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Ovarian Cancer CMG – January 2010 Final Version

REGIONAL GYNAECOLOGY GROUP

Document Title

Guidelines for the Screening, Investigation and Management of Ovarian Cancers

Document Date

January 2010 – Version 4 - Final

Document Purpose

This guidance has been produced to support the diagnosis, treatment and management of ovarian cancer Treatment decisions for individual patients require the weighing of a multiplicity of factors, which cannot all be accounted for in a CMG. The CMG provides a description of the range of treatment options available for a clinical scenario. To maximise the benefit of multiprofessional working management strategies for the individual are best discussed with a multidisciplinary meeting (MDM)

Authors

Dr Ian Harley, Consultant Gynaecologist Prof Glen McCluggage, Consultation Pathologist Dr Sarah McKenna, Consultant Oncologist Dr Joanne Millar, Consultant Oncologist Dr Geoff McCracken, Consultant Gynaecologist Ms Wendy Cunnigham, Clinical Trials Ms Maureen Clarke, Patient Representative Ms Elish McColgan, Clinical Nurse Specialist Ms Pippa McCabe, Physiotherapist

Version Changes

Changes made to version 3 by Dr Ian Harley, Dec 09 Appendix 2 score for Menopause changed from

4 to 3 Ms Pippa McCabe changed lymphodema paragraph – Dec 09


INTRODUCTION Ovarian cancer is the primary cause of mortality among gynaecological

malignancies. The lifetime risk of ovarian cancer by age 75 years, in women

from developed countries, is approximately 1 in 70 (Risch H.A, 2001). The

median age at diagnosis is 60 years. In Northern Ireland ovarian cancer

accounts for 4% of all cancers registered and is the commonest

gynaecological malignancy. There are approximately 168 cases diagnosed

annually in Northern Ireland. The mean overall survival is 32 months. (Cancer

registry Northern Ireland)

Primary ovarian tumours are histologically classified into those that are

epithelial (implying an origin from the surface / coelomic epithelium), those

that are of sex cord -stromal type, and originating from sex cord mesenchymal

elements), and those that are of germ cell type (originating from germ cells).

The majority of primary tumours (85-90%) are epithelial in origin (Im D.D,

2001). Less commonly ovarian tumours may be metastatic from other primary

sites, including non-gynaecological tumours.

Epithelial tumours are further classified into distinct histological/morphological

sub-groups (mainly serous, endometrioid, cleat cell and mucinous) based on

microscopic appearances. A simplified version of the WHO classification for

ovarian tumours is illustrated in Appendix 1.

The majority of ovarian tumours are sporadic. However, 12% are familial

cancers, due to an underlying genetic defect. Mutations in the BRCA1 and

BRCA2 genes account for the majority (75-90%) of familial epithelial ovarian

cancers, followed by mutations in Mismatch Repair genes (5-12%). Women

with a BRCA1 or BRCA2 gene mutation have a 40-60% and 20-40% lifetime

risk of developing epithelial ovarian cancer by age 75 years respectively. Risk

of borderline and non-epithelial tumours do not appear to be greater in BRCA

1/2 carriers than the background risk within the population.


Patients with ovarian cancer commonly present with vague symptoms and

signs. Consequently, most patients (85%) present with advanced disease.

Thus a minority will present with early stage disease. In women with

macroscopic disease confined to the ovary 25% will have a normal Ca125.

30% will have microscopic spread to the lymph nodes and 22% will be

upstaged by a comprehensive surgical staging procedure.

Surgery is the primary treatment of choice. The aim of surgery is to remove as

much tumour as is possible, provide surgical staging and histological

diagnosis. Residual disease after initial surgery remains one of the most

important variables in the prognosis for women with epithelial ovarian

carcinoma (EOC). Although there are no randomized studies, nor are there

likely to be, the best evidence available has resulted in cytoreductive surgery

being the primary treatment in EOC. The aim is to debulk the tumour to less

than 1cm of residual disease remaining in any site of the abdomino-pelvic

cavity. If achieved, this is termed “optimal cytoreduction (debulking)”.

A meta-analysis by Bristow et all (2002) of 81 cohorts of patients (totalling

6,885 cases) of stage III or IV EOC identified a significant improvement in

survival in women who had maximal cytoreductive surgery. Maximal

cytoreductive surgery was defined according to the largest diameter of

residual disease. 95% of studies used 1cm or 2cm as discriminating criteria.

