On this page
Study tools
Write your answer
Saved on this device. No marking — you are the marker.
Stem
A 58-year-old woman presents with 3 months of progressive abdominal bloating, early satiety, and increasing waist size. On examination: ascites, palpable right adnexal mass. CA-125 520 U/mL. CT shows peritoneal deposits and omental cake.
Questions
a) What is the diagnosis and what is the characteristic spread pattern? (2 marks)
Diagnosis: Ovarian cancer (Stage III — peritoneal spread). Spread: Transcoelomic spread — tumour cells shed from ovarian surface into peritoneal cavity → seed peritoneal surfaces → omental cake + ascites + peritoneal carcinomatosis.
b) What is the standard surgical staging procedure? (3 marks)
Staging laparotomy with optimal debulking:
- Total abdominal hysterectomy (TAH)
- Bilateral salpingo-oophorectomy (BSO)
- Omentectomy (omentum is common site of spread)
- Peritoneal biopsies (multiple sites)
- Pelvic and para-aortic lymphadenectomy
- Ascitic fluid cytology
Goal: optimal debulking — residual disease less than 1cm.
c) What is the standard first-line chemotherapy? (2 marks)
Carboplatin + paclitaxel (6 cycles, 3-weekly). Alternatively, neoadjuvant chemo (3 cycles) → interval debulking → 3 more cycles if unresectable at presentation.
d) What is the significance of BRCA1 mutation and what management is recommended? (3 marks)
BRCA1 carriers have approximately 40% lifetime risk of ovarian cancer (BRCA2: 20%). BRCA1 is involved in DNA repair — mutation → genomic instability. Management for carriers: prophylactic bilateral salpingo-oophorectomy (BSO) after completing family (age 35 to 45) — reduces risk by 80 to 95%. Also annual breast MRI from age 25. If BRCA-mutated ovarian cancer develops: PARP inhibitors (olaparib) as maintenance therapy improve progression-free survival.