Ovarian Cancer-Route to Diagnosis Waseem Kamran Consultant Gynaecological Oncologist St James’s Hospital Beacon hospital

Facts Second most common cancer of female reproductive organs. Average age of diagnosis is sixth decade Life time risk is 1.4% Epithelial ovarian cancer is the most common type

Diagnosis Clinical Biochemical Imaging Biopsy Surgery

Clinical-I Risk Factors Caucasian origin. Never being pregnant Early age of menarche and late age of menopause. Family history of ovarian cancer Germline mutation-BRCA-I & BRCA-II Lynch syndrome 60% risk of endometrial cancer 10-12% risk of ovarian cancer

Clinical-II Signs and symptoms No particular symptoms in early stage cancer Often vague and ill-defined Bloating, abdominal discomfort, feeling full Urinary symptoms-Urgency and frequency May mimic GI symptoms Back pain, respiratory symptoms in advanced stage cancer.

Clinical-III General Examination Pelvic Examination PR Examination Ascites Abdominal mass Lymph adenopathy Pleural effusion Pelvic Examination Mass in POD Fixed uterus PR Examination

Diagnostic modalities Modality Sensitivity Specificity Transvaginal ultrasonography 82-91% 68-81% CT scan 86% 91% MRI 90% 75% PET CT 67% 79% CA125 78% 92% HE4 72% 95%

CA125 not very helpful in early stage cancer Can be normal in 50% of stage I ovarian cancer.

HE4 Human Epididymis secretary protein Used as Risk of Ovarian Malignancy Algorithm (ROMA) Initial reports showed positive results Does not contribute positively in the diagnosis of ovarian cancer* May have a role in diagnosing persistent disease following cytoreductive surgery** *British Journal of Cancer (2011) 104, 863 – 870. doi:10.1038/sj.bjc.6606092 www.bjcancer.com Published online 8 February 2011 & 2011 Cancer Research UK **The Clearance of Serum Human Epididymis Protein 4 Following Primary Cytoreductive Surgery for Ovarian Carcinoma. Thompson C1, Kamran W1, Dockrell L1, Khalid S1, Kumari M2, Ibrahim N2, OʼLeary J3, Norris L2, Petzold M4, OʼToole S2, Gleeson N. Int J Gynecol Cancer. 2018 Jul;28(6):1066-1072. doi: 10.1097/IGC.0000000000001267

Imaging Ultrasound scan Abdominal Trans-vaginal CT scan MRI

Imaging-I Asymptomatic patients with adnexal pathology Ultrasound-IOTA consortium Pattern recognition 95% sen, 91%spec

Imaging-II IOTA-LR2 model

Imaging-III CT scan CT TAP PET CT MRI

Biopsy Not recommended Metastatic/Advanced malignancy Recurrence Early cancers Confined pathology Metastatic/Advanced malignancy Epithelial carcinoma Germ cell tumours Sex cord stromal Recurrence

Surgery-I Laparoscopy No obvious disease. Evaluate abdominal cavity Biopsy Staging surgery in early stage cancer.

Surgery-II Laparotomy Surgical Staging in advanced malignancy Cytoreduction

Summery Clinical Examination Early stage Advanced stage TVUS, then CT TAP/MRI Advanced stage CT MRI Tissue diagnosis None of the imaging techniques can replace surgical evaluation

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