Ovarian Cancer

Question 1

Incidence and survival of ovarian cancer

Answer 1

Increased incidence with increasing age (highest incidence in 75-79 years)
10% associated with inherited risk 
Mortality (5 years)
- Stage 1 = 85%
- Stage 4 = 10%

Question 2

What are the four main pathologies of malignancy ovarian tumours

Answer 2

Epithelial ovarian cancer (90%)
Germ cell tumours -arise from oocytes
Ovarian stromal tumours - non germ cell/non epithelial components
Metastsis - a.k.a. Kurkenburg

Question 3

What are the two types of epithelial ovarian cancer

Answer 3

High grade serious
- resembles the fallopian tube mucosa
- p53 mutations
Arise from ovarian surface epithelium and Mullerian inclusion cysts
- endometrioid, clear cell, mucinous and low grade serous

Question 4

What is a borderline epithelial tumour

Answer 4

Low malignant potential because there is no stromal invasion
- however can get metastatic implants (invasive or non-invasive)
Generally a good prognosis
Seen in all ages, but generally the younger population

Question 5

What are the ways in which ovarian cancer can spread

Answer 5

Direct extension
- transcoelomic
Exfoliation into the peritoneal cavity
Lymphatic invasion

Question 6

Risk factors for ovarian cancer

Answer 6

Smoking
Low parity (one child is protective)
Oral contraceptives
Infertility
Tubal ligation 
Early menarche 
Late menopause 
- higher probability of spontaneous mutations with repetitive disruption and repair 
Genetics

Question 7

Describe the genetic element of ovarian cancer

Answer 7

10% of cases
BRCA1 - chromosome 17q
- 30% lifetime risk
BRCA2 - chromosome 13q
- 27% lifetime risk
Lynch syndrome/HNPCC - mutation in Mismatch Repair Genes
- endometrial, ovarian and colon cancers 
Undiscovered genes

Question 8

What features are suggestive of an ovarian cancer being as a result of a gene mutation

Answer 8

Male breast cancer
Early onset breast cancer <40 years
Ashkenazi Jewish ancestry
Bilateral breast cancer
Multiple genetically related family members with breast, colon, ovarian, stomach, upper renal tract, endometrial and small bowel cancer

Question 9

What is the risk reducing surgery that can be used in those with genetic mutations

Answer 9

Prophylactic bilateral salpingo-oophorectomy
- remove ovary AND entire fallopian tube
Risk reduction of 96% of ovarian cancer and 53% of breast cases
2% have occult cancer at time of RRS
Risks associated with premature menopause

Question 10

Clinical features of ovarian cancer

Answer 10

Vague and non-specific - often found at an advanced stage 
Altered bowel habit
Abdominal pain/bloating
Abdominal distension
- mass 
- ascites
Feeling full quickly
Difficulty eating 
Urinary/pelvic symptoms 
Bowel obstruction 
SOB - pleural effusion 
Nodules on PV exam

Question 11

What investigations are required in?ovarian cancer

Answer 11

USS (TA or TV)
Ca125
- glycoprotein antigen
Caluculate RMI (risk of malignancy index)
CT
- determines initial treatment (surgery vs chemo)
- monitors response to treatment

Question 12

What can elevate Ca125

Answer 12

Ovarian cancer
Pancreatic cancer
Breast cancer
Lung cancer
Colon cancer 
Menstruation 
Endometriosis
PID
Pleural and pericardial effusions 
Recent laparotomy

Question 13

Describe the risk of malignancy index (RMI)

Answer 13

RMI = U x M x Ca125

U - ultrasound

• multilocular, solid areas, ascites, intra-abdominal metastasis
• score 0 = 0, 1 = 1 and 2/+ = 3

M - menopausal state

• 1 = pre-menopause
• 3 = post-menopause

Ca125 in units/m

RMI >200 carries a risk of malignancy
- CT and refer MDT/CNS

Question 14

How are ovarian cancers managed

Answer 14

MDT
- guides investigations and makes decisions on management
Surgery
Chemotherapy

Question 15

How are ovarian cancers diagnosed

Answer 15

Cytology - pleural/ascitic fluid
Biopsy
- percutaneous under US/CT guidance
- laparoscopic

Question 16

What surgery is required for the management of ovarian cancer

Answer 16

Midline laparotomy
Total abdominal hysterectomy,
bilateral salpingo-oophorectomy,
omentectomy +/- appendicectomy/resection of peritoneal disease
Ultra-radical surgery involves splenectomy, bowel resection and peritoneal stripping
Fertility conserving surgery (9% risk of recurrence in contralateral ovary)
The aim is to leave no residual disease or optimal cytoreduction (<1cm)

Question 17

How is chemotherapy used in the management of ovarian cancer

Answer 17

Neoadjuvant
- advanced disease, not possible to resect
- poor performance status
Adjuvant (post-op) if
- completely resected or optimally cytoreduced
- MDT decision
1st line should include a platinum agent in combination or as a single agent
- carboplatin
- paclitaxel in combination
Intraperitoneal - post op if completely or optimally cytoreduced
Other chemo
- biologics (antiangiogenesis) VEGF inhibitor
- hormonal therapy
(tamoxifen/aromatase inhibitor)

Question 18

Describe the FIGO surgical staging for ovarian cancer

- Stage 1

Answer 18

1A: tumour on one ovary, capsule intact, no surface tumour and negative washings
1B: both ovaries
1C: ruptured capsule, surface tumour or positive washings limited to one or both ovaries

Question 19

Describe the FIGO surgical staging for ovarian cancer

- Stage 2

Answer 19

Limited to pelvis
2A: extension and/or implantation onto the uterus and/or fallopian tubes
2B: extension to other pelvic tissue

Question 20

Describe the FIGO surgical staging for ovarian cancer

- Stage 3

Answer 20

Limited to abdomen
3A: positive retroperitoneal lymph nodes and/or microscopic mets beyond the pelvis
3a1) positive retroperitoneal lymph nodes only
3a2) microscopic, extrapelvic peritoneal involvement +/- retroperitoneal lymph nodes
3B: macroscopic, extrapelvic peritoneal metastasis <2cm
3C: macroscopic, extrapelvic peritoneal metastasis >2cm

Question 21

Describe the FIGO surgical staging for ovarian cancer

- Stage 4

Answer 21

Distant mets
4A: pleural effusion with positive cytology
4B: hepatic/splenic parenchymal metastasis, metastasis to extra abdominal organs including inguinal lymph nodes