Ovarian Cancer Flashcards
Incidence:
Most common gynae malignancy
Epithelial Ovarian CA: Majority present with advance disease therefore prognosis and survival poor
- Lifetime incidence 1:80
- Mainly postmenopausal women
Factors to note in History
- Risk factors:
- Family history
- Nulliparity (Theory of incessant ovulation with trauma to surface epithelium, increased risk of malignant transformation
- Early menarche/late menopause
- Ovarian stimulation
- BRCA carrier status 5-10% associated with BRCA status and HNPCC
- Protective factors:
- COCP use (50% reduction with 5
years use) - Hysterectomy
- Tubal ligation
- Breastfeeding
- Symptoms:
*Constitutional: fatigue, weight loss/gain - Abdominal: bloating, pain
- GI: poor appetite, altered bowel habit
- Urinary: frequency, incontinence
- Risk factors as above
- Assess fitness for surgery
Histology
- 90% of ovarian cancers are epithelial
o Serous >50% - Secrete Ca-125
o Endometrioid 20% - Usually well differentiated
- May have synchronous endometrial cancer
o Mucinous 5-10% - Well differentiated
- Secrete Ca19.9
- Pseudomyxoma peritoneii – likely to have GI primary
o Clear cell 5-10% - Poor prognosis
- Associated with endometriosis
- Germ Cell 10%
- more common in younger women
- DysgerminomasL LDH (Most common malignant tumour in pregnancy)
- yolk sac tumours: Secrete AFP
- Malignant teratoma
- Choriocarcinoma: Secrete Beta HCG
- Sex cord stroma
- any age
- granulosa cell: Secrete Oestrogen
- Sertoli-Leydig secrete testosterone
- Metastatic 5-10%
o Breast (most common), colorectal, stomach ( Krukenberg tumours with signet ring on Histopathology), endometrial
Spread
- Transperitoneal or Coelomic:
Breach of Ovarian capsule
Spread to peritoneal surface such as diaphragm, bowel or omentum - Lymphatic: Para-aortic and pelvic LN
- Haemotogenous: Late to lungs and liver
Examination
- CV and resp to assess fitness for surgery
- Abdominal and bimanual examination
Palpable masses/tenderness/ Ascites
Investigations
o Pelvic ultrasound:
M rules: at least one and nil benign
- irregular solid tumour
- irregular/multilocular solid mass >10cm
- >/= 4 papillary structures
- Ascites
- High Doppler signal
B rules: At least one and nil malignant
- unilocular cyst
- smooth multilocular tumour <10cm
- solid components of <7mm
- Presence of acoustic shadows
- No detectable Doppler flow
o Tumour markers: Ca-125, CEA, Ca19.9
- AFP, HCG and LDH in younger women
o Pre-operative workup: FBE, UEC, LFTs, coags, G&H, CXR, ECG
o Consider CT Abdo/Pelvis for further assessment of anticipated stage
- Consider use * Risk of Malignancy Index
o Ca-125 x menopausal status x USS features
§ Menopausal = 3, premenopausal = 1
§ 1 abnormal ultrasound finding=1, >=2 abnormal ultrasound findings=2
* Multiloculated
* Solid areas
* Papillary projections
* Bilateral
* Ascites
* Metastases
o Score >200 suggests high risk of malignancy
Management
- Referral to gynae-oncology unit
o MDT discussion - Surgical staging
- Procedure
§ Midline laparotomy
§ Pelvic washings
§ Extrafascial TAH/BSO
§ Omental biopsy +/- omentectomy (essential if stage 1c or above)
If disease in 1 ovary only and yound woman: Remove affected ovary, Biopsy contralateral ovarly, stage with peritoneal washings, oentectomy and para-aortic lymph nodes
§ Peritoneal biopsy
§ Pelvic and para-aortic lymph node sampling
§ Debulking (aim all deposits <1cm) - Achieving optimal debulk improves survival
§ Appendicectomy if mucinous - Postoperative care
o Thromboprophylaxis
o Further MDT and histopath review to plan adjuvant therapy - Chemotherapy
o Adjuvant chemotherapy - Carbotaxol first line (Epithelial Ca)
- Given routinely for stage 1c and above
- Consider for stage 1a and 1b if high grade
o Neoadjuvant chemotherapy - Consider if bulky extraperitoneal disease or surgically unfit
- Aim for interval debulking
NB: Follow up
- 6/52 Post op with MDT
- 3-4 monthly for 1-2 years
- Yearly for 5 years
Symptoms of recurrence:
