Ovarian cancer is the deadliest of all the gynecologic malignancies. There will be approximately 22,430 new cases diagnosed in 2007. More than two thirds of patients in whom epithelial ovarian cancer is diagnosed eventually die from this disease (15,280/year in the United States) (Cancer J Clin 2007;57:43). Besides tumors arising from the ovarian coelomic surface, which are the most common, germ cell (often in younger patients) and stromal primary tumors can occur. Two thirds of epithelial ovarian cancers are diagnosed at advanced stages with extraovarian metastasis. Incidence increases steadily with advancing age to a total lifetime incidence of 1 in 68. Risk factors include nulliparity, late menopause, early menarche, use of infertility drugs, and personal or family history of breast or ovarian cancer. Genetic cancer syndromes including the presence of BRCA1 or BRCA2 mutations and hereditary nonpolyposis colon cancer also have been associated with an increased risk of ovarian cancer, and prophylactic removal of ovaries and fallopian tubes
decreases the risk of gynecologic cancer in these patients. Use of oral contraceptives, pregnancy, and tubal ligation appear to be protective.
Presentation and clinical features of Ovarian cancer .Women with early-stage disease are generally asymptomatic. In advanced stages, patients may present with vague abdominal pain or pressure, nausea, early satiety, weight loss, or swelling.TABLE 36-4 Ovarian Cancer Staging
TNM FIGO Definition T1 I Tumor limited to one or both ovaries T1a IA Tumor limited to one ovary; capsule intact, no tumor on ovarian surface, no malignant cells in ascites or peritoneal washings T1b IB Tumor limited to both ovaries; capsule intact, no tumor on ovarian surface, no malignant cells in ascites or peritoneal washings T1c IC Tumor limited to one or both ovaries with any of the following: capsule ruptured, tumor on ovarian surface, malignant cells in ascites or peritoneal washings T2 II Tumor involves one or both ovaries with pelvic extension T2a IIA Extension and/or implants on uterus and/or tubes; no malignant cells in ascites or peritoneal washings T2b IIB Extension to other pelvic tissues; no malignant cells in ascites or peritoneal washings T2c IIC Pelvic extension with malignant cells in ascites or peritoneal washings T3 III Tumor involves one or both ovaries with microscopically confirmed peritoneal metastasis outside the pelvis and/or regional lymph node metastasis T3a IIIA Microscopic peritoneal metastasis beyond the pelvis T3b IIIB Macroscopic peritoneal metastasis beyond the pelvis ≤2 cm in greatest dimension T3c IIIC Peritoneal metastasis beyond the pelvis >2 cm in greatest dimension and/or regional lymph node involvement M1 IV Distant metastasis (excludes peritoneal metastasis) FIGO, International Federation of Gynecology and Obstetrics; TNM, tumor, node, metastasis.
Diagnosis of ovarian cancerat early stages has proved to be clinically difficult (Table 36-4). No cost-effective screening test has proven to be reliable in detecting stage I disease (confined to the ovaries). Bimanual examination remains the most effective means of screening, followed by surgery for histologic diagnosis. Ultrasonography of the pelvis (preferably transvaginal) and CT scan are effective adjuncts. CA 125 antigen is not effective for mass screening but serves as an effective tumor marker in patients with initial elevations once diagnosis has been established and treatment is initiated.
Treatment is primarily aggressive surgical for Ovarian cancerdebulking for all patients. Complete staging includes pelvic washings on entering the peritoneum, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic and para-aortic lymph node dissection, and peritoneal biopsies. Optimal cytoreduction (residual disease <1 cm) improves response to adjuvant chemotherapy and overall survival. In young women with early-stage disease, fertility-sparing surgery can often be performed with removal of the uterus and contralateral ovary after childbearing is completed. However, complete staging at initial surgery is still necessary. Patients with disease outside the ovary are treated with six cycles of paclitaxel and platinum–based chemotherapy either intravenously or intraperitoneally.
Prognosis for Ovarian cancer correlates directly with stage and with the residual disease after debulking. Median survival depends on optimal cytoreduction at initial laparotomy