Ovarian Cancer

Question 1

What is ovarian cancer?

Answer 1

a malignancy originating from various cell types found within the ovary.

Question 2

What are features of epithelial ovarian tumours?

Answer 2

1. Originate from the epithelium which lines the fimbria of the fallopian tubes or the ovaries
2. Epithelial tumours are partially cystic, and the cysts can contain fluid
3. The initial metastatic spread typically involves the peritoneal cavity, with seeding particularly affecting the bladder, paracolic gutters and the diaphragm
4. Around 90% of ovarian cancers are epithelial ovarian tumours.

Question 3

What are features of germ cell tumours?

Answer 3

1. Originate from the germ cells in the embryonic gonad
2. These tumours typically grow rapidly and spread predominantly via the lymphatic route
3. Germ cell tumours most commonly arise in young women, which is atypical for most cases of ovarian cancer
4. Tumour markers include alpha-fetoprotein and sometimes beta human chorionic gonadotrophin (B-HCG).

Question 4

What are features of sex cord stromal tumours?

Answer 4

1. Originate from connective tissue
2. Rare, making up less than 5% of all ovarian tumours.
3. Malignant tumours, but are much less aggressive than epithelial tumours
4. Can be secondary to another cancer elsewhere, which has metastasised to the ovary. A Krukenberg tumour refers to a ““signet ring”” sub-type of tumour, typically gastrointestinal in origin, which has metastasised to the ovary.

Question 5

What are risk factors for ovarian cancer?

Answer 5

Advanced age
Smoking
Increased number of ovulations (early menarche, late menopause)
Obesity
Hormone replacement therapy (HRT)
Genetic predisposition (BRCA 1 and 2 genes)

Question 6

What are protective factors?

Answer 6

Childbearing (parity)
Breastfeeding
Early menopause
Use of combined oral contraceptive pill (COCP)

Question 7

When do clinical features present and what are they?

Answer 7

Present late

Abdominal discomfort
Bloating
Early satiety
Urinary frequency or change in bowel habits

Question 8

What can the disease cause in later stages?

Answer 8

Ascites (due to vascular growth factors increasing vessel permeability)
Pelvic, back and abdominal pain
Palpable abdominal or pelvic mass

Question 9

What are possible differentials?

Answer 9

1. GI conditions (eg. IBS): abdominal pain, bloating, and changes in bowel habits
2. Fibroids: heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation
3. Ovarian cysts: pelvic pain, fullness or heaviness in the abdomen, and bloating
4. Other cancers: May present with symptoms such as abnormal bleeding, pelvic pain, and urinary symptoms

Question 10

What are investigations for suspected ovarian cancer?

Answer 10

Blood test for CA-125
Pelvic and abdominal ultrasound scan
Can be used to calculate RMI (Risk of Malignancy Index) which stratifies likelihood of cancer

Further investigations:
CT scans for staging
AFP and beta-hCG tests for younger women who may have germ cell cancers
Laparotomy for tissue biopsy

Question 11

What are salient points about ovarian cancer staging?

Answer 11

Stage 1: Limited to ovaries
Stage 1A: One ovary, intact capsule
Stage 1B: Two ovary, intact capsule
Stage 1C: Ovarian tumour with capsule ruptured, tumour on ovarian surface, malignant cells in ascites or peritoneal washings.

Stage 2: One or both ovaries with pelvic extension and/or implants.
Stage 2A: Uterus + Fallopian tubes
Stage 2B: Other pelvic tissue
Stage 2C: Stage 2A/2B + malignant cells in ascites or peritoneal washings.

Stage 3: Microscopically confirmed peritoneal implants outside the pelvis
Stage 3A: microscopic peritoneal metastasis beyond pelvis (no macroscopic tumour)
Stage 3B: macroscopic peritoneal metastasis beyond pelvis <2 cm
Stage 3C: peritoneal metastasis beyond pelvis >2 cm and/or regional lymph node metastasis.

Stage 4: tumour involving one or both ovaries with distant metastasis.

Question 12

What does management of ovarian cancer depend on?

Answer 12

Stage of cancer and patient’s fitness for treatment

Question 13

What option is used for early ovarian cancer?

Answer 13

removal of the uterus, ovaries, Fallopian tubes and infracolic omentectomy via surgery

Question 14

What surgery may be needed in advanced ovarian cancer

Answer 14

debulking surgery

Question 15

What are chemotherapy options?

Answer 15

Adjuvant chemotherapy in combination with surgery
Intraperitoneal chemotherapy may be performed at the time of operation
Biological therapies are being trialled.