Definition
A.Ovarian cancers are classified by cells they are derived from.
B.There are three main types of ovarian cancer: Epithelial tumors (accounting for 95%), germ cell tumors, and sex cord stromal tumors.
Incidence
A.It is the second most common cancer among women, with endometrial cancer being first, but it is the most lethal of all gynecologic malignancies.
B.In a woman’s lifetime, there is a 1.3% risk of developing ovarian cancer and 1 in 100 risk of dying from ovarian cancer.
C.Approximately 22,280 new cases were reported in 2016.
Pathogenesis
A.The origin and pathogenesis of epithelial ovarian cancer are poorly understood though dedifferentiation of cells overlying the ovary is thought to be an important source.
B.Ovarian cancer typically spreads by local extension with significant dissemination within the peritoneal cavity.
C.Ovarian cancer often goes undetected as symptoms are vague and there is no approved screening test. Therefore, patients are typically diagnosed with advanced stages.
Predisposing Factors
A.Age.
B.Family history of ovarian, breast, or colon cancer.
C.Genetic predisposition.
D.Reproductive and endocrine abnormalities.
1.Infertility.
2.Endometriosis.
3.Hormonal replacement therapy.
E.Obesity (body mass index of ≥30).
Subjective Data
A.Common complaints/symptoms.
1.Abdominal bloating.
2.Increase in abdominal girth.
3.Pelvic/abdominal pain.
4.Early satiety.
5.Difficulty eating.
6.Nausea and vomiting.
7.Fatigue.
B.Common/typical scenario.
1.Ovarian cancer was dubbed the silent killer
due to women presenting with vague symptoms.
2.Additionally, there are no approved screening methods for ovarian cancer.
3.Because of the vague symptoms, the majority of women are not diagnosed until they have advanced stage disease.
Physical Examination
A.In patients with early disease, physical examination findings are uncommon.
B.Ovarian/pelvic mass, fluid in the abdomen (ascites), pleural effusion, and abdominal mass or a bowel obstruction may be present in advanced disease.
C.Physical examination includes, and is not limited to:
1.General assessment.
2.Survey of the lymphatic system.
3.Abdomen: Assess for pain, palpable masses, fluid waves, bowel sounds.
4.Pelvic examination: Assess for bleeding, masses, position of cervix if present, uterine size.
5.Rectovaginal examination: Assess for bleeding, masses, uterosacral ligaments, and cul-de-sac.
Diagnostic Tests
A.Ultrasound, CT, or MRI of the abdomen/pelvis.
B.Tumor markers.
C.Complete blood count and comprehensive metabolic panel.
D.Urinalysis to rule out other causes of pain (urinary tract infection [UTI], kidney stones).
E.Diagnosis.
1.Final diagnosis is based on the pathologic review of tissue specimen obtained through surgery or biopsy.
2.Initial surgery (exploratory laparotomy vs. laparoscopic). If there is a strong clinical suggestion for ovarian cancer, laparotomy is preferred for diagnosis and staging.
3.Fine needle aspiration (FNA) or diagnostic paracentesis should be performed in patients with diffuse carcinomatosis or ascites without an obvious ovarian mass.
F.Staging: Ovarian cancer is clinically staged based on the Federation International de Gynecologue et d’Obstetrique (FIGO) staging system.
Differential Diagnosis
1.Adnexal tumors.
2.Ectopic pregnancy.
3.Cysts.
4.Endometriosis.
5.Cervicitis.
6.Cancer of surrounding structures.
7.Pelvic inflammatory disease.
8.Uterine leiomyomas.
Evaluation and Management Plan
A.General plan.
1.All women diagnosed with ovarian, fallopian tube, or peritoneal cancer should have genetic counseling and be considered for genetic testing.
2.Surgery.
3.Chemotherapy.
4.Radiation therapy: Not used as first-line treatment; however, it may be used occasionally to treat small, localized recurrent tumors.
5.Hormonal therapy.
6.Targeted therapy.
7.Biotherapy/immunotherapy.
Follow-Up
A.Follow-up for ovarian cancer is based on National Comprehensive Cancer Network (NCCN) guidelines for tumor type and stage.
B.Many providers recommend pelvic examination every 2 to 4 months for the first 4 years after resection and every 6 months for 3 years thereafter.
Consultation/Referral
A.Gynecological oncologist: Typically will involve surgery, medical oncology, and radiation oncology.
B.Gastroenterologist: Patients may present with primarily gastrointestinal complaints.
C.Palliative care: Due to the very poor prognosis, may be beneficial early on.
Special/Geriatric Considerations
A.Ovarian cancer increases with advancing age, peaking in the seventh decade of life.
B.Discuss aggressive treatment with the patient, based on life expectancy, quality of life goals, and functional status.
Bibliography
National Cancer Institute. (2016, September 12). Surveillance, epidemiology, and end results program. Retrieved from https://seer.cancer.gov/faststats/selections.php?series=cancer
Prat, J. (2014). Staging classification for cancer of the ovary, fallopian tube, and peritoneum. International Journal of Gynaecology and Obstetrics, 124(1), 1–5.