Ovarian cancer

Question 1

Risk factors

Answer 1

• Genetic components e.g. BRCA1 , BRCA2
• Lynch syndrome

Question 2

Epidemiology

Answer 2

• 60 years peak
• Any factor that increases the number of ovulations: = Nulliparity
  = Early menarche
  = Late menopause
• Smoking
• HRT

Question 3

Classification

Answer 3

• Surface epithelial tumours
• Germ cell tumours
• Sex cord-stromal tumours

Question 4

Surface epithelial tumours (MC)

Answer 4

Cystadenomas/Cystadenocarcinomas : form a cystic mass
- serious
- mucinous
Endometrioid (composed of endometrial-like tissue)
Brenna tumours (composed of bladder-like epithelial)

Question 5

Germ cell tumours

Answer 5

Epid: females of child-bearing age deprived from haploid germ cells
Types:
- Teratoma (MC): cystic tumour consisting of 2/3 embryological layers = dermoid cyst is the most common type and contains mature tissue such as hair or teeth
- Dysgerminoma: malignant tumour, elevated LDH
- Endodermal sinus (yolk sac) tumour: Malignant. mimics the yolk sac. Seen in children. Elevated AFP
- Choriocarcinoma: Malignant composed of syncytiotrophoblasts and cytotrophoblasts. High β-hCG

Question 6

Sex cord-stromal tumours

Answer 6

• Granulosa theca cell: Malignant = Secrete oestrogen : present in postmenopausal women with vaginal bleeding due to endometrial hyperplasia
• Sertoli-Leydig: Benign = Secrete androgens causes hirsutism and virilization
• Fibroma: Benign = Meigs’ syndrome : ovarian fibroma, ascites and pleural effusion

Question 7

Signs

Answer 7

• Adnexal mass
• Ascites
• Abdominal distention

Question 8

Symptoms

Answer 8

• Abdominal bloating
• Diarhhoea or constipation
• Urinary urgency
• Nausea
• Dyspepsia or early satiety

Question 9

Diagnosis

Answer 9

FIRST LINE = CA125 > 35 IU/mL
Next: Pelvic + abdo USS
- Transvaginal USS most useful
- Multiloculated complex cysts, or solid papillary masses
- Risk of Malignancy Index (RMI): takes into account menopausal status, ultrasound findings, and CA125. Px ≥ 250 must be assessed by a specialist
- Biopsy: usually performed during surgery but can be percutaneous
- Alpha-foetoprotein (AFP) and hCG: Px < 40 years checked to screen for germ cell tumours

Question 10

Staging

Answer 10

The International Federation of Gynaecology and Obstetrics (FIGO) staging system for ovarian cancer
- Stage I: Limited to the ovaries
- Stage II: Pelvic extension
- Stage III: Peritoneal involvement and/or regional lymph nodes
- Stage IV: Distant metastasis

Question 11

Treatment early stage disease I

Answer 11

• Comprehensive staging : extensive pelvic clearance = total abdominal hysterectomy
  = bilateral salpingo-oophorectomy
  = infracolic omentectomy = peritoneal and lymph node assessment
• Adjuvant chemotherapy : if high grade or stage IC with platinum-based drugs

Question 12

Treatment Advanced stage disease: stage II- IV

Answer 12

• Debulking surgery: remove all tumour tissue > 1 cm in diameter (optimal debulking)
• Neoadjuvant and/or adjuvant chemotherapy : with platinum-based drugs

Question 13

Complications

Answer 13

Disease progression:
- Metastasis: MC to liver
- Bowel or bladder involvement
- Hyperthyroidism
Iatrogenic:
- Myelosupression and neutropenic sepsis
- Recurrent infections

Question 14

Prognosis

Answer 14

Poor prognosis due to late detection owing to non-specific symptoms. 80% of women have advanced diseases at initial presentation:
5-year survival
I: 90%
II: 70%
III: 25%
IV: 15%