Ovarian Cancer

By | June 30, 2018

An enlarged ovary with a papillary serous carcinom

Practice Essentials

Ovarian cancer is the most common cause of cancer death from gynecologic tumors in the United States. Malignant ovarian lesions include primary lesions arising from normal structures within the ovary and secondary lesions from cancers arising elsewhere in the body. Primary lesions include epithelial ovarian carcinoma (70% of all ovarian malignancies). Current research suggests that the majority of these originate from the fallopian tubes.

Stromal tumors of the ovary include germ-cell tumors, sex-cord stromal tumors, and other more rare types. Metastases to the ovaries are relatively frequent; common sources are tumors in the endometrium, breast, colon, stomach, and cervix. See the image below

Signs and symptoms

Early ovarian cancer causes minimal, nonspecific, or no symptoms. The patient may feel an abdominal mass. Most cases are diagnosed in an advanced stage.

Epithelial ovarian cancer presents with a wide variety of vague and nonspecific symptoms, including the following:

  • Bloating; abdominal distention or discomfort

  • Pressure effects on the bladder and rectum

  • Constipation

  • Vaginal bleeding

  • Indigestion and acid reflux

  • Shortness of breath

  • Tiredness

  • Weight loss

  • Early satiety

Symptoms independently associated with the presence of ovarian cancer include pelvic and abdominal pain, increased abdominal size and bloating, and difficulty eating or feeling full. [1] Symptoms associated with later-stage disease include gastrointestinal symptoms such as nausea and vomiting, constipation, and diarrhea. [2] Presentation with swelling of a leg due to venous thrombosis is not uncommon. Paraneoplastic syndromes due to tumor-mediated factors lead to various presentations.

Diagnosis

Physical findings are uncommon in patients with early disease. Patients with more advanced disease may present with ovarian or pelvic mass, ascites, pleural effusion, or abdominal mass or bowel obstruction.

The presence of advanced ovarian cancer is often suspected on clinical grounds, but it can be confirmed only pathologically by removal of the ovaries or, when the disease is advanced, by sampling tissue or ascitic fluid.

Screening

The US Preventive Services Task Force (USPSTF) recommends against screening (with serum CA125 level or transvaginal ultrasonography) for ovarian cancer in the general population. [3] The US Food & Drug Administration (FDA) recommends against the use of tests marketed for ovarian cancer screening. [4] The National Cancer Institute (NCI) cites evidence of lack of mortality benefit with screening, and potential harms relating to false-positive test results. [5]

Laboratory testing

No tumor marker (eg, CA125, beta-human chorionic gonadotropin, alpha-fetoprotein, lactate dehydrogenase) is completely specific; therefore, use diagnostic immunohistochemistry testing in conjunction with morphologic and clinical findings. Also, obtain a urinalysis to exclude other possible causes of abdominal/pelvic pain, such as urinary tract infections or kidney stones.

Imaging studies

Routine imaging is not required in all patients in whom ovarian cancer is highly suggested. In cases in which the diagnosis is uncertain, consider the following imaging studies:

  • Pelvic ultrasonography [6, 7] : Warranted

  • Pelvic and abdominal computed tomography (CT) scanning [6, 7] : Warranted

  • Pelvic and abdominal magnetic resonance imaging: Increases specificity of imaging when sonography findings are indeterminate [8]

  • Chest radiography: Routine imaging to exclude lung metastases

  • Mammography: Part of preoperative workup for women older than 40 years who have not had one in the preceding 6-12 months; estrogen-producing tumors may increase the risk of breast malignancies, and breast cancers can metastasize to the ovaries and are often bilateral

In patients with diffuse carcinomatosis and GI symptoms, a GI tract workup may be indicated, including one of the following imaging studies:

  • Upper and/or lower endoscopy

  • Barium enema

  • Upper GI series

Procedures

Fine-needle aspiration (FNA) or percutaneous biopsy of an adnexal mass is not routinely recommended, as it may delay diagnosis and treatment of ovarian cancer. Instead, if a clinical suggestion of ovarian cancer is present, the patient should undergo laparoscopic evaluation or  laparotomy, based on the presentation,  for diagnosis and staging. An FNA or diagnostic paracentesis should be performed in patients with diffuse carcinomatosis or ascites without an obvious ovarian mass.

Management

Standard treatment for women with ovarian cancer involves aggressive debulking surgery and chemotherapy. The aim of cytoreductive surgery is to confirm the diagnosis, define the extent of disease, and resect all visible tumor.  Neoadjuvant chemotherapy is increasingly used.

Surgery

The type of procedure depends on whether or not disease is visible outside the ovaries. When no disease is visible outside the ovaries, or no lesion greater than 2 cm is present outside of the pelvis, the patient requires formal surgical staging, including peritoneal cytology, multiple peritoneal biopsies, omentectomy, pelvic and para-aortic lymph node sampling, and biopsies of the diaphragmatic peritoneum.

If visible disease is noted, aggressive surgical debulking, with the intent to remove all visible disease should be undertaken. If the surgeon determines that optimal debulking is not possible, then neoadjuvant chemotherapy should be considered. For patients with stage IV disease, surgery should be individualized on the basis of presentation.

Surgical procedures that may be performed in women with ovarian cancer are as follows:

  • Surgical staging

  • Cytoreductive surgery

  • Interval debulking

  • Laparoscopic surgery

  • Secondary surgery

Chemotherapy

Postoperative chemotherapy is indicated in all patients with ovarian cancer, except those who have surgical-pathologic stage I disease with low-risk characteristics. Standard postoperative chemotherapy for ovarian cancer is combination therapy with a platinum compound and a taxane (eg, carboplatin and paclitaxel). Additional agents for recurrent disease include the following:

  • Liposomal doxorubicin
  • Etoposide
  • Topotecan
  • Gemcitabine
  • Vinorelbine
  • Ifosfamide
  • Fluorouracil
  • Melphalan
  • Altretamine
  • Bevacizumab
  • Olaparib
  • Niraparib
  • Rucaparib
  • Pazopanib

Adjunctive medications include the following:

  • Cytoprotective agents (eg, mesna)

  • Antiemetics (eg, ondansetron, granisetron, palonosetron, dexamethasone)

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