Essay 348

a) Initial assessment would involve history. The rapid onset, weight loss, anorexia are features more likely associated with malignant tumour. Menstrual history will give additional information about other problems; there are may be dysmenorrhoea, deep dyspareunia, chronic pelvic pain, heavy bleeding, intermenstrual bleeding.

It is important to elicit the family history of ovaian, breast cancer, endometriosis to identify risk factors for cancer. Patient wishes to preserve fertility would impact on further management. Examination is important to identify the spread of disease such as presence of ascitis, lymphoadenopathy, hepatomegaly, pelvic examination whether mass is fixed, mobile, tender; previous surgery; all of this would help to decide on the type of surgery.

b) Additional investigations are tumour markers: Ca125, CEA, CA19-9. FBC, LFTs, U&E are required depending on clinical findings or planned therapy/surgery. Women of this age in addition measuring AFP and beta-HCG may be useful to identify epithelial ovarian cancer. Risk malignancy index is calculated based on USS, serum CA-125 and menopausal status.Women with RMI of 250 or greater should be referred to a specialist cancer centre.

CXR to evaluate ascities, lungs involvement (secondaries); CT scan of the pelvis and abdomen should be performed to establish the extent of disease if metastasis. The thorax should be included if clinically indicated.

c) Explanation of findings would include the possibility that ovarian cyst may malignant (cancer) or benign. The focus is mainly on discussion of surgical intervention as a treatment and confirmation the nature of the cyst. Type of surgery would depend on findings, it is important to agree on extend of intervention, more likely in this case laparoscopic cystectomy/ oophorectomy including additonal washings/biopsy if there are suspicious findings needs to be performed and further histological assessment if no other systems involvement.

If evidence malignancy identified in women at moderate risk undergoing laparoscopic treatment should be counselled that a full staging laparotomy will be required 

A) History is taken about the nature of her discomfort including severity and duration. Information is obtained if she has been feeling abdominal distension and feeling full. Enquiry is made regarding loss of weight , fatigue and loss of appetite. She should be asked if she is feeling mass per abdomen and abdominal or pelvic pain. History is taken regarding urgency and frequency of urine suggestive of pressure symptoms .

Detailed menstrual history is taken regarding regularity, cycle length, flow, dysmenorrohea, and LMP. History is taken about any abnormal vaginal discharge and dysparuenia. Details of methods of contraception are noted if any. Parity is checked and her intention for future conception is noted.

Information is noted about altered bowel habit including rectal bleeding.

History is taken about cough and haemoptysis which indicate lung involvement. Family history of breast or ovarian cancer is obtained.

Examination should include recording her weight , assessment of BMI and assessment general nutritional status to exclude cachexia which is suggestive of malignancy. Examination is performed to identify supraclavicular lymphnode which could indicate metastasis. Chest is auscultated to identify abnormality suggestive of lung involvement.

Abdominal examination is directed to identify clinical ascites, mass per abdomen along with the details such as consistency, mobility of the mass. Vaginal and rectal examination are useful in obtaining details regarding fixed pelvic mass suggestive of malignancy.

B) Serum CA 125 is measured as there is suspicion of ovarian cancer. Tumour markers such as serum alfa fetoprotein and serum beta HCG levels are measured to identify the presence of non epithelial ovarian cancer, as her age is less than 40 years . Detailed ultrasound of abdomen and pelvis is done to identify ascites, multilocularity and solid areas which aid in calculation of RMI. If ultrasound, serun CA 125 level and clinical status suggest ovarian cancer, CT Scan of pelvis and abdomen is done to establish the extent of the disease. In case of clinical suspicion of lung involvement CT is the investigation of choice for detection of disease in the thorax.

MRI should not be used routinely for assessing women with suspected ovarian cancer.

C) Information is provided regarding the nature of ovarian cyst benign or malignant and counseled accordingly. With RMI index of less than 25 can be managed in a gynaecological unit. RMI index between 25- 250 would be refered to a cancer unit. Information is provided that RMI of 250 or greater should be referred to a specialist cancer centre. 

In case of ovarian cancer, 

Psychological support is provided at every stage to help the woman and her family to cope with the effects of the disease and its treatment. Specialist interventions are made available for the woman and her partner to help to understand and cope with the effects of treatment on sexual relationships. She should be provided access to a named oncology clinical nurse specialist with counselling expertise.

She should be given information about the stage of the disease. Explanation is given that good chance of a cure if ovarian cancer is diagnosed and treated when the disease is at an early stage (confined to the ovary and has not spread The later the stage and the higher the grade of the cancer, the poorer the outlook.

Treatment options are explained which include surgery, chemotheralpy or both depending upon staging. If the cancer is at a very early stage (just confined to the ovary and not spread), then an operation to remove the affected ovary and associated Fallopian tube may be all the treatment required.

Chemotherapy is a treatment of cancer by using anti-cancer drugs which kill cancer cells or stop them from multiplying.

Her interests regarding future fertility and hormone treatment should be addressed and advised according to her requirements.

Symptoms and signs of recurrence are informed for eg: abdominal distension, pain abdomen, cough and haemoptysis

Written information is provided along with separate leaflet for chemotherapy including common side effects and their management to enhance the well being.

information about the support groups such as Ovacome (ovarian cancer support) and Macmillan Cancer Support

A) History is taken about the nature of her discomfort including severity and duration. Information is obtained if she has been feeling abdominal distension and feeling full. Enquiry is made regarding loss of weight , fatigue and loss of appetite. She should be asked if she is feeling mass per abdomen and abdominal or pelvic pain. History is taken regarding urgency and frequency of urine suggestive of pressure symptoms .

Detailed menstrual history is taken regarding regularity, cycle length, flow, dysmenorrohea, and LMP. History is taken about any abnormal vaginal discharge and dysparuenia. Details of methods of contraception are noted if any. Parity is checked and her intention for future conception is noted.

Information is noted about altered bowel habit including rectal bleeding.

History is taken about cough and haemoptysis which indicate lung involvement. Family history of breast or ovarian cancer is obtained.

Examination should include recording her weight , assessment of BMI and assessment general nutritional status to exclude cachexia which is suggestive of malignancy. Examination is performed to identify supraclavicular lymphnode which could indicate metastasis. Chest is auscultated to identify abnormality suggestive of lung involvement.

Abdominal examination is directed to identify clinical ascites, mass per abdomen along with the details such as consistency, mobility of the mass. Vaginal and rectal examination are useful in obtaining details regarding fixed pelvic mass suggestive of malignancy.

