Ovary

Question 1

Explain why nulliparity is a risk factor for epithelial ovarian cancer.

Answer 1

Theory that repetitive disruption and repair of ovarian epithelium with repeated ovulation increases the probability of mutation leading to cancer

Question 2

List three things which protect against ovarian cancer.

Answer 2

Increasing parity
Ovulation suppression with contraception
Tubal ligation
Breastfeeding

Question 3

What histologic sub-type of ovarian cancer is most often found in BRCA positive women?

Answer 3

High-grade serous

Question 4

Your patient is BRCA positive. What recommendations would you make to her regarding cancer screening and risk reduction?

Answer 4

Risk-reducing BSO once completed childbearing
Use OCPs prior to BSO
Breast cancer screening with mammography or MRI starting age 30 (or younger, if family members developed breast cancer in their 30s)

Question 5

What are the components of the RMI II? What should be done if the patient scores > 200?

Answer 5

Menopausal status (pre = 1, post = 4) x CA125 x high-risk ultrasound features (no/one abnormality = 1, two or more abnormalities = 4)

US features: bilaterality, ascites, multilocular cyst, solid elements to mass, intra-abdominal mets

RMI II > 200 warrants a referral to gyne oncology prior to surgery

Question 6

List five prognostic factors for ovarian cancer.

Answer 6

Stage (most important)
Histologic sub-type
Age
Performance status
Volume of ascites
Extent of residual disease following primary surgery

Question 7

How would you counsel a woman with a borderline tumour who desires fertility preservation?

Answer 7

Acceptable to resect affected ovary only
Risk of recurrence is increased, but recurrences are generally curable with surgery
Follow with serial ultrasound

Question 8

What are the oncologic benefits to debulking ovarian cancer?

Answer 8

Bulky tumours are poorly vascularized & poorly oxygenated and have more quiescent cells - this makes them more chemoresistant (debulking makes residual tumour more chemosensitive)

Fractional kill hypothesis: each cycle of chemo kills a constant fraction of cells (debulking may allow chemo to reduce tumour to microscopic disease more quickly)

Question 9

Why might you opt not to use CA125 to surveil for cancer recurrence?

Answer 9

No survival benefit to initiating treatment when CA125 rises compared with when the patient experiences symptoms (quality of life may be worse as the patient is likely to be receive more chemo overall)

Question 10

Describe a patient for whom debulking of recurrent disease might be beneficial.

Answer 10

Platinum-sensitive disease
Localized recurrence (ie. complete cytoreduction feasible)
No ascites
Good performance status
Optimal debulking at initial surgery

Question 11

Why do germ cell tumours sometimes arise in extragonadal sites?

Answer 11

Embryonic migration of germ cells

Question 12

Which primitive germ cell tumour is associated with elevated AFP?

Answer 12

Classically: yolk sac tumour (endodermal sinus tumour)
Occasionally: embryonal carcinoma
Rarely: immature teratoma

Question 13

Which tumour marker can be used to assess success of treatment or recurrence of a granulosa cell tumour?

Answer 13

Inhibin B

estradiol levels are not sufficiently sensitive

Question 14

List five kinds of cancer that may metastasize to the ovary.

Answer 14

Other gyne cancers
Breast
Krukenberg tumour 
Other GI cancers
Melanoma
Carcinoid
Leukemia
Lymphoma

Question 15

When staging a granulosa cell tumour, what additional test must be performed (that is not part of staging epithelial ovarian cancer)?

Answer 15

D&C - rule out concomitant uterine cancer

Question 16

What is the most common choice of adjuvant chemo for early or advanced germ cell tumours?

Answer 16

BEP: bleomycin, etoposide, cisplatin

Question 17

Which germ cell tumour is highly radiation-sensitive?

Answer 17

Dysgerminoma

Despite this, RT is rarely used as fertility preservation is typically desired

Question 18

How might your surgical approach be different in a patient with an advanced embryonal carcinoma versus a similarly advanced Sertoli-Leydig tumour?

Answer 18

Surgically more aggressive with Sertoli-Leydig tumour since SCSTs are less chemosensitive than GCTs
(Avoid heroic resections of GCTs as this might delay chemo, but try to debulk all macroscopic disease with SCSTs)

Question 19

Describe the typical location and timing of relapse of GCTs and SCSTs.

Answer 19

GCTs - 75% of relapse within 1 year, typically in the peritoneum
SCSTs - may relapse late (even decades later), typically in upper abdomen or pelvis