Ovarian oncology Flashcards
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
how can ovarian tumours be classified 4
eipthelial cell tumours
dermoid cysts/ Germ cell tumours
sex cord-stromal tumours
metatsis from other tumour sites
what is the most common ovairian tumour type
epithelial cell tumours
subtypes of epithelial cell ovarian tumours 5
serous tumours (most common)
endometrioid carcinomas
clear cell tumours
mucinous tumours
undifferentiated tumours
are dermoid cyst/germ cell tumours benign or malignant
benign
what can dermoid cyst/germ cell tumours include 4
various types of tissue such as skin, teeth, hair and bone
what are dermoid cyst/germ cell tumours associated with 1
ovarian torsion
what biochemical markers are dermoid cyst/germ cell tumours associated with 2
raised alpha-fetoprotein (å-FP)
raised human chorionic gonadotrophin (hCG)
what do sex cord-stromal ovarian tumours arise from 2
sex cords - embyronic structures assocaited with the follicles
stroma - connective tissue
main types of sex cord-stromal ovarian tumours 2
sertoli-leydig cell tumours
granulosa cell tumours
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)
characterisitc finding in krukenberg tumours 1
‘signet-ring’ cells on histology
-look like signet rings under a microscope
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)
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
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
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
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
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
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
