‘I am menopausal and my abdomen is distending’

• Morag, a 72-year old woman, presents with gradual enlargement of the abdomen, abdominal discomfort and urinary incontinence. She is concerned that she might have ovarian cancer as this is a condition that her aunt died from aged 60

History of presenting complaint: Morag was fit and well until approximately 4

months ago. Around this time she noticed that it was getting more difficult to fasten her skirts and trousers. Morag also reports that she has abdominal discomfort, which has been getting gradually worse and that she is off her food. She denies any alteration in her bowel movements but has had a few episodes of urinary incontinence. She also denies any post-menopausal bleeding.

Past medical history: Ductal carcinoma of the breast, age 51 yearsFamily history: Maternal aunt developed ovarian cancer and died at age 60.Medications: Calcium, vitamin DAllergies: None knownPast obstetric and gynaecological history:

Menarche at age 13 yearsMenopause aged 51 years Two spontaneous vaginal deliveries with no pregnancy complications. One first trimester miscarriage No history of abnormal Pap smearsNo STIs

Social history: Lives alone, widowed. Has a glass of red wine every night. Life-long non-smoker.

What symptoms might a woman with ovarian cancer experience?

What symptoms might a woman with ovarian cancer experience?

■ Abdominal bloating

■ Increased abdominal girth

■ Indigestion

■ Lack of appetite

■ Feeling full after only a small amount of food

■ Weight gain or weight loss

■ Change in bowel habits

■ Urinary frequency or incontinence

■ Abdominal or pelvic pain

■ Feeling of pressure in the abdomen

Supporting Resource

What risk factors and protective factors

does Morag have, if any, for developing ovarian cancer?

Risk factors and protective factors

Relative risk Lifetime probability, percent*

Familial Ovarian CA Syndromes (Hereditary breast-ovarian cancer syndrome + Lynch II (HNPCC) Syndrome) Unknown 30 to 50

Two or three relatives with ovarian cancer 4.6 5.5 (15 if first degree)

One relative (first or second degree) with ovarian cancer 3.1 3.7 (5 if first degree)

Nulligravity 1.6  

Infertility 2.8  OTHER- early menarche (before 12)

late menopause (after 50)

endometriosis, PCOS

personal history of breast CA (particularly young)

family history of breast cancer

smoking

BMI >30

?talc

No risk factors 1 1.8

Past breast feeding 0.81  

Past oral contraceptive use 0.65 0.8

Tubal ligation 0.59  Past pregnancy

0.5 0.6

OTHER-?vitamin D

* Indicates probability for ovarian cancer in a 50-year-old woman.

What risk factors and protective factors does Morag have, if any, for developing

ovarian cancer?

Morags Risk Factors: one relative with ovarian CA, ?Late

menopause, Hx breast CA

Protective factors: past pregnancies, ?past breastfeeding, ?vit D

use

Why…. Relates to pathogenesis

“Although the cause of ovarian cancer is unclear, it is believed to result from malignant transformation of ovarian tissue after prolonged periods of chronic uninterrupted ovulation. Ovulation disrupts the epithelium of the ovary and activates the cellular repair mechanism. When ovulation occurs for long periods of time without interruption, this mechanism is believed to provide the opportunity for somatic gene deletions and mutations during the cellular repair process”

ie. Anything that interrupts (prevents) ovulation will decrease risk- OCP, pregnancy, breastfeeding OR

Anything else that (could) disrupt the epithelium of the ovary increases risk eg. PCOS, endometriosis, smoking (?)

What clinical examination would you perform?

What clinical examination would you perform on a woman suspected of

ovarian cancer and why?

ASSESSMENT of a pelvic mass aims to differentiate between • a gynaecological and non-gynaecological (eg, bowel, urinary, bladder) c • benign masses (eg, fibroid, benign torted ovary, endometrioma ) and ovarian or

uterine cancer

Physical Examination should include:• External abdominal examination• vaginal examination• Rectal examination (determines the presence of cancerous nodules in the pouch of

Douglas)• breast examination is performed to detect breast masses

What investigations would be most helpful in a woman presenting with a pelvic mass and why?

What investigations would be most helpful in a woman presenting with a

pelvic mass and why?INITIALLY

Ultrasound • is most valuable in characterising a pelvic mass.• Features of cancer on ultrasound include: septation, combined solid and cystic areas, papillary

projections and ascites

Laboratory studies• Human chorionic gonadotropin (hCG) to exclude pregnancy in any reproductive age woman

who presents with an adnexal mass• Complete blood count — A complete blood count to look for leukocytosis is helpful when an

infectious etiology such as pelvic inflammatory disease or tuboovarian abscess is suspected.• faecal occult blood testing are performed to exclude a rectal mass or bleeding

Tumour markers • are unreliable for distinguishing between benign masses and malignancy, but if elevated can help

to characterize the ovarian neoplasm

• However CA125, CA19.9 and CEA are usually done as part of assessment…. And CA125 is use determine RMI.

The risk of malignancy index (RMI)

Refer

The risk of malignancy index (RMI) is a score based on age at presentation, features on ultrasound and serum CA125 values. It is used as a tool to triage women with pelvic masses.

• >200+ is suggestive of ovarian cancer, refer to a gynaecological oncologist

• <200 mass is likely to be benign, risk of ovarian cancer is <3%. Refer to a general gynaecologist, who will decide about further management (conservative management and re-scanning in a few months, or immediate surgical exploration).

Supporting Resource

Options for further investigation

CT scans (MRI or PET in future) • are essential to exclude parenchymal involvement (liver, lung) and may also

give a hint as to whether surgery in this case will result in optimal cytoreduction.

Explorative Surgery • is necessary for diagnosis, staging, and treatment of EOC. A surgical

procedure is necessary to: obtain tissue to confirm the diagnosis; assess the extent of disease (ie, staging); and attempt optimal cytoreduction, which is crucial for successful treatment. 

Paracentesis or thoracentesis •  In patients with ascites, paracentesis or thoracentesis may be performed

What is Ca-125 and how might it be useful in ovarian cancer?

Ovarian cancer has a high mortality rate as the majority of patients present with advanced disease. For advanced disease the 5-year survival rates are reported to be less than 30%, whereas for patients diagnosed with stage I disease, the 5-year survival is reported to be in excess of 90%.5 In order to improve the mortality rate for ovarian cancer, detection in the early stages of the disease is required.

For this reason the possibility of screening for ovarian cancer has been explored. Is this viable?