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Laura MRCOG Part 2 > 17) Gynae-oncology: Ovarian > Flashcards

17) Gynae-oncology: Ovarian Flashcards

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1
Q

Percentage of women requiring surgery for ovarian mass in their lifetime

A

10%

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2
Q

Risk of ovarian malignancy in premenopausal woman/at age 50

A

Pre-menopausal: 1 in 1000

Age 50: 3 in 1000

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3
Q

What percentage of suspected ovarian masses are non-ovarian in origin?

A

10%

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4
Q

Investigations in premenopausal woman with ovarian mass

A
  • TV USS according to IOTA rules
  • If suspected malignancy, tumour markers including CA-125, and if age < 40 years - LDH, aFP, hCG.
  • Calculate RMI
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5
Q

How is RMI calculated?

A

RMI = menopause status x ca125 x ultrasound score

Menopause status: 1 = pre, 3 = post
Ultrasound score: 0= 0 features, 1=1 feature, 3=2-5 features.
Features include: solid component, multiloculated, ascites, metastases, bilateral lesions.

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6
Q

What are the IOTA “B” and “M” rules?

A

B rules:

  • Unilocular
  • Solid components < 7mm
  • Acoustic shadowing
  • Multilocular smooth < 100mm
  • No blood flow

M rules:

  • Irregular solid
  • Ascites
  • > 4 papillary structures
  • Multilocular irregular solid > 100mm
  • Very strong blood flow
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7
Q

Management of premenopausal ovarian mass

A
  • RMI > 200 or any M rules refer to gynae-oncology
  • If simple cyst <5cm no follow up required (physiological and likely to resolve within 3 cycles)
  • If simple cyst 5-7cm - annual follow up
  • If >7cm consider MRI/surgical intervention
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8
Q

Risk of chemical peritonitis with spillage of dermoid cyst

A

0.2%

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9
Q

Which port should cyst be removed from?

A

Umbilical

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10
Q

Incidence of ovarian masses in postmenopausal women

A

5-17%

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11
Q

Management of postmenopausal women with ovarian mass

A
  • Calculate RMI
  • If RMI >200 refer gynae-onc
  • If RMI <200 and cyst is asymptomatic, simple, <5cm, unilocular and unilateral can consider conservative management with repeat RMI in 4-6 months (95-99% benign and 70% will have resolved). If any of those criteria not met recommend BSO.
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12
Q

Ethnic variation in Ca-125

A

Higher in Caucasian than African/Asian

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13
Q

Risk of malignancy based on RMI score

A

<25: <3%
25-250: 20%
>250: 75%

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14
Q

Diagnostic accuracy of cyst aspiration in detecting malignancy

A

25%

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15
Q

Risk of recurrence if aspiration only treatment for cyst

A

25%

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16
Q

Lifetime risk of ovarian cancer

A

1:50

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17
Q

Peak incidence of ovarian cancer based on age

A

> 60 years (highest rate group 75-79 years)

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18
Q

Top 6 female cancers

A
  1. Breast
  2. Lung
  3. Bowel
  4. Uterus
  5. Melanoma
  6. Ovarian
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19
Q

Risk factors for ovarian cancer

A
  • 15% genetic component (BRCA 1 - 50% risk, BRCA 2 - 20% risk, HNPCC - 10% risk)
  • Nulliparity
  • Early menarche, late menopause
  • Inferility
  • Perineal talc
  • Obesity
  • HRT
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20
Q

Classification of ovarian cancers

A
  1. Epithelial (90%)
  2. Sex cord stromal (5%)
  3. Germ cell (5%)
  4. Metastatic
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21
Q

Most common type of epithelial ovarian cancer

A

Serous 60% (then endometrioid 10-15%)

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22
Q

Most common type of stromal ovarian cancer

A

Granulosa cell 70%

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23
Q

Most common type of germ cell tumour

A

Dysgerminoma

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24
Q

FIGO staging ovarian cancer

A

STAGE 1: OVARIES
A) 1 ovary, capsule intact
B) 2 ovaries, capsule intact
C) Capsule not intact

STAGE 2: TUBES/UTERUS
A) Tubes/uterus
B) Other pelvic intraperitoneal tissues

STAGE 3: PELVIC PERITONEUM (includes capsule of liver/spleen but not parenchyma)
A) Retroperitoneal LN +/- microscopic mets
B) Retroperitoneal LN +/- macroscopic mets <2cm
C) Retroperitoneal LN +/- macroscopic mets >2cm

STAGE 4: EVERYWHERE ELSE
A) Pleural effusion
B) Liver/spleen/extra-abdominal organs

