Ovarian cancer diagnosis and management (radio and chemo lecture)

Question 1

What are the risk factors for the development of ovarian cancer ?

Answer 1

• >50yrs
• nulliparity (or low parity)
• family history of breast or ovarian cancer - BRCA1 (40%) and BRCA2 (18%), lynch syndrome
• Obesity/diabetes
• Smoking
• Endometriosis

Question 2

What are some of the protective factors against ovarian cancer ?

Answer 2

• Combined pill
• Hysterectomy or tubes tied
• Pregnancy and breastfeeding

Question 3

What the symptoms of ovarian cancer ?

Answer 3

• Ascites/ bloating - that doesnt come and go
• Persistent pelvic and abdominal pain
• Eating less and feeling fuller
• Pelvic mass/ bladder dysfunction
• Pleural effusion/shortness of breath
• Change in bowel habit
• Bladder symptoms - freq or urge urination
• Weight loss/anaorexia

Question 4

Roughly what stage do most ovarian cancers present at ?

Answer 4

Late stage

Question 5

Screening for ovarian cancer is not recommended but when should a women be referred for a genetics risk assessment +/- testing ?

Answer 5

Women with ovarian cancer who have a family history of breast ovarian or colon cancer should have a genetic risk assessment.

Question 6

Who should be offered BRAC1 and BRCA2 testing ?

Answer 6

All women with non-mucinous ovarian or fallopian tube cancer should

be offered BRCA1 and BRCA2 mutation testing.

Question 7

Who should be offered Prophylactic salpingo-oophorectomy?

Answer 7

Women with genetic mutations of BRCA1 or BRCA2 genes should be

offered prophylactic oophorectomy and removal of fallopian tubes

at a relevant time of their life.

Question 8

When should you carry out investigations for ovarian cancer ?

Answer 8

In women presenting with one or more of the following symptoms on a persistent or frequent basis – particularly more than 12 times per month:

1. Abdominal distension or bloating with or without abdominal pain
2. Feeling full quickly
3. Difficulty eating
4. Increased urinary urgency or frequency

Question 9

What are the 2 first investigations you should carry out for someone with histroy suggestive of ovarian cancer (previously mentioned guidelines for when to investigate)

Answer 9

1st line = blood test to check CA125 levels along with an abdominal or transvaginal US

Question 10

What should you do if a womens symptoms persist or worsen despite normal CA 125 and a negative ultrasound scan?

Answer 10

Refer to secondary care.

Question 11

What should you measure in women <40 with suspected ovarian cancer and why?

Answer 11

AFP and beta HCG

To identify women who may not have epithelial ovarian cancer.

Question 12

What are some of the other reasons for raised CA125?

Answer 12

Raised in ≈80% ovarian cancers but Normal level does not exclude cancer

Moderate elevation seen in numerous situations e.g.

• Endometriosis
• Peritonitis/infection
• pregnancy
• Pancreatitis
• Ascites from any cause.e.g. liver disease
• Other malignancies gynae/non gynae.

Question 13

After results of CA125 and US suggesting ovarian cancer what should be calculated ?

Answer 13

Risk of malignancy index 1(RMI 1) score

Question 14

Appreicate this (refer to pic 19 of ovarian cancer lecture if needed) but these are the take home points:

• Bascially if postmenopausal they have a higher number for calculation
• If they have more suspicious features on US then a higher number is put in for that bit of the calculation
• The higher the CA125 the higher the RMI 1

Question 15

How is someones RMI 1 calculated and what is the level which would be raised indicating malignancy ?

Answer 15

RMI 1 >200

Question 16

What are the US features which as suggestive of ovarian cancer ?

Answer 16

• Complex mass with solid & cystic area.
• Multi-loculated
• Thick septations
• Associated ascites
• Bilateral disease.

Question 17

What should be done next after calculating someones RMI 1 score in someone suspected of having ovarian cancer and finding it is >200?

Answer 17

Send for CT of abdo and pelvis

Question 18

After doing CT what is the last investigation which needs to be done to obtain the definite diagnosis of ovarian cancer and the type of it?

Answer 18

CT guided biopsy for histological study

Question 19

What is the FIGO staging for ovarian cancer ?

Answer 19

FIGO stage:-

• I- confined to 1 or both ovaries
• II-spread to other pelvic organs eg uterus, fallopian tubes
• III- spread beyond the pelvis within the abdomen
• IV- spread into other organs eg liver, lungs

Question 20

What are the 2 main ways in which ovarian cancer spreads?

Answer 20

• 1.transcoelomic spread/ peritoneal seeding within pelvis → abdominal cavity
• 2.haematogenous spread → liver, lungs, brain- late and rare

Question 21

Define early ovarian cancer and late/advanced ovarian cancer ?

Answer 21

Early = stage Ia to Ib (confined to the ovaries)

Late = stage Ic to IV

Question 22

What should be done for optimal surgical staging of early stage ovarian cancer (done during the main surgical treatment procdure) ?

Answer 22

Optimal surgical staging should be done and should include:

• Biopsies of suspicious looking peritoneal nodules
• Infracolic omentectomy
• Iliac and peri-aortic lymph node sampling (retro-peritoneal lymph node sampling)”

Note retro-peritoneal lymph node sampling rather than systematic lymphadectomy (block dissection of lymph nodes from the pelvic side walls to the level of the renal veins) is recommended

Question 23

What is the surgical management of early ovarian cancer ?

Answer 23

Women with stage Ia, grade 1 or grade 2 disease, fertility conserving surgery is an option as long as the contralateral ovary appears normal and there is no evidence of omental or peritoneal disease - this procedure is a unilateral Salpingo-oophorectomy

Women with stage Ib or grade 3 will undergo a total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO). (removal of both ovaries uterine tubes and uterus + cervix)

Question 24

When is adjuvant chemotherapy adviced for early stage (I) ovarian cancer ?

Answer 24

Do not offer adjuvant chemotherapy to women who have had optimal surgical staging and have low-risk stage I disease which is - (grade 1 or 2, stage Ia or Ib).

Offer women with high-risk stage I disease (grade 3 Ia or Ib or stage Ic) adjuvant chemotherapy consisting of six cycles of carboplatin.