B) Serum CA 125 is measured as there is suspicion of ovarian cancer. Tumour markers such as serum alfa fetoprotein and serum beta HCG levels are measured to identify the presence of non epithelial ovarian cancer, as her age is less than 40 years . Detailed ultrasound of abdomen and pelvis is done to identify ascites, multilocularity and solid areas which aid in calculation of RMI. If ultrasound, serun CA 125 level and clinical status suggest ovarian cancer, CT Scan of pelvis and abdomen is done to establish the extent of the disease. In case of clinical suspicion of lung involvement CT is the investigation of choice for detection of disease in the thorax.

MRI should not be used routinely for assessing women with suspected ovarian cancer.

C) Information is provided regarding the nature of ovarian cyst benign or malignant and counseled accordingly. With RMI index of less than 25 can be managed in a gynaecological unit. RMI index between 25- 250 would be refered to a cancer unit. Information is provided that RMI of 250 or greater should be referred to a specialist cancer centre. 

In case of ovarian cancer, 

Psychological support is provided at every stage to help the woman and her family to cope with the effects of the disease and its treatment. Specialist interventions are made available for the woman and her partner to help to understand and cope with the effects of treatment on sexual relationships. She should be provided access to a named oncology clinical nurse specialist with counselling expertise.

She should be given information about the stage of the disease. Explanation is given that good chance of a cure if ovarian cancer is diagnosed and treated when the disease is at an early stage (confined to the ovary and has not spread The later the stage and the higher the grade of the cancer, the poorer the outlook.

Treatment options are explained which include surgery, chemotheralpy or both depending upon staging. If the cancer is at a very early stage (just confined to the ovary and not spread), then an operation to remove the affected ovary and associated Fallopian tube may be all the treatment required.

Chemotherapy is a treatment of cancer by using anti-cancer drugs which kill cancer cells or stop them from multiplying.

Her interests regarding future fertility and hormone treatment should be addressed and advised according to her requirements.

Symptoms and signs of recurrence are informed for eg: abdominal distension, pain abdomen, cough and haemoptysis

Written information is provided along with separate leaflet for chemotherapy including common side effects and their management to enhance the well being.

information about the support groups such as Ovacome (ovarian cancer support) and Macmillan Cancer Support

Assessment of the patient include extensive history taking about the nature, duration and the pain score of the patient , accompanying  change in of bowel or urinary  habits, recent loss of weight, early satiety  and easy fatigue.

Family history of cancer specially colon, prostate or breast disease.

Previous diagnosis with IBS, endometriosis and or PID.or symptoms suggestive either of them,ike dysparunia of dysmenorrheal.

Recent menstrual irregularity, break through bleeding.

Intake of medications like contraceptions Progesterone only piles.

Fertility related issues.

Previous similar condtions

Examination , General for the weight , signs of cashexia, Jaundice or Anemia. Hirsutism.

Chest examination for  pleural effusion.

Abdominal examination for the presence of masses , pelvic or pelviabdominal, Ascitis ,nodules, tenderness ,rigidity.tender renal angle.

Pelvic examination for palpable pelvic masses, fixity of the mass, its relation to the utres , cervical excitation. Sign Hard masses suggestive of fibroids .

B

In addition to the detailed ultrasound scan , patient should go for tumor marker, examination, like CA125,either alone or in combination of HE4 protein. Patient is classified according to the results into high risk and low risk. having high specificity  and sensitivity. Used mainly to assess the effectiveness of the treatement.Ca125 with us, and menopausal status of the women are used to assess the RMI, values less than 25 low risk, values 25-250 are moderate risk in malignancy , and values more than 250 highly suggestive of malignancy, needs urgent referral to specialized oncology centre.

Other tumor marker that can be used CAE, Alpha fetoprotein, HCG .

CT is also used to assess the chest and the peritoneal disease, low coast and more available than MRI. Not operator dependant like US scans.

Needle aspiration biopsy in few cases.

Chest X ray, and blood work to assess the Liver and   kidney functions .with FBC.

C

Senior Gynecologist should discuss the result of the investigation and the finding to the patient in the presence of her family member as per her wish. In clear sensitive manner.

Explaining that her finding is suspecting ovarian cancer and the survival of the diseases depends on the early diagnosis and the effective treatment and she will be treated by MDT.

She should be operated by specialist Gynecologist to assess her disease stage. Early stages may need only removal of the mass, in case she is wishing to preserve fertility.But main treatement is  total abdmoninal hysterectomy with bilateral salpingooverectomy with omentectomy , lymph nodes and peritoneal wash.

Optimum treatment is depending on maximum depluking, removing all the disease from the pelvis

Chemotherapy can be also used to help kill the cancer cells in case of advanced disease.route of use and side effects of the drugs is explained with the add of information leaflets.

Information about cancer support group should be also used.

Patient is encouraged to ask Questions with their family.

Full information about sexuality, pain management, Hospital stay, side effect of medications, especially chemotherapy should be discussed.

Referral to psychiatrist and social worker with oncology nurse is also helpful especially after surgery.

Her need for HRT can be also discussed after surgery by oncology team.

a) Additional history should be taken to exclude differential diagnosis. If additional symptoms of dyspareunia and dysmenorrhoea is present, endometrioma should be suspected. Any abnormal vaginal discharge and history of STI would suggest a tubo-ovarian abscess. Family history of breast cancer, ovarian cancer and colon cancer should be enquired into to rule out familial syndromes. Associated menstrual irregularities or virilisation along with sudden onset weight loss, anorexia would suggest hormone secreting tumours. History of medications and contraception should be sought. Any additional pressure symptoms must be enquired into. History of previous ovarian cysts must be enquired into.  A detailed abdominal and vaginal examination should be done to assess the mobility of the mass and assess for other organomegaly. If cancer is suspected, lymph nodes should be assessed along with examination of the chest. Tumour markers including CA125, AFP, HCG, CA19-9, CEA and inhibin A should be done which will point towards the type of ovarian malignancy being dealt with. The USS examination should also comment on the other ovary, the presence of ascities, presence of solid components, multilocularity and evidence of metastasis to be able to calculate the risk of malignancy index.

b) If ovarian cancer is suspected, the tumour markers as mentioned above should be done. Chest XRay should be performed to rule out secondaries and to assess the operative fitness. CT abdomen and pelvis should be done to assess the extent of tumour, size, lymph node metastasis, omental, liver or any other organ involvement to assess the stage of the tumour.

c) Diagnosis of cancer and breaking bad news require adequate knowledge, adequate surroundings, presence of family members and empathy. The entire management plan including the type of surgery, the place of management, the follow up, need for chemotherapy/radiotherapy, symptoms of recurrence should all be discussed. She should be informed about the involvement of  a multi disciplinary team including the gynae-oncologist, cancer specialist nurse and radiologist and decision made for the appropriate place and management of the cancer depending on the stage of the cancer. If the cancer is advanced, she would be referred to the cancer centre managed by the gynae-oncology specialist where depending on the stage a staging laparotomy with appropriate debulking of the tumour would be the aim. If the ovarian cancer is in ealry stage and she has not completed her family, fertility preserving options should be discussed in the form of unilateral oopherectomy after a detailed discussion about the risks of recurrence and need ofr further surgery or chemotherapy/ radiotherapy. She should be allotted a key worker who would answer her queries if any arose later on. She should be given opportunity to ask questions and clear her doubts. She should be informed about the prognosis and survival rate depending on the stage. Her need to preserve her fertility and need of HRT should be discussed.

