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Pelvic Mass and Ovarian Cancer - Coggle Diagram
Pelvic Mass and Ovarian Cancer
Pelvic Masses
Classification
Tubal
Para-tubal cyst
Ectopic pregnancy
Tubo-ovarian abcess
Hydroalpinx
Uterine
Pregnancy
Fibroids
Adenomyosis
Uterine neoplasm
Congenital uterine anomaly
Pyometra
Cervical neoplsm
Ovarian
Functional cysts
- overgrowth of normal
Endometrioma
(cyst due to endometriosis)
Benign tumour
Primary ovarian malignancy
Metastasis (GI / Breast)
Ovarian abcess
Non-Gynaecological
Urological
GI
Assessment
History / Symptoms
HxPC
Localising signs / symptoms
Precipitating factors
Timeline
Impact on wellbeing / QOL
Gynae hx
Previous diagnoses
Previous investigations
Surgeries
Menopausal status
Screening hx - STI / Cervical
Fhx
Genetic predisposition
Review of Systems
Effects on other systems / other sites of origin
Assess comorbidities, surgical / anaesthetic risk / consiferations in tx plan
Mhx
Surghx
Meds + Allergies
Fertiltiy / Obs hx
Examination
BMI
Nutritional status
Respiratory exam
Lower limb exam
Lymph nodes - supraclavicular and groin
Abdominal exam
Distension
Tenderness
Organomegaly
Masses
Cannot 'get below' → pelvic origin
Bimanual and speculum exam
PR exam if fixed pelvic mass on bimanual / rectal symptoms
Investigations
Serum CA125
Indication
Symptoms of ovarian cancer
≥ 35IU/ml + pelvic mass
USS abdo pelvis
USS Abdo pelvis
Indication
≥ 35IU/ml + pelvic mass
Suspicious ovarian lesion features
Solid areas
Multilobular cystic
Ascites
Bilateral lesions
5.Intra-abdominal metastases
Risk of Malignancy Index (RMI) Score
After USS
RMI = U x M x CA125
Ultrasound Score
1 point for:
Multinodular cysts
Solid ares
Metastases
Ascites
Bilateral lesions
Menopause Status
1 = Pre-menopausal
3 = Post-menopausal
Serum CA125 level
0-hundreds
Refer RMI ≥ 250 to MDT
Thresholds
200 → 78% SE, 87% SP
250 → 70% SE, 90% SP
Under 25 → 3% risk of malignancy
25-250 → 20% risk of malignancy
Over 250 → 75% risk of malignancy
GP Referral Pathway
Symptoms
Depends on site of origin, size, location adn attachments
Small amy be asymptomatic
Pelvic pain - rupture / torision
Pelvic has space for masses to develop to considerable size before symptoms
Mass effect
Pain
Pressure
Bloating
Symptoms in pelvis, abdomen, lower back
Gynae
Prolapse symptoms
Dyspareunia
GI
Large bowel
Constipation
Symptoms of obstruction / invasion
Small bowel
Nausea / vomiting with obstruction
Stomach
Anorexia
N/V with obstruction
Urinary
Urinary frequency
Urinary retention
Hydronephrosis
Lumbar pain
Oligo/anuria
Vascular DVT/PE
Lower limb pain
Lower limb swelling
Respiratory symptoms - SOB
Respiratory
Reduced capacity - mass effect
PE
Effusion
USS Findings for IOTA
International Ovarian Tumour Analysis
B features (benign)
B1 Unilocular
B2 Presence of solid components with largest diameter <7mm
B3 Presence of acoustic shadows
B4 SMooth multilocular tumour with largest diameter < 100mm
B5 No blood flow (colour score 1)
M features (malignant features)
M1 Irregular solid tumour
M2 Presence of ascites
M3 At least 3 papillary structures
M4 Irregular multilocular-solid tumour with largest diameter ≥ 10m
M5 Very strong blood flow (colour score 4)
Rule 1
≥ 1 M features + absence of B features : Classified as Malignant
Rule 2
≥ 1 B features + absence of M features : Classified as benign
Rule 3
Both B+M features, or neither : Classified as inconclusive
Second stage test recommended
Tumour Markers
CA125
