23 Ovarian Cancers

David G. Mutch

QUESTIONS

Each of the numbered items below is followed by lettered answers. Select the ONE lettered answer that is BEST in each case unless instructed otherwise.

Question 23.1 A 35-year-old premenopausal woman of Ashkenazi-Jewish ancestry presents to you because her 60-year-old paternal aunt was recently diagnosed with ovarian cancer, and she is concerned about her own risk for ovarian cancer. She has no siblings, and there is no other family history of cancer. She has two living children and is in good health, and her pelvic examination is unremarkable. You should advise her that:

A. Ovarian cancer cannot be inherited through the paternal side and she does not need any particular screening.

B. A single second-degree relative with cancer at age more than 50 years does not confer a significantly increased risk for her.

C. She should visit a genetic counselor.

D. Annual transvaginal ultrasound and CA-125 screening can reduce her risk of mortality.

E. She should have a prophylactic total abdominal hysterectomy/ bilateral salpingo-oophorectomy (TAH/BSO) if/when she does not want to have any more children.

Question 23.2 A 35-year-old woman presents to you for recommendations regarding therapy of her newly diagnosed mucinous ovarian cancer. This was a 5-cm, grade 1, left-sided mass that was incidentally found at the time of surgery for endometriosis as part of an infertility workup. The ovary was removed, and the operative note states that there was no evidence of tumor on the external surface of the ovary or elsewhere in the abdomen, but full surgical staging was not performed. A postoperative computed tomography (CT) scan of the abdomen and the pelvis is unremarkable, and CA-125 is within normal limits. Pelvic examination is unremarkable. The patient would like to have children but does not want to compromise her survival. You should advise her that:

A. She is unlikely to have any residual cancer or a recurrence, and further surgery or chemotherapy is not needed.

B. She should have a positron emission tomography (PET) scan, and if there is no uptake, she does not need further surgery or chemotherapy.

C. Because her CT scan and CA-125 are normal, she is unlikely to have any residual disease, and further surgery is not needed. However, because the mucinous subtype of ovarian cancer has a very poor prognosis, she will require three to six cycles of carboplatin/paclitaxel chemotherapy.

D. She should have complete surgical staging, if possible, via laparoscopy, with the option of preserving her uterus and contralateral ovary if there is no further evidence of tumor, which is associated with a >90% chance of 5-year survival and does not require chemotherapy.

E. She should have complete surgical staging, including TAH/BSO. If no further disease is found, she will need only three cycles of carboplatin/paclitaxel chemotherapy, but if there is disease outside the ovary, she will need six cycles.

Question 23.3 In what aspect of ovarian cancer management is CA-125 most useful?

A. Screening

B. Diagnosis

C. Monitoring treatment

D. Equally useful in all of the above

Question 23.4 Which of the following increases the risk of a woman developing ovarian cancer?

A. Use of oral contraceptives for >5 consecutive years

B. Nulliparity

C. Breastfeeding

D. Tubal ligation

Question 23.5 A 50-year-old woman presents with a pelvic mass. She is found to have a tumor of low malignant potential. With TAH/BSO and staging, there is no gross disease but the washings were positive on final pathology and there was one positive lymph node, making her disease stage IIIC. What is the most appropriate therapy postoperatively?

A. Intraperitoneal cisplatin and intravenous (IV) taxane

B. IV platinum and a taxane

C. Hormonal therapy with tamoxifen or an aromatase inhibitor

D. No further therapy

Question 23.6 A 50-year-old woman was diagnosed with stage III ovarian cancer and underwent primary resection followed by chemotherapy. She is asymptomatic but has an elevated CA-125. Imaging studies do not identify recurrent disease. Which of the following is the best treatment option?

A. Hormonal therapy

B. Platinum-based chemotherapy

C. Single-agent doxorubicin

D. Single-agent paclitaxel

Question 23.7 Which of the following is/are a founder BRCA mutation(s) associated with individuals of Ashkenazi descent?

A. 185delAG

B. 5382insC

C. 617delT

D. All of the above

Question 23.8 What percentage decrease in the incidence of ovarian cancer is associated with oral contraceptive use for more than 5 years?

A. 5%

B. 10%

C. 20%

D. 50%

E. 80%

Question 23.9 A 25-year-old woman has her left ovary removed because of an ovarian mass. The final pathology shows that this is a moderately differentiated papillary serous cancer. There was no other evidence of disease in the abdominal cavity. What is the likelihood that this patient has a positive pelvic or para-aortic lymph node metastasis?

