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Ovarian cancer…..
in 15 minutes
Robert MacdonaldConsultant Gynaecological Oncologist
Liverpool Womens Hospital
Overview
• Diagnosis• Investigations• Treatment• Palliation• Genetics
Diagnosis• No gynae symptoms !
– Bloating/ distension• Constant, not intermittent
– Bladder symptoms• Increasing frequency
– Abdominal pain W Hamilton 2009
– Nausea• Early satiety• Loss of appetite
– Bowel symptoms• Change in bowel habit• “IBS”
– IBS does not present in post menppausal women
– PV bleeding– Breathlessness– Cahexia– Bowel obstruction
Investigations
• NICE– Ca125
• If raised, then…
– Ultrasound• If abnormal, then….
– Secondary referral• TVS• CT • Laparotomy• Laparoscopy
– Biopsy and primary chemotherapy
However….
• Ca125– Not a good predictive test– Can be of limited value
• Premenopausal– Raised with
» Endometriosis» PID» A period
• Post menopausal– Not raised in 20% of
ovarian cancers» Mucinous tumours
• Also increased with…..– Diverticular disease– Appendicitis– Cirrhosis– Heart failure– Cancer
• Bowel • Pancreatic• Breast
Pragmatic approach• Examination
– Obvious ascites • Refer
• Post menopausal woman– Raised Ca125
• Refer if symptomatic• Scan if asymptomatic
– Large mass even if Ca125 in normal• Refer
• Pre menopausal woman– Borderline Ca125 (25-50) and normal scan
• Repeat Ca125 and review– Normal Ca125 and small cyst (<5cm) on scan
• Repeat scan and review– Raised Ca125 and abnormal scan
• Refer if not endometriosis
• If in doubt, ASK– Gynae Oncology email address for advice/ discussion
Treatment
Primary Surgery• If deemed resectable• Laparotomy
– TAH BSO Omentectomy• Bowel resection• Peritoneal stripping
• 3-5 days in hospital• Chemotherapy
Primary Chemotherapy• If extensive disease/
unresectable• CT guided biopsy/
laparoscopic biopsy• 3 cycles chemotherapy• MDT review
– Interval debulking surgery
• Completion of chemotherapy
New treatment
• Surgery– Increasingly radical surgery
• More use of bowel resection• Splenectomy• Upper abdominal peritoneal resection
• Chemotherapy– Anti angiogenic agents
• Bevacizumab
– Trials• ICON 8
– Weekly chemotherapy
• PETROC– Intraperitoneal chemotherapy
Palliation
• 60-70% of patient die• Long palliative phase– Ascites– Nausea– Pain– Cahexia– Bowel obstruction
Palliation
• Ascites– Day case paracentesis
service– Diuretics
• Pain and nausea– CG 140
• Opioid use in palliative care
– Early use of opiates– Syringe driver
• Bowel obstruction– Steroids– Surgery
• LWH– Mulberry Suite– Orchid Suite– Symptom control– End of life care
Familial • BRCA 1 and 2
– Historically• 1-2% of ovarian cancer hereditary
– 15-40% lifetime risk of ovarian cancer
– Now gene testing• 15-20% of high grade ovarian cancers carry BRCA gene defects• It will change treatment and outcome
– Better outcome in BRCA +ve tumours– PARP inhibitor due to be licensed 2015
» Olaparib
• HNPCC• Lynch syndrome• MLH1 / MSH2• 30% lifetime risk of ovarian cancer• Commonest initial presentation in women
– Pre menopausal endometrial cancer– 80% lifetime risk
Familial
• Screening– Not ideal
• Transvaginal ultrasound• Ca125• Annual
– High false positive• Pre menopausal women
– Significant false negative • No pre-malignant condition• Natural history not well
understood– Fallopian tube cancer?– Primary peritoneal
cancer?
• Prophylactic surgery– Laparoscopic BSO– Laparoscopic bilateral
salpingectomy– Total laparoscopic
hysterectomy BSO• 24-36 hours in hospital
In conclusion
• Increasing incidence• We need to increase awareness
– Symptoms– Treatment– Family history
• Treatment progress– Surgery– Chemotherapy– Genetics testing
• It WILL change treatment and patient expectation
• Familial cancer and screening– Target Ovarian GP module
• http://www.targetovariancancer.org.uk/health-professionals/information-gps