Ovarian carcinoma

Question 1

What is the 10yr survival for ovarian carcinoma and why is this figure so low?

Answer 1

40-50%

Silent nature of malignancy means it is only picked up in late disease

Question 2

How many new cases of ovarian cancer are diagnosed in the UK each year?

Answer 2

7000, causing 4200 deaths
Lifetime risk of 1/60
Rates have been decreasing since 2000’s, hypothesised due to increased use of COCP

Question 3

What is the classical age of onset for ovarian tumours?

Answer 3

75-84yrs

Question 4

What is the pathophysiology of ovarian tumours?

Answer 4

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

Question 5

What are the risk factors for ovarian cancer?

Answer 5

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

Question 6

What factors are protective against ovarian cancer?

Answer 6

Pregnancy
Breastfeeding
COCP
Tubal ligation (female sterilisation)

Question 7

What grade of ovarian cancer exist?

Answer 7

Borderline
Low grade
High grade

Question 8

Can young women get ovarian cancer?

Answer 8

Rare but most common type is germ cell cancer (<30y)

Question 9

Is there a role for screening in patients at risk of ovarian cancer?

Answer 9

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

Question 10

How does ovarian cancer present?

Answer 10

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

Question 11

What may be found on examination of a woman with ovarian cancer?

Answer 11

Fixed abdo/pelvic mass
Ascites
Omental mass
Pleural effusion
Supraclavicular lymph node enlargement
Cachexia
Breast tenderness

Question 12

What staging system is used for ovarian cancer?

Answer 12

FIGO 2013 system
Note that ovarian cancer spreads directly within abdo/pelvis (transcolemic spread)
Staging surgical and histological

Question 13

What factors increase the likelihood that the ovarian mass is malignant?

Answer 13

Rapid growth >5cm
Ascites
Advanced age
Bilateral masses
Solid/separate nature on USS
Increased vascularity

Question 14

What Ix should be performed in suspected ovarian cancer?

Answer 14

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

Question 15

How does the FIGO system stage for ovarian cancer?

Answer 15

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

Question 16

What are the 5yr survival of ovarian cancer according to the FIGO staging system?

Answer 16

I - 75-90%
II - 45-60%
III - 30-40%
IV - <20%

Question 17

Why should a Ca125 be performed?

Answer 17

In women >50y with abdominal symptoms where ovarian cancer is suspected
If >35, send for TVS and RMI

Question 18

How is a risk of malignancy index calculated?

Answer 18

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

Question 19

What surgical options are available for the management of ovarian cancer?

Answer 19

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

Question 20

What chemotherapy is available for ovarian cancer?

Answer 20

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

Question 21

What are borderline ovarian tumours?

Answer 21

Epithelial and not benign
More common in younger women
Staged as for ovarian cancer

Question 22

What are the characteristics of BOTs?

Answer 22

Confined to one ovary
Pre-menopausal
Metastatic implants
Difficult diagnosis histologically
Better prognosis vs ovarian cancer

Question 23

How are BOTs managed?

Answer 23

Conservative surgery - unilateral oophorectomy and staging biopsies
Recurrence may take 25 yrs to resurface

Question 24

What is pseudomyxoma peritonei?

Answer 24

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