Pelvic masses and ovarian cancer Flashcards
What are risk factors for the development of ovarian cancer?
- Age - incidence risses with age
-
INCREASED OVULATION - relating to the number of ovultary cyces ina women’s lifetime ie not missed many menstrual cycles/never been on pill/never been pregnant
- Nulliparity
- Early menarche/Late menopause
- History of fertility treatment - clomifene
-
FH/FH of breast cancer
- BRCA1/2
- HNPCC/Lynch type 2 (FH of bowel cancer)
- Obesity/Diabetes
- Smoking
What factors protect against the development of ovarian cancer?
- Pregnancy
- Breastfeeding
- COCP
- Tubal ligation
- Hysterectomy
- Exercise
- Aspirin
When would you consider referring someone for genetic counselling if the had ovarian cancer?
- Two primary cancers in one 1st/2nd degree relative
- Three 1st/2nd degree relatives with breast, ovary, colorectal, stomach or endometrial cancers
- Two 1st/2nd degree relatives - 1 with ovarian cancer any age, and other with breast cancer age < 50
- Two 1st/2nd degeree relative with ovarian cancer any age
How does ovarian cancer present?
Often vague symptoms:
- Bloating/distension - persistant
- Unexplained weight loss/Loss of appetite/early satiety
- Fatigue
-
Pressure symptoms
- Urinary symptoms - Frequency/urgency
- Change in bowel habits
- Abdominal/Pelvic pain
- Vaginal bleeding
- Pelvic mass
70-80% of women with overain cancer have these symtpoms but 1% with these symptoms has ovarian cancer
What can ovarian cancer present like?
- IBS
- Diverticular disease
What might you find on examination in someone with ovarian cancer?
- Fixed abdominal/pelvic mass
- Ascites
- Omental mass
- Pleural effusion
- Supraclavicular lymphadenopathy
What are the main types of ovarian tumours?
- Epithelial - serous, endometriod, clear cell, mucinous and undifferentiated types
- Germ cell
- Sex cord-stromal
- Metastatic
- Miscellaneous
Where do epithelial cell tumours arise from?
Mesothelial layer covering the peritoneal surface of the ovary and associated inclusion cysts
What are different types of epithelial ovarian cancers?
- Serous
- Mucinous
- Endometroid
- Clear cell
- Brenner
- Mixed epithelial
- Mixed mullerian
What are the different types of germ cell malignancies seen in ovarian cancers?
- Dysgerminoma
- Teratoma
- Yolk sac tumour
- Choriocarcinoma
What are the different types of sex cord-stromal tumours?
- Thecoma
- Granulosa cell tumour
- Androblastoma
- Gonadoblastoma
- Fibroma
What investigations would you consider doing in someone with suspected ovarian cancer?
- Examine Abdo and Pelvis
- Bloods - FBC, U+E’s, LFTs, CA-125, CA 19-9, AFP, BHCG, placental ACP, LDH, serum inhibin
- Imaging - Pelvic US, CXR, CT abdo/pelvis, MRI
- Other - ascitic tap/pleural tap, biopsy
Where can ovarian secondaries arise from?
Breast, GI, haemopoietic system, uterus or cervix
What might you see on pelvic USS in someone with ovarian cancer?
Presence of solid, complex, septated, multi-loculated mass, with high blood flow
When would transvaginal ultrasound be used when investigating ovarian cancer?
If pelvic mass palpated on examination
What is CA-125?
Glyco-protein used in detecting and monitoring epithelial ovarian tumours
>/= 35U/ml then urgent ultasound scan of abdo and pelvis should be ordered
What proportion of epithelial cancers is CA-125 positive in?
80%
What else can elevate CA-125?
- Heart failure
- PID
- Endometriosis
- Uterine fibroids
- Pregnancy
- Menstruation
- Ovarian cysts
- Pancreatic, breast, lung, gastric and colon cancer
How would you make the diagnosis of ovarian cancer?
- Extirpation of affected ovary
- Pleural/ascitic fluid aspiration
Why might you do CXR in someone with suspected ovarian cancer?
- Look for pleural effusion, lung mets
- Used in staging
How is the risk of malignancy index calculated?
US x M x CA125
- US = US score (1-3)
- M = Menopausal status (1 - pre, 2-peri, 3 - post)
- CA125 = serum CA125 levels
If <200 unlikely to be OC
If >200 suspect risk of OC (REFER)
What is the scoring for US scan based on when calculating RMI index?