Cohorts with <25% maximal cytoreduction had a mean weighted median

survival of 22.7 months. This is in contrast to cohorts with >75% maximal

cytoreduction who had a mean weighted median survival of 33.9 months

(p<0.001). This correlation remained after controlling for other prognostic

variables.

Following surgery adjuvant chemotherapy is usually recommended in

advanced tumours and selected early stage disease.


SCREENING FOR OVARIAN CANCER As stated above, in the general population the lifetime risk of developing

ovarian cancer by the age of 75 years is 1.4% (1 in 70). In the absence of a

mutation in BRCA 1/2 the relative risk for women with one affected first

degree relative is 3.1 (95% CI 0.3-1.6), ie: the lifetime risk is increased to

4.3%. When more than one relative is affected (first or second degree) the

relative risk is increased to 11.7 (95% CI 5.3 – 25.9), ie: the lifetime risk is

increased to 16.38%.(Stratton J F).

Patients with a strong family history of malignancy (including ovary, breast,

bowel, pancreatic and prostate) should be referred to medical genetics for a

risk assessment.

Only those patients testing positive for BRCA1/2, HNPCC or on recommendation of medical genetics should be referred to the familial ovarian cancer screening clinic for ovarian screening or prophylactic surgery. The UKTOCS trial of ovarian cancer screening in the general population does

not currently provide enough evidence to support the screening of

asymptomatic women in the general population (Menon U et al Lancet 2009).

Screening asymptomatic low risk women may lead to a larger number of

unnecessary surgical interventions. However, the mature data should be

available in 2014, including the outcome for unscreened women.

The evidence does support screening high risk women for Ovarian Cancer.

Screening methods currently used include a combination of history,

examination, ultrasound scan of pelvis and Ca125.

Women considered at high risk of ovarian cancer should be counselled for prophylactic surgery. The minimal surgical intervention should be a laparoscopic (or open if unsuitable for minimum access surgery) bilateral salpingo-oophorectomy. There is currently no data to support hysterectomy in addition to a BSO for prophylaxis of malignancy in patients with BRCA1/2 mutation.


HRT therapy after Prophylactic Surgery in BRCA 1/2 mutation carriers Approximately 3% of invasive breast cancers are attributed to BRCA1 and 2

(Newman B 1998). Women who carry a mutation in the BRCA 1 gene have a

60-80% lifetime risk of developing breast cancer. This risk can be reduced by

50% with prophylactic oophorectomy before menopause (Eisen A 2005,

Rebbeck T 2009). Because the reduction of risk is believed to be due to the

withdrawal of ovarian hormones, there is concern about the administration of

exogenous hormones in women with the BRCA 1 or BRCA 2 mutation, to

alleviate climacteric symptoms.

In case control studies, BRCA1 and BRCA 2 carriers, who have had

prophylactic BSO and are prescribed HRT, do not appear to loose the risk

reduction for breast cancer (Rebbeck T 2005, Eisen A 2008). In these studies

there appeared to be no difference in HRT preparation (Oestrogen alone or

combined oestrogen and progesterone).

BRCA 1 and BRCA 2 carriers who undergo prophylactic BSO should be

carefully counseled of the effects of surgical menopause before surgery is performed. Post operative use of HRT should be discussed, including

alternative treatments to relieve menopausal symptoms and prevent

osteoporosis. Patients may be offered referral to the HRT clinic.


DIAGNOSIS Suspicion for ovarian cancer should be made by the GP, Medical / Surgical

clinician or Gynaecologist on taking a good clinical history and full

examination. Appropriate initial investigations should be carried out on all

women with a suspected ovarian malignancy before referral to the Lead

Clinician of the Gynae. Cancer Unit.

Investigations should include:

Ultrasound scanning,

relevant tumour markers (Epithelial: Ca125, Ca19-9 and CEA Germ

Cell: AFP, hCG and LDH Sex Cord Stromal: Inhibin ) [Germ cell

tumour markers should always be considered in younger women. It

may be useful in young people to perform a serum calcium since

ovarian small cell carcinoma of hypercalcaemic type, a rare but

aggressive form of ovarian malignancy in young women, is associated

in most cases with a raised serum level]

+/- CT / MRI scan.

