Transcript Ovarian cancer….. in 15 minutes

Ovarian cancer…..
in 15 minutes
Robert Macdonald
Consultant Gynaecological Oncologist
Liverpool Womens Hospital
Overview
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Diagnosis
Investigations
Treatment
Palliation
Genetics
Diagnosis
• No gynae symptoms !
– Bloating/ distension
• Constant, not intermittent
– Bladder symptoms
• Increasing frequency
– Abdominal pain
– Nausea
• Early satiety
• Loss of appetite
– Bowel symptoms
• Change in bowel habit
• “IBS”
– IBS does not present in post menppausal women
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PV bleeding
Breathlessness
Cahexia
Bowel obstruction
W Hamilton 2009
Investigations
• NICE
– Ca125
• If raised, then…
– Ultrasound
• If abnormal, then….
– Secondary referral
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TVS
CT
Laparotomy
Laparoscopy
– Biopsy and primary chemotherapy
However….
• Ca125
• Also increased with…..
– 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
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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
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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
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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/healthprofessionals/information-gps