Ovarian Cancer

• Most common gynaecological malignancy
• Most often in women aged 45-60
• Life time risk of 1%
• Overall survival of 30%
• Familial predisposition (5-10%) - BRCA I, BRCA II, Lynch II syndrome (hereditary non-polyposis colorectal cancer)
• Less common with oral contraception, increased pregnancies, longer duration of breast feeding and early menopause
• Incidence related to number of ovulatory cycles
• Major risk factors nulliparity and a family hx
• Associated with mutations in p53 and Rb

• 90% are adenocarcinomas arising from the epithelial cells on the ovary surface

Clinical Presentation

• Often referred to as a ‘silent’ disease – 60% of patients present with advanced disease
• Can present with abdominal discomfort and fullness due to ascites
• May be changes in bowel habit, urinary frequency and colicky pain
• General malaise and weight loss
• Abdo examination may reveal ascites, ‘omental cake’ or umbilical lymph node involvement (Sister Jospeh’s node)
• Vaginal or rectal examination may reveal masses in the Pouch of Douglas
• Local metastic deposits may be present in the cervix, vagina and vulva
• Distant metastases may be malignant pleural effusion, parenchymal liver deposits, axillary or inguinal lymph node deposits, subcutaneous nodules or brain metastases
• Spread of ovarian cancer

· Transperitoneal

· Lymphatic – para- aortic, external iliac and hypogastric nodes, inguinal nodes

Pathology

• Serous – most common (50%)
• Endometroid – (30%) may arise from malignant transformation of the endometrium
• Mucinous – (20%)
• Natural history not well understood, no known premalignant change

Investigations

• FBC
• U&E’s
• Liver function tests
• CXR
• Ultrasound of abdomen
• CA125 (can be raised in pregnancy, endometriosis, pelvic inflammatory disease, benign ovarian cysts, cirrhosis, pericarditis, pleurisy)
• Laproscopic surgery

Staging

• Stage 1 – confined to ovaries
• Stage 2 – involvement of other pelvic structures
• Stage 3 – involvement above pelvic brim
• Stage 4 – spread throughout peritoneal cavity

Surgery

• Basic operation – bilateral salpingo-oophorectomy, total hysterectomy, omentectomy, appendectomy and selective lymphadenectomy
• Aims – diagnosis, staging, debulking
• Bowel most common site of metastases in advanced disease
• ‘Interval’ debulking refers to operations that take place are a number of courses of chemotherapy without previous initial debulking surgery

Chemotherapy

Mostly carboplatin in combination with paclitaxol

Paclitaxol causes alopecia

Carboplatin side effects are myelosuppression

Chemotherapy response rate 70% but most patients will relapse often with drug resistant disease (mean time 18 mth)