Biological and psychosocial issues

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Ovarian Cancer

 

Ovarian cancer is the second most common gynecologic malignancy, but the most common cause of death among women who develop gynecologic cancer, and it is the fifth most common cancer in females.

Clinical manifestations

Most ovarian cancers are diagnosed between the ages of 40 and 65. Symptoms of early stage disease are often vague. Acute symptoms due to ovarian rupture or torsion are unusual. As a result, 75 to 85 percent of cases of ovarian cancer are advanced at the time of diagnosis. More advanced disease is typically associated with abdominal distention, nausea, anorexia, or early satiety due to the presence of ascites and omental or bowel metastases.
Most women have nonspecific symptoms, such as lower abdominal discomfort or pressure, gas, bloating, constipation, irregular menstrual cycles/ abnormal vaginal bleeding, low-back pain, fatigue, nausea, indigestion, urinary frequency, or dyspareunia.

Physical examination

Palpation of an asymptomatic adnexal mass during a routine pelvic examination is the usual presentation for ovarian cancer. The presence of a solid, irregular, fixed pelvic mass on pelvic examination is highly suggestive of an ovarian malignancy.
However, endometriomas and tubo-ovarian abscesses are benign tumors that may be fixed, while cystadenofibromas and tubo-ovarian abscesses are benign masses that feel irregular. The diagnosis of malignancy is almost certain if a fixed, irregular pelvic mass is associated with an upper abdominal mass or ascites.

Diagnostic evaluation

The finding of a pelvic mass usually requires surgery for definitive histologic diagnosis. Tumor markers and ultrasound examination can help distinguish between malignant and benign pelvic masses.
A complete pelvic examination and assessment of cervical cytology should be performed preoperatively. Routine hematologic and biochemical assessments should be obtained prior to surgery.
It is reasonable to pursue a period of observation in a premenopausal woman with an adnexal mass if the mass is not clinically suspicious on ultrasonography. Adnexal masses that are mobile, purely cystic, unilateral, less than 8 to 10 cm in diameter, and have smooth internal and external contours by ultrasound are highly unlikely to be malignant and can be followed for two months; the majority of physiologic cysts will regress during this time.
Exploration is indicated if there is no resolution within two months. However, women who have solid, fixed, irregularly shaped, or large masses should undergo surgery. A mass that increases in size or does not regress must be presumed to be neoplastic and should be removed surgically.

Staging

Surgery is necessary for diagnosis, accurate staging and optimal cytoreduction, and is crucial for the successful treatment of EOC.

Definitions of the Stages in Primary Carcinoma of the Ovary :

Stage I:

• A. Growth is limited to the ovaries.
• B. Growth is limited to one ovary; no ascites present containing malignant cells; no tumor on the external surface; capsule is intact.
• C. Growth is limited to both ovaries; no ascites present containing malignant cells; no tumor on the external surfaces; capsules are intact.
• D. Tumor is classified as either stage A or B but with tumor on the surface of one or both ovaries; or with ruptured capsule(s); or with ascites containing malignant cells present or with positive peritoneal washings

Stage II:

• A. Growth involves one or both ovaries with pelvic extension.
• B. Extension and/or metastases to the uterus and/or tubes.
• C. Extension to other pelvic tissues.
• D. Tumor is either stage A or B but with tumor on the surface of one or both ovaries; or with capsule(s) ruptured; or with ascites containing malignant cells present or with positive peritoneal washings

Stage III:

• A. Tumor involves one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes; superficial liver metastasis equals stage III; tumor is limited to the true pelvis but with histologically proven malignant extension to small bowel or omentum.
• B. Tumor is grossly limited to the true pelvis with negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces.
• C. Tumor involves one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces, none exceeding 2 cm in diameter; nodes are negative.
• D. Abdominal implants greater than 2 cm in diameter and/or positive retroperitoneal or inguinal nodes

Stage IV:

• Growth involves one or both ovaries with distant metastases; if pleural effusion is present, there must be positive cytology findings to assign a case to stage IV; parenchymal liver metastasis equals stage IV.

Treatment of ovarian cancer

Cytoreductive surgery improves response to chemotherapy and survival of women with advanced ovarian cancer. Operative management is designed to remove as much tumor as possible.
When a malignant tumor is present, a thorough abdominal exploration, total abdominal hysterectomy, bilateral salpingo-oophorectomy, lymphadenectomy, omentectomy, and removal of all gross cancer are standard therapy.

Adjuvant therapy

Patients with stage I(A,B)disease (who have been completely surgically staged) and who have borderline, well- or moderately differentiated tumors do not benefit from additional chemotherapy because their prognosis is excellent with surgery alone.
Chemotherapy improves survival and is an effective means of palliation of ovarian cancer. Sequential clinical trials of chemotherapy agents demonstrate that cisplatin (or carboplatin) given in combination with paclitaxel is the most active combination identified.