Ovarian Cancer
This guideline is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
Stages and types of ovarian cancer
Diagnosis
- Many cancers present with an abdominal mass &/or ascites. Always assess distension & vague abdominal pain in a patient over 50 years.
- Most patients, but not all, are postmenopausal & present with advanced disease (60% StageIII). Epithelial ca can occur in a younger patient. A cyst in a child (pre-menstrual) is a germ cell malignancy until proven otherwise
- Suggestive ovarian cyst ultrasound findings include:
- Solid elements
- Papillary projections
- Bilateral cysts
- Septated cysts
- Ascites
- Risk of Malignancy Index (RMI) from the RCOG (there are others) is U x M x CA125. U= ultrasound score, M= menopause status. With a cut off of 250, sensitivity is 70%, specificity 90%. Its use – to guide referral to an oncology surgeon. If the tumour is confined to the ovary the CA125 may not be raised
- Look for metastases – pleural effusion (tap), peripheral nodes (FNA), Sister Joseph’s nodule at umbilicus (remove for histology, or biopsy)
- Not all is at it seems: Dermoid ovarian cysts have solid elements & are benign & the pleural effusion of Meig’s syndrome is from an atypical benign ovarian mass
Assessment and Investigations
- Full history and examination
- Look for primary tumors (breast, stomach, bowel etc.) that may metastasize & appear as ovarian cancers (Krukenberg tumors)
- Omental cake, liver enlargement & pleural effusion may be found on examination
- Ultrasound may show enlarged liver or omental cake. Obviously a pelvic mass must be scanned
- Chest X-ray may show metastases or a pleural effusion
- Pleural effusion, tap the fluid for cytology
- Lumps or nodules, e.g. Sister Joseph’s nodule, biopsy
- An abdominal CT scan may show extent of disease
- Tumor markers:
- For possible epithelial tumors take serum CA-125 – values >30u/ml suggest malignancy. Also raised in endometriosis, PID, fibroids, pregnancy, menstruation
- For possible germ cell tumors (age<30), take hCG, AFP & LDH
Pre-operative preparation
- Prepare as for TAH & BSO, with special additions below
- Cross-match 2-3 units packed cells on standby for theatre
- Bowel prep: Go-lytely or fleet enema
- Colostomy (usually not performed) may need to be discussed; consult the stomatherapy staff if necessary
- ICU bed may be needed, consult with the anaesthetists
Treatment
- TAH & BSO & omentectomy with removal of all tumor deposits >1 cm is the standard for all epithelial cancers – ‘bulk reduction’
- If optimal debulking is NOT achieved at the first operation, multi-centre studies have shown interval repeat surgery (post chemotherapy, or part of it) offers the same prognosis/benefit with less complications
- Platinum-based chemotherapy plus Taxol (Paclitaxel) is given to all tumors except stage 1a
- Chemotherapy is started 2-3 weeks postoperatively, ideally
- Six courses are given at 2-3 week intervals, as an out-patient in most cases
- Alopecia is the rule. Carboplatin is less nephrotoxic but myelosuppressive. Cisplatin is more nephrotoxic & causes high tone deafness at toxic levels & peripheral neuropathy
- Arrange chemotherapy at Johannesburg Hospital area 495 (0114883495). All details plus histology must be faxed
- Germ cell & stromal tumors may be treated with relative conservatism, depending on tumor type, stage, & age of the patient – MUST be presented
- The chemotherapy unit will follow up
Stages & types of ovarian cancer (FIGO 2018)
- Stage 1a: Limited to one ovary, capsule intact, no malignant ascites
- Stage 1b: Limited to both ovaries, capsule intact, no ascites
- Stage 1c1: Capsule ruptured at surgery
- Stage 1c2: Rupture before surgery or tumour on outside of the capsule
- Stage 1c3: Malignant ascites
- Stage 2a: Extension to uterus or fallopian tubes
- Stage 2b: Extension to bladder, rectum, sigmoid
- Stage 2c: Any pelvic organs involved with capsule not intact, malignant ascites or positive peritoneal cytology
- Stage 3a1: Limited to pelvis, with positive pelvic or para-aortic nodes
- Stage 3a2: Pelvic cancer with microscopic abdominal spread (+/- nodes)
- Stage 3b: Abdominal implants ≤2cm (+/- nodes)
- Stage 3c: Abdominal implants >2cm (+/- nodes)
- Stage 4a: Malignant pleural effusion
- Stage 4b: Parenchymal liver, spleen, lung, bone mets or +ve nodes other than retroperitoneal
The majority of cancers (85%) are epithelial - serous & mucinous cystadeno- carcinomas. 85% secrete CA125. Sadly, only 50% stage 1 cancers secrete CA125 making it a poor screening test. Endometrioid cancer coexists with endometrial cancer in 30% of cases. Germ cell tumors are rare & include dysgerminomas, endodermal sinus tumours, embryonal carcinomas, choriocarcinomas, immature teratomas, & mixed tumours. Germ cell tumors occur mainly in younger patients. Sex cord stromal tumours are usually not malignant, but some granulosa cell tumors may recur. Granulosa or theca tumours may secrete oestrogen & result in precocious puberty, irregular vaginal bleeding associated with endometrial hyperplasia, & post-menopausal bleeding.