Ovarian cancer _ geeky medics

Ovarian cancer is one of those nightmare cancers: its vague, insidious onset means that it tends not to present until it is too late, and there is currently no effective screening programme in place to detect it at an earlier stage. Leaking clear fluid early pregnancy Like endometrial cancer, it tends to affect older women and it is vital to consider it a possibility in women over 60 with vague abdominal or urinary symptoms. Ovarian cancer tends to present with a pelvic mass, so I’ve included a differential diagnosis for this.

Chronic fluid in ear I’ve also described efforts to develop an ovarian screening programme – the UKFOCSS trial is currently underway to investigate its effectiveness. Clear mucus discharge during early pregnancy Introduction • the ovaries are a pair of small oval-shaped organs located in the female pelvis. Clear discharge during early pregnancy They are the female equivalent of the testes. How to get rid of fluid in ear They function as gonadsby producing female germ cells called ova, and also as endocrine glands which secrete the female sex hormones oestrogenand progesterone. • the ovaries are surrounded by a thin fibrous capsule called the tunica albuginea, which is covered externally by a modified layer of peritoneum called the germinal epithelium. • they are usually located on the lateral wall of the pelvis in a depression known as the ovarian fossa, with the external iliac vessels above, the obturator nerve laterally, and the internal iliac vessels and ureter running behind them. How to get rid of fluid in the ear However, their position can be extremely variable and they tend to move around a lot during and after pregnancy. • they are held in place by ligaments connecting them to other structures – the ovarian ligament is continuous with the round ligament and connects them to the uterus, and the suspensory ligament of the ovary (or infundibulopelvic ligament) is part of the broad ligament which connects them to uterine tubes and the lateral wall of the pelvis, and transmits the ovarian vessels and nerves. • the ovaries are the only totally intraperitoneal organs in the body – this is important as it means that ectopic pregnancies can implant onto abdominal organs, and ovarian cancer can easily metastasise across the peritoneal cavity (this is known as transcoelomic spread). • the ovaries usually take it in turns each month to mature and release an ovum (ovulate) during the menstrual cycle – the ovum enters the uterine tube, where it can undergo fertilisation by a sperm and develop into a fetus. Fluid trapped in ear If it is not fertilised, it is shed along with the endometrial lining of the uterus. • the developing ovarian Graafian follicle produces oestrogen , which stimulates the proliferation of the endometrium and changes in cervical mucus which make it more welcoming to sperm. Fluid in eardrum It also causes a wide variety of systemic effects. • the “theory of incessant ovulation” basically states that the more a woman ovulates in her lifetime, the higher her risk of ovarian cancer, due to the increased cumulative damage to the epithelium and the increased risk of mutations during its subsequent repair and regeneration • factors leading to “ incessant ovulation” include early menarche, late menopause, delayed childbearing, nulliparity, use of HRT for >5 years, use of fertility drugs such as clomiphene to stimulate ovulation, and increasing age • family history is important as several inherited genetic traits can significantly increase risk, for example BRCA1(46% risk by age 70), BRCA2(12% risk by age 70) and HNPCC (12% lifetime risk). • increasing tumour size results in pressure effects causing chronic abdominal, pelvic or back pain, urinary frequency/urgency (pressure on bladder), constipation/altered bowel habit/bowel obstruction (pressure on bowel), leg swellingand DVT/PE (pressure on pelvic veins) • less commonly, sudden torsion, rupture or infection of the tumour in early disease can present with acute abdominal or pelvic pain– this is a blessing in disguise as it can lead to early diagnosis. • tumour markers are very useful in the diagnosis of ovarian cancer: CA-125(a coelomic epithelial antigen) is elevated in 90% of cases of advanced disease and 50% of cases of early disease. Fluid in ear symptoms adults It is very sensitivefor ovarian cancer but not particularly specific – it can also be raised in other gynaecological cancers, GI cancers, benign abdominal and pelvic disorders, breast cancer and diseases affecting the pleura, pericardium or peritoneum. How to get rid of fluid behind the eardrum However, performed in the correct clinical context it can be very informative and should be a standard test for suspected ovarian cancer. • other tumour markers for specific types of ovarian cancer include CA19-9 (mucinous epithelial), beta-hCG and placental ALP (dysgerminomas, embryonal cancers, choriocarcinoma), AFP(endodermal sinus/yolk sac tumours) , inhibin (granulosa-thecal cell tumours) and LDH (some dysgerminomas) – these are usually arranged and interpreted by a specialist gynae-oncologist. Initial investigations are usually carried out by GPs in primary care, and the risk of malignancy index (RMI) score provides guidance on which patients to refer to gynaecology. Clear watery discharge early pregnancy sign It provides a composite assessment of risk and allows gatekeeping of referrals to specialist centres. How to relieve fluid in ear