Ovarian

• True / False: ovarian cancer is the fourth most common cancer

  • false: ovarian cancer is the fifth most common cancer
• True / False: ovarian cancer is the leading cause of death in gynecologic cancers

  • True: ovarian cancer is the leading cause of death in gynecologic cancers
• Age: > 63 years

  • exception: germ cell tumour is prevalent in younger women
• Epidemiology:

  • most present with more advanced disease → non specific symptoms
  • white women
• Etiology:

  • family history
  • BRCA mutation
  • Lynch syndrome
  • increased number of pregnancies (protective effect)
  • oral contraceptive (protective effect)
  • obesity
  • CA - 125 (greatest in ovarian cancer)
• True / False: the most common subtype of ovarian cancer is adenocarcinoma

  • true: the most common subtype of ovarian cancer is adenocarcinoma
• Natural History:

  • primary malignant tumours: epithelial ovarian (most common), germ cell, sex cord
  • mets from other sites: uterine, gastrointestinal, breast
  • epithelial ovarian cancers have high mortality: lack effective screening (usually detected at late stage)
• Spread:

  • trans peritoneal (primary mode of spread for epithelial ovarian)
  • find mets in: paracolic gutters, diaphragmatic surfaces, liver capsule, intestinal surfaces, momentum, spread to uterus or contralateral ovary
  • lymphatic - second most common
  • commonly involved: para aortic, internal iliac, external iliac, inguinal
  • hematogenous - infrequent
  • 2 - 3% parenchymal liver or lung disease
• Presentation:

  • non specific - present late stage
  • abdominal bloating or swelling
  • discomfort / pressure in pelvis
  • lower back pain
  • changes in menstruation
• Diagnostic tests:

  • history and physical
  • ultrasound - nodular vs papillary
  • CT - abdomen and pelvis
  • MRI - abdomen and pelvis
  • CA - 125 usually elevated
  • transvaginal ultrasound - routine examination (TVUS)
• Prognostic indicators:

  • most important: stage
  • cancer in ascites or peritoneal washing - poor prognosis
  • residual disease - poor prognosis
  • extra ovarian spread - poor prognosis
  • ovarian stromal tumour - good prognosis
  • young age - good prognosis
  • CA - 125 lowered after chemo - good prognosis
• Lymphatics:

  • para aortic nodes → cisterna chyli → thoracic duct
  • external iliac → common iliac → para aortic → cisterna chyli → thoracic duct
  • superficial or deep inguinal → external iliac → common iliac → para aortic → cisterna chyli → thoracic duct
• Peritoneal seeding: cancer has spread anywhere within peritoneal cavity
• Local spread = spread within peritoneal cavity

  • locally advanced disease in pelvis
  • impact on reproductive organs (uterus, fallopian tube, ovaries) and sigmoid colon
  • omentum always transformed by tumour (80% of the time)
• Stage 1:

  • 1A: one ovary
  • 1B: both ovaries
  • 1C: one or both ovaries + surgical spill, broken capsule, cancer in ascites or peritoneal cavity
• Stage 2:

  • 2A: uterus, fallopian tubes, or both
  • 2B: other pelvic organs (ex. rectum)
• Stage 3:

  • 3A: retroperitoneal lymph nodes, microscopic disease in intestine
  • 3B: macroscopic disease in intestine
  • 3C: peritoneum outside of pelvis (more than 2 cm away), capsule around liver or spleen (but not inside the organ)
• Stage 4:

  • 4A: pleural cavity - pleural effusion
  • 4B: inside other organs (liver, lungs), lymph nodes outside abdomen
• Stage 1 and 2A management:

  • young patient: fertility preserving staging
  • older patient: total abdominal hysterectomy + bilateral salpingoophorectomy + staging
  • stage 1A, 1B, grade 2:
  • observation and chemo (depends on histological subtype)
  • stage 1C, 2A, grade 3:
  • chemo: carboplatin and paclitaxel (3 - 6 cycles)
• Stage 2B, 2C management:

  • if medically unfit for debulking: chemo
  • macroscopic disease: 6 cycles
  • microscopic disease: 3 - 6 cycles
  • if able to debulk:
  • chemo: 3 - 6 cycles (carboplatin and paclitaxel)
  • if incomplete primary debulking:
  • surgical debulk again +/- chemo
  • chemo
• Stage 3 and 4 management:

  • if medically unfit for debulking:
  • chemo - 6 cycles
  • chemo: 3 - 6 cycles + interval debulking surgery
  • if able to debulk:
  • chemo: 3 - 6 cycles (carboplatin and paclitaxel)
  • if incomplete primary debulking:
  • surgical debulk again +/- chemo
  • chemo
• early stage: Stage 1 and Stage 2A

  intermediate stage: Stage 2B and 2C

  advanced stage: stage 3 and stage 4
• EBRT:

  • goal: improve local control
  • use:
  • micrometastatic disease in peritoneal cavity after surgery
  • clear cell
  • focal metastatic disease
  • palliation of advanced disease
  • isolated nodal recurrence
• Previous EBRT technique: whole abdominal radiation

  • 1 : AP beam (22.5 - 30 Gy, 1 - 1.5 Gy / fr, low daily dose to mitigate toxicity)
  • 2 : boost pelvis to 50 Gy total
  • use kidney blocks
  • huge toxicity: diarrhea, nausea, bowel toxicity
  • OAR: kidney, liver
  • borders:
  • sup: 2 cm above diaphragm
  • inf: below obturator foramen
  • lat: 2 cm beyond lateral peritoneum
• Current EBRT:

  • IMRT field in field: 45 - 60 Gy, 1.8 - 2 Gy / fr
  • SBRT: 20 - 30 Gy / 2 - 5 fr
  • salvage RT: residual or limited metastatic disease
  • minimal dose to OAR
  • volume: para aortic nodes, pelvic nodes, liver
• OVAR - IMRT - 02 Study:

  • stage 3 ovarian cancer with remission after chemo
  • IMRT: whole abdominal radiation as consolidation therapy
  • main goal: tolerability
  • secondary goal: toxicity, quality of life, overall survival
  • use: intermediate and high risk group - improve overall survival
• HIPEC treatment: hyperthermic intraperitoneal chemo

  • heated chemo during surgery → positive effect on immune response in abdominal cavity
  • receive half of chemo first → then surgery (no tumours > 1 cm) → HIPEC → complete chemo → improved overall survival
• Acute toxicities:

  • urinary frequency, urgency, dysuria
  • constipation
  • diarrhea
  • fatigue
  • nausea and vomiting
  • dehydration
  • erythema
• Chronic toxicities:

  • infertility
  • radiation induced menopause
  • chronic cystitis
  • chronic proctitis
  • necrosis
  • decreased sexual drive