These initial investigations may be supplemented by cytology or histology

where appropriate.

To avoid treatment delay diagnostic work up should be completed in a timely fashion with advice from the Unit Lead Clinician if required.

All General Gynaecologists and Gynaecological Cancer Unit Lead Clinicians

should calculate the Risk of Malignancy Index (RMI) score in an attempt to

discriminate between benign and malignant ovarian pathology. Calculation of

the RMI is detailed in appendix 2. RMI scores > 250 should be discussed at the Specialist Gynae. Oncology MDT.

25% of women with an early stage epithelial malignancy confined to the ovary

may have a normal Ca125. Therefore in some women the RMI may fall below

250. However, if radiological imaging shows complex features and

malignancy is suspected, the case must be reviewed, with all relevant

investigations, at the Regional Gynae. Oncology MDT. Women with ovarian

lesions associated with normal Ca125, “benign” radiological features and RMI


<250 should not be referred to the Regional MDT unless abnormal pathology

is reported.

All suspected or diagnosed cases of ovarian cancer must be presented to the

Regional Gynaecological MDT for discussion and a management plan

constructed. All relevant investigations should be made available to the

Regional MDT in a timely fashion, prior to the patients case discussion. This

should include:

clinical history,

radiological/haematological/cytological/histological investigations; and

calculation of the RMI.

All histopathology should have a central review by a Consultant pathologist

within the MDT. All relevant radiological imaging should be reviewed by

Consultant radiologists within the MDT.

TREATMENT A treatment plan for each case must be discussed and documented at the

Regional Gynaecological MDT. All those involved in the patient care should

have access to the MDT documentation and treatment plan. Treatment should

be discussed with the patient as early as possible. Patients should not be

given an appointment for treatment until diagnosis has been discussed with

the patient by the referring clinician.

If a patient is not fit for surgery, or optimal debulking is felt to be unachievable,

a tissue diagnosis must be obtained before commencing alternative

treatment. Cytology alone is not sufficient for a patient be started on

chemotherapy.

1. Surgery Outside the setting of clinical trials, patients should be offered primary

surgery, if appropriate.


Standard Surgical Procedure

A. Washings of pelvis and abdomen or collection of ascitic fluid

B. Complete description of upper abdomen: diaphragms, liver, stomach,

spleen, pancreas, omentum, large / small bowel (incl. mesenteries), paracolic

gutters, para-aortic lymph nodes and pelvis: tubes, ovaries, uterus, cervix,

sigmoid / rectum, Pouch of Douglas, peritoneal surfaces and pelvic lymph

nodes.

Staging

The minimal Surgical Staging should include Total Hysterectomy (TH) and

Bilateral Salpingo-Oophorectomy (BSO) [Unilateral Salpingo-Oophorectomy

only if fertility conservation appropriate], infracolic ometectomy. .Where

appropriate peritoneal biopsies of upper abdomen / pelvis, plus pelvic and

para-aortic lymph node dissection may be performed.

Debulking

A. TAH and BSO, Omentectomy and resection of tumour

B. If the patient’s tumour is debulkable to < 1cm, any of the following

procedures may also be done to achieve optimal debulking: (i) Bowel Resection

(ii) Partial Cystectomy

(iii) Pelvic / Diaphragmatic Peritoniectomy

(iv) Splenectomy

(v) Pelvic / Para-Aortic Lymphadenectomy

Early Disease (Disease apparently confined to the ovary)

Staging of disease apparently confined to the ovaries should be carried out by

a Gynaecological Oncologist within the cancer centre. This is to allow

comprehensive staging – Hysterectomy, BSO, (USO only if fertility sparing),

infracolic omentectomy, peritoneal biopsies of upper abdomen and pelvis, and

a pelvic / para-aortic lymphadenectomy. The information obtained in

comprehensive staging will allow patients to be selected for adjuvant

chemotherapy where appropriate.


Staging of Borderline Tumours

Borderline tumours account for 10-15% of all ovarian tumours. Most are of a

serous or mucinous subtype. 7-18% of serous borderline tumours have lymph

node spread. All borderline tumours should be discussed at the Regional MDT.

