Ovarian Cancer Flashcards
Describe the different classifications of ovarian cancer [+]
Epithelial tumours: 90%: - Majority arised from ovarian surface epithelium. Lots of subtypes:
- Serous (60-70%); develop from fallopian tube epithelium
- Endometrial
- Clear cell
- Mucinous
- Transitional cell (Brenner tumours)
Non-epithelial ovarian carcinomas:
- Germ cell tumours: most common non-epithelial ovarian cancer and in women < 35
- Sex cord and stromal tumours
- Carcinosarcoma
- Small cell cancer
Which type of ovarian cancer is particularly associated with ovarian torsion? [1]
Dermoid Cysts / Germ Cell Tumours
- Teratomas that may contain various tissue types, such as skin, teeth, hair and bone.
Germ cell tumours may have which hormones raised? [2]
Germ cell tumours may cause raised alpha-fetoprotein (α-FP) and human chorionic gonadotrophin (hCG).
Describe what is meant by a Krukenburg tumour [1]
What is their defining histological feature? [1]
A Krukenberg tumour refers to a metastasis in the ovary, usually from a gastrointestinal tract cancer, particularly the stomach.
Krukenberg tumours have characteristic “signet-ring” cells on histology, which look like signet rings on under a microscopy.
What are the risk factors for ovarian cancer?
- Hormonal [3]
- Env [6]
- Genetic [3]
Risk increases with number of ovulatory cycles and age
Hormonal:
* Nulliparity (never having given birth)
* Early menarche & late menopause (as leads to longer ovulatory cycle)
* HRT
Genetic:
* Positive family history
* BRCA 1/ BRCA 2
* Lynch syndrome
Environmental:
* Talcum powder: The use of talcum powder in the genital area has been associated with a slight increase in risk, possibly due to inflammation caused by talc particles.
* Diet: High-fat diet and consumption of animal fats have been implicated in ovarian cancer risk. However, the evidence remains inconclusive.
* Endometriosis: Women with endometriosis have a higher risk of developing certain types of ovarian cancer, particularly clear cell and endometrioid carcinomas. Disputed link
* Smoking
* Asbestos
* Obesity
State stages I-IV of ovarian cancer [4]
- Stage I: Cancer is confined to one or both ovaries.
- Stage II: Cancer has spread to other pelvic structures.
- Stage III: Cancer has spread beyond pelvis or to retroperitoneal lymph nodes.
- Stage IV: Distant metastasis has occurred, such as in liver or lung parenchyma.
Describe the clinical features of ovarian cancer [5]
Often asymptomatic / has non specific symptoms so is diagnosed late - silent killer!
Symptoms:
* abdominal distension and bloating
* abdominal and pelvic pain
* urinary symptoms e.g. Urgency
* early satiety
* diarrhoea
TOMTIP: An ovarian mass may press on the obturator nerve and cause referred hip or groin pain. The obturator nerve passes along the inside of the pelvic, lateral to the ovaries, where an ovarian mass can compress it.
Name three protective factors for ovarian cancer [3]
Combined contraceptive pill
Breastfeeding
Pregnancy
All stop the number of lifetime ovulations
Refer directly on a 2-week-wait referral if a physical examination reveals: [3]
Ascites
Pelvic mass (unless clearly due to fibroids)
Abdominal mass
If you suspect cancer (but not indicated for a 2ww), what initial investigation should you perform? [1]
What level of ^ would indicate further imaging? [1]
What further imaging? [2]
if the CA125 is raised (35 IU/mL or greater) then an urgent ultrasound scan of the abdomen and pelvis should be ordered
Name 4 TVUS findings that would indicate ovarian cancer [4]
- solid areas within the cyst
- irregularity of the cyst wall or septa
- presence of ascites
- increased vascularity on Doppler flow studies.
Which serum marker is used alongisde CA125 to improve S&S? [1]
HE4 (Human epididymis protein 4): This serum marker is used alongside CA-125 to improve sensitivity and specificity in predicting malignancy.
How do you make a definitive dx of ovarian cancer? [1]
A definitive diagnosis of ovarian cancer is made by histopathological examination following surgical removal or biopsy of the mass.
When considering ovarian cancer, it’s essential to differentiate from other conditions that may present similarly. The three most likely alternative diagnoses include [3]
When considering ovarian cancer, it’s essential to differentiate from other conditions that may present similarly. The three most likely alternative diagnoses include endometriosis, ovarian cysts and pelvic inflammatory disease.
How would you differentiate ovarian cancer from endometriosis - symptoms [3]; exam [1]’ TVUS [1]
Symptoms:
- cyclic pelvic pain that correlats with menses
- dyspareunia
- infertility
Physical exam:
- tender nodules in posterior fornix
TVUS:
- characteristic ‘chocolate’ cysts.
Endometriosis is characterised by the presence of endometrial tissue outside the uterus
How would you differentiate ovarian cancer from ovarian cysts on TVUS [1]
The key difference lies in imaging studies: ultrasound findings for ovarian cysts typically show simple fluid-filled cavities without any solid components or septations. In contrast, malignant lesions such as ovarian cancer often display complex features including thick walls or septa and solid areas within the cyst.
Ovarian cysts are fluid-filled sacs within or on an ovary’s surface. Patients
How would you differentiate ovarian cancer from PID [3]
PID often has a more acute onset than ovarian cancer and is associated with sexual activity and menstrual cycle.
