Ovarian carcinoma Flashcards
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What is the 10yr survival for ovarian carcinoma and why is this figure so low?
40-50%
Silent nature of malignancy means it is only picked up in late disease
How many new cases of ovarian cancer are diagnosed in the UK each year?
7000, causing 4200 deaths
Lifetime risk of 1/60
Rates have been decreasing since 2000’s, hypothesised due to increased use of COCP
What is the classical age of onset for ovarian tumours?
75-84yrs
What is the pathophysiology of ovarian tumours?
Initially thought to be due to irritation of ovarian surface from ovulation; recent evidence suggests fallopian tubes involved in cancer development (especially high grade serous adenocarcinomas/serous tubal intraepithelial carcinoma, STIC)
95% are epithelial carcinomas
What are the risk factors for ovarian cancer?
Nulliparity
Early menarche and/or late menopause (related to number of ovulations rather than a single cyst changing from benign to malignant)
Gene mutations in BRCA genes (BRCA1>2)
HNPCC
What factors are protective against ovarian cancer?
Pregnancy
Breastfeeding
COCP
Tubal ligation (female sterilisation)
What grade of ovarian cancer exist?
Borderline
Low grade
High grade
Can young women get ovarian cancer?
Rare but most common type is germ cell cancer (<30y)
Is there a role for screening in patients at risk of ovarian cancer?
Yet to be proven - no UK screening programme
Refer to clinical genetics counselling and testing if two primary cancers in one 1st or 2nd degree relative
If a genetic mutation identified, consider yearly TVS and Ca125 (RMI)
If BRCA +ve, offer BSO and warn of risk of incidental finding on surgery
How does ovarian cancer present?
Vague symptoms (may be confused with IBS or diverticular disease; 75% present once at FIGO stage III) Bloating Dyspepsia Unexplained weight loss, loss of appetite, early satiety Change in bowel habit Fatigue Urinary symptoms e.g. frequency, urgency Abdo/pelvic pain PV bleed Pelvic mass palpable Breast symptoms
What may be found on examination of a woman with ovarian cancer?
Fixed abdo/pelvic mass Ascites Omental mass Pleural effusion Supraclavicular lymph node enlargement Cachexia Breast tenderness
What staging system is used for ovarian cancer?
FIGO 2013 system
Note that ovarian cancer spreads directly within abdo/pelvis (transcolemic spread)
Staging surgical and histological
What factors increase the likelihood that the ovarian mass is malignant?
Rapid growth >5cm Ascites Advanced age Bilateral masses Solid/separate nature on USS Increased vascularity
What Ix should be performed in suspected ovarian cancer?
Bloods (FBC, U&E, LFT)
Tumour markers (Ca125 - think RMI, CEA - raised in CRC and normal in ovarian ca, Ca199 may be raised in mucinous tumours; if woman <40y, check AFP, LDH and hCG)
TVS
CXR (pleural effusion, lung mets, needed for staging)
CT abdo/pelvis, MRI
Ascites/pleural effusion sampling and cytology
How does the FIGO system stage for ovarian cancer?
I - Limited to one/both ovaries; 1c if capsule is breached, tumour present on ovarian surface or peritoneal washings are positive; rupture of cyst at time of surgery is 1c
II - Limited to pelvis
III - Limited to the abdomen, including region LN mets
IV - Distant mets outside abdo cavity
What are the 5yr survival of ovarian cancer according to the FIGO staging system?
I - 75-90%
II - 45-60%
III - 30-40%
IV - <20%
Why should a Ca125 be performed?
In women >50y with abdominal symptoms where ovarian cancer is suspected
If >35, send for TVS and RMI
How is a risk of malignancy index calculated?
USS x M x Ca125
USS = 0 points for no features, 1 point for 1 feature, 3 points for 2+ features (multilocularity, solid areas, mets, ascites, bilateral lesions)
M = menopausal status; 1 for pre-menopausal (inc peri), 3 for postmenopausal
Ca125 = serum Ca125
Score then compared to guidelines
- Low risk = RMI <25 with 3% risk cancer
- Moderate risk = RMI 25-200/250 with 20% risk cancer
- High risk = RMI >250 with 75% risk cancer
What surgical options are available for the management of ovarian cancer?
Full staging laparotomy + removal of any discovered tumours - debulking to <1cm of mass (neoadjuvant chemo may be required in stage III/IV) Hysterectomy BSO Omentectomy Para-aortic and pelvic LN sampling Peritoneal washings and biopsies Appendectomy
(performed as indicated)
In younger women, sparing of uterus/fertility prioritised
What chemotherapy is available for ovarian cancer?
Confirmed tissue diagnosis required before commencing therapy
All pts postoperatively unless stage 1a/b and low grade
Platinum agents (carboplatin + paclitaxel, from pacific yew trees)
For advanced/relapsed ovarian cancer, options include paclitaxel, pegylated liposomal doxorubicin, topotecan
Palliative care can be used for extensive peritoneal disease
What are borderline ovarian tumours?
Epithelial and not benign
More common in younger women
Staged as for ovarian cancer
What are the characteristics of BOTs?
Confined to one ovary Pre-menopausal Metastatic implants Difficult diagnosis histologically Better prognosis vs ovarian cancer
How are BOTs managed?
Conservative surgery - unilateral oophorectomy and staging biopsies
Recurrence may take 25 yrs to resurface
What is pseudomyxoma peritonei?
Very rare, arises from primary tumour of appendix
May be associated with mucinous cystadenoma (thick, jelly-like deposits throughout abdomen)
Poor prognosis, difficult to treat