The minimal staging for borderline tumours should include a Hysterectomy

and BSO (USO / cystectomy alone if fertility sparing), plus infracolic

omentectomy. Pelvic and para-aortic lymphadenectomy should be considered

in serous borderline tumours.

Frequently the histological diagnosis of a borderline cystadenoma comes after

surgery for a tumour thought to be benign. Therefore a staging procedure may

not have been conducted. Restaging should be discussed at the MDT and

based on additional information (histological subtype, radiological evidence of

incompletely excised disease and patient’s fitness for surgery).

Restaging

Patients who have had a diagnosis of ovarian cancer following a previous

surgical procedure, but have not been comprehensively surgically staged

should be offered further staging surgery if:

(i) restaging (laparotomy / laparoscopy) will provide additional

information that will impact on treatment or prognosis

(ii) restaging will spare an individual from chemotherapy (i.e.

apparent stage 1, grade 1/2 with no staging including

omentectomy and lymphadenectomy).

Surgery following relapse after primary surgery

Patients who have a clinically isolated (confirmed radiological) recurrence

should be considered for surgery where there is a disease free interval > 12

months.


2. Chemotherapy Chemotherapy may be used as a primary or adjuvant treatment of ovarian

cancers. Underpinning principles are as follows ;

Primary chemotherapy

Primary chemotherapy alone may be offered if

considered unfit for surgery

poor performance status

clinically or radiologically non-debulkable disease

Adjuvant treatment – early stage disease

Adjuvant treatment should be offered to poorly staged patients of all

histological grades. Patients with comprehensively staged well differentiated

FIGO 1A or 1B disease should not be offered adjuvant chemotherapy.

Palliative chemotherapy for advanced disease

Surgically staged patients with advanced disease should be offered standard

palliative chemotherapy _ Carboplatin/Taxol

[(Note all patients receiving neoadjuvant chemotherapy should be discussed at the gynae MDM following the 6th cycle of chemo and the discussion documented in the notes] Neoadjuvant

Applies to chemotherapy given prior to debulking surgery. Chemotherapy will

only be offered after the diagnosis of ovarian cancer is confirmed on

histological sample. Surgery will be performed after 6 courses of standard

chemotherapy (Carboplatin/Taxol) if:

(i) It is anticipated that optimal residuum (<1cm) can be achieved. This

anticipation should be based on clinical examination,

radiological imaging +/- laparoscopy

(ii) The patient is medically fit for surgery

The next section provides in detail the protocols governing the medical

management of ovarian cancer in Northern Ireland.


PROTOCOLS FOR THE MEDICAL MANAGEMENT OF OVARIAN CANCER Early Stage Disease (Stage I)

Patients who should be offered Chemotherapy

Stage I (A-C) and high grade [all clear cell tumours are considered high grade]

Patients with whom chemotherapy should be discussed

Stage I (A+B) and Grade II and comprehensive staging (including pelvic & para-aortic lymph node dissection and no evidence of nodal involvement

Patients who should not be offered chemotherapy

Stage I A/B AND well differentiated tumours

Offered Paclitaxel 175mg/M2 and Carboplatin AUC 5 for 6 cycles.

or Carboplatin AUC 6 for 6 cycles for less fit patients or when side

effects of Paclitaxel are unacceptable. Evidence: 8% improvement in overall survival at 5 yrs Monitoring while on chemotherapy Baseline CXR and CT scan abdomen and pelvis if not performed pre-op CA 125 prior to each chemotherapy cycle Follow-up post chemotherapy: 4 monthly for 2 years 6 monthly for 3 years Annually from year 5


Advanced Ovarian Cancer (Stage 2-4)

Post Surgical Debulking OR Neoadjuvant Treatment for Patients unfit for chemotherapy or whose disease is not optimally debulkable.

