Trick or Treatment
What's first? Chemo or surgery?
If surgical candidate, do debulking followed by consolidation chemotherapy
SO + TAH
Goal is for residual disease to be <1cm
If not surgical candidate, neoadjuvant chemotherapy to try to make surgery possible
What imaging and labs are part of an initial workup?
US (Abdominal or transvaginal)
CT or MRI
Bloodwork (Ca 125, Ca 19-9, CEA)
Describe the typical clinical presentation and symptoms of ovarian cancer
Typical presentation is nonspecific: abdominal pain, bloating, early satiety, urinary urgency/frequency, and pelvic/abdominal mass
Is routine screening recommended for ovarian cancer? If so, what is it?
Routine screening is not recommended due to lack of mortality benefit and potential harms; no effective screening test exists for average-risk women
How do you treat relapsed/refractory platinum-sensitive disease?
If platinum sensitive (no recurrence x6 months)
Secondary cytoreduction if possible
Rechallenge with carbo/taxol
Followed by PARP or bevacizumab
True/false
70-80% of epithelial cancers are "low grade"
FALSE. High-grade serous carcinoma is the most common subtype, accounting for 70–80% of epithelial ovarian cancers and the majority of ovarian cancer deaths
What is the role of CA-125 in the diagnosis and management of ovarian cancer?
CA-125 is useful for monitoring and treatment planning, but is not specific for diagnosis; elevated levels correlate with disease extent
Name 3 genetic syndromes/factors associated with increased risk of ovarian CA
BRCA 1/2
Lynch syndrome
Peutz-jeghers
mutations in gene MUTYH
What maintenance therapy is used for BRCA+ or HRD status?
Olaparib
Name the four stages (and what's the acronym for the system?)
Stage 1 = confined to ovary
Stage 2 = spread to pelvis
Stage 3 = spread to abdomen or nodes
Stage 4 = distant metastatic disease
What is the most common histologic subtype of ovarian cancer? Name 1-2 uncommon ones
Epithelial (90% of cases)
- serous (low grade, very indolent)
- mucinous
- germ cell
How do you manage ovarian cancer risk in a Lynch syndrome patient?
Ovarian cancer prevention in individuals with Lynch syndrome centers on risk-reducing surgery, patient education, and individualized counseling.
NCCN recommends risk-reducing BSO +/- TAH after childbearing is complete. Usually consider at age 40 for MLH1, MSH2, EPCAM carriers. Later, for MSH6, PMS2 (lower risk).
Routine screening (TVUS, Ca 125) is NOT recommended!!
Indication for mirvetuximab soravtansine?
It is an antibody-drug conjugate (ADC) used to treat platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer (EOC) in patients whose tumors express folate receptor alpha (FRα).
What is the lowest staging threshhold for needing adjuvant chemotherapy?
Stage 1c and up (positive ascitic or peritoneal washings)
What general chemotherapy is mucinous ovarian cancer treated with?
They're platinum resistant (do not choose carbo/taxol)
CapOx or FOLFOX (similar to GI regimens)
True/false
For stage I ovarian CA, you can get away with just doing a BSO if the patient wants to preserve fertility (no need for TAH/TLH).
True
Most common side effect to be aware of for mirvetuximab?
Eye problems, such as blurred vision, dry eyes, and keratopathy. Need regular ophthalmology follow up
Name two kinds of subtypes of ovarian cancer that are automatically high-grade by definition
high-grade endometrioid
clear cell
carcinosarcoma
undifferentiated carcinomas
Name 2 kinds of germ cell tumors
**THEY ALL GET BEP***
Dysgerminomas (analogous to seminomas)
Endodermal or sinus yolk sac tumors (They have schiller duval bodies)
Immature teratomas (chemo for stage 1a grade 1)
Who gets tested for germline mutations?
A) only low grade
B) only high grade
C) any grade
Test everyone with high grade ovarian cancers for germline mutations
American Society of Clinical Oncology (ASCO) recommends that all women diagnosed with epithelial ovarian cancer—including those with low-grade tumors—should be offered germline genetic testing for BRCA1, BRCA2, and other ovarian cancer susceptibility genes, regardless of clinical features or family history