Best available single-protein biomarker
Useful in assessing risk and for surveillance
Lacks sensitivity for early stages - raised in 50%
Low specificity due to rise in Ca125 in benign conditions
Endometriosis, fibroids, inflammatory process
Can be influenced by age, ethnicity, BMI
CEA, CA19-9
Alpha fetoprotein, HCG, LDH
Perform in women <40 - risk of germ cell tumours
Ovarian Cancer
Epidemiology
6th most common in cancer in women
Highest mortality of all gynaecological cancers
400 new cases / year in IRE
Cumalative lifetime risk of diagnosis 1:57 (1.7%)
80% post-menopausal
70% pt diagnosed with advance disease - late presentation
Risk Factors
Obseity
Smoking
HRT
Endometriosis
Age
Genetic cancer syndromes : Lynch, BRACA1/2
Hx breast / bowel cancer
Fhx breast / ovarian / bowel cancer
Ethnicity
Ovulation - nulliparity
Early menarch / late menopause
Classification
High Grade Serous Carinoma 70%
Origins
Tubal - Exfoliation of STIC fimbria fibria to ovary
(Serous tubal intraepithelial carcinoma)
Patient profile
Postmenopausal usually
Genetic predispostition
BRCA1 / BRCA2 germline mutations in 15-20%
Presentation
Advanced stage - III/IV
Ca125 raised
Masses
Variable size
Mixed solid / cystic lesions
Papillary projections
Thick septations
Endometrioid 10%
Origin
Endometriois 40%
Endometrial cancer 15-30%
Patient profile
Mean age 55yrs
Lynch syndrome associated
Presentation
Low grade 0 diagnosed at early stages
Ca125 raised - advanced stages
Cystic lesion with solid area + haemorrhage
95% unilateal
Clear cell 7%-10%
Origins
Endometriosis 50-70%
Patient profle
Mean age 55
Lynch syndrome associated
Presentation
Aggressive
Poor chemosensitivity
Usually uilateral, large unilocular cyst with solid nodule, chocolate cyst
Mildly elevated CA-125 (≤200 U/ml)
Mucinous 5%
Origins
75% metastases
25% Ovarian primary tumours
Borderline variant
Patient Profile
30-50 yrs
Need OGD / Colonoscopy if diagnosed
Presentation
Distant mets rare
Early stage - 5yr survival 95% stage 1
Large unilateral lesions, smooth capsule, mucinous contents, multilocular with thin septations
Low grade serous carcinoma 3%
Carcinosarcoma
Rare, aggressive, advanced stage, poor prognosis
Sex Cord - Stromal Tumours (<2%) - Gonadal Stroma - Endocrine function
Granulosa cell tumour
Low grade
Indolent nature
Associated with late recurrences - juveile version recurs sooner)
Inhibin levels used for surveillance
Sertoli leydig cell tumour
Combination cell types
Grade corresponds to behaviour
Steroid cell tumour
Uncommonly malignant
Thecoma / Fibfroma group
Usually benign except fibrosarcoma
Germ cell tumours <3% - Undifferentiated Primordial germ cells
Yolk sac tumour
Dysgerminoma
Embryonal carinoma
Choriocarinoma
Teratoma
Rare
Children / adolescents
Agressive disease course
Excellent response to chemotherapy
Markers:
HCG
AFP
LDH
Metastasis
HGSC
HGSC cancers metastasise early
Spread
Intraperitoneal
Lymphatic
Haematogenous
Transcoelomic spread around peritoneal cavity in peritoneal fluid - really common
Can effect all surfaces in abdomen through peritoneal deposits / carinomatosis
Staging
Staging Imaging
MRI Pelvis
Assess lesions for estimation of risk of malignancy
Surgical planning - bowel / bladder / ureteric invasion
CT TAP
Assess metastases
FIGO staging
Stage 1
Tubes/ Ovaries
1A Completely inside one tube / ovary
1B completely inside both tubes / ovaries
1C One or both tubes / ovaries and ruptured - cancer on surface of ovary or malignant cells in washing / ascites
