Ovarian Cancer

What is Ovarian Cancer?

Ovarian Cancer, also known as Ovarian Carcinoma, is cancer that arises from the cells of the ovaries, which are an important part of the female reproductive system. The two ovaries on either side of the uterus and are responsible for the production of the oocytes (eggs) and the female sex hormones.

Is Ovarian Cancer a Medical emergency?

It is not a medical emergency, but early detection and management are essential to prevent complications and mortality.

Types

Ovarian Cancer in women may be of the following types based on the cells within the ovary from which cancer arises:

• Epithelial cell ovarian tumors: Most common and account for more than 85-90% of all ovarian tumors: These ovarian neoplasms arise from the cells that form the outer lining of the ovary
• Stromal Cell Ovarian Tumors: These ovarian neoplasms arise from the hormone-producing cells of the ovaries; these are the next most common ovarian neoplasms after epithelial ovarian tumors and may be of the following types:
  • Sertoli leydig cell tumor
  • Granulosa cell tumor
• Germ cell ovarian tumors: These ovarian neoplasms arise from the cells that produce the oocytes; this type of Ovarian Cancer is more often seen in the younger age group and maybe of the following types:
  • Dysgerminoma
  • Endodermal sinus tumor
  • Malignant teratoma
  • Choriocarcinoma
• Metastatic Ovarian Cancer: This is cancer that has spread to the ovaries either from a neighboring or distant organ

Causes

The exact cause of Ovarian Cancer in women is not fully understood and known, but ovarian neoplasms arise due to mutations of the cell within the ovaries, and the uninhibited growth of these mutated cells. Several risk factors can contribute to the development of ovarian tumors. A longer period of ovulation is considered one of the biggest factors that can cause ovarian tumors.

Risk factors

Some risk factors for Ovarian Cancer in women include:

• Age: Usually seen in older women (above the age of 50 years)
• Early menstruation
• Late menopause
• No history of childbirth or pregnancy (nulliparity)
• Genetic factors and family history
• Hormone therapy with estrogen
• Endometriosis
• Obesity
• Stress

Signs & symptoms

Most ovarian tumors are asymptomatic in the early stages of the disease. Symptoms of ovarian carcinoma as it progresses include:

• Bloating  and abdominal discomfort
• Swelling of the abdomen: Ovarian Cancer Ascites
• Pelvic and abdominal pain
• Nausea and vomiting
• Constipation and/or diarrhea
• Pressure effects on the bladder and rectum
• Vaginal bleeding
• Indigestion and acid reflux
• Shortness of breath
• Tiredness
• Weight loss
• Fullness and early satiety

Investigations

Some investigations that may be done for ovarian tumors may include:

• Laboratory tests:
  • CBP & ESR
  • Liver and renal function tests
  • Complete urine examination
  • Complete metabolic panel
  • Carcinoembryonic Antigen (CEA) levels to exclude GI cancer
  • Tumor markers: CA 125 for epithelial Ovarian Cancer
  • Tumor markers: Including beta-hCG, alpha-fetoprotein, and lactase dehydrogenase if germ cell tumors are suspected
• Imaging tests:
  • Ultrasound: Abdomen, and pelvis
  • Chest X-Ray
  • CT scan
  • MRI
  • Mammography: Usually done as a preoperative investigation
• Gastrointestinal Tract Imaging is done to assess the spread of ovarian tumors:
  • Upper and lower GI endoscopy
  • Barium enema
  • Upper GI series contrast imaging
• Ovarian Cancer biopsy: This is not usually done to establish a diagnosis if there is strong suspicion. However, this may be done using a percutaneous biopsy, Fine Needle Aspiration (FNA), or abdominal paracentesis if there are no obvious Ovarian Cancer lumps and if there is a diffuse carcinoma or ascites. Ovarian Cancer biopsy is done on the tissue that is removed during surgery to confirm the diagnosis.

Diagnosis

A diagnosis of ovarian carcinoma in women is established based on medical history, clinical evaluation, and results of the investigations done.