Offered

Paclitaxel 175mg/M2 and Carboplatin AUC5 for 6 cycles or

Single agent Carboplatin AUC6 for 6 cycles could be considered for: Patients less medically fit Older patients Evidence: 70-80% response to Paclitaxel/Carboplatin. 60-70% response to Carboplatin Average progression free interval - 1-2yrs Average overall survival 2-3 years BUT small number of long term survivors Monitoring while on chemotherapy Baseline CXR and CT scan abdomen and pelvis No need to repeat if normal If abnormal repeat on completion of 6 cycles of chemotherapy unless there is clinical evidence of disease progression CA 125 prior to each chemotherapy cycle Follow-up post chemotherapy: 4 monthly for 2 years 6 monthly for 3 years Annually from year 5


Relapsed Ovarian Cancer A - Platinum Resistant (ie relapsing ≤ 6mths after completion of platinum based therapy) Who should be offered Chemotherapy

Optimal timing of chemotherapy is uncertain. Consider offering chemotherapy when: patient has "significant" disease on CT scan or symptoms are developing. Patients who have evidence of bowel obstruction should not be offered further chemotherapy

For patients who had Carboplatin/Paclitaxel as initial chemotherapy:

Caelyx 50mg/M2 4 weekly Evidence: response rates 10-20% effect on survival uncertain Monitoring while on chemotherapy: Repeat CT scan abdomen and pelvis after 2 cycles Proceed to 6 cycles if response demonstrated

For patients who had Carboplatin as initial chemotherapy:

Paclitaxel 80mg/M2 weekly Evidence - response rate 10-20% effect on survival uncertain Monitoring while on chemotherapy:Repeat CT scan after 6 cycles Proceed to 18 cycles if response demonstrated

Follow up Review 3 monthly Discuss referral to palliative care team At Progression Consider Letrozole 2.5mg mane Request ER/PR status from pathology.


B – Partially Platinum Sensitive (ie relapsing 6-12mths following platinum based chemotherapy) Relapsing 6-12mths following platinum based chemotherapy as demonstrated by "significant" disease progression on CT scan or as evidenced by symptoms and rising CA 125. For patients who had Carboplatin/Paclitaxel as initial chemotherapy:

Caelyx 50mg/M2 4 weekly Evidence: response rates 10-30% effect on survival uncertain Monitoring while on chemotherapy: Repeat CT after 2 cycles Proceed to 6 cycles if response demonstrated

For patients who had Carboplatin as initial chemotherapy:

Paclitaxel 80mg/M2 weekly Evidence - response rate 10-20% effect on survival uncertain Monitoring while on chemotherapy:Repeat CT scan after 6 cycles Proceed to 18 cycles if response demonstrated

Follow up Review 3 monthly Discuss referral to palliative care team At Progression At progression: consider Paclitaxel 175mg/M2 Carboplatin AUC 5 or Carboplatin AUC 6 (poor PS or residual neurotoxicity from Paclitaxel) Evidence - response rate 30% probable small improvement in survival Follow up after chemotherapy: review 3 monthly discuss referral to palliative care team At progression: consider Letrozole 2.5mg (request ER/PR status from pathology)


C – Platinum Sensitive Relapse (ie relapsing > 12 months after platinum based chemotherapy) Relapsing > 12 months post platinum based chemotherapy as demonstrated by: “Significantly" progressing disease on serial CT scans development of symptoms. Secondary debulking surgery should be considered for all patients: those most likely to be suitable are those with:

good performance status limited sites of disease longer times to disease relapse

All patients who may be suitable should be discussed at the Gynae MDM Patients who have had secondary debulking may have immediate further platinum based chemotherapy or may delay chemotherapy until there is further evidence of disease progression. Consider delaying chemotherapy in the following patients:

Long disease free interval Single or limited sites of relapsed disease identified Completely resected disease

(There is no evidence to guide this decision) For patients who are not surgical candidates or who elect to have chemotherapy after surgery

Paclitaxel 175mg/M2

Carboplatin AUC 5 or

Carboplatin AUC6 (if poor PS or residual neurotoxicity from Paclitaxel)

Evidence: response rates >30% - dependant on specific platinum free interval improvement in survival (4-6mths) Monitoring while on chemotherapy:CT scan after 2 cycles and after 6 cycles of chemotherapy to monitor response Review 3 monthly

Patients at 3rd relapse following completion of 2nd line platinum based chemotherapy: < 6 months Caelyx as above

6-12 months Caelyx as above

> 12 months single agent Carboplatin (no evidence for Paclitaxel/Carboplatin in this in this situation)


SPECIAL CONSIDERATIONS

1. HRT and ovarian cancer: Women premenopausal at time of diagnosis: No evidence of adverse effect

Consider HRT for patients for:

1) Management of acute menopausal symptoms

2) For patients with early stage disease to prevent long term complications of

early menopause (these patients should be referred to the HRT clinic in the

RVH)

Women post menopausal at diagnosis: Little evidence to guide decision

Probably safe for short term use in patients with troublesome acute

symptoms.

