TEALE FENNING

Xerxes I · Posted: Sat Jun 21, 2008 3:28 pm Post subject: Management of ovarian cancer

Feel free to make ammendments to the question or the points.

You work in a cancer unit and you are seeing a 72 year old woman who is referred by GP with an incidental finding of complex 6 cm ovarian mass with evidence of ascites on ultrasound.

Describe the outline of your initial assessment. (9 points)

how would you plan your subseuent management based on the likely diagnosis. (11 points)

shachi · Joined: 10 Jun 2008 Posts: 16

[b]You work in a cancer unit and you are seeing a 72 year old woman who is referred by GP with an incidental finding of complex 6 cm ovarian mass with evidence of ascites on ultrasound.

Describe the outline of your initial assessment. (9 points)

The initial assessment should start with a history and duration of presenting complaint like history of progressive weight loss, bloating etc.
The purpose of initial assessment is to find out if the mass is malignant or benign.
Past gynae history is important as tubal ligation and hysterectomy (with ovarian conservation) decrease the risk of ovarian cancer, and use of COC is protective.
A family history of ovarian, breast, endometrial or colon cancer may indicate the presence of gynaecology cancer syndromes related to brca1 and 2 genes or HNPCC.
Medical history to check for comorbidities to assess for fitness for surgery and also to check for past history of breast or colon cancer.
Abdominal palpation to feel for tumor and ascites, surgey scars. Vaginal, speculum and bimanual examination to feel for size, mobility, consistency and regularity of mass. A hard, fixed tumour could indicate malignancy.
Blood test to check for full blood count, renal function tests and liver function tests. CA 125 to calculate risk malignancy index. Risk malignancy index is the product of ca 125 levels (in units per ml), the ultrasound score and menopausal status (3 for postmenopausal). This patient has an ultrasound score of 2 based on complex mass and presence of ascites.
RMI of <25 indicates low risk of ovarian ca, 25-250 indicates moderate risk and >250 indicates high risk.
Chest X ray and ECG to check for comorbidities.

Xerxes I · Posted: Mon Jun 23, 2008 7:12 pm Post subject:

Hi Shachi,

One important thing I would add is the fact that one major aim of initial assessment is to decide on where she should be managed (in this case it is likely to be a cancer centre and the question says you work in a cancer unit. I think in this sort of question what they want to know is if you are familiar with the way the system works. I think not mentioning MDT may be a big crime in this Q Wink

shachi · Joined: 10 Jun 2008 Posts: 16

I agree with the 1st bit but I think MDT will come into play in the management half of the question.

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 946

i'll add the following---

initial assessment

risks --

history of unexplained infertility
infertility treatment

presentation --

vague lower abd pain -- also called as Simpson's pain
change in bowel habits
pressure symptoms from the ascites

examination ---

you need to remember that the ovary is attached to a woman

start with gen exam - pallor, leg oedema etc
CVS / RS -- tachypnoea, tachycardia, abnormal sounds on auscultation
then state abd exam findings
then speculum, vaginal and rectal examination, assert the fact that staging is surgical to be confirmatory -- add about role of peritoneal washings, node sampling, debulking at the same sitting to get a histo diagnosis.

investigations ---

the staging bit can come under this or can be left with the above point.
you'll need baseline FBC, U&E, LFTs, -- to look for co-morbidities and confirm fitness.
tumor markers
genetic testing
urine testing
USS, XRay- abd, chest, MRI /CT
ascitic tap -- cyto

agree with the Xerxes on both accounts --

need to mention where the patient should be dealt with
MDT can be a part of stem 1 especially where mode of staging is in doubt -- i.e MRI alone or need for laparotomy.

now -- give stem 2 a try.

r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region