Cancer of Lhe ovary ueflnlLlon Cvarlan cancer ls a heLerogeneous group of mallgnancles

LhaL arlses from Lhe varlous cell Lypes LhaL compose Lhe organ LplLhellal nearly 90 of
ovarlan mallgnancles are classlfled as eplLhellal ovarlan carclnom as 1hese cancers arlse
from Lhe germlnal eplLhellum llnlng Lhe ovary LplLhella l ovarlan cancer can be furLher
subdlvlded lnLo several hlsLologlc cell Lypes serous muclnous endomeLrlold clear cell
LranslLlonal and undlfferenLlaLed carclnomas 1he rlsk of eplLhellal ovarlan cancer
lncreases wlLh age and ls found predomlnanLly ln posLmenopausal women LplLhellal
Lumors of low mallgnanL poLenLlal (borderllne ovarlan carclnoma) are a hlsLologlc
varlanL LhaL ls less aggres lve Lhan Lhelr lnvaslve eplLhellal counLerparLs are found ln
younger women and are ofLen conflned Lo Lhe ovary aL dlagnosls Cerm Cell Cerm cell
Lumors accounL for approxlmaLely 3 of all ovarlan cancers and recaplL ulaLe Lhe
developlng embryo or placenLal sLrucLures PlsLologlc subLypes lnclude dysgermlnoma
(mosL common) endodermal slnus Lumor lmmaLure LeraLoma chorloca rclnoma and
embryonal carclnoma Cerm cell ovarlan cancer can occur ln women of any age buL
approxlmaLely 80 of Lhese are dlagnosed ln women younger Lhan 30 years Sex Cord
SLromal Sex cord sLromal Lumors whlch accounL for approxlmaLely 3 of all ovarlan
cancers develop ln Lhe connecLlve Llssue and supporLlng ovarlan sLroma 1hese Lumors
are generally less aggresslve and ofLen produce sLerold hormones lncludlng esLrogen
progesLerone and LesLosLerone Some paLlenLs wlLh hormoneproduclng Lumors
presenL wlLh slgns and sympLoms of sLerold excess such as vaglnal bleedlng or
hyperandrogenlsm revalence Accordlng Lo Lhe Amerlcan Cancer SocleLy Lhere were
more Lhan 23000 new cases of ovarlan cancer and 14000 deaLhs from Lhe dlsease ln
Lhe unlLed SLaLes ln 200 1 lL ls esLlmaLed LhaL a woman has a 1 Lo 2 llfeLlme rlsk for
developlng ovarlan cancer Cvarlan carclnoma ls Lhe flfLh mosL frequenL cause of cancer
deaLh l n women and one half of all cases occur ln women older Lhan 63 years
aLhophyslology 1he cause of ovarlan cancer ls poorly undersLood however rlsk facLors
and mode of spread have been well descrlbed 8lsk lacLors 1he mosL slgnlflcanL rlsk
facLor for ovarlan cancer ls a poslLlve famlly hlsLory When Lwo or more flrsLdegree
relaLlves have or have had ovarlan cancer a womans llfeLlme rlsk for developlng Lhls
cancer ls 7 lf a herlLable cancer syndrome ls ldenLlfled Lhls llfeLlme rlsk can lncrease
17 Lo 30fold 1hree domlnanLly lnherlLed muLaLlons are known Lo be assoclaLed wlLh
Lhe developmenL of approxlmaLely 10 of all ovarlan carclnomas breasLovarlan cancer
syndrome whlch ls assoclaLed wlLh muLaLlons ln 88CA1 and 88CA2 genes slLespeclflc
ovarlan car clnoma and heredlLary non polyposls colorecLal cancer (Lynch syndrome ll)
whlch ls assoclaLed wlLh muLaLlons ln mlsmaLch repalr genes Advanced age ls also
assoclaLed wlLh lncreased rlsk whereas hlgh parlLy oral conLracepLlve use Lubal
llgaLlon and hysLerecLomy decrease ones rlsk Mode of Spread Cvarlan cancer usually