She should be given details of cancer support group and all this information should be backed by written information. She and her family should be given all the opportunities to ask questions and should be reassured of continuous support from the team.   

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A sensitive approach to this patient is considered taking the possibility of ovarian cancer in consideration. An enquiry about what the patient already knows of her condition is thought and how much this would affect the quality of her life. She should be seen and taken care of within 2 weeks of referral according to local guidelines and protocols(NICE). Will ask her about symptoms of malignancy as weight loss, anorexia, nausea,vomiting, and rapid swelling of her abdomen . Will ask of symptoms of metastasis as cough and hemoptysis, rectal bleeding , right upper abdominal pain( liver metastasis) or abnormal body swellings (lymph nodes supraclavicular). Will ask of her parity( Ovarian cancer more in nullipara) .Will ask of her fertility wishes (in case of conservative management is feasible).Will ask regarding her menstrual history, LMP, regularity of period ,periods of amenorrhea ( functioning ovarian tumours). Will ask if she used fertility treatment and type( May increase risk of ov cancer) or if she used contraceptive pills(reduce risk).

Will ask of personal or family history of cancer( Breast and colon) . Will ask if she has been genetically screened for BRCA1 and 2 gene mutations or for genetic mutations for the heriditay non polyposis colon cancer.

Will ask of her social history, with whom she is staying with, conditions at home, her habits regarding smoking and drinking. Will ask if she had any previous surgeries specilly abdominal ,as this may give idea about encountering adhesions in further surgery.

Will do general examination, BMI, pulse BP, pallor(anemia),jaundice, resp rate, chest examination for air entery ,lower limb for varicose veins , abdominal exam for hepatomegaly, abdominal masses that are hard and fixed, ascites, pelviabdominal examination for pelvi abdominal mass,its mobility and relation to uterus. Will feel pouch of Douglas for masses or nodules.

　

B)Investigatins will aim to detect her fittnes for different treatment modalities, detect her risk of malignancy index RMI,which will direct where she would be cared at(cancer center or unit), and to help in staging her cancer if it proved to be so by histopathological examination.

Routine investigations include, FBC, urea and electrolytes, liver function test, oxygen saturation , and clotting screen. Urine examined for glucose,protein,nitritis,ketones and blood.

Will measure tumour markers,CA125, CA19-9, CEA, Alpha feto protein, HCG.Will revise her ultrasound scan, to see if there is multulocularity,solid areas,ascites ,metastasis or bilatrality.RMI ( age before menopause 1 after menopause3 x scan finding one feature 1 ,two to five features 3 x level of CA125) . Count >250 has risk of malignancy 75%or more and should be treated in cancer center. Below this level can be treated in cancer unit.

Investigations that help in staging include chest x ray, abdominal ultrasound for intra hepatic metastasis, CT and MRI for para aortic lymph node metastasis.

　

　

C) Information should be given in a sensitive manner in a quite room and the patient is asked if she wants her partner or a family member to attend. Breaking bad news should be gradual and the patient is given time to express her self. The patient is told that the nature of the cyst is not yet known and that all the following procedures will aim to detect its nature and treat it.

She is told that she will be managed by a multidisciplinary team including oncology gynecologist,surgeon,medical oncologist,radiologist,and assisting staff. She will be cared directly after this session by the oncology nurse who will arrange her appointments and investigations. After finishing all investigations a multidisciplinary meeting will discuss her case and a staging lapar tomy is scadulled , to stage and secure a tissue diagnosis. The place of conservative surgery to secure her fertility is discused and this is usually limited to early disease stage1 a. She is told that if cancer is confirmed a major procedure that would include total abdominal hysterectomy,bilateral salpingo oophrectomy,mastectomy,lymphadenectomy with peritoneal sampling is done. She will be given information about the risks of surgery,including intestinal injuries and possibility of colostomy in case cancer has extended to intestine.

She will be given information about post operative recovery, care of colostomy, mobility and thromboprophylaxis.

She will be given information regarding chemotherapy if she will need it with its risks. Information about care at home. She is given information about her prognosis .

Late stages needing palliative care are given information about improvement of quality of life.Macmillan nurse is of help.

Patient given written information and contact details of support groups.

a)From the history, the presence of dysmenorrhoea, deep dysparunia and dyschezia should be enquired to rule out endometrioma. History suggestive of malignacy would be loss of appetite and loss of weight, early satiety, abdominal distension and spread of disease such as yellowish discolouration of eyes or skin, itching, pale coloured stools, tea coloured urine, dyspnoea and bone pain. Menstrual irregularities such as intermenstrual bleeding or menorrhagia might indicate an estrogen secreting tumour. Symptoms of sudden onset virilization such as hoarseness of voice, hirsutism suggest an androgen secreting ovarian tumour. History of gastrointestinal problems such as early satiety, upper or lower gastrointestinal bleed, altered bowel habits would suggest a possibility of Krukenberg tumour. Family history of ovarian or breast cancer or HNPCC should be enquired to rule out familial cancer syndromes. Personal history of combined oral contraceptive usage, parity and breastfeeding would be protective against malignancy. In contrast, nulliparity, and history of usage of ovulation drugs might increase the risk for malignancy. On examination, appearence of cachexia and palpable supraclavicular lymph node would indicate malignancy. A breast examination should be conducted to rule out malignancy which can cause secondaries to ovary. The abdomen maybe distended with overlying dilated veins in malignancy. A palpable abdominal mass would be smooth surfaced, firm or cystic in nature, able to get below with regular borders in benign condition. In malignancy, the mass would be irregular in surface with irregular borders, firm to hard in consistency and fixed. There could also be presence of ascites. On vaginal examination, there may be cervical motion tenderness, mass in the pouch of Douglas with restricted mobiltity, nodules in the rectovaginal pouch in case of endometrioma. Whereas in malignancy, the mass would be fixed and hard. There maybe palpable inguinal lymph nodes.