Presence of one of the following scores 1 point, presence of 2 scores 2 etc:
- Multilocularity
- Solid areas
- Metastases
- Ascites
- Bilaterality of lesions
What RMI score is regarded as high risk?
>250 - 75% risk of cancer
What RMI score is regareded as low risk?
<25 - <3% risk of cancer
What are functional ovarian cysts?
Enlarged or persistent follicular or corpus luteum cysts. They are so common that they may be consdiered normal if they are small. They can cause pain if ruptured
What is the most common type of ovarian cancer?
Serous epithelial
Are serous tumours of the ovary benign or malignant?
They can be either
Are mucinous tumours of the ovary benign or malignant?
Can be either benign or malignant
Are teratomas benign or malignant?
Almost always benign
How does ovarian cancer spread?
- Trans-coelomically
- Lymphatically
What is the RMI used for?
To differentiate benign from malignant lesions
What system is used to stage ovarian cancer?
FIGO system
What is stage I ovarian cancer?
Limited to one (Ia) /both ovaries (Ib). Ic represents breach of the ovarian capsule - tumour is present on the surface of the capsule, or peritoneal washings are positive/malignant ascites
What is classed as stage II ovarian cancer?
Limited to pelvis
What is regarded as stage III ovarian cancer?
Limited to abdomen, including regional lymph node mets
What is regarded as stage IV ovarian cancer?
Distant mets outside the abdominal cavity
When is chemotherapy recommended in ovarian cancer
Following stage II-IV surgery - unless low grade tumour
How would you manage ovarian cancer?
-
Surgery - exploratory laparotomy for debulking and staging
- TAH/BSO + LN biopsies
- Omentectomy
- Lapartomy - obtain tissue diagnosis,s tage disease, disease clearance, de-bulk disease
- Adjuvant chemotherapy
Why might you perform serum CA19-9 investigation?
Look for evidence of mucinous epithelial tumours
Why might BHCG/placental ALP be raised in ovarian cancer?
Can be marker of dysgerminomas, embryonal cancers, choriocarcinoma
Why might AFP be raised in ovarian cancer?
Can be raised in endodermal sinus/yolk sac tumours
Why might LDH be raised in ovarian cancer?
Can be raised in some dysgerminomas
What might your differential diagnosis be for a pelvic mass?
- Ovarian – ovarian cyst/benign tumour, ovarian cancer
- Tubal – tubo-ovarian abscess, tubal malignancy (treat as ovarian)
- Uterine – pregnancy, fibroids/benign tumour, uterine cancer
- Urological – distended bladder, pelvic kidney, transplanted kidney
- GI – the 6 Fs: fat, fluid, flatus, faeces, fetus, filthy big tumour
- Other – primary peritoneal cancer, retroperitoneal sarcoma.
Why might you do LFTs in someone with suspected ovarian cancer?
Look for signs of metastases
What is involved in exploratory laparotomy to treat ovarian cancer?
Midline laparotomy
- Total abdominal Hysterectomy
- Bilateral salpingo-oophrectomy
- Infracolic Omentectomy
- Pelvic/para-aortic lymph node sampling
- Peritoneal biopsies/multiple pelvic washings
- Sampling of ascites,
- Inspection/sampling of the underside of the diaphragm
What is generally used as first line adjuvant chemotherapy in ovarian cancer?
Carboplatin + paclitaxel
(platinum based)
What is regarded as second line adjuvant chemotherapy for ovarian cancer?
- Pegylated liposomal doxorubicin (PLDH)
- Topotecan
- Paclitexal
How can treatment efficacy be monitored in ovarian cancer?
Monitor CA125 levels
What would be the first line option for surgical management of an ovarian cyst in a young woman who want to maintain fertility?
- Ovarian cystectomy
- Unilateral salpingo-oophrectomy
What aree the surgical options for managing benign ovarian cysts?
- Ovarian cystectomy
- Unilateral salpingo-oophrectomy
- Bilateral salpingo-oophrectomy
Why are the fallopian tubes removed with the ovaries when in ovarian cancer?
Some ovarian cancers are thought to originate from the fallopian tubes - High grade serous type carcinoma
If abdo/pelvis examination was suspicious for a pelvic mass, what investigation would you consider doing first?
https://cks.nice.org.uk/ovarian-cancer#!scenario
CA-125 - If positive, proceed to pelvic ultrasound
What is meig’s syndrome?
Triad of ovarian cancer, ascites and pleural effusion