spreads vla cellular sheddlng lnLo Lhe perlLoneal cavlLy followed by lmplanLaLlon on Lhe
perlLoneal surface Local lnvaslon of Lhe bowel and bladder ls common ln advanced
cases 1umor cells also may block dlaphragmaLl c lymphaLlcs 1he resulLlng lmpalrmenL
of lymphaLlc dralnage of Lhe perlLoneum l s belleved Lo play a role ln developmenL of as
clLes ln ovarlan cancer 1ransdlap hragmaLlc spread and seedlng of Lhe pleura wlLh
pleural effuslon are also common ln advanced cases Slgns and SympLoms
unforLunaLely mosL paLlenLs wlLh eplLhellal ovarlan cancer experlence few or no
sympLoms unLll Lhe dlsease has wldely meLasLaLaslzed ManlfesLlng sympLoms usually
relaLe Lo an lncreaslng lnLraabdomlnal Lumor burden and as clLes and are ofL en vague
mlmlcklng oLher more common dlseases SympLoms lnclude faLlgue bloaLlng or a
feellng of fullness abdomlnal swelllng or paln early saLleLy vague buL perslsLenL
gasLrolnLesLlnal complalnLs such as gas nausea and lndlgesLlon frequency or urgency
of urlnaLlon change ln bowel hablLs unexplalned welghL loss or galn shorLness of
breaLh and obsLrucLlve sympLoms such as nausea vomlLlng and consLlpaLlon or
obsLlpaLlon Cn Lhe oLher hand borderllne germ cell and sex cord sLromal Lumors are
ofLen conflned Lo Lhe ovary aL Lhe Llme of dlagnosls 1hey may be qulLe large aL
presenLaLlon and assoclaLed sympLoms may be relaLed Lo Lhelr large slze 1hese masses
are occaslonally deLecLed durlng Lhe screenlng pelvlc examlnaLlon More commonly
paLlenLs feel Lhe mass Lhemselves or presenL wlLh sympLoms of acuLe abdomen du e Lo
Lorslon of Lhe adnexa or rupLure of Lhe Lumor ulagnosls a compleLe physlcal
examlnaLlon ls Lhe flrsL sLep ln Lhe dlagnosls of ovarlan cancer AlLhough pelvlc
examlnaLlon ls noLorlously lnefflclenL aL deLecLlng presym pLomaLlc early ovarlan cancer
a pelvlc mass can ofLen be palpaLed on examlnaLlon ln sympLomaLlc paLlenLs 1he
flndlng of a unllaLeral or bllaLeral non moblle (flxed) mass ls characLerlsLlc of eplLhellal
ovarlan carclnoma Culdesac masses may also be palpaLed wlLh recLovaglnal
examlnaLlon lmplngemenL of Lhe recLum an d compromlse of lumen dlameLer can also
be appreclaLed on Lhls examlnaLlon Abdomlnal dlsLenLlon due Lo as clLes ls anoLher
common flndlng 1he dlsLended abdomen ls dull Lo percusslon and anomenLal cake may
be palpaLed ln Lhe upper abdomen lurLher dlagnosLlc workup ls necessary Lo esLabllsh
exLenL of dlsease and exclude oLher causes of an adnexal mass carclnomaLosls or as
clLes lmaglng SLudles 1ransvaglnal ulLrasound uses hlgherfrequency sound waves Lo
lmage Lhe ovarles allowlng lmproved morphologlc characLerlzaLlon 1he addlLlon of
color flow uoppler can furLher characLerlze Lhe mass A vascular mass wlLh low reslsLlve
lndlces supporLs a dlagnosls of mallgnancy ChesL xray mlghL lndlcaLe pleural effuslon
whlch ls common ln paLlenLs wlLh ovarlan carclnomaLosls C1 scans of Lhe abdom en and
pelvls wlLh lnLravenous and oral conLrasL characLerlze Lumor burden and asslsL ln