References: Estrogen replacement therapy for ovarian cancer survivors-a randomised controlled trial. Guidozzi et al. Cancer 1999 Sept 15;86(6) :1013-8

2. Carboplatin allergies: Carboplatin allergies are well described typically in patients receiving 2nd and

subsequent lines of Carboplatin chemotherapy.

While desensitistation protocols have been described their efficacy is

uncertain.

Our management of Carboplatin allergy is as follows:

Patient should NOT receive further Carboplatin

Patient may be offered Cisplatin 100mg/M2 but should be counselled that

there is some cross reactivity between the 2 drugs and a proportion of

patients may also develop a reaction to Cisplatin References: The dilemna of Carboplatin-associated hypersensitivity reactions in ovarian cancer management. Markman M. Gynecol Oncol. 2007 Nov;107(2):163-5 Use of Cisplatin without desensitisation after Carboplatin hypersensitivity reaction in epithelial ovarian and primary peritoneal cancer. Callahan MB et al. Am J Obstet Gynecol. 2007 Aug;197(2):199


Quality of Life Issues Women with ovarian cancer can experience many challenges to their quality

of life, including psychosocial and survivorship issues. From diagnosis, all

women with ovarian cancer should have a named Key Worker, ideally a

Clinical Nurse Specialist, who can co-ordinate the various aspects of their

care, as well as giving information and support. The key worker may change

throughout the patient’s cancer journey, to, for example, Community Hospice

Nurse.

Patients should receive written information on support services available

locally and nationally. Patients having surgery or chemotherapy should

receive written information on their treatment, which includes possible side

effects and risks associated with treatment. Patients having chemotherapy

will be given information on the 24 hour helpline.

From initial presentation onwards, patients may need dietary advice and

symptom management. Referral to a dietician and Palliative Care Team,

either in hospital or the community is beneficial for many patients.

Patients may need assessed regarding ascites if it is affecting their activities

of daily living. It may be appropriate to tap for relief of symptoms, either in the

cancer centre or their referring hospital.

Surgery for ovarian cancer may, in a small number of cases, result in bowel

surgery. For this reason, all patients with suspect ovarian cancer should be

seen by a stoma nurse pre operatively, and have a site marked. This does

increase patient anxiety, but is of huge benefit to the small number of patients

who have stoma formation.

Written information should be given to all patients on how treatment may

affect their sexual functioning, relationships and fertility. Referral to a

counsellor or psychologist is often helpful for patients, and services are

available at the cancer centre or locally.


Patients rendered menopausal by their treatment will be advised regarding

risks and benefits of HRT. Post treatment assessment may indicate the need

to refer patients to their local menopause/HRT clinic for ongoing monitoring

and advice.

Lymphodema Lymphoedema is a chronic, life long condition that may occur as a result of

gynaecological surgery and/or radiotherapy involving the lymph nodes. In the

later stages of disease, lymphoedema may also occur when the lymph nodes

are involved in the disease process or when there is increased pressure

within the pelvis.

Written information should be given to all women at risk of developing

lymphoedema pre treatment. Patients who have lymph node dissection or

radiotherapy to lymph nodes are at risk of lymphoedema, and should be

referred to their local lymphoedema team at the first signs, in order to prevent

complex, long term problems. Those lymphoedema patients having

chemotherapy or radiotherapy will be seen in the cancer centre if

lymphoedema is an issue at that time.


