Ovaries 2 Flashcards
What is the staging for ovarian cancer?
Stage 1: disease macroscopically confined to the ovaries
1a: one ovary is affected, capsule is intact
1b: both ovaries are affected, capsule is intact
1c: one/both ovaries are affected, capsule not intact, or malignant cells in the abdominal cavity (ascites)
Stage 2: disease is beyond the ovaries but confined to the pelvis
Stage 3: disease is beyond the pelvis but confined to the abdomen (omentum, small bowel and peritoneum)
Stage 4: disease is beyond the abdomen (lungs or in liver parenchyma)
What are the investigations for ovarian carcinoma?
• CA125 should be measured in women >50yrs with abdominal symptoms
if CA125 is raised (>35IU/ml), an abdo & pelvic USS is arranged
is USS or physical examination identifies ascites and/o a pelvic/abdominal mass, urgent referral to secondary care is undertaken
• For women <40yrs, levels of alpha fetoprotein (AFP) and hCG are measure to identify women who may not have epithelial ovarian CA, as levels are raised in germ cell tumours
What is the risk of malignancy index?
calculated from the product of the USS score (U=0-3), menopause status (M=1-3) and serum CA125 level
all women with a RMI ≥250 are referred to MDT
RMI = U x M x C125
How is the RMI calculated?
• The USS result is scored 1 point for each of the following characteristics- U=3 is for points 2-5
o Multilocular cysts
o Solid areas
o Metastases
o Ascites
o Bilateral lesions
• Menopausal status is scored as 1 = pre-menopausal and 3 = post-menopausal
• CT pelvis and abdomen is performed to establish the extent of the disease, further staging is surgical
What is the management for ovarian cancer?
• A midline laparotomy allows a total hysterectomy, bilateral salpino-oophorectomy and partial omentectomy to be performed
with biopsies of any peritoneal deposits, random biopsies of the peritoneum and retroperitoneal lymph node assessment
o Stage 1- retroperitoneal LN are samples
o Stage 2 or higher- LN are removed through block dissection if enlarged
What is the management for advanced tumours?
the prognosis relates to the effectiveness of the initial debulking procedure
patients who have complete debulking have a better prognosis
• Ultraradical surgery is increasing- this may involve bowel resection, splenectomy and peritoneal stripping to achieve complete cytoreduction
• In young women wishing to preserve fertility, where disease appears early or is borderline- the uterus and unaffected ovary may be preserved, but meticulous further staging and follow up are required
What is needed before starting chemotherapy?
• A confirmed tissue diagnosis is required
tissue may be obtained through percutaneous image-guided biopsy or laparscopy if tissue cannot be gained, then cytology from paracentesis of ascites can be performed
• CA125 levels are used to monitor the response to chemotherapy
o Very early (low grade histology, stage 1a and 1b)- chemotherapy is not usually given
o Other stage 1 (high grade, stage 1c)- six cycles of the platinum agent carboplatin are used
o Stage 2-4 Carboplatin (or cisplatin) alone or in combination with paclitaxel is used
How do the tumours respond to chemotherapy?
- 2 out of 3 women whose tumours initially respond to 1st line chemotherapy will relapse within 2yrs of completing treatment
- Many women now receive neoadjuvant chemotherapy eg. they do not have surgery initially, but receive chemotherapy and have surgery half way through the course, this causes less mobidity, although there is no evidence to suggest a difference in survival
How are early stage malignant germ cell tumours treated?
removal of the adnexa, allowing preservation of fertility higher risk and more advanced germ cell tumours are usually treated with chemotherapy and are generally highly sensitive
• Dysgerminomas are sensitive to radiotherapy, but chemotherapy is more effective and so preferred
What are the poor prognostic factors in ovarian carcinoma?
• Levels of CA125 and CT scans are used to detect residual disease or relapse
• Poor prognostic indicators are
o Advanced stage
o Poorly differentiated tumours
o Clear cell tumours
o Slow or poor response to chemotherapy
• Death is commonly from bowel obstruction or perforation
What are the important issues in palliative care for ovarian carcinoma?
o The problems of prolongation of poor quality life
o Euthansia
o Symptom control vs. drug side effects
o Make the transition from curative to palliative care
o Resource allocation
What is used for symptom control in palliative ovarian carcinoma?
Pain- the analgesic ladder is used, along with co-analgesics (anti-depressants, steroids and cytotoxics). opioid analgesia can be ‘patient controlled’ (anti-emetic).
• Nausea & vomiting- affects 60% of patients with advanced carcinoma, may be due to opiates, metabolic causes (uraemia), vagal stimulation (bowel distention) or psychological factors
anti-emetics include anti- cholinergics, anti-histamines, dopamine antagonists and 5HT-3 antagonists
Heavy vaginal bleeding- high dose progestogens and radiotherapy
Ascites and bowel obstruction- drained slowly by repeated paracentesis and obstruction is ideally managed at home (metoclompramide, stool softeners, enemas with dexamethasone, cyclizine and hyoscine)