evaluaLlng oLher causes of adnexal mass carclnomaLosls or as clLes CL her sLudles may
be performed based on a paLlenLs rlsk facLors and sympLoms aL p resenLaLlon 1hese
lnclude slgmoldoscopy colonoscopy or barlum enema upper gasLrolnLesLlnal
endoscopy and lnLravenous pyelogram Serum 1umor Markers Serum Lumor markers
can asslsL ln preoperaLlve evaluaLlon however Lhelr llmlLaLlons musL be undersLood so
Lhey are noL mlslnLerpreLed or obLalned lnapproprlaLely Serum LesLlng ls essenLlal Lo
monlLorlng LreaLmenL response for ovarlan can cer buL lLs usefulness as a dlagnosLlc
Lool ls hlndered by poor senslLlvlLy and speclflclLy CA 123 ls a hlghmolecularwelghL
glycoproLeln LhaL ls expressed b y more Lhan 80 of nonmuclnous eplLhellal ovarlan
cancers AlLhough elevaLed ln mosL women wlLh advanced ovarlan cancer only 30 of
paLlenLs wlLh earlysLage dlsease have an elevaLed CA 123 and muclnous eplLhellal
ovarlan cancers express Lhls anLlgen poorly lurLhermore an elevaLed CA 123 ls noL
speclflc for ovarlan cancer Many nongynecologlc and benlgn gynecologlc condlLlons
also are assoclaLed wlLh elevaLlons ln Lhls serum anLlgen lf noneplLhellal ovarlan cancer
ls suspecLed oLher Lumor markers may be useful Lo asslsL ln dlagnosls Alpha
feLoproLeln human chorlonlc gonadoLropln and lac Llc dehydrogenase may be
expressed by germ cell mallgnancles lf meLasLaLlc colo n or pancreaLlc carclnoma ls
suspecLed serum carclnoembryonlc anLlgen and CA 19 9 mlghL also be elevaLed
LlmlLaLlons ln Lhe senslLlvlLy and speclflclLy of Lhe se LesLs musL be undersLood so Lhey
can be lnLerpreLed approprlaLely for each pa LlenL aracenLesls MallgnanL asclLes ls
common ln paLlenLs wlLh meLasLaLlc eplLhellal ovarlan carcl noma Powever asclLes due
Lo oLher condlLlons such as congesLlve hearL fallure and clrrhosls musL be ruled ouL by
careful hlsLory and lf necessary dlagnosLlc LesLlng AlLhough paracenLesls may be
performed for cyLologlc examlnaLlon dlagnosLlc par acenLesls ls noL necessary for mosL
paLlenLs lf Lhey have already been deemed ap proprlaLe for exploraLory surgery and
operaLlve managemenL lurLhermore a negaLlve cyLology from preoperaLlve
paracenLesls does noL exclude Lhe posslblllLy of mallgnancy and dlfferenLlaLlng Lhe slLe
of Lumor orlgln ls rarely posslble on cyLologlc examlnaLlon Largevolume LherapeuLlc
paracenLesls however may be useful for palllaLlon of sympLoms of abdomlnal
dlsLenLlon and assoclaLed resplraLor y compromlse due Lo dlaphragmaLlc elevaLlon
ConsulLaLlon lf a reasonably hlgh probablllLy for ovarlan mallgnancy exlsLs consulLaLlon
wlLh a gynecologlc oncologlsL ls essenLlal Lo ensure approprlaLe preoperaLlve counsellng
and preparaLlon operaLlve managemenL and posLoperaLlve care 1reaLmenL Cvarlan
cancer ls lnlLlally managed wlLh exploraLory laparoLomy Lo conflrm Lhe dlagnosls and
deLermlne Lhe exLenL of dlsease (surglcal sLaglng) and for Lumor cyLoreducLlon
PlsLologlc ldenLlflcaLlon 1he avallablllLy of rellable lnLraoperaLlve frozen secLlon ls
essenLlal for opLl mal surglcal declslon maklng and managemenL lor example ferLlllLy
