Ovarian Tid bits Flashcards
What are the five risks associated with oophorectomy in women prior to menopause?
- Osteoporosis
- Cardiovascular disease
- Vasomotor instability
- cognitive impairment
- death
What % of Mucinous Ovarian Ca are metastatic?
77%
What % of Mucinous Ov Ca are primary Ovarian?
23%
What features in a Mucinous Ovarian tumour increase the likelihood that it is an Ovarian primary?
- unilateral,
- “expansile” pattern of invasion,
- complex papillary pattern,
- size > 10 cm,
- smooth external surface,
- Histologically: microscopic cystic glands, necrotic luminal debris, mural nodules and
- Accompanying teratoma, adenofibroma, endometriosis or Brenner tumor
Histologically how are borderline tumours differentiated from carcinoma
Morphology of a BOT with invasion < 5mm with non invasive implants.
What are the type types of invasion characteristic of Muncinous carcinoma?
- expansile or infiltrative:
- Expansile tumors are usually stage I and behave “benign”
- Infiltrative tumors may demonstrate malignant behavior and cause death even if stage I
The cumulative incidence at 70 for Ovarian Ca in women with a MLH1 mutation is?
11%
The cumulative incidence at 70 for Ovarian Ca in women with a MSH2 mutation is?
15%
The cumulative incidence at 70 for Ovarian Ca in women with a MSH6 mutation is?
0 % - I suspect that means increased above the background level.
The cumulative incidence at 70 for Ovarian Ca in women with a PMS2 mutation is?
0% - I suspect that means increased above the background level.
Likely of finding Ca in an Endometrioma?
~1%
What, if any, is the increase in risk for epithelial ovarian cancer in women with Endometriosis?
2-3x
What is the effect of TIL (tumour infiltrating lymphoctyes) on OS in Ov Ca
NEJM 2003 found 5 yr OS in TIL - 38.0% vs 4.5% in No TIL.
With complete surgical and chemo response 5 yr OS in TIL 73.9% an 11.9% in no TIL.
How common is hypercalcaemia in malignancy
~20-30% of pts with ca will have Hypercalcaemia. 80% of those will have Humoral Hypercalcaemia of Malignancy (HHM)
How often do women with CCC of the Ovary have hypercalcaemia?
No idea. Overall 5% of Gyn Malignancies are astd with paraneoplastic hypercalcaemia.
Reported cases. Clear cell C most common epithelial ovarian Ca astd with para-neoplastic syndromes - including VTE, acute cerebellar degeneration or bilateral diffuse uveal melanocytic proliferation.
What % of people with an unexplained hypercalcaemia will have an occult malignancy detected?
~ 40%
Name 5 para-neoplastic syndromes associated with ovarian cancer.
VTE - Acute cerebellar degeneration bilateral diffuse uveal melanocytic proliferation. Thrombocytosis Hypercalcaemia
What investigations do you do for hypercalcaemia of malignancy?
Recheck serum Ca with Corrected Ca.
Measure intact PTH
- If high or mid to upper level of normal - likely Primary hyperparathyroidism ( in known Ca also check PTHrP)
- If low
- Measure PTHrP, 1,25 Vit D, 25-Hydroxy Vit D
if PTHrP elevated -hypercalcaemia of malignancy
if 1,25-dihydroxyvitamin D elevated - lmphom, granulomatois disease (e.g. sarcoid, TB) more likely.
What are the symptoms of Hypercalcaemia?
CALCIUM Constipation Anorexia and Nausea Lethargy Confusion Insipid - Weakness - like Pep's moustache Urine - polyuria Murine polydipsia.
What levels of Ca are an issue in hypercalcaemia
<3mmol/l - likely asymptomatic or ? constipation
3 - 3.5 mmol/ - CALCIUM
> 3.5 mmol/l More severe symptoms.
What are the treatment options for Hypercalcaemia?
MDT
Initially - Avoid - thiazide diuretics, Li, dehydration, prolonged inactive and high Ca diet. Maintain hydration.
Then - N/Saline to increase U/O to 100 - 150ml/hr
IV SALCATONIN - Salmon calcitonin - for acute management - repeat bloods q4h. If improved can used QID for up to 48 hrs ( leads to tachyphylaxis)
IV Bisphosphonate - Mostly Zoledronic Acid or pamidronate - can be used monthly after initial treatment.
Prolia - Denosumab - can be use in renal failure or in addition.
Is CA-125 a useful marker in pregnancy?
may be elevated during early gestation and immediately following delivery. May be useful between 15 weeks and term as they are unlikely to be elevated during this time solely due to pregnancy.
○ CA 125 in the range of 1000 to 10,000 is likely (but not invariably) related to cancer, but values in the range of 75 to 150 could be either pregnancy-related or due to ovarian cancer that does not demonstrate high expression of CA 125.
