What is ovarian cancer?
Ovarian cancer happens when normal cells in the ovary change into abnormal cells and grow out of control. Fallopian tube and primary peritoneal cancer is very similar to ovarian cancer and treated essentially the same. The ovaries are organs that are part of a woman’s reproductive system. Ovarian cancer occurs most often in women ages 40 to 65, and sometimes runs in families.
There are three types of ovarian cancers.
Epithelial (serous, papillary serous, or adenocarcinoma of the ovary) - This is the most common type of ovarian cancer making up to 80% of the caners. It develops from the surface of the ovary. Primary Pertioneal cancer is very similar to this type of ovarian cancer, but originates from the cells that line the abdominal cavity.
Germ Cell tumors - Originate from the cells that produce eggs with in the ovary. Most commonly these are not cancerous. Invasive tumors tend to occur in younger women and tend to be symptomatic because the grow rapidly.
Sex-Cord Stromal tumors – These tumors are derived from the connective tissue of the ovary and can produce excess hormones such as estrogen and testosterone and therefore may have symptoms associated with excess hormones.
What are the symptoms of ovarian cancer?
Symptoms of ovarian cancer can be very “vague” and include:
Abdominal bloating or discomfort
Increasing abdominal girth
Increasing urge or frequency of urination
Persistent gas, indigestion or nausea
Unexplained changes in bowel habits, including diarrhea or constipation
Unexplained weight loss or gain
Loss of appetite
Feeling full quickly during or after a meal
Low back pain
Shortness of breath
These symptoms are often from time to time and can be caused by conditions that are not ovarian cancer. But if you have these symptoms and they persist, you should see your doctor.
Is there a test for ovarian cancer?
Commonly the following tests are ordered if a patient has symptoms or suspected to have ovarian cancer:
- Ultrasound or CT scan – An ultrasound is very usefully to evaluate the ovaries and can identify suspicious looking ovarian masses. CT scans can help find metastatic disease such as ascites (fluid in the abdomen), enlarged lymph nodes, or omental “caking”.
- Blood tests – A blood test called “CA 125” is sometimes used to help diagnose ovarian cancer, however it is not a good screening test as it can be negative in ovarian cancer and positive in a number of benign diseases. Gynecologic oncologist use CA-125 more during treatment to evaluate response and post-treatment to monitor for recurrence.
- Surgery – The only way to know for sure if a woman has ovarian cancer is to do surgery and remove the ovary and have a pathologist evaluate the ovary during the surgery to diagnose the cancer. If cancer is diagnosed the surgeon will proceed with appropriate staging or “debulking”.
Ovarian cancer is surgically staged. Surgery includes pelvic washings, removal of both tubes and ovaries, uterus (can be preserved if patient desires future fertility), pelvic and para-aortic lymph node dissection, omentectomy (removal of a fatty pad that overlies the intestines), and peritoneal biopsies. If there is a large amount of disease in the abdomen the goal of the surgeon is to “debulk” all of the disease so there is no evidence of disease at the end of the procedure. This could include bowel resections, removal of the spleen, liver resections, and diaphragm resections.
OVARIAN CANCER STAGING
| Stage I ||A ||Tumor limited to one ovary with no surface involvement |
| ||B ||Tumor involves both ovaries with no surface involvement |
| ||IC ||Involves one or both ovaries with surface involvement, ruptured ovary or positive peritoneal fluid |
| Stage II ||IIA ||Tumor deposits on uterus or fallopian tubes |
| ||IIB ||Tumor deposits within the pelvis |
| ||IIC ||Tumor within the pelvis with positive peritoneal fluid or ascites |
| Stage III ||IIIA ||Microscopic disease outside the pelvis |
| ||IIIB ||Gross disease ≤ 2 cm outside the pelvis |
| ||IIIC |
|Gross disease > 2cm outside the pelvis or positive pelvic or/and para-aortic lymph nodes |
| Stage IV ||IV ||Distant metastatic disease |
Surgery alone is not typically curative alone, However in Stage IA, Grade 1 Tumors adjuvant chemotherapy is not necessary in this subset of patients. If fertility is an issue in those patients who have had a thorough staging procedure, the uterus and contra-lateral ovary may be conserved.
In Stages IA (Grades 2 and 3), IC, II, III, IV chemotherapy is recommended. If a patient is optimally “debulked,” meaning there is no residual disease left after surgery or the residual disease < 1 cm, then the best outcomes involve treatment with platinum and taxane chemotherapy intravenously and intraperitoneally. There is overwhelming evidence to support a significant improved survival with the use of intraperitoneal chemotherapy.
Patients that are not optimally “debulked,” meaning there is residual disease at the end of surgery > 1 cm, are recommended to receive intravenous chemotherapy. Occasionally these patients will be offered “interval debulking” after 3-4 cycles of chemotherapy.
After completion of chemotherapy, follow-up for the first 2 years is every 3 months, every 6 months for 3 more years and then yearly thereafter. Pelvic exam and CA-125 at each visit and PAP smear on an annual basis as indicated. Routine performance of imaging studies (CT scans, Chest X-ray, etc) are not routinely done but should be individualized and usually based on physical examination, CA-125 results, and/or patient symptoms.
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