Reproductive Malignancy Flashcards
Epidemiology of ovarian cancer
- Life time risk of developing ovarian cancer is 1 in 60
- Median age at diagnosis is 63years
- Oral contraceptives reduces the risk
Pathology of ovarian cancer
- 95% cancers are epithelial carcinomas
- Grade includes- low, borderline and high grade • <30 years –germ cell tumours are common
- Primary peritoneal cancer and fallopian tube cancers are rare but mimic ovarian cancer
Histological type of primary ovarian malignancy
- Serous adenocarcinoma 75%
- Endometrioid carcinoma 10%
- Clear cell carcinoma 10%
- Mucinous adenocarcinoma 3%
- Non epithelial ( germ cell an sex cord) <5%
Aetiology of ovarian cancer
- Risk is related to number of ovulations • Early menarche
- Late menopause
- Nulliparity
- Pregnancy/lactation/ use of pills –protective • Familial-5% ( BRCA 1, BRCA 2 and HNPCC)
Clinical features of ovarian cancer
- Non specific symptoms
- 75% present in late stages
- Abdominal bloating/distension or mass pain
- Loss of appetite
- Pelvic pain
- Increased urinary frequency and urgency
- Ask about breast and gastrointestinal symptoms
Examination
• Cachexia
• Abdominal or pelvic mass • Ascites
• Breast should be palpated
Spread of ovarian cancer
- Directly with in the pelvis and abdomen-trans coelomic spread
- Lymphatic and rarely blood borne spread also occur
- Staging is surgical and histological
Staging of ovarian cancer
Stage1
Disease macroscopically confined to ovaries
1a
One ovary is affected, capsule is intact
1b
Both ovaries are affected, capsule intact
1c
1a or 1b with tumour on the surface, ruptured capsule, cytologically positive ascites or positive peritoneal washings
Stage 2
Disease extending to the pelvis-uterus, fallopian tubes or other pelvic tissues
Stage 3
Abnormal disease and /or affected lymph nodes
Stage 4
Disease is beyond the abdomen e.g. in the lungs or liver parenchyma
Investigations for ovarian cancer
- CA125 –should be done in women above 50 with abdominal symptoms
- If ca125 >35 IU/ml –needs urgent ultrasound pelvis and abdomen
- <40years – AFP and HCG to rule out germ cell tumours
- RMI (Risk of Malignancy Index)-
- Ultrasound score (U)
- Menopausal status (M)
- U × M × CA125 level
- RMI >250 are referred to MDT
- CT scan Abdomen/pelvis/thorax
- Further staging is performed at surgery
Management of ovarian cancer
• Midline laparotomy allows through assessment of pelvis/abdomen
• Peritoneal washings for cytology
• TAH( Total Abdominal Hysterectomy)/BSO( Bilateral Salpingo
oophorectomy)/Partial omentectomy
• With biopsies of peritoneal deposits
• Lymph node dissection if indicated
The role of Chemotherapy in management of ovarian cancer
- Stage 1a and Ib- not given
- Stage 1c- 6 cycles of carboplatin are given
- Stage 2 -4- carboplatin plus paclitaxel
- Dysgerminomas are sensitive to radiotherapy
- Borderline tumours- preserve fertility by removing affected ovary and tube and meticulous follow up
Poor prognostic indicators in ovarian cancer
- Advanced stage
- Poorly differentiated tumour
- Clear cell tumours
- Slow /poor response to chemotherapy
Follow up
• CA125
• CT scan to detect relapse
Most common gynaecological cancer in developed world
endometrial cancer
What proportion of endometrial cancers occur pre-menopausally?
15% cases occurring premenopausal
<1% in women under 35years
Two main types of endometrial cancers
- Type 1 –low grade endometrioid cancers which are oestrogen sensitive
- Associated with obesity
- Less aggressive
Type 2- high grade endometrioid, clear cell, serous or carcinosarcoma cancers
•More aggressive
•Not oestrogen sensitive
•Not related to obesity
Risk factors for endometrial cancers
- Exposure to endogenous and exogenous oestrogens
- Obesity / PCOS (lack of progesterone to oppose oestrogens)
- Diabetes
- Early menarche
- Nulliparity
- Late menopause
- age >55years
- Unopposed use of Oestrogen HRT
- Use of tamoxifen
Combined pills and pregnancy are protective