b)She would require a risk malignancy index scoring. The characteristic features of the ovarian mass on ultrasound, Ca125 level and premenopausal status is incorporated into this. Other tumour markers such as CEA, Ca19-9, Ca15-3, alphafetoprotein may aid in diagnosis. Baseline full blood count, liver and renal function tests to assess general well being and to have an idea on systemic involvement. A CT scan should be carried out to know the extent and spread of disease prior to embarking on definitive treatment.

c) The counselling and informing the possibility of malignancy should be done in a quiet and conducive environment for the patient and her family. They should be informed that the diagnosis can only be confirmed from histopathology obtained at surgery. A brief disease process, including its spread and associated complications should be told. The prognosis would largely depend on the stage of the disease which is ideally performed surgically and treatment following that. If she is suspected to be of high risk for malignancy based on the RMI score, then she would be referred to a cancer center so she can be managed in a specialised setting. The management will be planned by a multidisiplinary team consisting of a gynaeoncologist, clinical oncologist, radiologist, cancer nurse and psychologist. Treatment modalities usually would entail surgery with or without chemotherapy. Surgery is usually more successful if done by a gynaeoncologist. She would require life long follow up. Despite adequate treatment, there is a risk of recurrence. If she has not completed her family, with an early stage of disease, fertility preserving operation is an option to be considered. They should be informed that the further course of action would be based on the investigation results and she will be contacted and informed the results. The impact of the disease on her psychology and sexual health needs to be addressed including the effects on immediate family and care givers with referral to counsellors or psychologist if required.  A leaflet or written information should be provided on support groups.

a)     In my initial assessment I will ask her other symptoms rather than abdominal discomfort.Is there any pain specially dysmenrrhoea,dysperaunia to exclude endometrioma,symptoms of excessive hair growth-hirsuitism,virilism for hormone secreting tumour . History of weight loss,loss of apetite,urinary symptoms,rectal bleeding for detecting extent of tumour. 

I will take detailed menstrual history—cycle length,menorrhagia,intermenstrual bleeding,oligomenorrhoea.I will ask about her fertility –how many children she is having and wishes for future fertility.Her contraceptive method,ocp or others I have to ascertain.

Next I will take her family history of ovarian cancer,breast cancer or other malignancy.History of her previous ovarian cyst or breast cancer and treatment history.

In general examination I will check her built-cachexia,anaemia,jaundice,hirsuitism.In systemic examination I will look for ascitis,hepatomegaly,pleural effusin,lymphadenopathy,pelvic mass-fixed or mobile.

b)    Additonal investigations I have to do are routine blood test like FBC,group and crossmatching,urea and electrolytes,LFT,RFT etc.In the ultrasound report complex 7 cm right ovarian cyst is detected.We have to check details of this-evidence of solid portions,multilocularity,papillary projections,ascites for the possibily of malignancy.

CA-125 is an important tumour marker and for detecting risk of malignancy index we have to ask for this investigation.Other tumour markers-CAE.alphafetoprotein,hCG not so much significant.When we are confirm that it is a malignancy then for tumour staging we can do CXR,MRI etc.

c)   The information that should be provided to the women and her family that with the history and investigations we will detect the nature of her cyst either benign or malignant.According to the diagnosis we have to proced for treatment.If malignancy is detected we have to arrange multidisciplinary care-gynaecologist,pscychiatric support,cancer specialist,special nurse.If we are planning for surgery we have to take her consent and give her written document.Support group address,name of special nurse etc can help her a lot.If she is willing for fertility preserving surgery we have to make sure that unilateral oophorectomy will not expose her to future risk.

For treatment purpose we have to detece her RMI(risk of malignancy index).If it is <25 she will be treated by general gynaecologist in gynaecology unit,if 25-250 then in cancer unit by lead clinician,if >250 she will be reffered to specialist cancer center and treated by gynaecological oncologist.Treatment options like laparoscopy,if malignancy suspected then laparotomy-total abdominal hysterectomy,bilateral sulpingo oophorectomy, infracolic omentectomy,pelvic lymphadenectomy etc all should be discussed with her.Options for chemotherapy,its side effects everything should be informed.

a,The aim of initial assessment of the patient is to find out the cause of the ovarian mass and to evaluate the factors which are helpful in the management of patient.

A comprehensive history must be taken including history of duration of symtoms , associated bowel or urinary problems , pressure effects, weight loss as this may help to assess the severity of condition.any gynaecological complain like irregular mentrual cycle, dysmennorhea or dyspareunia may point towards a bnign condition.Any high risk factor  for ovarian cancer like infertility ,use of ovulation induction drugs ,family history of breast , ovarian or endometrial cancer will be helpful, in addition , history of androgenization like hirsutism ,increase muscle mass and deepening of voice may be due to andragen producing tumor.Patients previous obstetric history and her wishes regarding further regnancies must be explored .

The next step in assessment include through examination including general examination an ill cachexic lady most likely will be due to malignancy , any enlarge lymph noder in supraclavicular region must be identified, breast should be examined for any lump,abdominal exam to access the size of liver , any masses must be assessed, ascites must be ruled out..

a vaginal examination will be helpful as hard ,fixed mass is of concern ,

The investigation required at this stage include ultrasound of pelvis, TVS is more sensitive than TAS in ythe detection of pelvic pathology, solid component, ascites , bilateral tumour are more of malignancy in addition Doppler u/s with increase blood flow will increase the chances of malig.

b,if the patient is suspected of having ovarian cancer yen further invest. include tumor markers like CA125 whicj is raised in 80%of epithelial tumors, as she is at risk of having germ cell tumour alfa feto protein, hCG,must also be send.

a CT scan of abdomin and pelvis will help in staging of tumour .

and U/s guided or CT guided histopathology will be necessary in order to make a plan and it is recommended by latest NICE guidrline also to have histology rather than cytology  before surgery.

c, information giving is very difficult  an empathetic, sympaathetic approach should be ther patient should be informed about diagnosis,

likely treatment options incluging surgery which may make her infertile

if itlookslikeas  stage 1a , then option of fertility sparing surgery can be disscussed

need of chemotherapy after surgery

prolong follow up

support groups and information leaflets .

1. A detailed history should be taken including onset, site duration of pain and any relieving or exacerbating factors. Enquire about associated symptoms such as abnormal uterine bleeding, abnormal vaginal discharge, recent loss of appetite and weight and any altered bowel habits. Also enquire about any pressure symptoms on bowels and bladder. Detailed obstetric history be taken including enquiring about number of children, mode of deliveries and any future desire for children. Menstrual history including menarche, duration of cycle be taken. A cervical smear history be taken.. Enquire about any family history of any gynaecological (uterine, ovarian or breast) and bowel cancer.

