Ovarian Cancer Flashcards

1
Q

Incidence:

A

Most common gynae malignancy
Epithelial Ovarian CA: Majority present with advance disease therefore prognosis and survival poor
- Lifetime incidence 1:80
- Mainly postmenopausal women

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2
Q

Factors to note in History

A
  • Risk factors:
  • Family history
  • Nulliparity (Theory of incessant ovulation with trauma to surface epithelium, increased risk of malignant transformation
  • Early menarche/late menopause
  • Ovarian stimulation
  • BRCA carrier status 5-10% associated with BRCA status and HNPCC
  • Protective factors:
  • COCP use (50% reduction with 5
    years use)
  • Hysterectomy
  • Tubal ligation
  • Breastfeeding
  • Symptoms:
    *Constitutional: fatigue, weight loss/gain
  • Abdominal: bloating, pain
  • GI: poor appetite, altered bowel habit
  • Urinary: frequency, incontinence
  • Risk factors as above
  • Assess fitness for surgery
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3
Q

Histology

A
  • 90% of ovarian cancers are epithelial
    o Serous >50%
  • Secrete Ca-125
    o Endometrioid 20%
  • Usually well differentiated
  • May have synchronous endometrial cancer
    o Mucinous 5-10%
  • Well differentiated
  • Secrete Ca19.9
  • Pseudomyxoma peritoneii – likely to have GI primary
    o Clear cell 5-10%
  • Poor prognosis
  • Associated with endometriosis
  • Germ Cell 10%
  • more common in younger women
  • DysgerminomasL LDH (Most common malignant tumour in pregnancy)
  • yolk sac tumours: Secrete AFP
  • Malignant teratoma
  • Choriocarcinoma: Secrete Beta HCG
  • Sex cord stroma
  • any age
  • granulosa cell: Secrete Oestrogen
  • Sertoli-Leydig secrete testosterone
  • Metastatic 5-10%
    o Breast (most common), colorectal, stomach ( Krukenberg tumours with signet ring on Histopathology), endometrial
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4
Q

Spread

A
  • Transperitoneal or Coelomic:
    Breach of Ovarian capsule
    Spread to peritoneal surface such as diaphragm, bowel or omentum
  • Lymphatic: Para-aortic and pelvic LN
  • Haemotogenous: Late to lungs and liver
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5
Q

Examination

A
  • CV and resp to assess fitness for surgery
  • Abdominal and bimanual examination
    Palpable masses/tenderness/ Ascites
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6
Q

Investigations

A

o Pelvic ultrasound:
M rules: at least one and nil benign
- irregular solid tumour
- irregular/multilocular solid mass >10cm
- >/= 4 papillary structures
- Ascites
- High Doppler signal
B rules: At least one and nil malignant
- unilocular cyst
- smooth multilocular tumour <10cm
- solid components of <7mm
- Presence of acoustic shadows
- No detectable Doppler flow
o Tumour markers: Ca-125, CEA, Ca19.9
- AFP, HCG and LDH in younger women
o Pre-operative workup: FBE, UEC, LFTs, coags, G&H, CXR, ECG
o Consider CT Abdo/Pelvis for further assessment of anticipated stage
- Consider use * Risk of Malignancy Index
o Ca-125 x menopausal status x USS features
§ Menopausal = 3, premenopausal = 1
§ 1 abnormal ultrasound finding=1, >=2 abnormal ultrasound findings=2
* Multiloculated
* Solid areas
* Papillary projections
* Bilateral
* Ascites
* Metastases
o Score >200 suggests high risk of malignancy

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7
Q

Management

A
  • Referral to gynae-oncology unit
    o MDT discussion
  • Surgical staging
  • Procedure
    § Midline laparotomy
    § Pelvic washings
    § Extrafascial TAH/BSO
    § Omental biopsy +/- omentectomy (essential if stage 1c or above)
    If disease in 1 ovary only and yound woman: Remove affected ovary, Biopsy contralateral ovarly, stage with peritoneal washings, oentectomy and para-aortic lymph nodes
    § Peritoneal biopsy
    § Pelvic and para-aortic lymph node sampling
    § Debulking (aim all deposits <1cm)
  • Achieving optimal debulk improves survival
    § Appendicectomy if mucinous
  • Postoperative care
    o Thromboprophylaxis
    o Further MDT and histopath review to plan adjuvant therapy
  • Chemotherapy
    o Adjuvant chemotherapy
  • Carbotaxol first line (Epithelial Ca)
  • Given routinely for stage 1c and above
  • Consider for stage 1a and 1b if high grade
    o Neoadjuvant chemotherapy
  • Consider if bulky extraperitoneal disease or surgically unfit
  • Aim for interval debulking

NB: Follow up
- 6/52 Post op with MDT
- 3-4 monthly for 1-2 years
- Yearly for 5 years

Symptoms of recurrence:
* Presentation with pain, ascites, pleural effusion
* Secondary surgery rarely indicated
* Trial of platinum-based chemotherapy if reasonable disease-free interval
* Symptomatic management/palliation may be required
o Stoma
o Pleurodesis
o Paracentesis

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8
Q

Granulosa cell Tumour

A
  • Comprise 70% of sex-cord stromal tumours and have malignant potential
  • Median age of onset 50-55 years
  • Risk factors – non white, obese, family hx breast or ovarian cancer
  • Protective factors – OCP use, increased parity, smoking
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9
Q