Appendix 1 Table 1 Histological Classification of Ovarian Tumours (5, 6) I Epithelial Tumours (Benign, Borderline or Malignant) A Serous tumour B Mucinous tumour C Endometrioid tumour D Clear Cell (mesonephroid) Tumour E Brenner tumour F Mixed epithelial tumour G Undifferentiated tumour H Unclassified tumour

II Sex Cord Stromal Tumours A Granulosa-Theca stroma cell tumour Granulosa tumour Thecoma B Sertoli-Leydig tumour Arrhenoblastoma Sertoli tumour C Gynandroblastoma D Unclassified tumour III Lipid Cell Tumours

IV Germ Cell Tumours A Dysgerminoma B Endodermal sinus tumour (yolk sac tumour) C Embryonal Cell Tumour D Polyembryoma E Choriocarcinoma G Teratoma Mature Teratoma Solid adult teratoma Dermoid Cyst

Struma Ovarii Malignant neoplasms secondarily arising from mature cystic teratoma

Immature Teratoma

V Gonadoblastoma VI Soft Tissue Tumours not specific to Ovary A Fibroma B Haemangioma C Leiomyoma D Lipoma E Lymphoma F Sarcoma VII Unclassified Tumours VIII Metastaic Tumours A Gastrointestinal tract B Breast C Endometrium D Lymphoma


Appendix 2 RISK OF MALIGNANCY INDEX (RMI)

Aim: To define patients with probable Ovarian carcinoma Measurement: RMI index if > 250 then 90% positive predictive

value for ovarian carcinoma RMI index = Menopausal score (M) x Ultrasound score (U) x CA 125 serum level Menopause score Pre-menopause = 1 Post-menopause = 3 Ultrasound score sum of: Multilocular cyst = 1 Solid areas in cyst = 1 Bilateral cysts = 1 Ascites = 1 Abdominal metastases e.g. omentum = 1 Then if total score 0-1 then U = 1 > 2 then U = 4 CA 125 - absolute serum level in U/ml Examples: 1 A 59-year old woman presents with a pelvic mass, USS shows a solid

ovarian cyst, ascites and an omental cake. CA 125 is 450 U/ml

RMI = M (3) x U (1+1+1 = 3 - score is 4) x C (450) = 4x4x450 = 6,600 REFER TO THE CANCER CENTRE

2 A 39 year old woman presents with a large mobile pelvic mass, USS

shows multilocular cyst with no ascites. CA 125 is 67 U/ml

RMI = M (1) x U (1 - score is 1) x C (67) = 67 NO NEED TO REFER TO CANCER CENTRE


Appendix 3 Table 3.1 FIGO Staging for Ovarian Carcinoma

FIGO Stage

Description

O No Evidence of Primary Tumour I Tumour Confined to the Ovaries

IA Tumour limited to one ovary, capsule intact, no tumour on ovarian surface, no malignant cells in ascites or perironeal washings.

IB Tumour limited to both ovaries, capsules intact, no tumour on ovarian surface, no malignant cells in ascites or peritoneal washings.

IC Tumour limited to one or both ovaries with any of the following: Capsule rupture, tumour on ovarian surface, positive malignant cells in ascites or peritoneal washings.

II Tumour involves one or both ovaries with pelvic extension

IIA Extension and/or implants in uterus and or tubes. No malignant cells in ascites or peritoneal washings.

IIB Extension to other pelvic organs. No malignant cells in the ascites or peritoneal washings.

IIC IIA/B with positive malignant cells in the ascites or peritoneal washings.

III Tumour involves one or both ovaries with microscopically confirmed peritoneal metastasis outside the pelvis and/or regional lymph node metastasis.

IIIA Microscopic peritoneal metastasis beyond the pelvis

IIIB Macroscopic peritoneal metastasis beyond the pelvis 2cm or less in greatest dimension.

IIIC Peritoneal metastasis beyond the pelvis more than 2cm in greatest dimension and/or regional lymph node metastasis

IV Metastasis beyond the peritoneal cavity

Table 3.2 FIGO / UICC TNM equivalents

UICC FIGO Stage T N M

IA T1a N0 M0 IB T1b N0 M0 IC T1c N0 M0 IIA T2a N0 M0 IIB T2b N0 M0 IIC T2c N0 M0 IIIA T3a N0 M0 IIIB T3b N0 M0 IIIC T3c N0 M0

Any T N1 M0 IV Any T Any N M1

N0: No Regional Lymph Nodes N1: Regional lymph node metastasis M0: No Distant Metastasis M1: Distant metastasis (excluding peritoneal mets)


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REGIONAL GYNAECOLOGY GROUP - Northern Ireland Cancer … CMG_010110_V4Final.pdf · REGIONAL GYNAECOLOGY GROUP . ... ovarian cancer by the age of 75 years is 1.4% (1 in 70). ... the