PID may show signs of inflammation in laboratory tests such as elevated white blood cell count and C-reactive protein levels, which are not typically seen in ovarian cancer.
Describe the management plan for ovarian cancer [+]
PassMed:
1. The primary treatment for most ovarian cancers is surgical debulking, aimed at removing all visible disease. The extent of surgery may include total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and lymph node dissection.
2. Chemotherapy: is typically administered postoperatively to treat any residual disease. The standard regimen is a combination of carboplatin and paclitaxel. Neoadjuvant chemotherapy may be considered in cases where optimal debulking is not achievable initially.
3. Targeted Therapy: For patients with advanced ovarian cancer, particularly those with BRCA mutations or homologous recombination deficiency, targeted therapies like PARP inhibitors (e.g., olaparib, niraparib) may be indicated.
Describe what is meant by primary debulking surgery for ovarian cancer [+]
Aim: Apply maximum surgical effort to achieve achieve complete cytoreduction removing all visible disease – R0:
* TAH BSO
* Omentectomy
* +/- Bowel resection
* +/- Stripping of peritoneal surfaces
* Removal of any large tumour masses or suspicious nodes or appendix (mucinous tumours
A 60-year-old woman presents lower abdominal discomfort, urinary frequency, bloating and abdominal distension - ovarian cancer
Does BRCA1 or BRCA2 give a high lifetime risk of ovarian cancer?
BRCA1
A 45-year-old woman presents with right hip pain that has been worsening over the past month. On examination, there is no significant hip pathology, but she reports a history of ovarian cysts.
Explain the mechanism causing the referred pain to the hip [1]
Referred pain to the hip from an ovarian mass occurs due to the shared innervation of the ovary and the hip region by the obturator nerve (L2-L4). The ovary is located near the pelvic sidewall, and when an ovarian mass enlarges or irritates surrounding tissues, it can stimulate the obturator nerve, leading to pain referred to the medial thigh, groin, and hip. This reflects the phenomenon of viscerosomatic convergence, where visceral organ pain is perceived as musculoskeletal pain.
A 55-year-old postmenopausal woman presents with abdominal bloating, early satiety, and weight loss. On examination, there is a palpable pelvic mass. CA-125 is elevated. What is the most likely type of ovarian tumor?
A) Germ cell tumor
B) Granulosa cell tumor
C) Serous epithelial tumor
D) Dysgerminoma
E) Sertoli-Leydig cell tumor
A 55-year-old postmenopausal woman presents with abdominal bloating, early satiety, and weight loss. On examination, there is a palpable pelvic mass. CA-125 is elevated. What is the most likely type of ovarian tumor?
A) Germ cell tumor
B) Granulosa cell tumor
C) Serous epithelial tumor
D) Dysgerminoma
E) Sertoli-Leydig cell tumor
A 50-year-old woman presents with unexplained weight loss, abdominal pain, and a pelvic mass. Imaging reveals bilateral ovarian masses. Histology confirms signet-ring cells. What is the most likely diagnosis, and what is the origin of this condition? [1]
The most likely diagnosis is a Krukenberg tumor, which is a metastatic ovarian tumor, typically originating from a gastrointestinal primary, most commonly gastric adenocarcinoma.
Key Features:
Krukenberg tumors are characterized histologically by signet-ring cells.
They often present bilaterally and can cause abdominal or pelvic pain, bloating, or ascites.
A 65-year-old woman with ovarian cancer is found to have omental deposits and involvement of para-aortic lymph nodes on CT. No distant metastases are detected. What is the most appropriate FIGO stage?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
C) Stage III
A 42-year-old woman with a long-standing history of endometriosis presents with pelvic pain and a complex ovarian mass on ultrasound. According to NICE guidelines, what is the most likely type of ovarian tumor associated with endometriosis?
A) Dysgerminoma
B) Mucinous cystadenoma
C) Clear cell carcinoma
D) Sertoli-Leydig cell tumor
E) Serous cystadenocarcinoma
C) Clear cell carcinoma
A woman with ovarian cancer presents with pelvic pain and bloating. Imaging reveals spread of the tumor to the fallopian tubes and the peritoneum within the pelvis. There is no involvement of lymph nodes or distant metastasis. What is the most likely stage of her ovarian cancer?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
A woman with ovarian cancer presents with pelvic pain and bloating. Imaging reveals spread of the tumor to the fallopian tubes and the peritoneum within the pelvis. There is no involvement of lymph nodes or distant metastasis. What is the most likely stage of her ovarian cancer?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
What is clinically significant about granulosa cell tumours? [2]
They can secrete oestrogen - which causes endometrial hyperplasia and risk of endometrial cancers
The following are all different types of ovarian cancers. Which can secrete oestrogen and therefore cause endometrial hyperplasia?
Granulosa cell tumour
Endometrioid
Theca cell tumours
Sertoli-Leydig cell tumour
Clear cell
The following are all different types of ovarian cancers. Which can secrete oestrogen and therefore cause endometrial hyperplasia?
Granulosa cell tumour
Endometrioid
Theca cell tumours
Sertoli-Leydig cell tumour
Clear cell
Which part of the large bowel does ovarian cancer commonly met. to? [1]
Colorectal