A. 5%

B. 15%

C. 30%

D. 50%

Question 23.10 A 55-year-old woman who has just achieved a complete clinical remission (normal CT scan, pelvic examination, and CA-125) after six cycles of chemotherapy for stage IIIC optimally debulked serous ovarian cancer presents to you for a second opinion regarding her prognosis and treatment options at this point. She is in excellent general health and tolerated chemotherapy well except for some numbness in her fingers and toes, which caused her treating oncologist to switch her treatment from paclitaxel/carboplatin to docetaxel/carboplatin after cycle three. You should advise her that:

A. The risk of eventual relapse for an optimally debulked patient with a complete clinical remission is approximately 30%. No therapy is proven to be of any further survival benefit at this point.

B. She should have second-look surgery. If residual disease is found, she should have four to six cycles of intraperitoneal platinum-based therapy because this can improve survival in patients with platinum-sensitive, minimal residual disease.

C. She should have a PET scan. If residual disease is found, she should have four to six cycles of a non–cross-resistant drug, such as topotecan.

D. Her risk of eventual relapse is approximately 70%. She should be offered consolidation therapy with paclitaxel 175 mg/m² every 3 weeks for 12 months with the expectation of a 30% improvement in survival.

E. Her risk of relapse is approximately 70%. No therapy is proven to be of any survival benefit at this point.

Question 23.11 Which of the following statement(s) is/are TRUE about granulosa cell tumors of the ovary?

A. They usually occur in premenopausal women

B. They are usually stage III/IV

C. Survival of patients with stage I disease is generally good, but they may relapse later

D. Survival of patients with stage III/IV disease is poor, and they should consider chemotherapy

E. They may be associated with endometrial cancer

F. C, D, and E

Question 23.12 Which of the following statements is TRUE about germ cell tumors of the ovary?

A. They occur more often in younger women.

B. They are usually stage III/IV.

C. Appropriate therapy includes TAH/BSO/full surgical staging and chemotherapy regimens similar to those used in male testicular cancer.

D. Survival of patients with stage III/IV disease is poor.

E. The chemotherapy will usually result in infertility.

Question 23.13 A 51-year-old woman presents to you for recommendations regarding the treatment of her recurrent ovarian cancer. She was optimally debulked for stage IIIC serous ovarian carcinoma and completed six cycles of carboplatin/paclitaxel 36 months ago with a clinical complete remission. She now has recurrent ascites, which is histologically positive for tumor compatible with her original primary. CT scan shows peritoneal carcinomatosis and a pelvic mass. You should advise her that:

A. Prognosis of recurrent ovarian cancer is poor. She may achieve short-term benefit from chemotherapy although hospice is a reasonable option.

B. Tamoxifen has a 40% chance of response.

C. She has a very high likelihood of disease shrinkage and symptom palliation with further platinum-based chemotherapy.

D. She has a chance of cure with autologous stem cell transplant.

E. Liver metastases and liver failure will probably be her ultimate cause of death.

Question 23.14 A 45-year-old woman has undergone surgical resection followed by adjuvant chemotherapy for her stage IIIC ovarian cancer. She is now in complete remission and is interested in further treatment to reduce the risk of recurrent disease. Which of the following would you recommend?

A. Maintenance treatment with single-agent paclitaxel for 12 months

B. Clinical surveillance

C. Maintenance treatment with single-agent topotecan

D. Maintenance treatment with bevacizumab

Question 23.15 Three randomized controlled trials utilizing intraperitoneal chemotherapy in optimally cytoreduced advanced ovarian cancer have shown:

A. All showed that intraperitoneal therapy has a progression-free survival (PFS) benefit over intravenous therapy.

B. All showed that intraperitoneal therapy has an overall survival (OS) benefit over intravenous therapy.

C. Intraperitoneal and intravenous therapy are equivalent in this patient population.

D. Dose-dense intravenous therapy is equivalent to intraperitoneal therapy.

Question 23.16 A 53-year-old patient presents with ascites, omental caking, and peritoneal nodularity. Her ovaries are normal. She undergoes surgery and all gross tumors are removed. The final diagnosis is papillary serous primary peritoneal cancer. How should this patient be treated?

A. As if she had a standard ovarian cancer

B. As if she had a peritoneal mesothelioma

C. As if she had breast cancer

D. As a germ cell cancer

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