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I. EPITHELIAL OVARIAN CANCER
A. Epidemiology and etiology. Approximately 21,980 new cases of ovarian cancer are diagnosed each year in the United States and 14,270 deaths were estimated to occur in 2014, as a result of this disease. Ovarian cancer remains the fifth most common cause of cancer death in women and the leading cause of death from gynecologic cancer. It has been estimated that 1 woman in 70 in the United States will develop ovarian cancer in her lifetime and 1 in 100 will die from this disease. Most of the (85% to 90%) malignant ovarian tumors are epithelial in origin. The median age at diagnosis is 63 years and incidence is higher in women of white race. Risk factors include a strong family history, nulliparity, early menarche, late menopause, increasing age, white race, and residence in North America and Europe. Oral contraception usage and pregnancy are associated with a decreased risk, suggesting that continuous ovulation may lead to malignant changes. The etiology of malignant changes of the ovarian epithelium, which is contiguous with the peritoneal mesothelium, is unknown and likely a combination of genetic, environmental, and endocrine effects.
B. Genetics/familial syndromes. Familial ovarian cancer may be related to a breast–ovarian cancer syndrome caused by an inherited mutation in one of two genes, BRCA1 and BRCA2 on chromosome 17 and 13, respectively. Certain ethnic groups such as Ashkenazi Jewish women have an increased risk of a mutation in one of these two genes. Women with a BRCA1 mutation are reported to have a 16% to 44% lifetime risk of ovarian cancer, whereas those with BRCA2 mutations have a lower risk at 10%. Women with ovarian cancer due to these mutations tend to have a more indolent course than those with sporadic disease. Site-specific familial ovarian cancer and Lynch syndrome II in which multiple individuals within a family develop tumors in the colon, endometrium, and ovary are other types of familial ovarian cancers. Inheritance in familial ovarian cancer is in an autosomal dominant manner with multiple members in successive generations affected. There is sufficient evidence for prophylactic oophorectomy in women with a known mutation in BRCA1 or BRCA2 after completion of childbearing or 35 years of age so as to prevent the development of both ovarian and breast cancers. All patients with epithelial ovarian, tubal, and peritoneal cancer should be offered genetic counseling.
C. Clinical presentation. Women present with vague, nonspecific symptoms of abdominal bloating, distension, dyspepsia, early satiety, anorexia, weight loss, or constipation. Women are often treated for gastrointestinal problems such as gastritis, irritable bowel syndrome, and gall bladder disease. Physical examination findings may include ascites, pleural effusion, or an abdominal mass. Most patients with early-stage disease are asymptomatic and given the vague nature of the symptoms, approximately 80% present with advanced stage (metastatic) disease. The National Cancer Institute (NCI) does support annual screening through both CA-125 measurements and transvaginal ultrasonography for women at high genetic risk based on family history; however, in the general population no data exists that screening is effective in improving length and quality of life in women with ovarian cancer. Several biomarkers with potential application to ovarian cancer screening are under development but have not yet been validated or evaluated regarding their efficacy for early detection and mortality reduction.
Women found to have a mass or ascites on examination or by radiographic or ultrasonographic imaging should be evaluated to assess the possible risk of abnormality representing a malignancy. Appearance and size on ultrasonography or computed tomography (CT) scan combined with patient age and family history are factors that help determine the need for surgical evaluation. A complex mass with both solid and cystic components with septations and internal echoes is suggestive of cancer. Benign-appearing and indeterminate lesions can be followed for a brief period to evaluate for progression of disease. Serum CA-125 cancer antigen can occasionally be of aid in postmenopausal patients. CA-125 is elevated in more than 80% of patients with ovarian cancer but this test is neither sufficiently sensitive nor specific enough to be diagnostic as this may be elevated in a number of other benign and malignant conditions. CA-125 is most useful in following response to postoperative chemotherapy and detecting disease recurrence. No definitive tests are currently available and definitive diagnosis is often only possible with surgical evaluation.
D. Surgical treatment. Surgery is typically performed for histologic diagnosis, staging, and tumor cytoreduction. Exceptions to an immediate surgical approach are patients who are poor surgical candidates secondary to other comorbid diseases or performance status. In these patients, a confirmatory biopsy or cytology is obtained to establish a diagnosis followed by chemotherapeutic treatment. Preoperatively, patients should undergo all age-appropriate cancer screening (Pap smear, mammogram, and colorectal cancer screening) as well as additional tests depending on the clinical scenario (barium enema, colonoscopy, and/or cystoscopy). Laboratory assessment should include complete blood count, type and screen, electrolytes, renal and hepatic panel, electrocardiogram, and chest radiograph. Additional studies depend on the patient’s medical condition(s). Given the likelihood of large and small bowel involvement requiring resection, a thorough bowel preparation is recommended. Staging of ovarian cancer is surgical and proper staging procedures should typically consist of the following: (a) midline abdominal incision; (b) evacuation of ascites or peritoneal washings for cytologic analysis; (c) resection of the primary ovarian tumor, total abdominal hysterectomy, and bilateral salpingo-oophorectomy; (d) biopsies of omentum or omentectomy; (e) biopsies of the pelvic and abdominal peritoneum, including pericolic gutters; and (f) retroperitoneal nodal sampling (pelvic and para-aortic), if indicated by lack of abdominal disease greater than 2 cm or if grossly involved with tumor. The surgical staging system established by the International Federation of Gynecology and Obstetrics is depicted in Table 23-1 and was recently updated as of January 2014 to improve utility and reproducibility across all ovarian tumor types (Int J Gynaecol Obstet 2014;124:1). Tumor debulking is a critical component of initial surgical management as women with residual disease of less than 1 cm have survival rates higher than those with residual disease.
Five-year survival in patients with early-stage disease (stage I or II) is often as high as 80% to 95%; however, patients with advanced disease (stage III or IV) have much lower survival rates of 30% to 40%.
Updated FIGO Ovarian Cancer Staging |
Stage | Definition |
IA | Tumor limited to one ovary with intact capsule and no tumor on surface |
IB | Tumor involves both ovaries |
IC | Surgical spill (IC1), capsule rupture or tumor on ovarian surface (IC2), malignant cells on the ascites or peritoneal washings (IC3) |
IIA | Extension or implant on uterus and/or fallopian tubes |
IIB | Extension to other pelvic intraperitoneal tissues |
IIIA1 | Positive retroperitoneal lymph nodes (IIIA1(i) ≤10 mm, IIIA1(ii) >10 mm) |
IIIA2 | Microscopic extrapelvic peritoneal involvement |
IIIB | Macroscopic extrapelvic peritoneal metastases ≤2cm |
IIIC | Macroscopic extrapelvic peritoneal metastases >2cm |
IVA | Pleural effusion with positive cytology |
IVB | Metastases to liver, spleen or extra-abdominal organs including lymph nodes |
E.
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