Ovarian Cancer Flashcards
What percentage of ovarian cancers are benign?
Approximately 80% are benign.
When is the peak age for ovarian cancer?
Peak age is 70-74 years of age.
Where do ovarian cancers usually spread to?
Spread is usually peritoneal and so present with late advanced cancers.
What are the risk factors for ovarian cancer?
- Obesity
- Nulliparity, early menarche and later menopause
- Unopposed oestrogen HRT
- Family history
- BRCA 1/2, HNPCC
- Smoking
- Endometriosis
What are the protective factors against ovarian cancer?
- Combined oral contraceptive pill
- Pregnancy
- Breast feeding
How do ovarian cancers usually present?
Usually quite nonspecific Abdominal swelling – bloating and distention Abdominal and/or pelvic pain Anorexia N and V Weight loss Vaginal bleeding Bladder and Bowel symptoms – urgency, diarrhoea etc. Early satiety
Approximately 50% spread to the other ovary
How are suspected ovarian cancers investigated?
USS
Serum CA-125 used in diagnosis and to monitor disease recurrence and progression. (Note CA125 can also rise in endometriosis, menstruation and ovarian cysts)
Surgical exploration – laparotomy
CXR for pleural effusion or lung metastases
Staging CT
How is the RMI calculated?
RMI – Risk of Malignancy Index = M x U x CA125
Factors Menopausal status (M) Premenopausal = 1 Postmenopausal = 3
Ultrasound score (U) • Multilocular cyst • Solid areas • Metastases • Ascites • Bilateral lesions
1 feature from list = 1
2 or more features from list = 3
CA125 Value in units/ml
How are the results from the RMI interpreted and acted upon?
If lower than 25 then follow up in 1 year with USS and CA125 if less than 5cm
Moderate 25-200 – surgery but no need for a cancer centre
If above 200 then should be referred to specialist gynaecologist for staging laparotomy
How are ovarian cancers staged?
Stage, description and 5 year survival 1 Limited to ovary, 90% 2 Spread to pelvic organs, 60% 3 Spread to rest of the peritoneal cavity Positive lymph nodes, 30% 4 Distant metastasis, 5%
How are ovarian cancers managed?
Epithelial cancer
• Staging laparotomy with total hysterectomy (TAH), bilateral Salpingo-Oophorectomy (BSO)and debulking
• Chemo – platinum based and Taxanes
• If reproductive age and confined to 1 ovary then may consider single oophorectomy
Non-epithelial tumours
• Often in young women and very chemo-sensitive
• Usually treated with combination of conservative surgery and chemo
Recurrent disease – palliative chemotherapy
What are the 3 type of ovarian epithelial tumours?
Ovarian Epithelial Tumours (90%)
Three main histological types: Serous, mucinous, endometrioid. All can be classified as: benign, borderline or malignant. Many are cystic.
Serous Ovarian Tumours (80%) – often spread to peritoneal surfaces and omentum, therefore commonly associated with ascites. Very friable so parts will break off when you touch it. Benign or malignant.
Mucinous Ovarian Tumours – often very large, cystic masses – can be >25kg, filled with sticky, thick fluid usually benign or borderline. Pseudomyxoma peritonei – Extensive mucinous ascites, epithelial implants on peritoneal surfaces, frequent involvement of ovaries. Can cause intestinal obstruction. Most likely primary is extra-ovarian, usually appendix. Benign or malignant
Endometrioid Ovarian Tumours
Uncommon and contain tubular glands resembling endometrial glands. Can arise in endometriosis (15-20% of cases). 15-30% have associated endometrial endometrioid adenocarcinoma, probably arising separately. Usually malignant
What are the different types of germ cell ovarian tumours?
Most are teratomas, usually benign, other types are malignant and include: Dysgerminoma (secretes HCG), Non-gestational choriocarcinoma (produces human chorionic gonadotropin, unlike gestational type they are aggressive and often fatal) and Yolk sac tumour (produces α-fetoprotein).
Ovarian Teratomas Three groups:
- Mature (benign) – most common
- Immature (malignant) – rare, composed of tissues that resemble immature foetal tissue
- Monodermal (highly specialised)
Ovarian Mature Teratomas
Most are cystic also called dermoid cysts as they almost always contain skin-like structures. Usually occur in young women, bilateral in 10-15% of cases. Usually contain hair and sebaceous material, can contain tooth structures. Often tissue from other germ layers also present, e.g., cartilage, bone, thyroid, neural tissue.
Monodermal Ovarian Teratomas
Most common are:
• Struma ovarii, benign, composed entirely of mature thyroid tissue. May be functional and cause hyperthyroidism
• Carcinoid, malignant, may be functional producing 5HT and can cause carcinoid syndrome (even without hepatic metastases!)
What are the different types of ovarian sex cord-stromal tumours?
Derived from ovarian stroma (which is derived from sex cords of the embryonic gonad). Sex cord produces Sertoli and Leydig cells in testes and granulosa and theca cells in ovaries. Tumours resembling all of these four cell types can be found in the ovary. These tumours can be feminising (granulosa/theca cell tumours) or masculinising (Leydig cell tumours).
Granulosa Cell Tumours – most occur in post-menopausal women. May produce large amounts of oestrogen – If in pre-pubertal girls this may produce precocious puberty. In adult women may be associated with endometrial hyperplasia, endometrial carcinoma and breast disease.
Ovarian Sertoli-Leydig Cell Tumours – often functional. In children may block normal female sexual development, in women can cause defeminisation and masculinisation: breast atrophy, amenorrhoea, sterility, hair loss, hirsuitism with male hair distribution, clitoral hypertrophy and voice changes. Peak incidence in teens or twenties.
When should you refer someone for BRCA1/2 testing?
When should people be referred for genetic testing?
• Two primary breast or ovarian cancers in one 1st or 2nd degree relative
• Three 1st and 2nd degree relatives with the following: breast, ovary, colorectal, stomach or endometrial cancers
• Two 1st or 2nd degrees relatives one with ovarian cancers and the other with breast under the age of 50
• Two 1st or 2nd degree relatives with ovarian cancer
