Ovarian Cancer
Background
In the U.S., where does ovarian cancer rank as a cause of cancer death in women?
In the U.S., epithelial ovarian cancer (EOC) is the 5th leading cause of cancer mortality in women. It is the 2nd most common gyn malignancy and the leading cause of death in this group.
What is the annual incidence and mortality of ovarian cancer in the U.S.?
Annually, there are ~22,000 new Dx and ~14,600 deaths from ovarian cancer in the U.S. (ACS, Facts and figures 2009).
What is the median age at Dx of ovarian cancer?
The median age at Dx of ovarian cancer is 63 yrs. The incidence increases with age and is most prevalent during the 8th decade of life.
Is routine screening for ovarian cancer recommended?
No. Routine screening is not recommended for ovarian cancer. A prospective randomized trial failed to show that screening with transvaginal US and CA 125 led to the detection of more early-stage cancers. (Partridge E et al., Obstet Gynecol 2009). However, preliminary data from the ongoing UKCTOCS trial, which compares US and CA 125 vs. US vs. no screening, suggests that more early-stage cancers are being detected with multimodal screening (Menon U et al., Lancet Oncol 2009).
What are the histopathologic subtypes of ovarian cancer in order of decreasing frequency?
Ovarian cancer subtypes: EOC (80%) > ovarian stromal tumors > germ cell neoplasms > carcinosarcomas/malignant mixed mullerian tumors (MMMTs)
What risk factors are associated with the development of ovarian cancer?
Risk factors associated with the development of ovarian cancer:
Nulliparity
Advanced age at time of 1st birth (>35 yrs)
HRT
High fat/lactose diet
Hx of ≥2 1st-degree relatives with ovarian cancer
Family Hx of BRCA1/2 or HNPCC
Older age
(Finch A et al., JAMA 2006)
What is the role of prophylactic oophorectomy in BRCA1/2-positive women?
Prophylactic oophorectomy has been shown to reduce the risk of ovarian and fallopian tube malignancies in BRCA1/2 women; however, the risk of primary peritoneal cancer persists. (Finch A et al., JAMA 2006; Rebbeck TR et al., J Natl Cancer Inst 2009)
What factors portend a decreased risk for the development of ovarian cancer?
Factors associated with decreased lifetime risk of ovarian cancer:
Younger maternal age at 1st birth (≤25 yrs)
Use of oral contraception
Breast-feeding
What are the regional LN drainage routes from the ovaries?
Regional LNs of the ovaries include internal iliac, obturator, sacral, external iliac, common iliac, para-aortic, and inguinal LNs.
What are the most common sites of DMs for ovarian cancer?
Common sites of DMs from ovarian cancer include the liver parenchyma, lung, bone, and axillary and supraclavicular LNs. Whereas intra-abdominal spread to the peritoneum and diaphragmatic and liver surfaces is common, these are formally FIGO III Dz.
What are the common presenting signs and Sx of ovarian cancer?
The NCCN has released the following consensus guidelines for ovarian cancer Sx: bloating, abdominal/pelvic pain, difficulty eating, early satiety, new urinary Sx (frequency/urgency >12 days/mo), palpable abdominal/pelvic mass, and ascites. Identification of such Sx should prompt a workup for ovarian cancer.
Workup/Staging
What is CA 125, and what is its utility in ovarian cancer?
CA 125 is a mucinous protein encoded by the MUC16 gene and is used to assess response to Tx and predict prognosis after Tx for ovarian cancer. Due to its low sensitivity and specificity as a diagnostic test, it is not used as a screening tool.
What is OvaSure, and can it be used as a diagnostic test for ovarian cancer?
OvaSure is a serum-based test for leptin, prolactin, osteopontin, IGF II, macrophage inhibitory factor, and CA 125 being investigated as a screening tool for ovarian cancer. The Society of Gynecologic Oncologists has not yet endorsed its routine use due to lack of adequate clinical validation. (Visintin I et al., Clin Cancer Res 2008)
What are the initial steps in the workup of pts with an undiagnosed pelvic mass?
Pts with signs/Sx suspicious for ovarian cancer should undergo a full H&P, including a thorough family Hx and pelvic examination, CBC, CMP, CA 125, US, CT abdomen/pelvis, and CXR. Final staging is determined through surgical/pathologic evaluation of the abdomen and pelvis. (NCCN 2010)
What is the FIGO staging system for ovarian cancer?
Stage IA: limited to 1 ovary with capsule intact; no tumor on ovarian surface; no malignant cells in ascites or peritoneal washings
Stage IB: limited to both ovaries with capsules intact; no tumor on ovarian surface; no malignant cells in ascites or peritoneal washings
Stage IC: limited to 1 or both ovaries with any of the following: ruptured capsule, tumor on ovarian surface, malignant cells in ascites, or peritoneal washings
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