Week 6 - H - Ovarian cancer - Presentation, diagnosis, staging, management - Early, advanced and recurrent

Question 1

What are risk factors for ovarian cancer?

Answer 1

>50 years of age Nullpaity Late menopause Family history of breast or ovarian cancer BRCA1 mutations BRCA2 mutations HRT users

Question 2

Do BRCA1 or BRCA2 mutations carry a higher risk of developing ovarian cancer? How long do you have to be a HRT user for to increase the risk?

Answer 2

BRCA1 mutation carriers carry a higher risk of developing ovarian cancer - 40% BRCA2 mutation carries - roughly 20% HRT uses of greater than 10 years have double the risk compared to non-users

Question 3

Ovarian cancer often presents late What are the signs and symptoms? (often non specific)

Answer 3

Ascites - sign Pelvic mass -sign Symptoms fatigue, unexplained weight loss, changing bowel habit - red flag Abdominal distension/fullness Urinary sympotms

Question 4

BEAT is the acronym for ovarian cancer, w at do the letters stand for?

Answer 4

• B - is for bloating that is persistent and doesnt come and go
• E - is for eating less and feeling fuller (early satiety and not as hungry)
• A - is for abdominal pain
• T - is for telling your GP

* Persistent pelvic and abdominal pain * Increased abdominal size/persistent bloating - not bloating that comes and goes * Difficulty eating and feeling full quickly

Question 5

If GP gets a female patient with any of the BEAT symptoms, especially if she is over what age? then he should measure CA-125 What are the BEAT symptoms again?

Answer 5

Especially if she is over age 50 Bloating that doesnt come and go Eeating less and feeling fuller Abdominal pain (and pelvic pain) Time to tell GP Also if women reports unexplained weight loos or change i nbowel habits - red flags (can also make one think bowel cancer)

Question 6

Women with ovarian cancer who have a family history of breast, ovarian or colon cancer should have a genetic risk assessment. What should be tested in these patients?

Answer 6

Offer BRCA1and2 testing in these patients

Question 7

Women who have ovarian or fallopian tube cancer but isn’t which type of epithelial ovarian cancer should also be offered BRCA testing?

Answer 7

All women with non-mucinous ovarian or fallopian tube cancer should be offered BRCA1 and BRCA2 mutation testing.

Question 8

Even in high risk groups eg FH or known BRCA mutation, CA125/US, pelvic examination-not effective at detecting ovarian cancer at an early stage, therefore no evidence that screening will effect mortality even in high risk population Women with identified BRCA 1 or 2 mutations should be offered what prophylactic treatment at a relevant time int heir life?

Answer 8

Bilateral prophylactic salpingo-oopherectomy

Question 9

In the ovarian cancer diagnosis, after presenting to the GP with the beat symptoms, and CA-125 is carried out, if the concentration in the blood is greater than what, is what carried out?

Answer 9

If the concentration is greater than 35IU/ml, carry out an ultrasound of abdomen and pelvis If symptoms persist or worsen despite normal CA 125 and a negative ultrasound scan, refer to secondary care.”

Question 10

Risk of malignancy index is calculated from the patients, menopasual status, CA125 and from their uss score How does each factor contribute? Women with an RMI score of what are referred to a specialist gynaecological cancer multidisciplinary team?

Answer 10

RMI = Menopausal status x CA125 x USS Woomen with an RMI of >250 are referred to a specialist gynaecological cancer multidisciplinary team

Question 11

Describe the ovarian cancer staging?

Answer 11

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Question 12

What is the pattern of ovarian cancer spread?

Answer 12

Transcolaemic / transperitoneal - periotneal wshings/peritoneum invaded Haematgenous - liver/lung/brain - rare and late

Question 13

Ovarian cancer >90% epithelial cell tumours of ovary * serous * mucinous * endometrioid * clear cell * Brenner * undifferentiated <10% germ cell, granulosa cell Where is cytology usually carrid out from for the cancer?

