Rodabough – Ovarian Cancer – Flashcards
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What is the incidence of ovarian cancer?
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-7th most common cause of cancer -5th most common cause of cancer deaths -1/68 lifetime probability of getting ovarian cancer -27,000 women will develop ovarian cancer each year in US -70% are beyond ovaries at the time of diagnosis -incidence increases with age
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What is the 5 year survival of ovarian cancer?
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-45% -25% for advanced disease
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What types of cells cause ovarian cancer?
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-epithelial cells 60-70% -germ cells 20% -sex cord cells/stromal cells 10%
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What do ovarian cancers look like grossly?
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-smooth outside, segmented inside
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What are the risk factors for ovarian cancer?
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-increased age, family history, infertility/low parity, personal cancer history
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What factors are protective against ovarian cancer?
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-OCPs (0.5 RR after 5 yrs of use, RR for 10 years; 0.6 RR in BRCA pos women when used for 6 years) -pregnancy (full term preg under age of 25; also # of pregs) -tubal ligation/hysterectomy RR 0.33/0.67 -breast-feeding -prophylactic oophorectomy (risk of primary peritoneal cancer remains) (all of these interrupt the menstural cycle)
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What is the theory behind the cause of ovarian cancer?
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-"incessant ovulation" injures the ovarian surface leading to dysplasia and cancer--Pretty much disproved though
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What is the distribution of ovarian cancer by stage?
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24% Stage I (95% survival) 6% Stage II (65% survival) 55% Stage III (15-30% survival) 15% Stage IV (0-20% survival)
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What percentage of ovarian cancers are probably due to inherited predisposition? What are the three hereditary syndromes?
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-5-10% -rare, site specific ovarian cancer -hereditary breast and ovarian cancer (HB-OC) -hereditary non-polyposis colorectal cancer (lynch)
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What are some red flags that a pt might be at increased risk for hereditary cancer?
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-breast cancer before age 50 (7% chance of BRCA) -ovarian cancer at any age (9% chance of BRCA) -both breast and ovarian cancer diagnosed in the same individual -male breast cancer -Ashkenazi jewish ancestry (23% chance of BRCA) -with more of these, there is also an increased change of BRCA1 or BRCA2 mutation
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What are the chances of breast and ovarian cancers with BRCA1/BRCA2 mutations?
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Breast cancer 56-87% Ovarian cancer 27-44%
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What can we do for a women at risk?
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-Surveillance doesn't work! (pelvic exams, transvaginal US and CA 125) -Chemoprevention with OCPs (decrease CA in 60%) -Prophylactic surgery to remove ovaries -DNA testing (for BRCA)
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What does elevated CA 125 mean?
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-elevated in >80% of advanced EOCs -elevated in 25-50% of stage I cancers -poor specificity, esp in premenopausal women -not a screening test for the general population (leads to unnecessary surgery)
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Does prophylactic surgery work to prevent breast and ovarian cancer?
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-mastectomy: >90%RR for b reast ca (total/simple mastectomy better than subcutaneous mastectomy -oophorectomy: 96% RR for ovarian ca; breast ca by 68% -mastectomy and oophorectomy reduces breast cancer in 95% -laparoscopic oophorectomy reduce postsurg morbidity -robotic surgery decreases recovery time
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Why dose oophorectomy not completely remove risk of ovarian ca?
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-primary peritoneal carcinoma occurs in a small percentage of patients
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What are the screening recommendations for ovarian cancer?
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-Comprehensive family history on all patients (3 gens) -none or 2 family history: annual rectovaginal pelvic exam -2 or more family members: genetic counseling, semi-annual rectovaginal pelvic exams, CA125, tansvaginal ultrasound -consider clinical trial participation and preventative surgery
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What advice should you give specifically to people with BRCA mutations?
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-consider OCPs -consider completing family early, followed by prophylactic oophorectomy at age 35 -risk of primary peritoneal carcinoma -BRCA 1 out by 35 -BRCA 2 out by 40
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What are some of the symptoms of ovarian cancer?
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-abdominal bloating, increased girth -fatigue -urinary symptoms -GI disturbances -abdominal/pelvic pain -menstrual irregularities -nausea, anorexia -early satiety
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What are the diagnostic modalities for ovarian cancer?
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-rectovaginal pelvic exam -TVS and/or CT scan or MRI -CA125 -if diagnosis is uncertain, laparoscopy can be useful -surgical exploration
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How is diagnosis confirmed in a premenopausal woman?
