Ovarian neoplasms

Published on 09/03/2015 by admin

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Chapter 21 Ovarian neoplasms

Amy Tang

Features of malignant versus benign ovarian neoplasms

• Age: in childhood and in older women, there is an increased risk of malignancy.
• Pain: pain can occur in both. Acute pain usually indicates torsion or haemorrhage.
• Rapid growth: suspect malignancy.
• Bilaterality: 75% of malignant disease and 15% of benign lesions are bilateral.
• Consistency: solid, nodular and/or irregular features are suggestive of malignancy.
• Fixation of the mass: suspect malignancy.
• Ascites: ascites is associated with malignancy.
• Leg/vulval oedema, venous obstruction/thrombosis: this is strongly suggestive of malignancy.
• Evidence of distant metastasis: indicates malignancy.

Risk of Malignancy Index (RMI)

RMI is useful to help determine those women with a pelvic ovarian mass who would benefit from direct referral to a tertiary gynaecological oncology unit.

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• menopausal status: premenopausal = 1; postmenopausal = 3
• ultrasound features (multiloculated, solid areas, bilateral pathology, ascites, metastases): no features = 0; one feature = 1; more than one feature = 3

If RMI >=200, there is a high risk of malignancy and the woman should be referred to a gynaecological oncologist.

Screening for ovarian cancer

Screening for ovarian cancer has not been proven to reduce ovarian cancer deaths in the general population. It may have a role in high-risk patients (e.g. a strong family history).

• Bimanual pelvic examination: low-cost, requires no special equipment but not specific or sensitive in the detection of ovarian cancer.
• Ultrasound scan: malignant features include semisolid or cystic areas, thick septa, surface papillary growths, neovascularisation, bilateral masses and/or ascites.
• Cytology: routine cervical cytological tests give abnormal results in 10%–30% of advanced ovarian cancer cases. Peritoneal cytology is not specific or sensitive, and is time-consuming and painful to perform.
• Prophylactic salpingo-oophorectomy: this should be considered in women with a strong family history of ovarian cancer or women who are BRCA carriers; 7% of women with ovarian cancer have had a previous laparotomy; 0.2% of women who have had their ovaries conserved during operations for benign gynaecological disorders develop ovarian cancer.

Tumour markers for ovarian cancer

• Markers are used in diagnosis, prognosis and to detect subclinical disease.
• The four types of potential markers for ovarian cancer are oncodevelopmental markers, carcinoplacental, metabolic and tumour-specific/tumour-associated antigens. None has sufficiently high specificity for screening.
• CA125 tumour-associated antigen is a high molecular weight glycoprotein expressed in coelomic epithelium during embryogenic development; 80% of patients with ovarian carcinoma have levels >35 IU/mL. It is elevated in about 1% of healthy women and also in non-malignant conditions such as endometriosis, inflammation, benign tumours and pregnancy. CA125 levels fall with age. It is a good marker for epithelial carcinoma, except mucinous tumours, but has poor specificity (not useful for screening).
• CA19.9 is usually elevated in mucinous tumours and pancreatic cancers.
• CEA is useful to exclude metastatic bowel primary if patient complains of bowel symptoms.
• The markers may be used in combination to improve specificity and sensitivity.
• False-negative results can occur in early-stage disease.

Ovarian cancer

Epidemiology

There are geographical variations in the incidences of ovarian cancer. The peak incidence by age group occurs in the seventh to eighth decade. Ovarian cancer accounts for up to 35% of all gynaecological cancers.

Risk factors

• nulliparity, infertility
• family history: a woman with a mother or sister with ovarian cancer has a twenty-fold increased risk; increased risk is associated with inherited mutations in the BRCA1 and BRCA2 genes
• previous other cancers: breast, endometrial
• oral contraceptive pill affords protection
• other risk factors: blood group A, Peutz-Jeghers syndrome

Pathology of ovarian cancer

• epithelial tumours: make up 90% of ovarian malignancies
• types of epithelial ovarian cancer: serous, mucinous, endometroid, Brenner, clear-cell
• sex cord stromal tumours: granulosa cell, Sertoli-Leydig cell (androblastoma, arrhenoblastoma), fibroma, sex cord tumours with annular tubules
• germ cell tumours: dysgerminoma, non-dysgerminoma (endodermal sinus tumour, embryonal carcinoma, choriocarcinoma, mature and immature teratomas)
• secondary tumours: Krukenberg (gastrointestinal, especially stomach), breast

Presentation

• Ovarian cancer is often asymptomatic in early disease.
• The woman may present with:

• abdominal pain, pelvic pressure, frequency of urine
• abdominal swelling, dyspepsia, back pain
• constipation, deep venous thrombosis

Examination

• general examination
• assess for lymphadenopathy
• examination of breasts, thyroid, abdomen/liver, ascites
• pelvic and rectal examination

Investigations for ovarian masses

• tumour markers: CA125, CA19.9, CEA
• consider human chorionic gonadotrophin (hCG), alpha-fetoprotein, inhibin, lactate dehydrogenase (LDH) if suspect non-epithelial ovarian tumours
• full blood count, electrolytes, liver biochemistry
• radiology: abdominopelvic ultrasound and/or computed tomography (CT) scan, chest X-ray, colonoscopy

FIGO staging for ovarian cancer

Staging is based on clinical examination, laparotomy, histology and cytology findings.

• stage 1: growth limited to ovaries

• 1A: growth limited to one ovary, capsule intact, no ascites, negative peritoneal cytology
• 1B: growth limited to both ovaries, no ascites, no tumour on the external surfaces, capsule intact
• 1C: tumour either stage 1A or 1B, but with tumour on surface of one or both ovaries; or capsule ruptured; or with ascites present containing malignant cells or with positive peritoneal washings

• stage 2: growth involving one or both ovaries with pelvic extension

• 2A: extension and/or metastases to the uterus and/or tubes
• 2B: extension to other pelvic tissues
• 2C: tumour either stage 2A or 2B, but with tumour on surface of one or both ovaries; or with capsule(s) ruptured; or with ascites present containing malignant cells or with positive peritoneal washings

• stage 3: tumour involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes; superficial liver metastasis equals stage 3; tumour is limited to the true pelvis but with histologically proven malignant extension to the small bowel or omentum

• 3A: tumour grossly limited to the true pelvis with negative nodes, but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces
• 3B: tumour involving one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces; none >2 cm in diameter
• 3C: abdominal implants >2 cm in diameter and/or positive retroperitoneal or inguinal nodes

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