Stage 2
Grown outside ovaries and within pelvis
2A fallopian tuves or uterus
2B Grown on peritoneum but just within pelvis - includes serosa of bowel / bladder
Stage 3
Spread Outside pelvis
3A Lymph nodes or microscopic peritoneal spreas
3B Growth 2cm or smaller in abdomen
3C Growth larger than 2cm in abdomen
Stage 4
Other body organs some distance away from the ovaries such as liver / lungs
4A Causing malignant build of fluid in lungs - pleural efffusion
4B Spread to lymph nodes outside of abdomen / inside other organs
MDT
Histopathology
Radiology
Surgical oncolody
Medical oncology
Radiation oncology
Palliative care
Cancer specialist nurse
Gyae oncology
Managment
Triage
Suspicious Pelvic Mass
Aims
Removal all visible disease
Assess cancer spread
Ovarian Staging Surgery
BSO
TH
Omentectomy
Pelvic and para-aortic lymph node assessment
Appendicetomy
Multiple peritoneal biopsies
Consider fertility sparing staging if appropriate (retaining one adnexa + uterus)
Peritoneal washings / ascites sampling
Advanced Disease (FIGO II-IV)
Primary Cytoreductive Surgery → Chemotherapy
Aims
Chemotherapy to treat expected microscopic residual disease
Remove all visible disease at surgery
Neoadjuvant Chemotherapy → Interval Cytoreductive Surgery → Adjuvant Chemo
Aims
Reduce disease extent to facilitate complete resection at surgery
Indications
Unfit for radical surgery
Unlikely to be able to resect all visible disease
Significant disease burden that surgery would be extremely morbid
Reassess
Reasses suitability for srugery after 3 chemo cycles
Surgical Approach
Midline Laparotomy
Indication
Stage III - IV
GOal
Complete resection of all visible disease
Systemic Therapy
Caboplatin and Paclitaxel
CarboTaxol
Regime
Adjuvant therapy
( Surgery → Chemo)
6 cycles
Neoadjuvant
(Chemo → Surgery)
3 cycles → surgery if suitable → adjuvant therapy
Total max 8 cycles
Additional systemic therapies
PARP Inhibitors - Olaparib
(Poly ADP-ribose polymerase)
Maintenance tx of BRCA-mutated advanced ovarian cancer in adults
Anti-angiogenics - Bevacizumab (Avastin)
Recombinant humaised monoclonal antibody
Blocks angiogenesis by inhibting vascular endotherlial growth factor (VEGF-A)
Follow -Up
Example Schedule
3 monthly for year 1 and 2
6 monthly for years 3,4,5
Assessment
History
New and potentially tumour-related symptoms
Clinical examination
CA125 + Imaging if suspicious symptoms / rising CA125
High Suspicion of relapse
CT TAP 1st line imaging
Survival Rate
5 year 37%
Genetic Pre-Dispositions
BRCA
BRCA 1 Risk
Ovary 45%
Breast 72 %
Worst
BRCA2 Risk
Ovary 27%
Breast 69%
Risk-reducing bilateral salpingo-oophorectomy (RRBS)
Risk of ovarian cancer reduced to <5%
BRCA1 : 35-40 yrs
BRCA2: 40-45 yrs
Lynch Syndrome
Risks
Ovary 6-20%
Colorectal 60-80%
Endometrial 40%
Background risk 1.7%
Risk reducing TLH BSO according to personal risk
UKCTOCS: UK Collaborative Tiral of Ovarian CAncer Screening
Groups
Control
Multimodal screening (MMS) - annual CA125 measurement + TVUSS if raised
Annual TVUSS
Outcome
39% increase in the incidence of women diagnosed with Stage I and II
ovarian and tubal cancer
10% decrease in incidence of those diagnosed with
Stage III and IV
No reduction in deaths due to ovarian and tubal cancer in the multimodal or the ultrasound group compared to the no screening group
Reduction in stage III and IV incidence in the multimodal group was not sufficient to translate into lives saved