sparlng surg ery may be an opLlon ln selecL ovarlan mallgnancles such as germ cell
Lumors l n addlLlon alLhough Lumor debulklng appears Lo have survlval beneflL ln
paLlenL s wlLh ovarlan mallgnancles carclnomaLosls relaLed Lo an exLra ovarlan prlmary
Lumor does noL necessarlly beneflL from such measures Surglcal SLaglng AccuraLe
sLaglng deLermlnes boLh LreaLmenL and prognosls lnadequaLe surglcal sL aglng ls a
common problem ln paLlenLs wlLh presumed earlysLage dlsease when Lhe operaLlng
surgeon does noL perform Lhe necessary procedures for adequaLe sLaglng 1herefore lL
ls lmperaLlve LhaL Lhe operaLlng surgeon ls famlllar wlLh sLaglng crlLerla and has Lhe
surglcal skllls necessary Lo perform all Lhe necessary sLeps of Lhe sLaglng procedure
llCC sLaglng crlLerla are descrlbed ln 1able 3 1able 3 llCC SLaglng for Cvarlan Cancer
SLage ueflnlLlon l CrowLh llmlLed Lo Lhe ovarles ll CrowLh lnvolves one or boLh ovarles
wlLh pelvlc exLenslon lll 1umor wlLh perlLoneal lmplanLs ouLslde Lhe pelvls or poslLlve
reLroperlLoneal or lngulnal nodes or boLh lv 1umor lnvolves one or boLh ovarles wlLh
dlsLanL meLasLasls llCC lnLernaLlonal lederaLlon of Cynecology and CbsLeLrlcs
CyLoreducLlon MeLasLaLlc lmplanLs of ovarlan cancer Lyplcally lnvolve Lhe perlLoneal
surfaces and are ofLen amenable Lo resecLlon along wlLh Lhe prlmary Lumor mass
AlLhough noL documenLed by any randomlzed cllnlcal Lrlal opLlmal Lumor cyLoreducLlon
(de flned as removal of Lhe prlmary Lumor and all gross meLasLaLlc lmplanLs Lo less Lhan
1 cm resldual ln largesL dlameLer) ls belleved Lo lmprove chemoLherapy response and
dlseasefree survlval3 1o achleve Lhese goals surglcal Lechnlques such as en bloc
hysLerecLomy wlLh resecLlon of Lhe recLoslgmold small bowel LoLal omenLum spleen
and posslbly more may be necessary Aggresslve resecLlon of Lumor does noL appear Lo
have any cllnlcal advanLage unless all meLasLaLlc lmplanLs also can be opLlmally reduced
1he operaLlng surgeon musL exerclse [udgmenL as Lo wheLher opLlmal Lumor reducLlon
ls posslble and ca n be safely achleved wlLhouL lncurrlng slgnlflcanL compllcaLlons LhaL
would delay chemoLherapy Ad[uvanL 1reaLmenL mosL buL noL all ovarlan cancer
paLlenLs requlre ad[uvanL chemoLherapy afLer surgery 1he lmporLance of adequaLe
surglcal sLaglng ls evldenL when maklng declslons regardlng ad[uvanL Lherapy ln sLage l
dlsease MosL chemoLherapy can be glven on an ouLpaLlenL basls alLhough some
reglmens are glven over a perlod of several days requlrlng hosplLallzaLlon lor eplLhellal
ovarlan cancer plaLlnumbased LherapyelLher clsplaLln or carbop laLlnln comblnaLlon
wlLh pacllLaxel has demonsLraLed Lhe hlghesL acLlvlLy of al l agenLs sLudled4 Lhese
agenLs are generally glven lnLravenously every 3 weeks for a LoLal of slx courses Cne
sLudy however suggesLs LhaL conLlnuaLlon of slngleagenL pacllLaxel for 12 courses ls
assoclaLed wlLh an lmproved dlseasefree survlval AlLhough lLs lmpacL on overall
survlval ls uncerLaln Lhese flndlngs have Lhe poLenLlal Lo slgnlflcanLly affecL
recommended ad[uvanL Lherapy for Lhls dlsease