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25
Percentage of Granulosa cell tumours which secrete oestrogen
70%
26
Percentage of women with granulosa cell tumours who have endometrial cancer and endometrial hyperplasia
Hyperplasia - 1/3 | Cancer - 10-15%
27
Feature of sertoli-leydig cell tumours
Masculinising due to testosterone production
28
Percentage of people with epithelial ovarian cancer diagnosed at stage 3 or 4
>70%
29
Why should every woman with high grade serous adenocarcinoma or G3 endometriosis cancer be offered BRCA testing?
>10% will have a mutation (and 44% of these did not have a family history)
30
Associations with endometrioid ovarian cancer
Ovarian endometriosis | 15% endometrial cancer
31
Associations with clear cell ovarian cancer
Pelvic endometriosis Paraneoplastic hypercalcemia VTE
32
Relevant fact for mucinous cancer
May be ovarian primary but if invasive more likely to be mets from GI. Need to consider upper and lower GI endoscopy and at surgery remove appendix.
33
Treatment for ovarian cancer
Early stage: - Complete resection + platinum based chemo post-op Late stage: Cytoreduction of all macroscopic disease with chemo post-op (or neo-adjuvant chemo and then interval debulking if thought not to be possible as primary debulking)
34
Prognosis for ovarian cancer
``` 5 year survival based on stage: I - 90% II - 45% III - 18% IV - 4% ``` Average 1 year survival 72% Average 5 year survival 46% Average 10 year survival 35%
35
Side effects carboplatin
``` Hypersensitivity Nausea and vomiting Nephrotoxicity Neutropenia Thrombocytopenia Hypersensitivity ```
36
Side effects paclitaxel
``` Hypersensitivity Nausea and vomiting Nephrotoxicity Neutropenia Alopecia Neurotoxicity Arthralgia/myalgia ```
37
Percentage of epithelial tumours which are borderline
15%
38
Explanation of borderline ovarian tumours
No invasive characteristics (don't grow into ovarian stroma, grow slowly and in more controlled way) but can break away e.g. into peritoneum and become invasive.
39
Risk of recurrence in borderline ovarian tumour in contralateral ovary if only one removed
5%
40
Cure rate for germ cell tumours
85%
41
Percentage of dysgerminomas which are bilateral
15%
42
What percentage of women with germ cell tumours present at early stage?
60-70%
43
Management of germ cell tumours
Unilateral oophorectomy Peritoneal washing Omental biopsy Selective removal of enlarged LN If stage 1c or higher - Bleomycin/etoposide/cisplatin chemo. If 1a/b can do surveillance - recurrence rate 20% the majority of which will then be cured by chemo.
44
What percentage of recurrences of germ cell tumours occur in the first year?
75%
45
Follow up of patients with germ cell tumours
Tumour markers and CXR every 2 months for 2 years and then 3-6m for next 3 years.
46
What percentage of residual mature teratoma progresses as mature teratoma growing syndrome?
30%
47
Percentage of women who regain menstrual function and fertility within 1 year of competing chemo
87-100% (3% have premature menopause)
48
When is a family history considered significant when assessing ovarian cancer risk?
- Known carrier of cancer gene mutation - Untested 1st degree relative of someone with known cancer gene - Untested 2nd degree relative (via unaffected male) of someone with known cancer gene First degree relative in a family with: - >2 ovarian cancers (first deg of each other) - 1 ovarian cancer (any age) and 1 breast cancer <50 - 1 ovarian cancer (any age) and 2 breast cancer <60 - 3 colon cancers or 2 colon and 1 stomach/ovarian/endometrial/urinary/small bowel (one <50) - one individual with both breast and ovarian cancer.
49
What is the conventional chemotherapy used for ovarian cancer?
Carboplatin + paclitaxel - 6 cycles at 3 weekly intervals.
50
What is the benefit of intraperitoneal chemo?
In women with optimally resected disease, it reduces risk of recurrence and prolongs survival.
51
What is meant by, and what is the benefit of, dose-dense schedules?
Weekly carboplatin + paclitaxel. | Clinical benefit and reduced toxicity.
52
What is bevacizumab?
A monoclonal antibody targeting VEGF under investigation.
53
What are the types of relapsed disease?
Platinum refractory disease: Recurrence whilst receiving chemo. Platinum resistant disease: Recurrence within 6m of finishing chemo. Platinum sensitive disease: Recurrence >6m after finishing chemo (partially sensitive if 6-12m)
54
Response rate to chemo in relapsed disease
Platinum sensitive - 40-75% Partially sensitive - 25-30% Resistant - 10-20% Refractory <10%
55
What may be of benefit in BRCA mutation patients?
PARP inhibitors
56
Complications of mucinous tumour rupture?
Pseudomyxoma peritonei and small bowel obstruction
57
Raised tumour markers in serous ovarian tumour
Ca 125
58
Raised tumour markers in mucinous ovarian cancer
CEA and CA-125
59
What percentage of clear cell cancers are bilateral?
10%
60
Prognosis of clear cell cancers
Poor. Highly malignant.
61
Proportion of clear cell cancers associated with a primary in the uterus
15%
62
Feature of Brenner tumours
Transitional epithelium. Usually benign. If malignant may be associated with bladder tumour.
63
Sertoli cell tumours
Usually benign
64
Hormones secreted by Sertoli cell tumours
70% oestrogen, 20% androgenic, 10% no secretion
65
What proportion of germ cell tumours are malignant?
2-3%
66
What do dysgerminomas secrete?
LDH, placental ALP. | 3% - bhCG.
67
What percentage of mature cystic teratomas (dermoid) are bilateral?
15%
68
What percentage of mature cystic teratomas (dermoid) undergo malignant change?
1%
69
What can be secreted by immature teratomas?
``` Thyroid hormones (struma ovaria) Serotonin (Carcinoid) ```
70
What is secreted by embryonal carcinoma?
bhCG and AFP
71
What is secreted by yolk sac or endodermal sinus tumour
AFP

Laura MRCOG Part 2 (56 decks)

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