It is calculated as menopausal status score x ultrasound assessment score x CA-125 result. Dry cervical mucus early pregnancy A score of >200 indicates a 75% risk of cancer and should prompt referral to a specialist gynae-oncology centre. Fluid behind the eardrum A score of <200 represents a 3% risk of cancer and should be monitored using 4-monthly CA-125 and ultrasound. • imaging – CXRto check for pleural effusion or lung metastases, CT +/- MRI abdomen and pelvis to assess mass, pelvic nodes and any metastases; a PET scanmay be required in advanced disease There are multiple grading systems available depending on the type of ovarian cancer the patient has, e.g. Ear pain and sore throat FIGO, WHO, Silverberg… basically they are far too complicated to cover in detail here. Cervical mucus early pregnancy Generally tumours are graded low- to high-grade, with high-grade carrying a much poorer prognosis. Fluid in middle ear symptoms Staging – how far has it spread? Ovarian cancers are staged using the International Federation for Gynaecology and Obstetrics (FIGO) system. Draining fluid in ear The TNM system can also be used, but generally gynae-oncologists prefer to use FIGO. The mortality figures shown are for epithelial ovarian cancers, and the prognosis varies significantly depending on the type of cancer. Fluid in inner ear For example, dysgerminomashave an excellent cure rate, whereas endodermal sinus (yolk sac) tumours have a very poor prognosis. Ear and jaw pain on left side Management • this is a major procedure which generally comprises total abdominal hysterectomy (TAH)and bilateral salpingo-oophorectomy (BSO), infracolic omentectomy, pelvic and para-aortic lymph node sampling, peritoneal biopsies, multiple pelvic washings, sampling of ascites, inspection and sampling of the underside of the diaphragm, and removal of pretty much anything else that looks suspicious e.g. Fluid behind eardrum in adults symptoms bowel, appendix, liver, spleen… This excellent little video from TeamCirisano on YouTube shows the removal of a large cystic ovarian mass at laparotomy. Remedy for fluid in ear Most of the cyst fluid is drained first to prevent unnecessary spillage and seeding of cancer cells into the abdominal cavity, then the ovary and tumour are removed. • adjuvant chemotherapy is given to all patients >stage Ic, plus anyone stage Ia/Ib with a high grade malignancy. Fluid in ear remedy The standard first-line treatment is carboplatin + paclitaxel (response rate 70-80%). Fluid in your ear Second-line agents to consider include pegylated liposomal do
xorubicin (PLDH) and topotecan. Fluid in ears allergies Response to treatment can be monitored using CA-125 levels, which decrease if treatment is effective and increase if there is a relapse. • radiotherapy is not really used in the management of ovarian cancer as the tumours tend to be very radioresistant. Symptoms of fluid in the ear It is sometimes used in early stage low-bulk disease. • biological immunotherapy is emerging as a potential new treatment – specific monoclonal antibodies like bavacizumab(anti-VEGF) and olaparib (anti-PARP) are currently undergoing trials • advanced metastatic cancer (which is unfortunately very common) requires individualised palliative treatmen t with tumour debulking, chemoradiotherapy and symptom control • women who undergo surgery for ovarian cancer are usually followed up and monitored by a specialist gynae-oncology centre, with regular pelvic examinations and CA-125 levels • genetic screeningcan be offered to high-risk women with a significant family history of cancer (e.g. Sinus drainage in ear ovarian, endometrial, breast, gastric, colorectal) – this generally involves testing for BRCA1, BRCA2 and/or HNPCC. Ear and tooth pain on one side Patients who test positive for a mutation can be monitoredusing CA-125 levels and TVUSS, or may choose to undergo prophylactic interventions such as BSO +/- hysterectomy. • CA-125(cancer antigen 125) is a glycoprotein shed by epithelial tumours. Fluid in ears in adults The normal range is 30-65IU/L. Ear and jaw pain after tooth extraction It is a sensitive test for ovarian cancer but not very specific, as it can also be raised in several other cancers and a range of benign abdominal and pelvic conditions. Fluid in the ear in adults Despite the high false positive rate, it has been estimated that CA-125 screening could detect ovarian cancer up to 3 years earlier. • t ransvaginal ultrasound (TVUSS) is very useful in detecting ovarian cysts and assessing their malignant potential, but requires specialist sonographers and would be expensive to perform on a population screening basis. It is clear that a screening programme for ovarian cancer would be greatly valued, as the disease characteristically does not present until it is at an advanced stage. Fluid in ear symptoms in adults CA-125 and TVUSS are both sensitive tests, but carry a 2-3% false positive rate in postmenopausal women – this is generally considered too high, as it could potentially lead to unnecessary surgical interventions and cause harm. Jaw pain on left side near ear However, the use of the two tests together would significantly improve the reliability of screening. Symptoms of fluid in ear The UKFOCSS trialis currently underway to assess the combined effectiveness of CA-125and TVUSS in screening for ovarian cancer in high-risk patients with a significant family history. How to get rid of fluid in inner ear References Click to show