1. Ovarian cancer….. in 15 minutes
Robert Macdonald
Consultant Gynaecological Oncologist
Liverpool Womens Hospital

2. Overview
Diagnosis
Investigations
Treatment
Palliation
Genetics

3. Diagnosis No gynae symptoms ! Bloating/ distension Bladder symptoms
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

4. Investigations NICE Ca125 Ultrasound Secondary referral
If raised, then…
Ultrasound
If abnormal, then….
Secondary referral
TVS CT
Laparotomy
Laparoscopy
Biopsy and primary chemotherapy

5. 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
Also increased with…..
Diverticular disease
Appendicitis
Cirrhosis
Heart failure
Cancer
Bowel
Pancreatic
Breast

6. Pragmatic approach Examination Post menopausal woman
Obvious ascites
Refer
Post menopausal woman
Raised Ca125
Refer if symptomatic
Scan if asymptomatic
Large mass even if Ca125 in normal
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 address for advice/ discussion

7. Treatment Primary Surgery Primary Chemotherapy If deemed resectable
Laparotomy
TAH BSO Omentectomy
Bowel resection
Peritoneal stripping
3-5 days in hospital
Chemotherapy
If extensive disease/ unresectable
CT guided biopsy/ laparoscopic biopsy
3 cycles chemotherapy
MDT review
Interval debulking surgery
Completion of chemotherapy

8. New treatment Surgery Chemotherapy 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

9. Palliation 60-70% of patient die Long palliative phase Ascites Nausea
Pain
Cahexia
Bowel obstruction

10. Palliation Ascites Pain and nausea Bowel obstruction LWH
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

11. Familial BRCA 1 and 2 HNPCC Historically Now gene testing
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

12. Familial Screening Prophylactic surgery Not ideal High false positive
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

13. 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