Ovarian Cancer

Types of Ovarian Cancer
§ Epithelial
§ Germ Cell
– Dysgerminoma
– Immature teratoma
– Endodermal sinus tumor
– Embryonal carcinoma
– Polyembryonal
– Choriocarcinoma
– Mixed
§ Sex Cord Stromal
– Granulosa cell
– Sertoli-Leydig
– Gynandroblastoma
– Unclassified
§ Metastatic
– Breast
– Kruckenberg- Primary usually stomach, signet ring cells on pathology



Ovarian Cancer Risks
§ Increase Risk
– Age most important independent risk factor
– Family history
– BRCA1 (60x increased risk), BRCA2 (30x), HNPCC (13x)
– Nulliparity, infertility, endometriosis
§ Decrease Risk
– Prophylactic oophorectomy
– Oral contraceptive pills

Exam
§ Physical
– Malignancy: irregular, solid consistency, is fixed, nodular, or bilateral, is associated with ascites

§ Ultrasound
– Low positive predictive value for cancer
– Cancer: excrescences, ascites, and mural nodules
– Benign: unilocular, thin-walled sonolucent cysts with smooth, regular borders, regardless of menopausal status or cyst size


Labs
§ Tumor markers
– Epithelial: CA 125, elevated in 80%
§ 35 U/mL is upper limit of normal
§ Also elevated in many benign conditions
– Malignant germ cell tumors: b-hCG, LDH, AFP
– Embryonal carcinoma: AFP, BhCG
– Endodermal Sinus tumor: AFP
– Granulosa cell tumors: inhibin

Work-up
§ Premenopausal
– Symptomatic : evaluate as appropriate for tuboovarian abcess, ectopic, torsion, ruptured ovarian cyst
– B-HCG, CBC, transvaginal USN, cervical cultures
Work-up
§ Postmenopausal
– Exclude common diagnoses: endometriosis, cyst, abcess
– Higher index for suspicion: transvaginal USN, CA 125
– Unless simple cysts, most likely will need surgery
– Need breast exam, digital rectal, mammography


Treatment of Epithelial Ovarian Cancer

§ Chemotherapy
§ Cytoreductive surgery (debulking)
§ Debulking



§ Carboplatin and Paclitaxel
– First line
– Mechanism of action
§ Carbo: binds and crosslinks DNA
§ Taxol: promotes formation and inhibits disassembly of stable microtubules, inhibiting mitosis
– Side effects
§ Carbo: thrombocytopenia, leukopenia, anemia, vomiting, hair loss
§ Taxol: neutropenia, leukopenia, anemia,
hair loss, muscle pain, vomiting, diarrhea