Clinical features of Granulosa cell tumour

A

o Present as large unilateral masses, usually >10cm
o Secrete oestrogen
- 55% of patients have abnormal uterine bleeding
* At endometrial biopsy, 50% have hyperplasia and 10% have overt endometriod adenocarcinoma
- Breast tenderness, sexual precocity in children
o Non-specific features ie ascites, bloating, abdominal pain
o May present acutely with ovarian torsion or tumour rupture

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10
Q

Granulosa cell tumours NB other NB Ix

A
  • Inhibin B raised
  • NB to check ET: Often associated with Hyperplasia or Endo Ca
  • Histological diagnosis at time of surgical excision
    § Yellow-coloured tumour due to accumulation of lipids
    § On histopath show coffee-bean grooved nuclei and Call-Exner bodies
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11
Q

Differences in management for Granulosa cell tumours

A
  • If post menopausal manage as for Epithelial ca
  • NB to perform Endometrial biopsy prior to surgery
  • If fertility desired and confined to one ovary (and endometrial biopsynegative)
  • Unilateral salpingo-oophorectomy reasonable
  • This is because most tumours are stage 1a at diagnosis
    o Adjuvant chemotherapy may be considered if stage 1c or above
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12
Q

Granulosa cell prognosis and follow up

A
  • Prognosis
    o Stage 1a have 90% 5-year survival
    o Tend to relapse late, at a mean 4-6 years but up to 40 years later
    o Ultrasound and inhibin 6 monthly for the first 5 years then annually for life
    o Recurrent localised disease may be suitable for surgical resection
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13
Q

Sertoli- Leydig cell tumours

A
  • Rare tumours, only 20% are malignant
  • Clinical features
  • Mean age at diagnosis 25 years
  • Large (mean diameter >16cm) unilateral adnexal mass
  • Androgen-secreting
    § Virilisation a common presentation
    § Hirsuitism, voice deepening, acne, amenorrhea, breast atrophy, baldness, clitoromegaly
    o Elevated testosterone levels
  • Management
    o Surgical staging as per epithelial ovarian
    o TAH/BSO preferred but USO reasonable if fertility desired (especially if diagnosis confirmed with intraoperative frozen-section)
    o Lymphadenectomy often omitted as nodal metastases rare
    o Adjuvant therapy not required unless metastatic
    § Chemotherapy (BEP) advised for these cases
  • Prognosis
    o >95% are stage 1a at diagnosis
    o 5-year survival 70-90%
    o Tend to recur early, only 6-7% recur after 5 years
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14
Q

Germ cell tumours

A
  • 10% of all ovarian cancers
  • 60% of cancers in patients <age 20 years
    Dysgerminoma: Most common germ cell tumour, chemosensitive, secrete LDH
    Yolk sac tumour: Often in premenarchal patients, Worst prognosis
    Choriocarcinoma: BHCG
    Immature Teratoma
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15
Q

Germ cell tumour management

A
  • Referral to gynae-oncology
    o MDT care
  • Primary surgery
    o Given age of patients, good prognosis (owing to chemosensitivity), fertility
    sparing treatment usually preferred
    o Pelvic washings, unilateral salpingo-oophorectomy, surgical staging
  • Frozen section if available to help with surgical planning (may need to proceed to full TAH/BSO of epithelial ovarian cancer found)
  • Cystectomy of other ovary if lesion found
  • Biopsy from normal contralateral ovary if dysgerminoma

Adjuvant treatment
o Stage 1a dysgerminoma and immature teratoma do not require adjuvant treatment
o All other require adjuvant chemotherapy with BEP (bleomycin, etoposide, cisplatin)
* Prevent pregnancy
o OCP recommended during treatment and follow-up
o Also beneficial in suppressing ovarian function and damage during treatment
Follow-up
* Surveillance of contralateral ovary with ultrasound
* Tumour marker tracking if was initially elevated

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16
Q

Borderline Ovarian Tumours

A

Definition: Ovarian tumours of uncertain malignant potential defined histologically by atypical epithelial proliferation without stromal invasion

17
Q

Borderline Ovarian tumours Histopath

A

Histology
* Serous or mucinous (rarely endometrioid)
* At least two of: nuclear atypia, stratification of epithelium, mitotic activity, microscopic papillary projections, cellular pleomorphism
Clinical features
* Do not invade/metastasize but can have direct intraperitoneal spread

18
Q

Borderline Clinical assessment

A

Nil specific findings on History or Examination
Assessment and Investigations as for other pelvic/ovarian masses

19
Q

Borderline tumour management

A

Management
* Gynae oncology
* Diagnosis and staging
o Diagnosis requires histology
o Staging system as per epithelial ovarian cancer
o Rarely fully staged as prognosis good regardless and therefore limited surgery often performed
* Surgical management
o All patients should have washings and frozen section if available
o Laparotomy vs laparoscopy
- Laparoscopy increases risk of cyst rupture, but recurrence no different
- If rupture does occur, thorough irrigation of peritoneal cavity required
o Depending on desire for fertility
- Ovarian cystectomy – 25-30% recurrence
- Unilateral oophorectomy -10-15% recurrence on contralateral side
- TAH/BSO – 6% recurrence

20
Q

Borderline Tumour management

A

Follow-up
* Gynae onc follow-up
* 6/12 review for 5 years then annually
o Follow Ca-125 if was initially elevated
* If fertility preserving surgery, 6/12 TV USS
* Consider OCP
* Pregnancy does not alter disease progression
* Completion surgery once child-bearing complete
Recurrence
* Usually respond to surgical cytoreduction