Examination should include abdominal examination looking for any mass, tenderness and guarding. Pelvic examination should be done including , first,  speculum examination to look for any evidence of local metastases. A smear should be taken if not done is last 3 years or if any suspicious mass seen. Vaginal examination be done to assess uterine size, fixity of any mass and tenderness.

Investigations should include CA 125. As USS has already been done by GP, there is no need to repeat it. However,  a CT scan can be requested to assess cyst in more detail.

2) Further investigations should include blood tests including FBC; LFT’s to check for metastases. Imaging modality should include CXR to look for chest metastases. MRI be done to assess uterine and cervical involvement and assess lymph node status. BRCA 1 and 2 can be requested after discussing with geneticist.

3) Patient should be seen by a multidisciplinary team including Gynaecologist, Oncologist and McMillan nurses. She should be explained that she will need laparotomy, TAH, BSO, infracolic omentectomy +/- lymphadenectomy. She might require chemotherapy or radiotherapy depending on the staging of disease. Due to her being of young age, she will require HRT until the age of natural menopause to prevent her from osteoporosis and menopausal symptoms. Her family will need to be screened for BRCA 1 nad 2 genes and will need referral to geneticist if there is any evidence of that.

a) Initial assessment needs a detailed history including: onset and duration of pain,nature and pattern of pain,associated symptoms such as

nausea,vomiting, constipation,bleeding per rectum,altered appetite,weight loss,and urinary symptoms.It is important to ask about her reproductive status and her wishes about her future fertility as it will affect the plan of management.Family history of ovarian cancer or breast cancer should be taken.History of any medical illness should be asked to assess her fitness for treatment either surgical or chemotherapy.she should be asked about history of previous surgery.

General examination to check her weight,BMI,if she looks cachectic and to look for any palpable lymph nodes.Abdominal and pelvic examination to assess site,size,consistency and mobility of the mass and its relation to surrounding structures.

Investigations should include:pelvic ultrasound scan as it can differentiate between benign and malignant features of the mass.It can also detect presence of ascites and omental caking.Magnetic resonance imaging or computed tomography may be useful as they can identify metastasis and lymph node involvement.Serum CA125 should be performed as it is raise in most of cases with epithelial ovarian cancer.CEA may help to exclude possible  primary gastrointestinal tumour.AFP and HCG also should be checked to rule out germ cell tumours which can occur in this age group.

b)If ovarian cancer is suspected,surgery is most likely to be first line management so preoperative investigations are required to assees her fittness for surgey such as:full blood count, serum urea ,electrolytes and creatinine and liver functon tests.Chest x-ray to assess her fittness for surgery and to exclude lung metastasis.Liver and renal ultrasound may be required if metastasis is suspected.ECG and echocardiogram may be considered if she has pre-existing medical illness or if clinically indicated.Bowel imaging may be required if bowel involvement is suspected.

c) The woman and her family should be counceled in a quiet and sensitive manner with sympathy taking into consideration their emotional and psycological condition.They should be informed about the findings,the mass may be benign or malignant.She should be informed that she will need  laparotomy and wheather she will need fertility reserving surgery or total abdominal hysterectomy + bilateral salpingoophrectomy ,this will depend upon the tumour stage,her reproductive status and her wishes about her future fertility.She should be adviced that she needs referal to an oncology center under care of multidisciplinary team for appropriate management and follow up.She shoud be informed that the definitive diagnosis can be made only after full surgical staging and histological diagnosis.She should be councelled that she may need postoperative chemotherapy in case of advanced ovarian cancer.

a) My initial assessment would be firstly ascertain the patients fears as she may well have thoughts of cancer and explain that this process is to find this out. I would then start of by taking a hstory asking about pain, abdominal bloatiing, change in bowel habit, any recent need to go up in sizes of skirts (?ascites) or rapid weight loss likewise any change in her periods. A family history of breast, and ovarian cancer should be ascertained likewise any history of BRACA gene carrier status. Has she had children or attempted fertility treatment in the past and age of menarche should also be sought. I would also like to know if she has used any oral contraceptive pills in the past as well.  The next step would be an examination wherebyI would see if she is obviously cachectic or jaundiced. I would perform a chest examination to exclude any pathology - could be metastases and an abdominal exmination palpating for ascites, tenderness and if there are any palpable masses as well as palpating for lymphadenopathy. A bimanual examination is waranted next to see if there is any masses in the pelvis, and cervical excitation or adnexal masses palpable. A per recatl examination may also be done if a mass is felt in the pouch of douglas as this could differentiate a pelvic mass versus a rectal one. The next step would be to initail investagations which would be a CA125 test

b) A Full Blood Count, Urea and Electrolytes and Liver Function Test would be warantted as the may indicate an anemia which may complicate surgey or a neytrophilia that may indicate an infection that should be treated first or metastasis to the liver hence deranged LFT's or lastly any pathology with the kidneys. A cest X-Ray should also be performed to exclude chest mets and an IVU should also be performed to exclode a hydronephrosis or obstruction to the renal system. Lastly a Chest, Abdominal and Pelvic CT is waranted to help stage the disease.

c) Fistly explain the diagnosis of cancer and then explore the treatment options. If she is nulliparous then fertility sparing treatmnt options should be explored with full informed consent otherwise A Total abdominal hysterectomy and bilateral salpingo-oophrectomy with pelvic node biopsy is the standard method of treating ovarian cancers. This is usualy done in an Cancer centre with a multidisciplinary team where she can have accurate staging and this would have impact on her future survival rates. The operation does carry risks of infection, injust to other organs and significant co-morbidity afterwards with a risk of thromboembolism.In some cases this operation can be curative but the staging should still be performed as it would also determine whether she would require adjuvant chemotherapy which with standard modern day treatments available these are done as an out patient process and the common side effects are nausea, vomiting, diarrhea, hypersensitivty reactions, myelosuppression, alopecia, nephropathy and neuropathy but this would be managed by the gynea-oncologists. Afterwards she would be followed up in the clinic 3 monthly then 6 monthly then yearly for 5 years

(A)

History of presenting complaints including abdominal pain its nature onset duration and other characteristics of pain is important.

Nausea and or vomiting may indicate bowel and or ovarian origin .Constipation if any may point towards ovarian cause resulting from mechanical obstruction. Diarrhea and blood in stools may indicate irritable bowel syndrome.

Urinary symptoms like frequency dysuria may result from pressure symptoms.

Menstrual history including last menstrual period regularity cycle length presence or absence of dysmennorhea,cycle flow can help in considering endometriosis unovulatory abnormal uterine bleeding due to polycystic ovaries.

