Ovarian Cancer

Question 1

Outline the Epidemiology of Ovarian Cancer

Answer 1

• Presents late so 5yr survival is <35%
• 80% in over 80s

Question 2

Outline the Histology & Pathology of Ovarian Cancer & Tumours

Answer 2

1. Epithelial (90%)
   
   1. Serous
   2. Endometroid
   3. Clear cell
   4. Muccinous
   5. Brenner
2. Germ wall [from primite germ cells] (young women)
   
   1. Dermoid
   2. Solid teratoma
   3. Dysgerminoma
3. Sex cord
   
   1. Granulosa cell
   2. Thecomas
   3. Fibromas
4. Transtromal
5. Mets [breast or bowel]

• Tumour like conditions
  
  • Endometriotic cysts
  • Follicular and lutein cysts

Question 3

Outline the Aetiology of Ovarian Cancer

Answer 3

• Benign cysts can undergo malignant change
• ↑No. of ovulations ↑risk
  • ↑: Early menarche, late menopause, nulliparity
  • ↓: Pregnancy, lactation, COCP
• Familial; BRCA1, BRCA2 & HNPCC [hereditary non-polyposis colorectal cancer] genes

Question 4

Outline the screening for Ovarian Cancer

Answer 4

• Currently no UK national screening
• FHx: Offered testing for BRCA1 & BRCA2

Question 5

Outline the clinical presentation of Ovarian Cancer

Answer 5

• Initialy absent/ vague so presents late
• Bloating, ↓Appetite, ↑Bloating
• ↑Urgency & ↑Freq.
• Palpable mass
• Abdo/ pelvic pain [uncommon]
• Ascites
• PV Bleeding

Question 6

Outline the spread and staging of Ovarian Cancer

Answer 6

• Adenocarcinoma spreads transcoelomically (directly within abdo/ pelvis)
  
  • Lymphatic/ blood spread is rarer
• Stages of spread
  
  1. Ovaries
     
     • **1​​(a) **1 ovary
     • 1(b) both ovaries, capsule intact
     • 1(c) 1/borg, capsule not intact
  2. Pelvis
  3. Abdomen [omentum, SB, peritoneum]
  4. Beyond [lungs, liver]

Question 7

Outline the risk of malignancy index

Answer 7

RMI = U x M x CA125

U is Ultrasound scan score

M is Menopausal status

Question 8

Outline the investigations for Ovarian Cancer

Answer 8

• **CA125 **(1º)
  
  • Women >50 with any abdo symptoms
  • CA125 >35IU/mL **⇒ USS **(2º)
    
    • Ascites/ Mass ⇒ Urgent referral
• AFP & hCG
  
  • Women <40 to detect germ cell tumours
• **RMI calculated **(UxMxCA125); >250 referred to MDT
• CT Pelvis/ Abdo for staging

Question 9

Outline the treatments for Ovarian Cancer

Answer 9

• Exploratory laparotomy for histological confirmation/ staging/ tumour debulking
• Surgery: TAH + BSO
• Chemotherapy
  
  • ​Histological confirmation required (US biopsy/ laparoscopy/ ascitic fluid)
  • Stage 1(c) = Carboplatin
  • Stage 2-4 = Carboplatin/ Cisplatin + Paclitaxel
• No radiotherapy (only in dysgerminomas)

Question 10

How do you follow up Ovarian Cancer

Answer 10

• CA125 useful
• CT aids residual disease/ relapse
• Interval debulking (if all cant be removed)
• Support

Question 11

Outline the neccesary steps in Palliative Care for terminal Gynae Cancers

Answer 11

• Pain
  
  • Analgesic ladder
  • Non-opioids (NSAIDs) → Milder opioids (codeine) → Stronger opioids (morphine)
• Nausea & vomiting [60%]
  
  • Anticholinergics
  • Antihistamines
  • Dopamine antagonists
  • 5HT-3 antagonists
• **PV bleeding **[cervical & endometrial]
  
  • Progestogens
• Ascites & bowel obstruction [ovarian] [1/3 spontaneously resolve]
  
  • Repeat paracentesis
  • Mild obstruction: Metoclopramide & Stool-softeners, Enemas
  • Severe obstruction: Cyclizine & Ondansetron [N&V], Hyoscine [spasm]
  • Surgery if acute single site obstruction
• Terminal distress