer

Answer 11

Prognosis is not good, but is improving and survival has almost doubled in the last 40 years
80% of women have advanced disease at presentation
The all-stage 5-year survival is 46%
Survival is strongly related to stage of disease at time of diagnosis