Ovarian Cancer

Question 1

When do most ovarian cancers present?

Answer 1

Most ovarian cancer present in stage III or IV

Question 2

GOPC: Mrs Wu, 64/F complains of abdominal bloating. What should we ask in Hx?

Answer 2

• Abdominal distension - duration, associated symptoms
• Abdominal pain
• Urinary / bowel symptoms
• Mass palpable
• Bleeding - urinary tract, genital tract, GI tract
• Risk factors of ovarian cancer - G_P_
• ?HRT (COCP reduce risk of ovarian cancer)
• Previous gyn history - ovarian cyst
• FH - ovarian, breast cancer
• Constitutional symptoms

Question 3

Abdomen slightly distended. What should the GP do?

Answer 3

U/S
Sees ovarian cysts: mixed cystic-solid compoenent

Positive doppler flow = vascularity

Question 4

What bloods will you take for further Ix for ovarian cancer?

Answer 4

CBP (anaemia from bleeding or cancer related marrow suppression)
LFT (liver mets)
RFT
CA125 (esp. epithelial ovarian cancer)
CEA (GI involvement)
CA19.9 (GI involvemet)
AFP, HCG, LDH, E2 (<40y/o) [germ cell tumors, sex cord stromal tumours or hormone-producing tumors]
E2

Do other tumour markers if above >40 or strong suspicion of other tumours

Question 5

What are other causes of raised CA125? (Gyanecological vs Non-gynaecological)

Answer 5

Question 6

How to tell if mass is malignant or not?

Answer 6

• Clinical
• RMI
• IOTA (in pre-menopausal women, since CA125 can change with menses)

Question 7

What is RMI?

Answer 7

• RMI is the most utilised, widely available and validated effective triaging system for women with suspected ovarian cancer
• Although RMI score with threshold of 200 is recommended to predict likelihood of ovarian cancer and to plan further management, some centres utilise an equally acceptable threshold of 250 with lower sensitvity but higher specificty

Question 8

What are the IOTA ultrasound rules for suspicion on benign vs malignant ovarian cysts?

Answer 8

Question 9

ROMA - risk of malignancy algorithm

Answer 9

Question 10

What other particular signs would you look for on examination?

Answer 10

• Abdomen: Palpate for abdominal masses, hepatosplenomegaly, and pelvic organ abnormalities.
• Chest: Auscultate for abnormal breath sounds, decreased breath sounds, or dullness on percussion suggestive of pleural effusion.
• Neck: Palpate cervical, supraclavicular, and submandibular lymph nodes for lymphadenopathy. [Virchow’s node, left supraclavicular lymph node: common met from abdominopelvic malignancies]
• Head: Assess for signs of cachexia, jaundice, or alopecia.
• Legs: Examine for lower extremity edema and signs of deep vein thrombosis, such as warmth, tenderness, or palpable cord-like structures.

Question 11

What imaging should be done for ovarian cancer?

Answer 11

• CXR => CT thorax
• CT, MRI, PET-CT

Question 12

What are common sites of spread for ovarian cancers?

Answer 12

• Direct
• Peritoneal cavity - omentum
• Haematogenous
• Lymphatic

Question 13

If operable, what operation should be done for ovarian cancer?

Answer 13

• Laparotomy, TAHBSO + staging [peritoneal bx (L + R paracolic gutters, bladder flap, POD), omentectomy, PLND, PALND, peritoneal washing]
• TAHBSO, debulking operation – omentectomy

Question 14

What are the risks of lymphadenectomy?

Answer 14

• Lymphocyst
• Lymphoedema

Question 15

What are the common histology for ovarian cancer?

Answer 15

• Epithelial
• Non-epithelial is uncommon

Question 16

Simplification of surgical staging (FIGO)?

Answer 16

• Stage 1 : Ovaries
• Stage 2 : Pelvis
• Stage 3 : Abdomen and LN
• Stage 4 : Distant - lung / liver

Question 17

Mrs Wu’s report
* High-grade serous adenocarcinoma involving left ovary
* Peritoneal deposit and omentum: metastatic adenocarcinoma
* Ascitic fluid: carcinoma cells present

Post-op treatment?

Answer 17

• Chemotherapy
• Genetic risk assessment and germline/somatic testing * Maintenance treatment (PARPi)

Question 18

Prognosis and follow-up for ovarian cancer

Answer 18

• Clinical
• Tumour markers
• Imaging – clinically indicated

Question 19

SBA
* A 65-year-old woman presented to the Gynaecology Clinic with abdominal distension for 3 months. Her past health was unremarkable. Abdominal and pelvic examination showed a 10cm mobile mass in the left pelvis.
* What is the MOST appropriate first-line investigation ?
A. CA125
B. Colonoscopy
C. PET-CT
D. Ultrasound

Answer 19

D

Question 20

SBA
* A 65-year-old woman presented to the Gynaecology Clinic with abdominal distension for 3 months. Her past health was unremarkable. Abdominal and pelvic examination showed a 10cm mobile mass in the left pelvis. USG of pelvis confirmed a 10cm multiloculated mass with solid papillary projections in the left adnexa and moderate amount of ascites.
* What is the MOST likely diagnosis ?
A. Endodermal sinus tumour
B. Granulosa cell tumour
C. Serous carcinoma
D. Squamous cell carcinoma

Answer 20

C

Question 21

• A 65-year-old woman presented to the Gynaecology Clinic with abdominal distension for 3 months. Her past health was unremarkable. Abdominal and pelvic examination showed a 10cm mobile mass in the left pelvis. USG of pelvis confirmed a 10cm multiloculated mass with solid papillary projections in the left adnexa and moderate amount of ascites. CT confirmed USG findings, no obvious peritoneal disease or distant metastasis.
• What is the MOST appropriate management ?
  A. USO
  B. BSO
  C. TAHBSO
  D. TAHBSO + staging

Answer 21

D

Question 22

SBA
* A 65-year-old woman presented to the Gynaecology Clinic with abdominal distension for 3 months. Her past health was unremarkable. Abdominal and pelvic examination showed a 10cm mobile mass in the left pelvis. Ultrasound of pelvis confirmed a 10cm multiloculated mass with solid papillary projections in the left adnexa and moderate amount of ascites. CA 125 was 200 U/mL.
* What is the RMI ? A. 200
B. 600
C. 1200
D. 1800

Answer 22

D

3x3x200