Answer 13

Usually cytology in ascitic fluid or pleural effusion

Question 14

What tumour markers are measured in women under 40 with suspected ovarian cancer and why? What tumour maker is measured as it can exclude a GI met to the ovaries?

Answer 14

In women under 40 with suspected ovarian cancer, measure levels of alpha fetoprotein (AFP) and beta human chorionic gonadotrophin (beta-hCG) as well as serum CA125, to identify women who may not have epithelial ovarian cancer. Can measure CEA (carcinoembryonic antigen) to exclude met from GI

Question 15

If the ultrasound, serum CA125 and clinical status suggest ovarian cancer, perform a CT scan of the pelvis and abdomen to establish the extent of disease. Include the thorax if clinically indicated. When is tissue diagnosis required for ovarian cancer and how is this carried out?

Answer 15

If offering cytotoxic chemotherapy to women with suspected advanced ovarian cancer, first obtain a confirmed tissue diagnosis by histology (or by cytology if histology is not appropriate) Carried out by CT guided biopsy of an omental deposit - best way or folllwing laparscopy guided biopsy of an abn ovary

Question 16

When is cytotoxic chemotherapy not given in the management of ovarian cancer?

Answer 16

Stage IA or IB ovarian cancer not routinely offered cytotoxic chemotherapy - just TAH + BSO here

Question 17

Patients with early stage low-risk disease (e.g., stage IA and stage IB) and favourable tumour characteristics (e.g., grade 1 or grade 2) do not require adjuvant chemotherapy. In a young women, with what stage disease, may be the uterus and other ovary be left for fertility?

Answer 17

In women with stage Ia, grade 1 or grade 2 disease, fertility conserving surgery is an option as long as the contralateral ovary appears normal and there is no evidence of omental or peritoneal disease.

Optimal staging must be carried out where biopsy of any suspicious tissue is taken

Question 18

In women with Stage Ic or advanced stage (Stage II to IV), what is carried out?

Answer 18

Primary surgery and chemotherapy

Question 19

What drug is used for chemotherapy?

Answer 19

Platinum based compound - carboplatin or in combo chemotherapy carboplatin and paclitaxel If performing surgery for women with ovarian cancer, whether before chemotherapy or after neoadjuvant chemotherapy, the objective should be complete resection of all macroscopic disease.

Question 20

When may neoadjuvant chemotherapy be considered for ovarian cancer treatment? ie neoadjuvant, surgery, then post-op chemotherapy

Answer 20

Patients with stage IIIC (lining of peritoneum >2cm tumour size) and stage 4 disease where resection of all macroscopic disease in unlikely are increasingly being treated with neoadj chemotherapy. We know that treating such patients with upfront chemo prior to surgery enables more women to be “optimally debulked” and reduces surgical morbidity

Question 21

Cytoreduction literally means a reduction in the number of cells. So cytoreductive surgery refers to a treatment of advanced ovarian cancer in which surgery attempts to remove as many cancerous cells as possible. For patients with recurrent ovarian cancer who are platinum-sensitive, what is carrried out?

Answer 21

Secondary cytoreductive surgery and further chemotherapy may be carried out

Question 22

For all woman with high grade (grade 3) early stage (Stage Ia and Ib) disease, what should be given?

Answer 22

TAH + BSO + Adjuvant cytotoxic chemotherapy

Question 23

“First line chemotherapy treatment of epithelial ovarian cancer should include a platinum agent either in combination or as a single agent, unless specifically contraindicated.

• * Carboplatin is the platinum drug of choice in both single and combination therapy.
• * Paclitaxel is recommended in combination therapy with platinum

In women with recurrent, platinum resistent disease, what can be offered? in the first line post-surgery treatment of epithelial ovarian cancer where the potential benefits justify the toxicity of the therapy.

Answer 23

Can offer hormonal therapy eg Tamoxifen particularly where their original tumour is expressing the oestrogen receptor.

Question 24

How does tamoxifen work?

Answer 24

Tamoxifen is a selective estrogen-receptor modulator (SERM) that works both by decreasing factors that increase the growth of breast cells and increasing factors that decrease the growth of breast cells.