Contraceptive history including method and duration of usage in past and present is important as MIRENA is associated with ovarian cysts.

Cervical smear screening is noted.

Obstetric history including use of any drugs for ovulation if any.

Vaginal discharge in past or current and treatment taken is noted as it may indicate PID or tubo-ovarian masses.

Loss of appetite or early satiety along with history of weight loss is a pointer of underlying malignancy.

Family history of ovarian malignancy and breast malignancy is noted.

Examination includes assessment of BMI, blood pressure and general condition.

Pallor, icterus, hirsutism may indicate other or underlying clinical status.

Lymph node assessment including virchow’s node is needed.

Abdominal examination for size, swelling mobility and pain as it might help in making a diagnosis regarding the cause for swelling. Any surgical scars if any noted.

Speculum and bimanual examination will help in confirmation of abdominal findings.

 Per rectal if malignancy suspected.

(B)

Sympathetic approach is needed.

Tumour markers like Ca 125,CEA, Ca15-3, b HCG, Serum Inhibin, Alpha fetoprotein will all help in identifying the origin of tumour however some of them can be raised in physiological conditions as well.

CT scan for further delineation of ovarian swelling but associated with significant radiation exposure.

MRI helps in identifying positive pelvic and /Para aortic lymph nodes.

Full blood count, urea & electrolytes, Chest xray and ECG for assessing fitness for chemotherapy and pre surgery.

(C)

Patients and her family wishes are to be considered in management.

Referral to tertiary cancer centre is needed.

 Management will be done by gyn-oncologists, pathologist with interest in gynecology, clinical oncologist, radiologist and nurse in oncology.

The type of ovarian tumour, type, staging if done and her fertility wishes will guide further planning.

Surgery including staging laparotomy along with pelvic and para aortic lymph node dissection is discussed along with complications of same. Need for debulking surgery is also discussed.

Chemotherapy including drugs, route of administration (Oral/IV) and cycle length and its complications are discussed in details.

Intra-peritoneal chemotherapy discussed and correct information given.

Support care groups information provided and appropriate information leaflets regarding ovarian cancer given.

Prognosis and 5 year survival is discussed sympathetically.

My answer – Nee(written on A4 size paper in 25 min)

My initial assessment-

Sympathetic approach towards patient as diagnosis of ovarian cyst must have raised lot of anxiety in her.

I will ask her last menstrual period ,menstrual history, regularity of menstrual cycle . if she has severe dysmenorrhoea. I will ask her marital status , her parity is important & whether she has completed her family. Her sexual history , if she has dysparunia. As dysmenorrhoea & dysparunia can be associated with  endometriotic  cyst. If she is using any contraception. Her fertility history, is she on ovulation induction drugs. History of taking treatment of subfertility.  I will ask her medical history – if hypertensive & diabetic. I will ask her family history of ovarian cancers. If family history of or she is carrier of BRCA1 & 2 mutation. If family history of HNPCC(Hereditory nonpolyposis colon cancer).

I will also ask her if weight loss , loss of appetite , abdominal bloating or any fatigue she has noticed in recent past.

Iwill examine her general conditions to see pallor, pedal edema, icterus which may suggest advanced malignancy. Her respiratory & cardiovascular system auscultation. I will do per abdominal examination to assess for the mass , ascites, hepatomegaly/organomegaly. If required for the assessment per vaginal examination  to see cervical tenderness , adnexal tenderness & assessment of mass. I will assess her fertility wishes,

Additional investigations

   In 77% of ovarian cancers CA -125 is above 35 iu/l so I would like to see CA 125 levels. I will also rule out pregnancy in her, Other tumour markers like alpha fetoprotein, B –HCG may be helpful according to type of tumour. CT/MRI will also aid in knowing the details like metastasis. X-Ray chest for pleural effusion.

The information I will provide the woman in presence of her supportive family member will be in sensitive & sympathetic manner .

I will tell her that as malignancy is suspected she needs treatment in cancer centre where multidisciplinary team approach including oncosurgeon, gynaecological oncologist, anaesthetist & Mc Millan Nurses will assess & treat her.

She is required to undergo laparotomy which is exploratory . If tumour is grade I , only removal of that ovary/ovarian mass will suffice.

If tumour id advanced stage , she requires to undergo Total abdominal hysterectomy, bilateral salpingoophorectomy , peritoneal washing, peritoneal & omental biopsies, pelvic & paraaortic lymphnode sampling. If the tumour is advanced7 inoperable then only multiple biopsies & closing of abdomen & palliative care will be done.

I will tell her that she will also require chemotherapy.

I will provide her information leaflet by NICE.I will also provide her address & contact number of support group.

a) Her initial assessment would inlude a detailed history and examination.Her history would include duration of vague abdominal discomfort,any associated symptom like abdominal distension ,pressure symptom like bladder or bowel complaintsor exacerbating factor.History of general wellbeing,loss of appetite and weight loss should be taken.Menstrual history including irregular periods,menarche,use of oral contraceptive pill, and cervical smear history.Obstetric history should include parity and her future fertility concerns.Family history of ovarian, breast or colon cancer.A general physical examination should be done to look for lymphedenopathy including supralavicular lymph nodes and whether patient cachexic looking. On Per abdomen examination one would look for ascites, any hepatomegaly and mass. Details of mass should be noted to assess malignancy -size,consistency(cystic or solid),fixity,tenderness,nodularity.A per speulum and per vaginum examination should be done to confirm these findings and also to look for any uterine involvement. Chest should also be auscultated for any lung involvement

b) Additional investigations would include CA- 125 ,high levels would indicate towards malignancy although may be raised in other conditions aswell, also would help as baseline in after treatment followup.RMI (Reid Malignancy Index )can be calculated using ultrasound score,CA125 and pre or post menopausal score.CT abdomen and pelvis is important to know the extent and stage of ovarian malignancy.It would also reveal any liver, omental and gross peritoneal involvement.CT chest and Barium enema can be requested for if symptoms suggest lung or bowel involvement. Preoperative investigations would include FBC,U&E,LFT,BG& Save,Chest Xray,ECG.

c)The issue should be dealt with sensitively and should involve the patient and her family. A clear and descriptive information should be given including details of findings, probability of malignancy, its consequences, treatment options and followup.Offer Support groups and information leaflets. At her age fertility sparing surgery by laparoscopy can be offered  if found to be stage 1a. A definitive treatment would be a Staging laparotomy in advanced stage(TAH+BSO+Omentectomy+removal of any visible disease+peritoneal biopsies) followed by chemotherapy depending on the stage of disease. Information should be given for follow up and details of chemotherapy. Multidisiplinary team including oncologist,oncosurgeon,onology nurse would be involved in care. Information should be given regarding recurrence and survival. Information on Post surgery HRT use should be given.