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--solid masses require biopsy, smaller cystic masses can be observed for two months and possibly treated with OCPs -any cyst over 8cm in diameter requires biopsy
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How is diagnosis confirmed in a postmenopausal woman?
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-any pelvic mass in a postmenopausal women should be considered malignant until proven otherwise -simple cysts less than 5 cm in diameter with a normal CA125 can be observed -all other masses require surgical diagnosis
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What are the components of the pre-op workup?
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-CA125 -AFP and beta HCG to evaluate for germ cell tumor -chest xray -CBC -LFTs -> 50 require colonoscopy to exclude colorectal cancer -mammogram -head CT, abdomen CT, bone scan if symptoms indicate
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How is ovarian cancer treated?
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-surgical staging (preferably by a gynecologic oncologist) -chemotherapy for most patients -radiation therapy when appropriate (Rare) -clinical trials
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What should be done in Stage I ovarian cancer?
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-TAH, BSO and surgical staging -younger women with stage IA may elect fro ispilateral ovarian resection and staging -33% of apparent stage I pts will be upstaged as the result of careful surgical staging
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What should be done in stage II and above ovarian ca?
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-TAH, BSO, complete omentectomy, debulking, cytoreductive surgery, pelvic and paraaortic lymph node dissections, and hystorectomy
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What are the components of the staging procedure?
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-midline incision -free fluid cytology -fluid washings -scrape each hemidiaphragm -infracolic omentectomy -retroperitoneal and paraaortic lymph node dissections
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Is adjuvant therapy used in ovarian cancer?
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-stage IA and B, grades 1 and 2 require no adjuvant therapy -stage I, grade 3 and more advanced tumors require 3-6 cycles of carboplatin and paclitaxel depending on age and co-morbidities -radiation is reserved for palliation
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How do ovarian cancers spread?
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-exfoliation into the peritoneal cavity; earliest and most common route; second most common site is the omentum -lymphatic to pelvic and paraaortic nodes -hematogenous to lungs and liver, rarely bones and brain -contiguous spread to other pelvic organs
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Why debulk?
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-debulking ovarian cancers is assoc with improved survival -physiological benefit, improved growth fraction, improved perfusion of residual tumor, immunologic benefit
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What are the components of surgical tmt of ovarian ca?
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-en bloc resection of uterus, ovaries and pelvic tumor -omentectomy -bowel resection -removal of diaphragmatic and peritoneal implants -splenectomy and appendectomy -partial liver resection --improved survival with less dx left behind
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Is chemotherapy used in ovarian cancer?
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-all pts should receive taxane and a platinum -73% response rate -median survival: 38 months for Stage III/IV -many new agents being tested -encourage clinical trial participation
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Why would you use intraperitoneal therapy in ovarian ca?
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-main spreading through peritoneal cavity -exposes tumor to increased concentration of drug for prolonged period of time -limitations: poor tumor penetration of bulk disease; less exposure of extraperitoneal disease to drug -complications: obstruction to flow or inadequate distribution; infection of peritoneum, abdominal wall or catheter; intestinal perforation
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Summarize the GOG 172 study comparing IP to IV therapy for ovarian ca.
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-IO regiment uses higher and more frequent dosing than the IV reginmen -toxicities were greater on the IP arm -fewer pts on the IP arm completed 6 cycles of therapy -statistically significant improvement in PFS and OS for pts randomized to the IP arm -IP arm had a longest survival reported to date in advances ovarian ca
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What is "second look surgery?"
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-planned repeat exploration after completing staging laraptomy and first line chemotherapy -50% of patients in remission will have disease detectable by surgery only -allows for improved decision making 0no study has demonstrated a survival benefit from second look surgery
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What is the follow-up after surgery for ovarian ca?
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-complete physical exam, pelvic exam and CA-125 level of 3 mo intervals for 2 years -CT scan for symptoms -after two years a 6 mo interval is recommended -most recurrences occur within first 2 years
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What percent of pts treated for ovarian ca relapse? What are the tmt options for relapse?
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-75% -secondary cytoreduction; retreatment with platinum/taxane; second-line therapies like chemo, radiation, immunologic and gene therapies -encourage clinical trials
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What are the TMT recommendations for relapse by timing?
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-6 mo: retreat with carboplatin ->12 mo: repeat debulking--will not prolong survival, but will improve QOL and prolong disease free survival
