Ovarian oncology Flashcards by Laurence Forsyth

why do ovarian cancers tend to have worse prognosis

present late due to non-specific symptoms

> 70% of ptx present after it has spread beyond the pelvis

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how can ovarian tumours be classified 4

eipthelial cell tumours

dermoid cysts/ Germ cell tumours

sex cord-stromal tumours

metatsis from other tumour sites

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what is the most common ovairian tumour type

epithelial cell tumours

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subtypes of epithelial cell ovarian tumours 5

serous tumours (most common)

endometrioid carcinomas

clear cell tumours

mucinous tumours

undifferentiated tumours

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are dermoid cyst/germ cell tumours benign or malignant

benign

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what can dermoid cyst/germ cell tumours include 4

various types of tissue such as skin, teeth, hair and bone

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what are dermoid cyst/germ cell tumours associated with 1

ovarian torsion

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what biochemical markers are dermoid cyst/germ cell tumours associated with 2

raised alpha-fetoprotein (å-FP)

raised human chorionic gonadotrophin (hCG)

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what do sex cord-stromal ovarian tumours arise from 2

sex cords - embyronic structures assocaited with the follicles

stroma - connective tissue

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main types of sex cord-stromal ovarian tumours 2

sertoli-leydig cell tumours

granulosa cell tumours

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what is a common metatsis to the ovaries and the name of the tumour

Krukenberg tumour
-usuusually from a GI tract cancer (particularly the stomach)

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characterisitc finding in krukenberg tumours 1

‘signet-ring’ cells on histology
-look like signet rings under a microscope

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risk factors for ovarian tumours 6

age (peak age 60)

BRCA1 and BRAC2 genes (consider FHx)

increased No of ovulations

obesity

smoking

recurrent use of clomifene (infertility drug)

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What else can impact the risk of ovarian cancer
-give some examples 3

increased number of ovulations-> incresed risk of ovarian cancer

examples
-early-onset periods
-late menopause
-no pregnancies

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what is a protective factor for ovarian cancer
-give some examples 3

factors that stop ovulation or reduce the number of lifetime ovulations-> reduce the risk of ovarian ca

examples
-combined contraceptive pill
-breastfeeding
-pregnancy

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what is important when assessing someone with a potential ovarian cancer

often presents with very non-sepcific syx

-in older women keep the possibility of ovarian cancer in mind and have a low threshold for considering further investigations

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symptoms of ovarian cancer 8

abdo bloating

early satiety (feeling full after eating)

loss of appetite

pelvic pain

urinary syx - frequency / urgency

weight loss

abdo or pelvic mass

ascites

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what can an ovarian mass compress and how does this manifest as symptoms

can press on the obturator nerve and cause referred hip or groin pain

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what symptoms after examination would prompt a direct 2-week-wait referral for ovarian cancer 3

ascites

pelvic mass -unless clearly due to fibroids

abdominal mass

what is the most important initial investigation in a possible ovarian cancer?

CA125 blood test

what other investigation is important for possible ovarian cancer 1

pelvic ultrasound

what is used to estimate the risk of an ovarian mass being malignant 1

risk of malignancy index (RMI)

what does the risk of malginancy index take into account when identifying if an ovarian mass is malignant 3

*-what is the calculation

menopausal status

ultrasound findings

CA125 levels

*-RMI= UxMxCA125

what ultrasound findings are used in the risk of malignancy index for ovarian cancer

-what is the menopausal status score

Multilocular
Solid areas
Ascites
Intra abdominal metastasis
Score
0 = 0
1 = 1
2/+ = 3

1- pre
3- post

an example risk of malgnancy index calculation for ovairna cancer

Example 60y, Postmenopausal, CA125 is 300, Bilateral complex ovarian masses, solid areas, ascites. Therefore RMI = U3 X M3 X 300 = 2700

what value of the risk malginacy index is used to indicate a probable malignancy in ovarian cancer

RMI >200

further investigaitons in secondary care for ovarian cancer 3

CT scan -establish diagnosis and stage the cancer histology (tissue sample) -using a CT guided biopsy, laparoscopy or laparotomy paracentesis (ascitic tap) -can be used to test the ascitic fluid for cancer cells

what investigations are important for a COMPLEX OVARIAN MASS in women UNDER 40 (2)

check for possible germ cell tumours so -alpha-fetoprotein (å-FP) -human chorionic gonadotropin (HCG)

what non-malignant causes of a raised CA125 can be found 6

endometriosis fibroids adenomyosis pelvic infection liver disease pregnancy

regarding staging ovarian cancer define stage 1

confined to ovary

regarding staging ovarian cancer define stage 2

spread past ovary but inside the pelvis

regarding staging ovarian cancer define stage 3

spread past pelvis but inside the abdomen

regarding staging ovarian cancer define stage 4

spread outside the abdomen (distant metastasis)

how can types of epithelial ovarian cancer be split

2 types high grade serous or arise from ovarian surface epithelium and Mullerian inclusion cysts

what do high grade serous epithelial ovarian tumours resemble

fallopian tube mucosa

what genetic mutations are found in high grade serous epithelial ovarian tumours

P53

what types of epithelial ovarian cancer arise from ovarian surface epithelium and mullerian inclusion cysts 4

endometriod clear cell mucinous low grade serous

how do ovarian cancers spread 3

direct extension (transcoelemic) exfoliation into the peritoneal cavity lymphatic invasion

screening for ovarina cancer

current trials but no evidence so far to support screening even in high risk women

ovarian cancer gene mutations 3

BRCA1- chromosome 17q BRAC2 chromosome 13q lynch syndrome -HNPCC -mutation in mismatch repiar genes *-also undiscovered genes

what cancer preentations suggest famial cause due to BRCA 1, BRCA2 and HNPCC 3

early onset breast cancer <50y male breast cancer bilateral breast cancer

what risk reducing surgery is available for high risk ovarian cancer patients *-what reduction in risk does this cause 2

prophylatic bilateral salpingo-oophrectomy -important to remove ovary AND entire fallopian tube *- 96% ovarian ca reduction -53% breast ca reduction

what value of the risk malginacy index is used to indicate a probable malignancy in ovarian cancer

RMI >200

overview of ovarian cancer managment. 4

all cases discussed at MDT -guides investigations eg biopsies -decison on management chemo-timing?, drugs? surgery- appropriate?, timing?, by whom?

surgery overview of ovarina cancer

midline laparotmy -TAH, BSO, Washings, Omentectomy +/- appendicetomy / resection of peritoneal deposits Ultra-radical – splenectomy, bowel resection, peritoneal stripping Aim to leave NO residual disease or OPTIMAL CYTOREDUCTION (less than 1cm)

chemo overview of ovarian cacner

neo adjuvant -in patients with advanced disease -poor perfomarance status adjuvant -post op MDT decison 1st line include platinum agent in combo -carboplatin -paclitaxel in combo *intraperitoneal as part of clinical trials

other opitnos for ovarian cancer managemnt 2

biological agent s -antiangiogenesis hormonal therapy -tamoxifen/ aromatase inhibiotr