Course & stages

The staging of ovarian neoplasms is as follows:

• Stage I: Cancer is limited to the ovary or ovaries
• Stage II: Cancer may involve one or both the ovaries, and extends below the pelvic brim into the pelvis to involve the uterus or the fallopian tubes, or other tissue within the intraperitoneal space
• Stage III: Tumor involves one or both the ovaries, the spread is beyond the pelvis into the peritoneal space and the regional lymph nodes are involved
• Stage IV: Cancer has spread to distant organs such as the lungs, liver, spleen, and distant lymph nodes outside the abdominal cavity

Treatment options

The treatment of Ovarian Carcinoma aims to remove the ovarian tumor tissue, prevent its spread and recurrence. Surgical intervention is the primary treatment of choice and is done along with chemotherapy and radiotherapy

Medical management

Medical management of ovarian neoplasms may include the following:

• Chemotherapy: Intraperitoneal chemotherapy with Carboplatin and Paclitaxel and docetaxel is usually done for Stage II-IV Ovarian Cancer in addition to surgery. Chemotherapy is also used for the management of Ovarian Cancer that recurs. Ovarian Cancer that recurs within 6 months is resistant to chemotherapy, while Ovarian Cancer that relapses after 6 months or more is sensitive to platinum chemotherapy.
• Targeted therapy with PARP inhibitors is effective in some ovarian neoplasms

Interventional including surgery and indications for surgery

The aim of the surgical treatment of Ovarian Cancer is to confirm the diagnosis, know the extent of the disease, and remove as much visible cancer as possible. Surgical intervention for the treatment of Ovarian Cancer may include the following:

• Unilateral Oophorectomy: The affected ovary on one side is removed
• Bilateral Oophorectomy: Both the ovaries are removed
• Hysterectomy with salpingo-oophorectomy: The uterus, the fallopian tubes, and both the ovaries are surgically removed
• Cytoreductive surgery: To ensure that there is very little cancer tissue present in advanced Ovarian Cancer one or more of the following may be done depending on the organs involved:
  • Bowel resection and/or appendectomy
  • Stripping of the diaphragm
  • Splenectomy
  • Bladder or ureter removal
  • Partial liver resection
  • Partial stomach resection
  • Gall bladder removal
  • Removal of the tail of the pancreas

Radiation

Radiotherapy may only be done as palliative therapy in advanced ovarian neoplasms.

Role of diet/ Exercise/ Lifestyle changes/ Preventive measures

Some measures that may help to reduce the risk of ovarian carcinoma include:

• Bearing children
• Use of combine oral contraceptive pills
• Undergoing tubal ligation: In women who are at a high risk
• Undergoing bilateral oophorectomy: In women who are at a high risk

Complications

Complications of ovarian carcinoma include:

• Spread to other organs
• Multi-organ failure
• Severely reduced quality of life
• Death

Prognosis

The prognosis of ovarian carcinoma in women that is detected early and managed well is generally good, but the overall prognosis for this cancer is generally poor as it is mostly detected in an advanced stage. The overall 5-year survival rate for Ovarian Carcinoma is around 45-50% with the prognosis being directly dependent on the stage at which the cancer is identified. The prognosis of ovarian tumors with low malignant potential (LMP tumors) is better with an overall survival rate of 80-85%. The prognosis is also poor in those women in whom the ovarian carcinoma recurs after treatment.

When to contact the doctor or hospital? / How to identify the emergency or complications?

It is advisable to seek medical attention if the symptoms and signs of ovarian carcinoma are noticed.

Indications for hospitalization if required

Hospitalization will be required for the surgical management of Ovarian Carcinoma.

Screening methods

Screening with transvaginal ultrasound and ovarian carcinoma CA125 markers is not recommended for low-risk women who are asymptomatic; screening with regular check-ups is however recommended for women who are at a high risk of Ovarian Cancer. Post-treatment surveillance is also advised for women who have been treated for Ovarian Carcinoma to detect recurrence.

Suggested clinical specialist/ Departments to consult for this condition

Ovarian carcinoma will be treated by specialists from the department of gynecological oncology.

Additional information

In Ovarian Cancer, CA125 is not a definitive marker for the common epithelial cell tumors. In Ovarian Cancer CA125 that is persistently elevated even after treatment and seen during surveillance after treatment may indicate the continuation of the disease and in some Ovarian Cancers CA125 may be within normal limits but the residual disease may be seen on laparotomy or laparoscopy.