Ovarian cancer
Secondary metastases from which primary tumours can occur in the ovary?
*endometrium* *breast* *GI tract* - A Krukenberg tumour refers to a "signet ring" sub-type of tumour, typically gastrointestinal in origin, which has metastasised to the ovary. *cervix* (rare)
OC sites of metastasis
*intraperitoneal structures and organs* (causing intestinal obstruction and cachexia) *liver* *para-aortic lymph nodes* *lungs* (causing pleural effusions)
Non-epithelial ovarian tumour features
10% of ovarian cancers Include *germ cell tumours*, *sex cord and stromal tumours*, ovarian carcinosarcoma, small cell and neuroendocrine tumours, squamous cell carcinoma arising within a dermoid cyst or teratoma, and struma ovarii malignum
Epithelial ovarian tumours features
90% of ovarian cancers Originate from the epithelium which lines the fimbria of the fallopian tubes or the ovaries Partially cystic; cysts can contain fluid Initial metastatic spread involves peritoneal cavity Seeding affects bladder, paracolic gutters, and diaphragm Include serous (70-85% of cases), mucinous, endometrioid, clear cell, transitional cell, and squamous tumours
Initial investigations for OC
CA-125 Pelvic and abdominal ultrasound - If CA-125 raised (≥35IU/L): urgent pelvic USS - If CA-125 normal OR pelvic USS normal, consider other causes
Further investigations for OC
CT scans for staging AFP and beta-hCG for younger women who may have germ cell cancers Laparotomy for tissue biopsy
OC management
Depends on fitness to receive treatment SURGERY - If early disease: surgical staging with TAH, BSO, appendectomy, omentectomy, and pelvic/para-aortic LN resection - In advanced disease debulking surgery can be performed. CHEMOTHERAPY: - Adjuvant chemotherapy should be given to the patient in an ideal world: *carboplatin AND paclitaxel/ docetaxel* - Intraperitoneal chemotherapy may be performed at the time of operation: *paclitaxel AND cisplatin/ carboplatin* - Platinum-resistant recurrent disease: *bevacizumab + chemo* - Biological therapies are being trialled.
Differentials of OC
GI conditions (eg. IBS) Fibroids Ovarian cysts Other malignancy (endometrial cancer, bladder cancer)
OC epidemiology
Leading cause of gynae cancer-related mortality in the UK High mortality because symptoms are often vague until relatively advanced Lifetime risk of diagnosis in women = 1 in 52
Risk of Malignancy Index formula
Multiple the following: menopause score (1 for pre-menopausal, 3 for post-menopausal) ultrasound score (0-3 for no. of abnormalities identified) Ca-125 level
OC risk factors
Older age Smoking Greater number of ovulations (early menarche, late menopause) Obesity HRT BRCA 1 and 2 genes
Sex cord & stromal tumours features in OC
Originate from connective tissue. Less than 5% of all ovarian tumours Malignant but less aggressive than epithelial tumours
Germ cell tumour features in OC
Originate from germ cells in embryonic gonad Grow rapidly Spread by lymphatic route Commonly seen in young women Tumour markers: alpha-fetoprotein, sometimes beta-HCG
OC protective factors
Parity Breastfeeding Early menopause COCP
Other causes of raised CA-125 (9)
Peritoneal trauma, disease, or irritation. Primary peritoneal cancer Lung cancer Pancreatic cancer Endometriosis PID Ovarian cyst torsion, rupture, or haemorrhage Pregnancy Heart failure
FIGO stage I of OC (limited to the ovaries)
Stage IA: limited to one ovary, the capsule is intact. Stage IB: limited to both ovaries, capsules intact. Stage IC: tumour limited to one or both ovaries with any of the following: capsule ruptured, tumour on ovarian surface, malignant cells in ascites or peritoneal washings.
FIGO stage II of OC (one or both ovaries with pelvic extension)
Stage IIA: extension and/or implants on the uterus and/or Fallopian tubes. No malignant cells in ascites or peritoneal washings. Stage IIB: extension to and/or implants on other pelvic tissues. No malignant cells in ascites or peritoneal washings. Stage IIC: pelvic extension and/or implants (Stage IIA or Stage IIB) with malignant cells in ascites or peritoneal washings.
FIGO stage III of OC (one or both ovaries with microscopically confirmed peritoneal implants outside the pelvis)
Stage IIIA: microscopic peritoneal metastasis beyond pelvis (no macroscopic tumour). Stage IIIB: macroscopic peritoneal metastasis beyond pelvis <2 cm. Stage IIIC: peritoneal metastasis beyond pelvis >2 cm and/or regional lymph node metastasis.
Referral criteria for OC
Urgent referral: - Ascites - Unexplained pelvic/abdo mass Investigate all patients over 50 with (especially over 12x/month): - Abdominal distension - Early satiety - Pelvic/abdominal pain - Urinary frequency/urgency
FIGO stage IV of OC
one or both ovaries with distant metastasis
OC presentation
palpable mass may be present abdominal discomfort bloating early satiety urinary frequency change in bowel habits pelvic, back and abdominal pain ascites in later disease (due to vascular growth factors which increase vessel permeability)