* Presentation with pain, ascites, pleural effusion
* Secondary surgery rarely indicated
* Trial of platinum-based chemotherapy if reasonable disease-free interval
* Symptomatic management/palliation may be required
o Stoma
o Pleurodesis
o Paracentesis
Granulosa cell Tumour
- Comprise 70% of sex-cord stromal tumours and have malignant potential
- Median age of onset 50-55 years
- Risk factors – non white, obese, family hx breast or ovarian cancer
- Protective factors – OCP use, increased parity, smoking
Clinical features of Granulosa cell tumour
o Present as large unilateral masses, usually >10cm
o Secrete oestrogen
- 55% of patients have abnormal uterine bleeding
* At endometrial biopsy, 50% have hyperplasia and 10% have overt endometriod adenocarcinoma
- Breast tenderness, sexual precocity in children
o Non-specific features ie ascites, bloating, abdominal pain
o May present acutely with ovarian torsion or tumour rupture
Granulosa cell tumours NB other NB Ix
- Inhibin B raised
- NB to check ET: Often associated with Hyperplasia or Endo Ca
- Histological diagnosis at time of surgical excision
§ Yellow-coloured tumour due to accumulation of lipids
§ On histopath show coffee-bean grooved nuclei and Call-Exner bodies
Differences in management for Granulosa cell tumours
- If post menopausal manage as for Epithelial ca
- NB to perform Endometrial biopsy prior to surgery
- If fertility desired and confined to one ovary (and endometrial biopsynegative)
- Unilateral salpingo-oophorectomy reasonable
- This is because most tumours are stage 1a at diagnosis
o Adjuvant chemotherapy may be considered if stage 1c or above
Granulosa cell prognosis and follow up
- Prognosis
o Stage 1a have 90% 5-year survival
o Tend to relapse late, at a mean 4-6 years but up to 40 years later
o Ultrasound and inhibin 6 monthly for the first 5 years then annually for life
o Recurrent localised disease may be suitable for surgical resection
Sertoli- Leydig cell tumours
- Rare tumours, only 20% are malignant
- Clinical features
- Mean age at diagnosis 25 years
- Large (mean diameter >16cm) unilateral adnexal mass
- Androgen-secreting
§ Virilisation a common presentation
§ Hirsuitism, voice deepening, acne, amenorrhea, breast atrophy, baldness, clitoromegaly
o Elevated testosterone levels - Management
o Surgical staging as per epithelial ovarian
o TAH/BSO preferred but USO reasonable if fertility desired (especially if diagnosis confirmed with intraoperative frozen-section)
o Lymphadenectomy often omitted as nodal metastases rare
o Adjuvant therapy not required unless metastatic
§ Chemotherapy (BEP) advised for these cases - Prognosis
o >95% are stage 1a at diagnosis
o 5-year survival 70-90%
o Tend to recur early, only 6-7% recur after 5 years
Germ cell tumours
- 10% of all ovarian cancers
- 60% of cancers in patients <age 20 years
Dysgerminoma: Most common germ cell tumour, chemosensitive, secrete LDH
Yolk sac tumour: Often in premenarchal patients, Worst prognosis
Choriocarcinoma: BHCG
Immature Teratoma
Germ cell tumour management
- Referral to gynae-oncology
o MDT care - Primary surgery
o Given age of patients, good prognosis (owing to chemosensitivity), fertility
sparing treatment usually preferred
o Pelvic washings, unilateral salpingo-oophorectomy, surgical staging - Frozen section if available to help with surgical planning (may need to proceed to full TAH/BSO of epithelial ovarian cancer found)
- Cystectomy of other ovary if lesion found
- Biopsy from normal contralateral ovary if dysgerminoma
Adjuvant treatment
o Stage 1a dysgerminoma and immature teratoma do not require adjuvant treatment
o All other require adjuvant chemotherapy with BEP (bleomycin, etoposide, cisplatin)
* Prevent pregnancy
o OCP recommended during treatment and follow-up
o Also beneficial in suppressing ovarian function and damage during treatment
Follow-up
* Surveillance of contralateral ovary with ultrasound
* Tumour marker tracking if was initially elevated
