Ovarian cancer (need differentials) Flashcards
How common is ovarian cancer?
6th most common cancer in woman
What is the peak incidence of ovarian cancer?
75-84 years
Starts to arise in patients >60 years
What are the 4 main subtypes of ovarian cancer?
Subtypes based on cell-type origin
Epithelial
- Endometriod
- Clear cell
- Serous cystadenoma
- Mucinous cystadenoma
Germ cell
- Choriocarcinoma
- Dysgerminoma
- Teratoma
Sex chord stroma
- Fibroma
- Granulosa- Theca cell tumour
- Sertoli-Leydig cell tumour
Malignant
* Krukenburg tumour
What is the most common subtype of ovarian cancer?
Epithelial ovarian cancer (90%)
What are the main subtypes of epithelial ovarian tumours?
Endometriod (Malignant)
Clear cell (Malignant)
Serous cystadenoma (Benign)
Mucinous cystadenoma (Benign)
Which 2 subtypes of epithelial ovarian tumours are malignant?
Endometriod
Clear cell
What are the main histological/lab features of endometrioid carcinoma?
Tubular glands
Raised Ca125
Mimics endometrium (form tubular glands ), therefore endometriosis is a risk factor.
What are the main histological/lab features of clear cell carcinoma?
Presence of clear cells
Clear cytoplsam
Hobnail appearance
What is the most common benign epithelial ovarian tumour?
Serous cystadenoma
What are the main histological/lab features of serous cystadenoma?
Psamomma bodies
Columnar epithelium
Mimics tubal epithelium i.e. columnar epithelium
What are the main histological/lab features of mucinous cystadenoma?
Mucin secreting cells
K-ras mutation (75%)
Mucinous cystadenoma is associated with which rare complication?
Pseudomyxoma peritonei
Define pseudomyxoma peritonei
Intraperitoneal accumulation of mucinous ascites due to mucin-producing neoplasm in the appendix
Appendix tumour → metastasis to abdomen, peritoneum and ovaries → pseudomyxoma peritonei
Pseudomyxoma peritonei is associated with which ovarian tumour
Mucinous cystadenoma
What are the main subtypes of germ-cell ovarian tumours?
Dysgerminoma
* Benign in adults
* Malignant in young women
Choriocarcinoma (malignant)
Teratoma
* Mature (Benign)
* Immature (Malignant)
Dysgermimoa is mostly benign (95%). In which individuals is it more likely to be malignant?
Mostly malignant in children
(Most common ovarian malignancy in young woman)
What is the most common ovarian malignancy in young woman?
Dysgerminoma (female counterpart to testicular seminoma)
Rare overall however
What is the most common benign tumour in young woman?
Teratoma (Mature teratoma/ dermoid cyst)
Mature teratoma are alternatively known as?
Dermoid cyst
What are the main histological features of mature teratoma/dermoid cyst?
Cystic
Differentiation into mature tisues:
* Hair
* Teeth
* Bone
* Cartillage
Which type of teratoma is malignant?
Immature teratoma
What are the main histological features of immature teratoma?
Solid
Contains Immature, embyronal tissue
Secretes AFP
Choriocarcinoma secretes which hormone
hCG (human chorionic gonadotropin)
What are the 3 main types of sex-chord stroma?
Fibroma
Granulosa-Theca cell tumour
Sertoli-Leydig cell tumour
Fibroma are associated with what syndrome?
Meig’s syndrome
What are the main features of Meig’s syndrome?
Triad of:
Fibroma
Ascites
R-sided pleural effusion
What are the histological features of Granulosa-Theca cell tumour?
Produces E2
Call-Exner bodies
Suspect if oestrogenic effects – irregular menstrual cycles, breast enlargement, endometrial/breast cancer
What are the main histological features of Sertoli-Leydig cell tumour?
Excretes androgens
Suspect if presentation of virilisation
Name the ovarian tumour which can arise secondary to gastric/colonic cancer metastases
Krukenberg tumour
What is the key histological feature of Krukenberg tumour
Mucin-secreting signet ring cells
What are the main risk factors for ovarian cancer?
Advanced age (>75)
Smoking
Increased number of ovulations:
- Early menarche
- Late menopause
Obesity
HRT
Genetic predisposition:
* BRCA 1 and 2
* Lynch syndrome
FHx ovarian cancer
Genetic mutations in which genes are associated with ovarian cancer?
BRCA1
BRCA2
What are protective factors against ovarian cancer?
Childbearing (parity)
Breastfeeding
Early menopause
COCP
What are the main clinical features of ovarian cancer?
Demographic: Age >60 (75-84)
Initial presentation:
Abdominal discomfort
Bloating
Early satiety
Urinary frequency/change in bowel habits
Late presentation
Ascites
Pain
* Pevic
* Back
* Abdominal
Palpable abdominal/pelvic mass
Initial symptoms typically presents late in disease onset
What investigations should be conducted in patients with suspected ovarian cancer?
Bloods:
CA-125
AFP
hCG
Imaging:
Transvaginal US: Indicated with elevated CA-125 (> 35 IU/ml)
Tissue biopsy: If abnormal US findings
CT chest/pelvis/abdomen: For staging
Ovarian cancer is non-specific, when is CA-125 indicated?
Woman > 50
AND
Persistent symptoms (Symptoms occuring _>_12 times per month)
What lab findings are indicative of ovarian cancer?
Elevated Ca-125 (> 35 IU/ml)
Elevated AFP: Germ-cell tumours
hCG: Germ-cell tumours
What findings are indicative of a germ-cell tumour?
Elevated AFP (alpha-fetoprotein)
Elevated hCG
What scoring system is used to estimate the likelihood of a malignant cyst?
Risk of Malignancy Index (RMI)
How is RMI score calculated?
RMI = U x M x Ca-125
U = Ultrasound (points 0-3)
- 1 ultrasound feature = 1 point
- 2-5 ultrasound features = 3 points
M = Menopause
- 1 point for premenopausal.
- 3 points for post-menopausal
Ca125
What is the RMI cutoff score for specialist referral?
250 or more
What is the 2-week wait referral criteria for ovarian cancer?
Examination shows evidence of ascites and/or pelvic abdominal mass
OR
US findings suggestive of ovarian malignancy
What staging system is used for ovarian cancer?
FIGO
What is considered stage 1?
ONLY in ovaries
What is considered stage 2?
Spread to pelvis
What is considered stage 3?
Spread to abdomen and/or regional node lymphadenopathy
What is considered stage 4?
Metastasis outside abdominal cavity (Distant met)
What is the management plan for patients with ovarian cancer?
Surgical:
Early disease: Removal of uterus, ovaries and fallopian tube + omentectomy (removal of omentum)
Advance disease: as above + further debulking
Medical:
Adjuvant chemotherapy
