Ovarian Cancer

1. Ovarian Cancer By Sarah and Kevin

2. OBJECTIVES • Review etiology, risk factors, signs and symptoms • Discuss Necessary Laboratory and Imaging Investigations • Review optimal management of ovarian cancer • Review the common pathways of ovarian cancer spread

3. CASE • A 63 yo G0 presents to you with a complaint of LLQ pain, intermittent nausea, abdominal pressure, and bloating. Her history is notable for mild obesity, right breast cancer, and hypertension. She and her husband desired children but were never able to conceive. Her family history is notable for premenopausal breast cancer in her mother and maternal aunt. She had a pelvic ultrasound showing a normal appearing uterus with a 9 cm left adnexal mass containing internal septations and papillary excrescences. She has moderate ascites and her CA-125 is 719.

4. Worrying Things on History? • LLQ with abdominal pressure & bloating • Risk factors of obesity, HTN • FHx pre-menopausal breast cancer (BRCA?) • 9 cm adenexal mass on U/S • Internal septations • Ascites • CA 125 elevated

5. Why do we care about ovarian cancer? • Most ovarian enlargements in the reproductive age group are functional cysts; about 25% are non-functional ovarian neoplasms • 90% of these neoplasms are benign, whereas the risk for malignancy increases to 25% in postmenopausal women • Ovarian masses in older women and in reproductive patients with no response to OCPs are concerningovarian mass in postmenopausal woman should be considered malignancy until proven otherwise • Ovarian cancer = 2nd most common gyne cancer, 1st cause of gyne death • Often presents late since it can be asymptomatic for a long time and/or vague complaints get attributed to something else

6. ETIOLOGY • 90% of ovarian cancers are sporadic • Lifetime risk ~ 1/70 (1.4%) • Highest mortality rate of all gyne malignancies • Some Genetic Causes • Genetic (BRCA 1 and 2) and HNPCC (hereditary nonpolyposis colorectal cancer) • Molecular mechanisms (loss of p53 tumor suppressor gene found in 55% of ovarian cancer) • Many different types • Epithelial (Serous, mucinous, endometrioid, clear cell, Brenner undifferentiated) • Germ Cell • Sex cord/stromal • Metastatic

7. RISK FACTORS • High dietary fat intake • Nulliparity • Infertility • Early menarche • Delayed menopause • Age (most diagnosed > 63 yrs) • Prevention: OCP reduces risk, Prophylactic oophorectomy (in cases of BRCA)

8. SIGNS & SYMPTOMS • Abdominal fullness or distension • Lower abdominal pain or back pain • Decreased energy or lethargy • Decreased appetite / Early satiety • Nausea & Vomiting • Respiratory (SOB) • Abdominal girth (may have ascities) • Bladder (increased frequency, dysuria) • Bowel (constipation) • Advanced Sx: pelvic pressure, cachexia, severe weight loss, massive ascities, mets

9. LABS • No screening test for ovarian cancer • BRCA1/2 screening if indicated • CA 125 = a tumor marker • A monoclonal antibody that binds to antigens expresed by 80% of epithelial ovarian cancers, but is NOT sensitive • Used in postmenopausal women ONLY, since it can be high for many other reasons in premenopausal women • Used primarily to monitor response to therapy and to evaluate for reoccurance of disease

10. IMAGING • Ultrasound • Transvaginal ultrasound not sensitive or specific for ovarian cancer in an asymptomatic woman as a screening test • However, transvaginal U/S best way to visualize ovaries • Used primarily for the work-up of a pelvic mass and for surgical planning • CT Scan Used mostly for surgical planning Do MRI if pregnant • Imaging to detect spread Consider CXR, CT abdo-pelvis etc.

11. Benign vs Malignant Features on U/S

12. Review optimal management of ovarian cancer • Q: How do we prevent ovarian cancer? • OCPs • Surgery • Impossible • 1 and 2

13. Prevention? • Patients using OCPs are less likely to have ovarian cancer • Look for BRCA1/2, KRAS, p53 genes Reduced incidences: • Salpingo-oophorectomy • Tubal ligation • Hysterectomy

14. Staging • Ovarian Cancer is Surgically Staged • Stage 1 – growth limited to the ovaries • Stage 2 – Growth involving one or both ovaries with pelvic extension • Stage 3 – Tumour involving one or both ovaries with peritoneal implants outside the pelvis or positive retroperitoneal or inguinal nodes or both. • Stage 4 – Growth involving one or both ovaries with distant mets

15. Basic Methods of Cancer Treatment • Early Stage-Disease • Surgery • 1. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolicomentectomy, and a thorough surgical staging • 2. If preserve fertility: unilateral salpingo-oophorectomy • If after surgical staging the stage is 1-2 – no further treatment necessary • You can add chemotherapy stage 3+

16. Basic Methods of Cancer Treatment 1. Advanced Stage: • If patient is in advanced disease - cytoreductive surgery or debulking is required • Remove the priamry tumour and all of the mets if possible • If they cannot be removed attempt to reduce the tumour nodules to 1cm or less in diameter • This is called optimal cytoreduction– 70% of patients • *Some bowel resection may be necessary Chemo? • If patient has a huge pleural effusion and massive ascites: give two or three cycles of neoadjuvant chemotherapy before radical surgery

17. Basic Methods of Cancer Treatment 2. Addition to surgery: • Following primary cytoreduction, combination chemotherapy is given (carboplatin and paclitaxel) • During treatment, monitoring with CA 125 lvls • Secondary cytoreduction can be done 24 months disease free interval

18. Review the common pathways of ovarian cancer spread • The spread really depends on: • The origin of the tumour (ovary, tubes, cervix, met?) • The type of tumour (epithelial, germ-cell, stromal) • Intrinsic tumour properties • Host characteristics

19. Mode of Spread • 2 main distributions of spread • Follow the circulatory pathway of the peritoneal fluid • Commonly seen on posterior cul-de-sac, paracolic gutters, right hemidaphragm, liver capsule, and omentum • They can grow around intestines (encasing the wall) and the bowel serosa without invading into bowel wall • Can cause carcinomatous ileus • Lymphatic Dissemination • Pelvic and para-aortic nodes are common (esp in advanced stages) • Can cause ascites

20. Mode of Spread • Death is usually from progressive encasement of the abdominal organs • This leads to anorexia, vomiting, and inanition • This can take months of progressive decline • Hematogenous spread is not common • Parenchymal mets to liver and lungs only 2% at initial presentation

21. QUIZ 1 • What is a risk factor for ovarian cancer? • A. Multiple Gestations • B. Nulliparity • C. Low fat diet • D. OCP

22. QUIZ 2 • What are some malignant features on U/S of ovarian cancer? • A. Unilateral, < 5cm, thin septations • B. Unilateral, hyperechoic solid component • C. Bilateral, thick septations, nodular solid component • D. Smooth surface, no ascities, no peritoneal mets

23. True or False • 1. Most ovarian enlargements in the reproductive age group are functional cysts • 2. Ovarian mass in post-menopausal woman should be considered malignancy until proven otherwise • 3. Ovarian cancer is the most common gynecological cancer diagnosed

24. Thank you!References: • UptoDate • Previous 2nd year notes (Dr. ManishaLamba) • Previous Obs/GYN Basecamp (Dr. Laura Hopkins) • Hacker NF, Moore JG, Gambone JC. Essentials of Obsetetrics and Gynecology: Ovarian Cancer. 4th edition. Pg 459-478.