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Gwen - Reproductive Medicine (Obs, Gyn, Breast) > Pelvic masses and ovarian cancer > Flashcards

Pelvic masses and ovarian cancer Flashcards

1
Q

What are risk factors for the development of ovarian cancer?

A
  • 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
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2
Q

What factors protect against the development of ovarian cancer?

A
  • Pregnancy
  • Breastfeeding
  • COCP
  • Tubal ligation
  • Hysterectomy
  • Exercise
  • Aspirin
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3
Q

When would you consider referring someone for genetic counselling if the had ovarian cancer?

A
  • 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
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4
Q

How does ovarian cancer present?

A

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

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5
Q

What can ovarian cancer present like?

A
  • IBS
  • Diverticular disease
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6
Q

What might you find on examination in someone with ovarian cancer?

A
  • Fixed abdominal/pelvic mass
  • Ascites
  • Omental mass
  • Pleural effusion
  • Supraclavicular lymphadenopathy
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7
Q

What are the main types of ovarian tumours?

A
  • Epithelial - serous, endometriod, clear cell, mucinous and undifferentiated types
  • Germ cell
  • Sex cord-stromal
  • Metastatic
  • Miscellaneous
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8
Q

Where do epithelial cell tumours arise from?

A

Mesothelial layer covering the peritoneal surface of the ovary and associated inclusion cysts

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9
Q

What are different types of epithelial ovarian cancers?

A
  • Serous
  • Mucinous
  • Endometroid
  • Clear cell
  • Brenner
  • Mixed epithelial
  • Mixed mullerian
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10
Q

What are the different types of germ cell malignancies seen in ovarian cancers?

A
  • Dysgerminoma
  • Teratoma
  • Yolk sac tumour
  • Choriocarcinoma
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11
Q

What are the different types of sex cord-stromal tumours?

A
  • Thecoma
  • Granulosa cell tumour
  • Androblastoma
  • Gonadoblastoma
  • Fibroma
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12
Q

What investigations would you consider doing in someone with suspected ovarian cancer?

A
  • 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
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13
Q

Where can ovarian secondaries arise from?

A

Breast, GI, haemopoietic system, uterus or cervix

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14
Q

What might you see on pelvic USS in someone with ovarian cancer?

A

Presence of solid, complex, septated, multi-loculated mass, with high blood flow

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15
Q

When would transvaginal ultrasound be used when investigating ovarian cancer?

A

If pelvic mass palpated on examination

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16
Q

What is CA-125?

A

Glyco-protein used in detecting and monitoring epithelial ovarian tumours

>/= 35U/ml then urgent ultasound scan of abdo and pelvis should be ordered

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17
Q

What proportion of epithelial cancers is CA-125 positive in?

A

80%

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18
Q

What else can elevate CA-125?

A
  • Heart failure
  • PID
  • Endometriosis
  • Uterine fibroids
  • Pregnancy
  • Menstruation
  • Ovarian cysts
  • Pancreatic, breast, lung, gastric and colon cancer
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19
Q

How would you make the diagnosis of ovarian cancer?

A
  • Extirpation of affected ovary
  • Pleural/ascitic fluid aspiration
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20
Q

Why might you do CXR in someone with suspected ovarian cancer?

A
  • Look for pleural effusion, lung mets
  • Used in staging
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21
Q

How is the risk of malignancy index calculated?

A

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)

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22
Q

What is the scoring for US scan based on when calculating RMI index?

A

Presence of one of the following scores 1 point, presence of 2 scores 2 etc:

  • Multilocularity
  • Solid areas
  • Metastases
  • Ascites
  • Bilaterality of lesions
23
Q

What RMI score is regarded as high risk?

A

>250 - 75% risk of cancer

24
Q

What RMI score is regareded as low risk?

A

<25 - <3% risk of cancer

25
Q

What are functional ovarian cysts?

A

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

26
Q

What is the most common type of ovarian cancer?

A

Serous epithelial

27
Q

Are serous tumours of the ovary benign or malignant?

A

They can be either

28
Q

Are mucinous tumours of the ovary benign or malignant?

A

Can be either benign or malignant

29
Q

Are teratomas benign or malignant?

A

Almost always benign

30
Q

How does ovarian cancer spread?

A
  • Trans-coelomically
  • Lymphatically
31
Q

What is the RMI used for?

A

To differentiate benign from malignant lesions

32
Q

What system is used to stage ovarian cancer?

A

FIGO system

33
Q

What is stage I ovarian cancer?

A

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

34
Q

What is classed as stage II ovarian cancer?

A

Limited to pelvis

35
Q

What is regarded as stage III ovarian cancer?

A

Limited to abdomen, including regional lymph node mets

36
Q

What is regarded as stage IV ovarian cancer?

A

Distant mets outside the abdominal cavity

37
Q

When is chemotherapy recommended in ovarian cancer

A

Following stage II-IV surgery - unless low grade tumour

38
Q

How would you manage ovarian cancer?

A
  • 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
39
Q

Why might you perform serum CA19-9 investigation?

A

Look for evidence of mucinous epithelial tumours

40
Q

Why might BHCG/placental ALP be raised in ovarian cancer?

A

Can be marker of dysgerminomas, embryonal cancers, choriocarcinoma

41
Q

Why might AFP be raised in ovarian cancer?

A

Can be raised in endodermal sinus/yolk sac tumours

42
Q

Why might LDH be raised in ovarian cancer?

A

Can be raised in some dysgerminomas

43
Q

What might your differential diagnosis be for a pelvic mass?

A
  • 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.
44
Q

Why might you do LFTs in someone with suspected ovarian cancer?

A

Look for signs of metastases

45
Q

What is involved in exploratory laparotomy to treat ovarian cancer?

A

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
46
Q

What is generally used as first line adjuvant chemotherapy in ovarian cancer?

A

Carboplatin + paclitaxel

(platinum based)

47
Q

What is regarded as second line adjuvant chemotherapy for ovarian cancer?

A
  • Pegylated liposomal doxorubicin (PLDH)
  • Topotecan
  • Paclitexal
48
Q

How can treatment efficacy be monitored in ovarian cancer?

A

Monitor CA125 levels

49
Q

What would be the first line option for surgical management of an ovarian cyst in a young woman who want to maintain fertility?

A
  • Ovarian cystectomy
  • Unilateral salpingo-oophrectomy
50
Q

What aree the surgical options for managing benign ovarian cysts?

A
  • Ovarian cystectomy
  • Unilateral salpingo-oophrectomy
  • Bilateral salpingo-oophrectomy
51
Q

Why are the fallopian tubes removed with the ovaries when in ovarian cancer?

A

Some ovarian cancers are thought to originate from the fallopian tubes - High grade serous type carcinoma

52
Q

If abdo/pelvis examination was suspicious for a pelvic mass, what investigation would you consider doing first?

A

https://cks.nice.org.uk/ovarian-cancer#!scenario

CA-125 - If positive, proceed to pelvic ultrasound

53
Q

What is meig’s syndrome?

A

Triad of ovarian cancer, ascites and pleural effusion

54
Q
A

Gwen - Reproductive Medicine (Obs, Gyn, Breast) (49 decks)

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