Ovarian Cancer Types Flashcards
Types
Epithelial Cell Tumours
Epithelial cell tumours (tumours arising from the epithelial cells of the ovary) are the most common type. Subtypes of epithelial cell tumours include:
Serous tumours (the most common)
Endometrioid carcinomas
Clear cell tumours
Mucinous tumours
Undifferentiated tumours
Dermoid Cysts / Germ Cell Tumours
These are benign ovarian tumours. They are teratomas, meaning they come from the germ cells. They may contain various tissue types, such as skin, teeth, hair and bone. They are particularly associated with ovarian torsion. Germ cell tumours may cause raised alpha-fetoprotein (α-FP) and human chorionic gonadotrophin (hCG).
Sex Cord-Stromal Tumours
These are rare tumours, that can be benign or malignant. They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles). There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours.
Metastasis
Ovarian tumours may be due to metastasis from a cancer elsewhere. A Krukenberg tumour refers to a metastasis in the ovary, usually from a gastrointestinal tract cancer, particularly the stomach. Krukenberg tumours have characteristic “signet-ring” cells on histology, which look like signet rings on under a microscopy.
Risk Factors
Age (peaks age 60)
BRCA1 and BRCA2 genes (consider the family history)
Increased number of ovulations
Obesity
Smoking
Recurrent use of clomifene
Factors that increase the number of ovulations, increase the risk of ovarian cancer. These include:
Early-onset of periods
Late menopause
No pregnancies
Protective Factors
Having a higher number of lifetime ovulations increases the risk of ovarian cancer. Factors that stop ovulation or reduce the number of lifetime ovulations, reduce the risk:
Combined contraceptive pill
Breastfeeding
Pregnancy
Present
Ovarian cancer can present with non-specific symptoms. In older women, keep the possibility of ovarian cancer in mind and have a low threshold for considering further investigations. Symptoms that may indicate ovarian cancer include:
Abdominal bloating
Early satiety (feeling full after eating)
Loss of appetite
Pelvic pain
Urinary symptoms (frequency / urgency)
Weight loss
Abdominal or pelvic mass
Ascites
An ovarian mass may press on the obturator nerve and cause referred hip or groin pain. The obturator nerve passes along the inside of the pelvic, lateral to the ovaries, where an ovarian mass can compress it.
Referral Criteria
The NICE “suspected cancer: recognition and referral” guidelines (2015) outlines the key referral criteria and red flags for ovarian cancer. They recommend either referring directly on a 2-week-wait urgent cancer referral or carrying out initial investigations in primary care depending on the presentation.
Refer directly on a 2-week-wait referral if a physical examination reveals:
Ascites
Pelvic mass (unless clearly due to fibroids)
Abdominal mass
Carry out further investigations before referral in women presenting with symptoms of possible ovarian cancer, starting with a CA125 blood test. This is particularly important in women over 50 years presenting with:
New symptoms of IBS / change in bowel habit
Abdominal bloating
Early satiety
Pelvic pain
Urinary frequency or urgency
Weight loss
Present
Ovarian cancer can present with non-specific symptoms. In older women, keep the possibility of ovarian cancer in mind and have a low threshold for considering further investigations. Symptoms that may indicate ovarian cancer include:
Abdominal bloating
Early satiety (feeling full after eating)
Loss of appetite
Pelvic pain
Urinary symptoms (frequency / urgency)
Weight loss
Abdominal or pelvic mass
Ascites
An ovarian mass may press on the obturator nerve and cause referred hip or groin pain. The obturator nerve passes along the inside of the pelvic, lateral to the ovaries, where an ovarian mass can compress it.
Referral Criteria
The NICE “suspected cancer: recognition and referral” guidelines (2015) outlines the key referral criteria and red flags for ovarian cancer. They recommend either referring directly on a 2-week-wait urgent cancer referral or carrying out initial investigations in primary care depending on the presentation.
Refer directly on a 2-week-wait referral if a physical examination reveals:
Ascites
Pelvic mass (unless clearly due to fibroids)
Abdominal mass
Carry out further investigations before referral in women presenting with symptoms of possible ovarian cancer, starting with a CA125 blood test. This is particularly important in women over 50 years presenting with:
New symptoms of IBS / change in bowel habit
Abdominal bloating
Early satiety
Pelvic pain
Urinary frequency or urgency
Weight loss
Investigate
The initial investigations in primary or secondary care are:
CA125 blood test (>35 IU/mL is significant)
Pelvic ultrasound
The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things:
Menopausal status
Ultrasound findings
CA125 level
Further investigations in secondary care include:
CT scan to establish the diagnosis and stage the cancer
Histology (tissue sample) using a CT guided biopsy, laparoscopy or laparotomy
Paracentesis (ascitic tap) can be used to test the ascitic fluid for cancer cells
Women under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour:
Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)
Causes of Raised CA125
CA125 is a tumour marker for epithelial cell ovarian cancer. It is not very specific, and there are many non-malignant causes of a raised CA125:
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
Staging
The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage ovarian cancer. A very simplified version of this staging system is:
Stage 1: Confined to the ovary
Stage 2: Spread past the ovary but inside the pelvis
Stage 3: Spread past the pelvis but inside the abdomen
Stage 4: Spread outside the abdomen (distant metastasis)
