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