1. ‘I am menopausal and my abdomen is distending’

2. 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

3. What symptoms might a woman with ovarian cancer experience?
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 years
Family history: Maternal aunt developed ovarian cancer and died at age 60.
Medications: Calcium, vitamin D
Allergies: None known
Past obstetric and gynaecological history:
Menarche at age 13 years
Menopause aged 51 years
Two spontaneous vaginal deliveries with no pregnancy complications. One first trimester miscarriage
No history of abnormal Pap smears
No 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?

4. 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?

5. 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.

6. 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

7. 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?

8. 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?

9. 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.

10. 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

11. 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

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

13. 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?