A healthy 38 year old woman has been referred to the gynaecology clinic because she complained of vague abdominal discomfort. Ultrasound scan requested by the general practitioner showed a complex 7cm right ovarian cyst. (a) Discuss your initial assessment of this patient [10 marks]. (b) She is suspected of having ovarian cancer. Discuss the additional investigations that may be necessary [3 marks]. (c) Discuss the information that should be provided to the woman a

a)      I’ll take a detailed history to assess the possible risk of malignancy and its complications and effects of having a mass in abdomen. I’ll ask her about rapid weight loss and anorexia or early satiety. Ask her about rapid onset of the symptoms and any other changes in her body like development of hirsutism  or virilisation. I’ll take menstrual history staring from her menarche regularity of her cycles and menstrual loss and any change from past  and her LMP and intermenstrual or post coital bleeding. I’ll inquire about dysmenorrhoea and deep dysparunea. I’ll take her obstetric history including number of pregnancies and live births she had and mode of deliveries and her future fertility aspirations. I’ll take bowel history any recent change in bowel habit or constipation alternating with diarrhea or passage of blood in stools. I’ll ask about urinary symptoms such as frequency or urgency pain in bladder or passage of frank blood in urine. T o know about having the metastasis I’ll ask about cough, severe abdominal pain, headache or blurring of vision or nausea and vomiting. I’ll examine her in detail including detailed general physical examination ,her BMI ,pulse and blood pressure  pallor, jaundice, lymhadenopathy in cervical ,supraclavicular inguinal and axillary areas. I’ll auscultate the chest for mets, auscultate the heart and look for any sensoneurenal dysfunction. I’ll palpate abdomen for any mass and organomegaly and check for ascities. I’ll perform speculum examination  to look for any obvious lesion in vulva and vagina and cervix and take cervical smear if not taken in past three years and do bimanual examination to assess the size and mobility of mass and note ant tenderness. If the mass seem to extend to pelvic wall I’ll ask special permission for rectal examination to assess its relation with pelvic wall.   I’ll request  for a detailed tertiary level ultrasound to know further details of mass and any abdominal mets and presence of asities. I’ll request for ca 125 and as she is under 40 I’ll ask for alpha feto protein and hcg levels also. I’ll ask for baseline full blood count and due to possibility of malignancy base line liver and kidney function tests. I’ll ask for chest x-ray to exclude any mets.

b)      I may need C-T scan of pelvis and abdomen to assess the extent of disease. I may need C-T scan of chest or head depending upon her clinical condition. If mass is penetrating parametrium or she is having urinary symptoms or blood in urine  I’ll ask for IVPand cystoscopy. If she has bowel symptoms she may need barium study of bowel.

I’ll talk to her with sympathy and in the presence of her partner or relative if she wants. I’ll not disclose the diagnosis abruptly rather I’ll give her some warning signs like, I am afraid we are going to have a serious discussion; it may not be a good news for you. Then I’ll give her time to be prepared to listen to the news and when she is ready I’ll disclose the diagnosis softly and politely in a sympathetic manner. I’ll ask her what and how much she  want to know at this moment and give her the details about her disease and management if she like to know. I’ll provide her with hospital phone numbers she can contact  and appointment with the hospital counseling nurse address of authentic websites for patient information and local support groups. I’ll give her another appointment  to discuss further details and appointment with her partner or family if she wants .           

I notice that for the 3 stem-regarding providing information to family and patient,most posts have omitted about counselling for Familial Malignancy. The patient is young and at a unlikely age for CA Ov and I think they must be told about screening ans UKFOCSS.

I notice that for the 3 stem-regarding providing information to family and patient,most posts have omitted about counselling for Familial Malignancy. The patient is young and at a unlikely age for CA Ov and I think they must be told about screening ans UKFOCSS.

a-   Duration of  pain, abdominal distension and sever pain now, associated symptoms like weight loss may suggest malignancy, nausea and vomiting due pressure effect from large cyst. Menstrual history irregularity due hormone release by tumour, virilisation effect from androgen secreting tumour like hair suitism, clitoromegally and breast atrophy, voice change.

     Family history of breast, ovarian and bowel cancer from first degree relative may suggest BRCA1, BRCA2 and LYNCH2.

Medical problem previous surgical operations to see how see fit for surgery.

    Examine the patient looking for loss of weight, jaundice suggest liver metastasis, mass size, consistency, mobility and surface smooth, features like cystic and solid consistency, irregular surface, non mobile cyst and lymph node involvement may suggest malignancy.

B-   full blood count looking for anaemia, may need blood transfusion to optimise her health before surgery, liver function and renal function test may affected by malignancy.

     Chest x ray. CT  or MRI Scan of chest and abdomen looking for metastasis and lymph nodes involvements.

     Tumour markers like CA125 elevated in 85% of ovarian cancer, CA19-9, carcino- embryonic antigen, alfa feto protein.

c- I inform the patient about suspension of finding, the management will be in cancer centre where meeting will held by gynaecologist oncologist, oncologist, radiologist, cancer nurse to plane best treatment options.

The operation more likely be total abdominal hysterectomy, bilateral salpengo oopherectomy, infra colic omentectomy, lymph adenoidectomy and chemotherapy.

I inform patient she will loss her ovaries and uterus she may need hormone replacement therapy until 50 years to control hot flush and menopause symptoms and osteoporosis.

After surgery  she needs chemotherapy now we use cisplatin or carboplatin with  paclitaxel is best combination to reduce recurrence and control micro metastasis.

X

Essay 348 ( Ovarian cancer management)

a)      History in regards to the pressure symptoms such as fullness, bloating , abdominal pain should be taken. Constitutional symptoms such as loss of weight and apetite should be taken. Per rectal bleed and altered bowel habit could indicate more advanced cancer. Menstrual history in regards to secondary dysmenorrhea could suggest endometrioma with history of subfertilty . Presence of virilisation such as acne, hirsutism, breast atrophy could indicate a androgen secreting tumour. Her fertility wishes must be noted in regards to fertility sparing procedure. Previous medical history should be taken such as hypertension, diabetes, asthma , venous thromboembolism must be taken for surgical risk. Previous history of breast cancer and family history of breast cancer or ovarian cancer could prompt presence of BRCA gene mutation. Previous surgical history is important to note any evolution of any ovarian mass prior , endometriosis which given rise to endometrioma or risk of adhesion. History of sexually transmitted disease or pelvic inflammatory disease could indicate tuboovarian mass.

