Ovarian_cancer_Flashcards
What is ovarian cancer?
Ovarian cancer is the fifth most common malignancy in females, with a peak incidence at 60 years. It generally has a poor prognosis due to late diagnosis.
What is the pathophysiology of ovarian cancer?
Around 90% of ovarian cancers are epithelial in origin, with 70-80% being serous carcinomas. The distal end of the fallopian tube is often the site of origin for many ‘ovarian’ cancers.
What are the risk factors for ovarian cancer?
Family history (mutations of the BRCA1 or BRCA2 gene), many ovulations (early menarche, late menopause, nulliparity).
What are the clinical features of ovarian cancer?
Abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms (e.g. urgency), early satiety, diarrhoea.
What investigations are recommended for ovarian cancer?
NICE recommends a CA125 test initially. If CA125 is raised (35 IU/mL or greater), an urgent ultrasound scan of the abdomen and pelvis should be ordered. A CA125 should not be used for screening asymptomatic women.
How is the diagnosis of ovarian cancer typically confirmed?
Diagnosis is difficult and usually involves diagnostic laparotomy.
What is the typical management for ovarian cancer?
Usually a combination of surgery and platinum-based chemotherapy.
What is the prognosis for ovarian cancer?
80% of women have advanced disease at presentation. The all stage 5-year survival rate is 46%.
Does infertility treatment increase the risk of ovarian cancer?
It is traditionally taught that infertility treatment increases the risk due to increased ovulations. However, recent evidence suggests there is not a significant link. The combined oral contraceptive pill and having many pregnancies reduce the risk.
summarise ovarian cancer
Ovarian cancer
Ovarian cancer is the fifth most common malignancy in females. The peak age of incidence is 60 years and it generally carries a poor prognosis due to late diagnosis.
Pathophysiology
around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas
interestingly, it is now increasingly recognised that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers
Risk factors
family history: mutations of the BRCA1 or the BRCA2 gene
many ovulations*: early menarche, late menopause, nulliparity
Clinical features are notoriously vague
abdominal distension and bloating
abdominal and pelvic pain
urinary symptoms e.g. Urgency
early satiety
diarrhoea
Investigations
CA125
NICE recommends a CA125 test is done initially. Endometriosis, menstruation, benign ovarian cysts and other conditions may also raise the CA125 level
if the CA125 is raised (35 IU/mL or greater) then an urgent ultrasound scan of the abdomen and pelvis should be ordered
a CA125 should not be used for screening for ovarian cancer in asymptomatic women
ultrasound
Diagnosis is difficult and usually involves diagnostic laparotomy
Management
usually a combination of surgery and platinum-based chemotherapy
Prognosis
80% of women have advanced disease at presentation
the all stage 5-year survival is 46%
*It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. Recent evidence however suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.
A 55-year-old woman presents to the GP with a 4-month history of persistent abdominal cramping, bloating, and diarrhoea. She denies passing any blood in her stools and denies any unexplained weight loss or fatigue. Her only past medical history includes obesity and there is no family history.
Her heart rate is 85 bpm, her blood pressure is 135/74 mmHg, and she is afebrile. An abdominal and pelvic examination are both unremarkable. There is no pallor or jaundice.
What is the most appropriate next step in her management?
Arrange a transvaginal ultrasound
Measure anti-TTG antibodies
Measure serum CA-125
Urgently refer to gastroenterology
Urgently refer to gynaecology
Measure serum CA-125
Suspect ovarian cancer in any woman >= 50 years of age presenting with symptoms suggestive of irritable bowel syndrome in the last 12 months. IBS rarely presents for the first time in this age group
Important for meLess important
The presence of persistent features suggesting irritable bowel syndrome (IBS, such as cramping, bloating, and diarrhoea) in female patients aged 50 or older should raise suspicion of ovarian cancer, even without constitutional symptoms such as unexplained weight loss or fatigue. This is because ovarian cancer often presents with very vague and non-specific symptoms similar to IBS, and rarely presents for the first time in patients aged 50 or older. IBS typically affects young people aged 20-39 years.