Is LDH a useful marker in pregnancy?
Can be elevated in with ovarian dysgerminomas
○ reliable marker for diagnosis and follow-up of these tumours in pregnant women
○ not elevated in normal pregnancy
○ May be elevated in HELLP and PET.
Is AFP a useful marker in pregnancy?
- AFP - (MSAFP) normally rise during pregnancy;
○ Used to screen for T21 and Foetal neural tube defects
○ High MSAFP also seen in ovarian germ cell tumours (e.g. endodermal sinus tumour, embryonal carcinoma and mixed tumours.
○ often >1000 ng/mL, especially with pure endodermal sinus (yolk sac) tumors, which can be associated with levels >10,000 ng/mL.
○ typically <500 ng/mL in pregnancies complicated by neural tube defects.
○ Typically expressed as MoM for each gestational week because these values are easy to derive, more stable and allow for interlaboratory variation.
○ MSAFP that are above 2.0 - 2.5 MoM are abnormal.
A Mom value of 0 or above should prompt concern for germ cell tumours of either gonadal or nongonadal origin in the absence of foetal abdominal defects or anencephaly.
Is AFP a useful marker in pregnancy?
- AFP - (MSAFP) normally rise during pregnancy;
○ Used to screen for T21 and Foetal neural tube defects
○ High MSAFP also seen in ovarian germ cell tumours (e.g. endodermal sinus tumour, embryonal carcinoma and mixed tumours.
○ often >1000 ng/mL, especially with pure endodermal sinus (yolk sac) tumors, which can be associated with levels >10,000 ng/mL.
○ typically <500 ng/mL in pregnancies complicated by neural tube defects.
○ Typically expressed as MoM for each gestational week because these values are easy to derive, more stable and allow for interlaboratory variation.
○ MSAFP that are above 2.0 - 2.5 MoM are abnormal.
A Mom value of 0 or above should prompt concern for germ cell tumours of either gonadal or nongonadal origin in the absence of foetal abdominal defects or anencephaly.
Is Inhibin a useful marker in pregnancy?
Inhibin is a useful for ovarian granulosa cell tumors in nonpregnant women, inhibin A is made in the developing placenta, and serum levels are elevated in early gestation
Is HE4 a useful marker in pregnancy?
HE4 - a product of the WFDC 2 (HE4) gene that is overexpressed in ovarian cancer.
unaffected by pregnancy
What is the incidence of adnexal masses in pregnancy?
Varies in studies from 0.05 - 2.4%
What % of adnexal masses in pregnancy are malignancy?
1-6%
Which cancers are common in pregnancy?
Ovarian Ca is the 6th most common after
breast, thyroid, cerviclal and hodgkin lymphoma
Torsion occurs in which % of women with an adnexal mass?
~5%
What size of adnexal mass is the most likely to tort in pregnancy?
Masses between 6 - 8 cm in diameter have a significantly higher rate of torsion - 22%, than either smaller or larger ones
When is the most likely time for a mass to tort?
60% of torsions occur between the 10 - 17th week of pregnancy.
only 6% occurred after 20 weeks.
What are 7 complex benign lesions in pregnancy?
FLETCCH
F - Fibroid L - Luteoma E - Endometrioma T - Theca Luteal cysts C - Cystadenoma / Corpus Luteum H - Heterotopic pregnancy
Which IHC markers are used to differentiate primitive germ cell tumours?
SALL4, OCT3/4, SOX2
Dysgerminoma - SALL4 & OCT 3/4 +ve
Yolk sac tumour - SALL4 only
Embryonal carcinoma - all 3.
What are the four molecular subtypes in Epithelial ovarian cancer?
Mesenchymal (~ 40%)
Immunoreactive (~20%)
Proliferative (~ 20%)
Differentiated (~20%)
What is the Mesenchymal molecular subtype of Ovarian Cancer?
Mesenchymal type is the most common type ~ 30 - 40%
desmoplastic stroma signature and associated with poor patient survival;
What is the Immunoreactive molecular subtype of Ovarian Cancer?
Accounts for ~ 20% of HGSC
○ high expression of T-cell markers, major histocompatibility complex genes, and programmed cell death and ligand 1 (PD1 and PDL1) levels,
○ Astd with Tumour infiltrating lymphocytes
The immunoreactive subgroup has a distinct immune-cell infiltrated microenvironment and a generally favourable out.
What are the short and long term complications of splenectomy?
Normal post operative complications, bleeding, infection, hernia formation, ileus, UTi. PUmonary complications are the most common. intraabdominal abscess.
Specific to Splenectomy
Pancreatic fistula in 1.5% of patients.