Examination should include general build in which cachexia could indicate advanced cancer, body mass index for surgical difficulty and venous thromboembolism risk. Lymph nodes such as supraclavicular lymph node should be palpated eventhough it is rare. Abdominal examination to assess size of mass, tenderness , mobility and presence of clinical ascited is important. Pelvic examination should be done to  assess the mass bimanually  if it is mobile, tender or spate from the mass. The presence of fixed retroverted uterus with nodularity could indicate endometriosis with a endometrioma. Blood investigation of full blood count to assess for anemia and tumour marker such as CA125 is important for risk stratification. I will also take other tumour markers such as, carcinoembryonic antigen, alpha feto protein and LDH.

b)      I would arrange a CT scan of the pelvis, abdomen and thorax to ascertain any distal metastasis and presence of enlarged internal lymph nodes. I would also arrange a colonoscope if any feature of bowel symptoms are present.

c)       Patients should be informed the risk of cancer based on risk malignancy index and ultimately it is a histopathological diagnosis.  She will be informed that a multidisciplinary team involving the gynae oncologist, oncologist, radiologist, patholgogist and nurses will be caring for her. Her fertiliy wishes must be ascertained and inform her that in malignancy the operation involves total abdominal hysterectomy, bilateral salphingoopherectomy with infracolic ommentectomy. But in fertility preservation a unilateral slphingoopherectomy with infracolic ommentectomy could be done for stage 1 ovarian cancer. The possible need for chemotherapy must be informed depending on the stage and grade of ovarian tumour. She will be requiring long term follow up. She should be referred to psychologist, counselors and support group to deal with her emotions. Her family members should be included in the discussion if she permits. She should be informed that her family member should be screened for BRCA mutation for screening purpose.

My initial assessment will include duration of vague abdominal discomfort, bowel symptoms (pointing towards irritable bowel syndrome), bloating/early satiety, history of weight loss, loss of appetite(pointing towards malignancy), urinary pregnancy, especially if symptoms are more than 12 times per month, abdominal fullness, shortness of breath (ascites or pleural effusion)

I will also enquire regarding her cervical smears and irregular bleeding.  I will ask about her fertility wishes and whether her family is complete or not.

On general examination, I will look for cachexia, pallor, jaundice, pedal oedema, lymphadenopathy for signs of mailgnancy.  I will do abdominal examination for fluid thrill/shifting dullness for ascites and feel for fixed irregular mass.  I will do vaginal examination to feel for firm, fixed or irregular mass in adenexae.  I will do baseline investigation- full blood count, urea and electrolytes, liver function test and clotting for assessing her current status for future treatments.

B- I will need to know risk malignancy index which is U*CA125*M (U=ultrasound features, M=menopausal status).  This will help to decide whether she is operated by general gynaecologist (RMI<25), Cancer unit (RMI 25-250) or Cancer centre (RMI>250).  I will do CT abdomen and pelvis for staging and MRI abdomen and pelvis for lymph node metastasis. Chest X-ray will be dome to rule out pulmonary metastasis.

C- Information will be provided according to RMI.  I will counsel her that we are suspecting ovarian malignancy but diagnosis is confirmed only after histology and prognosis will depend on staging laparotomy, type and grade of tumour.  I will discuss surgery which will include laparotomy for total abdominal hysterectomy, bilateral salphigo-oopherectomy, pre-operative washings/ascites, infra-colic omentectomy, visualtion/palpation of undersurface of diaphragm, liver, spleen and appendix.  She might need referral to cancer centre as prognosis is better if operated by gynaecological oncologists.  Depending on her RMI, CT/MRI findings and fertility wishes, unilateral oopherectomy can be considered.  She may need post-operative chemo-radiotherapy.  She will be seen by multidisciplinary team involving oncology nurse, medical oncology team and gynaecology oncologist.

A) This patient has a suspecious ovarian mass initial assessment should include a detailed history of the present complaint; when she started to have abdominal pain or discomfort,what other associated symptoms such as nausia, vomiting, anorexia, and any changes in her wieght or changes in her abdominal girth.

I will inquir about LMP and regularity of her periods .any personal or family history of malignancies such as breast, colon or ovarian cancers.

Her previous obstetric history and mode of deliveries and any previous surgical procedures , specialy abdominal or pelvic surgery. I will ask her about any medical problems and anyy previous treatment if any, and what are the effect of the mass on her daily activities.social history including cigarret smoking, alcohol and any illigal drug

physical examination will include general apperence,pale,jundice or catechexic

I will check her BMI and her vital signs including pulse, blood pressure and tempretuare, then, I will examine her chest, especialy if she has any reperatory symptoms,by ascultation to check if there is any abnormal findings such as decrease in respiratoty sounds or creptations.

Abdominal examinattion starting with inspection of any change in abdominal colour any distension and any previoussurgical scar.

by palpation I will check if the abdomin is soft and lax and if there is any signs of ascites. what is the size of the ovarian mass if it is palpable and is fixed or freely mobile and is it soft or hard.

vaginal examination including the vulva and vagina and speculum examination to exclude any associated cervical abnormalities and to have PAP smear nd vaginal swabs if it is indicated, vaginal examination with mimanual examination to assess the uterus size , to pllpate the adnexia and to assess the ovarian mass; size, testure and mobility.

　

B) The investigations will include; full blood count. to idintify any decreased in haemoglobin and possible need for blood transfusion later on,urea and electrolytes to check renal function,liver functions test esspecialy if she will have surgery.

Tumour markers, CA125- hCG-LDH-E2-CEA-AFP, may be helpful to determine the possible type of ovarian cancer and as base line for follow up later on.

other investigations may include CXR if there is respiratory symptoms or signs and if there is suspecion of pulmonary metastasis, abdominal US to check for possible hepatic metasis and /or any abdominal masses and to rule out hydronephrosis. IVP may be indicated to assess the ureter and it is helpful in the subsequent surgery esspecialy if there is indirect sings of urinary tract involvement by abdominal ultrasound.

CT scan and MRI may be idicated to assess the ovaien mass and to assess the involvement of pelvic lymph nodes and or any abdominal or pelvic metastasis

c) The ultrasound findings should be explained to the women and we should avoid medical jargons.

the risk of malignancy and further managment including possible need for abdominal hysterectomy and bilateral salpingoopherectomy that will lead her to infertile. and assess her wishes towrds hermanagment plan and make her participate in decision making

I will respect the patient wishes to disclose information to her partner or her family

information about the surgical procedure if any and possible need for chemotherapy and when the defenitive diagnosis can be made and the importance of follow up.

information about the surgical team including the anaesthatic and information about the hospital that the procedure will be carried out in and the date of the procedure.

the most appropriate contraception for her, and the reccurence risk.

patient should be provided with written information and support groups adress.