Measure serum CA-125 is correct. NICE recommends that all people with suspected ovarian cancer have an abdominal and pelvic examination carried out. If this is normal, then they recommend measuring CA-125 as the next step. Ovarian cancer cannot be ruled out if an abdominal examination is unremarkable, as the body habitus of patients can affect whether masses are picked up or not, or the ovarian cancer masses may not be large enough to be picked up via palpation.
Arrange a transvaginal ultrasound is incorrect. NICE recommends ultrasound scans of the abdomen and pelvis (as opposed to a transvaginal ultrasound) once CA-125 has been measured. If CA-125 is elevated, ultrasounds are performed. Since this patient has not yet had her CA-125 measured yet, this step may not be necessary, as if her CA-125 is normal, ovarian cancer is less likely. If these ultrasounds suggest malignancy, other ultrasounds including transvaginal ultrasound scans may be considered in secondary care under specialist guidance.
Measure anti-TTG antibodies is incorrect. This would be appropriate rule other causes of abdominal cramping, bloating, and diarrhoea, such as coeliac disease, however, IBS rarely presents for the first time in patients aged 50 or older, and particularly in female patients, this should raise suspicion of ovarian cancer.
Urgently refer to gastroenterology is incorrect. This would be appropriate if the patient had features of inflammatory bowel disease, such as bloody stools or features of iron deficiency anaemia. These features do not apply to this patient.
Urgently refer to gynaecology is incorrect as NICE recommends this if an abdominal examination demonstrates ascites or a pelvic or abdominal mass. This patient’s abdominal examination was unremarkable, therefore, the most appropriate next step according to the NICE guidelines is to measure serum CA-125.
buzz words
persistent abdominal cramping, bloating, and diarrhoea. (IBS symptoms)
A 33-year-old woman reports that both her mother and grandmother died of ovarian cancer in their 40s. She is worried that she too may develop the condition and would like to know more about screening for ovarian cancer in the UK
Which one of the following is true?
There is currently no screening programme for ovarian cancer
Screening is offered to all women after 50 with 3 yearly transvaginal ultrasounds
Screening is offered to all women after 50 with 3 yearly measuring of Ca125 levels
Screening is only offered to women who have a family history of ovarian cancer
Screening is only offered to women who have the BRCA1 or BRCA2 gene
There is currently no screening programme for ovarian cancer
At the moment, there is no screening test that reliably detects ovarian cancer at an early stage.
Ovarian cancer should be suspected and further tests should be carried out in any woman (particularly those over 50 years of age), who persistently have any of the following symptoms:
Abdominal distension/bloating
Feeling full (early satiety) or loss of appetite
Pelvic or abdominal pain.
Increased urinary urgency or frequency
A 55-year-old woman attends the GP surgery as she is worried about her risk of developing ovarian cancer, especially because of the amount of exposure ovarian cancer has received in the news. Which of the following is most associated with the development of ovarian cancer?
Early menarche
Early menopause
Combined oral contraceptive use
Multiple pregnancy
Low body mass index
Early menarche
The risk factors for ovarian cancer are hormonal in nature. A woman’s risk is greater if ovulation is not suppressed. In this way, early menarche and late menopause, both of which would increase ovulation, are risk factors for ovarian cancer. Hormone replacement therapy (HRT) and obesity, rather than low body weight, are also risk factors.
Pregnancy, which suppresses ovulation, is protective against ovarian cancer as is combined oral contraceptive use.
Ovarian cancer has received a lot of attention in the media, and often patients read about vague symptoms such as bloating being precursors to ovarian cancer. While this is true to an extent, it is important to reassure patients and carry out a thorough history and examination and identify and risk factors.
A 72-year-old woman with ovarian cancer is seen in the gynaecological oncology clinic. There, the consultant talks through her pre-surgical prognosis, based on her risk malignancy index (RMI). What are the three components of the RMI?
Age, CA125, ultrasound (US) findings
Age, number of children, ultrasound (US) findings
CA125, co-morbidities, menopausal status
CA125, co-morbidities, ultrasound (US) findings
CA125, menopausal status, ultrasound (US) findings
Risk malignancy index (RMI) prognosis in ovarian cancer is based on US findings, menopausal status and CA125 levels
Important for meLess important
The RMI is the pre-surgical prognostic criteria recommended by NICE, and is based on CA125 levels, menopausal status, and ultrasound score. Age, co-morbidities, and number of children are not part of the criteria.
