T5: Ovarian Cancer

Question 1

Where in the ovary can tumours arise from?

Answer 1

• Germ cells
• Stromal cells
• Epithelial cells - the most common types are serous (tubal mucosa), mutinous (endocervical) and endometriod (endometrium).

Question 2

What is the serum marker used in ovarian cancer?

Answer 2

Ca125

Question 3

What is epithelium in the ovaries capable of differentiating into?

Answer 3

The lining is capable of differentiating into serous epithelium (lines fallopian tube), mucinous epithelium (lines the endocervix) and endometroid (lines the endometrium). These are all types of glandular epithelium.

Question 4

Why are epithelial tumours described as broad spectrum?

Answer 4

There is a broad spectrum, they can be benign, borderline (abnormal architecture but no evidence of invasion) or malignant (evidence of invasion).

Question 5

What is the nomenclature used in ovarian cancer?

Answer 5

Ovarian epithelial tumours when benign have the suffix ‘oma’ and glandular begin tumours have the prefix ‘adeno’.
- If composed of cysts they are called ‘cystadenoma’
- If they are composed of fibrous tissue they are called ‘adenofibroma’
Cystic and fibrous tissue ‘cystadenofibroma.’

Malignant epithelial tumours have the suffix carcinoma rather than -oma. Malignant ovarian epithelium is therefore a cystadenocarcinoma

• This is then further classified by type of epithelium:
  i. e. Serous cystadenocarcinoma

Then further classified into:
	• High grade (aggressive)
Low grade (slower growing, less aggressive, better prognosis)

Question 6

Give the term given to a endometrium cystic and fibrous benign ovarian epithelial tumour.

Answer 6

Endometriod cystadenofibroma

Question 7

Give the term given to a malignant ovarian cystic epithelial tumour.

Answer 7

cystadenocarcinoma

Question 8

Give details of the epidemiology of ovarian cancer.

Answer 8

Epidemiology
- Most common gynaecological malignancy
- 90% of ovarian cancer are epithelial
- They present later
- Patients present with non-specific symptoms such as weight loss, bloating, fatigue, urinary frequency, PV bleeding
Since later presenting presentation may be due to metastases of late stage disease

Question 9

What are risk factors for ovarian cancer.

Answer 9

• Age
• Obesity
• Smoking
• Genetic susceptibility - 5-15% of ovarian cancer diagnoses are caused by BRCA1/2. There is also a 3X increased risk in females with a mother or sister with ovarian cancer
• Hormone replacement therapy

Question 10

What are protective factors of ovarian cancer.

Answer 10

• Having children
• Breast feeding
• COCP - combined oral contraceptive pill - if been using it for a certain period of time

Question 11

What are the differential diagnoses used in a dull ache in the lower abdomen?

Answer 11

• Ectopic pregnancy
• Ovarian neoplasm
• Epithelial / germ cell / sex-cord stromal
• Benign / malignant
• Other gynaecological causes – functional cyst, ovarian torsion, pelvic inflammatory disease, PCOS, fibroid
• GI tract causes

Question 12

What is a teratoma?

Answer 12

A tumour that has cells from all three germ lines: endoderm, ectoderm and mesoderm.

20% of all ovarian neoplasms are tumours. Most common germ cell tumour. Nearly all are benign (mature cystic teratoma), 1% show malignant transformation (immature teratoma). Generally occur in young women. They arise from an oocyte that has completes its first meiotic division.

Mature cystic teratoma "Tumour that contains elements of all germ cell layer"

- Ectoderm e.g. skin and hair 
- Mesoderm e.g. muscle bone and cartilage 
- Endoderm e.g. evidence of epithelium

Question 13

What is LDH a marker for?

Answer 13

Dysgerminoma - this is malignant and very rare. LDH is used as a tumour marker - sensitive to chemotherapy.

Question 14

What is alpha-FP a marker for?

Answer 14

Yolk sac tumour - malignant and sensitive to chemotherapy - alpha foetal protein can be used as a marker.

Question 15

What is beta-HCG a marker for?

Answer 15

Choriocarcinoma extremely rare. Malignant and differentiation towards placenta and produced beta HCGH. Another maker that can be used.

Question 16

What is Meg’s syndrome?

Answer 16

Meig’s syndrome - triad of ovarian tumours (fibroma), right sides pleural effusion and ascites.

Question 17

Give examples of sex cord stromal tumours.

Answer 17

1. Thecomas and fibroatheromas (fibroma) - these are benign. Both produce oestradiol. They commonly present in older women and since of the oestrogen they may present with abnormal uterine bleeding since post menopausal.
   
   2. Granulosa cell tumour - low grade malignant and produce oestradiol. Can present with post-menopausal abnormal uterine bleeding,
   3. Sertoli-Leydig cell tumours - Produce androgens, 10-25% are malignant. Presents in young women. Increase in testosterone causes anovulation, ache, hirsutism etc.

Question 18

What is a Krukenberg tumour?

Answer 18

Krukenberg tumour. This is a stomach tumour that metastasises to the ovaries and contains cells secreting mucin. Usually bilateral.

Question 19

How do metastatic ovarian tumours spread?

Answer 19

• Usually due to a direct spread or by lymphatic/ hematogenous spread
  
  • Most commonly originate from:
    
    • Colon
    • Stomach (Krukenberg tumour)
    • Breast

Question 20

What staging system is used in ovarian cancer?

Answer 20

FIGO - Stages 1-4