Ovarian Cancer

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Contents

More Specific Terms

Introduction

Etiology

  • (Risk factors)
  • personal history
  • family history
  • high-fat diet
  • reduced risk of epithelial ovarian cancer with

Epidemiology

  • 5th most common cancer in women
  • median age of diagnosis is 63 years
  • 4th leading cause of cancer deaths in women
  • 1.4% lifetime risk in the general population

Pathology

Microscopic-pathology

  • Brenner (transitional cell) tumors
  • immature
  • mature
  • solid
  • monodermal and highly specialized

Genetics

Clinical-manifestations

  • occult presentation
  • late stage of disease at the time of diagnosis
  • 70-75% of women present with advanced disease
  • most patients present with non-specific symptoms
  • * most common symptoms [5]; may be presenting symptoms [16]
  • # part of a 9 point screening [28]

Laboratory

  • useful for initial evaluation
  • not useful for follow-up [2]
  • combined set of 4 serum markers may be useful for early detection [15]
  • * only laboratory testing recommended by ref [2]
  • # part of a 9 point screening [28]

Radiology

  • little value in sreening [14]
  • recomended for evaluation of suspected ovarian cancer [2]

Staging

  • AJCC/TNM/FIGO 

* TNM   FIGO 
*  TX         primary tumor cannot be assessed 
*  T0         no evidence of primary tumor 
*  T1   I     tumor limited to 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:  
*             capsule ruptured, tumor on ovarian surface,  
*             malignant cells in ascites or peritoneal washings. 
*  T2   II    tumor involves one or both ovaries with pelvic  
*             extension &/or implants 
*  T2a  IIA   extension &/or implants on uterus &/or tubes, 
*             no malignant cells in ascites or peritoneal washings 
*  T2b  IIB   extension &/or implants on other pelvic tissues, 
*             no malignant cells in ascites or peritoneal washings 
*  T2c  IIC   pelvic extensions &/or implants (T2a or T2b) with  
*             malignant cells in ascites or peritoneal washings 
*  T3   III   tumor involves one or both ovaries with microscopically  
*             confirmed peritoneal metastasis outside the pelvis 
*  T3a  IIIA  microscopic peritoneal metastasis beyond pelvis  
*             (none macroscopic) 
*  T3b  IIIB  macroscopic peritoneal metastasis beyond pelvis 2 cm  
*             or less in greatestconfirmed dimension 
*  T3c  IIIC  peritoneal metastasis beyond pelvis, more than 2 cm in  
*             greatest dimension &/or regional lymph node metastasis 
*  note: - presence of ascites does not affect staging unless  
*          maligmant cells present 
*        - liver capsule metastasis T3/stage III 
*        - liver parencymal metastasis M1/stage IV 
*        - pleural effusion must have positive cytology for M1/ 
*          stage IV 
*  NX         regional lymph nodes cannot be assessed 
*  N0         no regional lymph node metastasis 
*  N1   IIIC  regional lymph node metastasis  
*  MX         distal metastases cannot be assessed 
*  M0         no distant metastasis 
*  M1   IVB   distant metastasis (excludes peritoneal metastasis) 
*  stage I      T1     N0      M0 
*  stage IA     T1a    N0      M0 
*  stage IB     T1b    N0      M0 
*  stage IC     T1c    N0      M0  
*  stage II     T2     N0      M0 
*  stage IIA    T2a    N0      M0 
*  stage IIB    T2b    N0      M0 
*  stage IIC    T2c    N0      M0 
*  stage III    T3     N0      M0 
*  stage IIIA   T3a    N0      M0 
*  stage IIIB   T3b    N0      M0 
*  stage IIIC   T3c    N0      M0 
*               any T  any N   M0 
*  stage IV     any T  any N   M1 
* Histologic grading: 
*  GX    grade cannot be assessed 
*  GB    borderline malignancy 
*  G1    well differentiated 
*  G2    moderately differentiated 
*  G3-4  poorly differentiated or undifferentiated


Complications

Differential-diagnosis

Management

  • prognosis:
  • 5 year survival is poor when presenting with advanced disease
  • disease is potentially curable even when presenting with malignant ascites
  • 5 year survival by stage at presentation
  • stage 1: 75 to >90%
  • stage 2: 60-70%
  • stage 3: 25-40%
  • stage 4: 10-15% [2]
  • 30-50% of patients with early stage disease confined to ovaries or pelvis, have micrometastases, & eventually relapse after ovariectomy & die [8]
  • treatment by a gynecologic oncologist improves prognosis [22]
  • overall survival better in BCRA2 mutation carriers than either BCRA1 mutation carriers or patients with normal BCRA1 & BCRA2 genes [26]; 61% vs 25% 5 year survival
  • treatment:
  • response to cisplatin better in BCRA2 mutation carriers than either BCRA1 mutation carriers or patients with normal BCRA1 & BCRA2 genes [26]; - response rate 100% vs 80-85% - duration of remission 18 months vs 12 months [26];
  • improves disease-free survival about 10% [8]
  • intraperitoneal cisplatin may improve survival [17] at a cost of higher toxicity [2]
  • follow-up
  • replase
  • drugs already used
  • residual toxicity
  • status of GI tract
  • toxicities of contemplated agents
  • convenience
  • screening:
  • not yet useful for reducing ovarian cancer mortality [25,27]
  • prevention

More General Terms

Additional Terms

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 30
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15 American College of Physicians, Philadelphia 1998, 2006, 2009
  3. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 674
  4. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 521, 607
  5. Journal Watch 21(18):145, 2001 Brewster WR Intent-to-treat analysis of stage Ib and IIa cervical cancer in the United States: radiotherapy or surgery 1988-1995. Obstet Gynecol. 2001 Feb;97(2):248-54. PMID: &dopt=Abstract
  6. Journal Watch 22(5):39, 2002 Schildkraut JM et al Impact of progestin and estrogen potency in oral contraceptives on ovarian cancer risk. J Natl Cancer Inst 94:32, 2002 PMID: &dopt=Abstract
  7. Journal Watch 22(5):40, 2002 Petricoin EF et al Use of proteomic patterns in serum to identify ovarian cancer. Lancet 359:572, 2002 PMID: &dopt=Abstract
  8. Journal Watch 23(5):44, 2003 International Collaboratice Ovarian Neoplasm, J Natl Cancer Inst 95:105, 2003 International Collaboratice Ovarian Neoplasm, J Natl Cancer Inst 95:125, 2003 Trimbos JB et al, J Natl Cancer Inst 95:113, 2003 Young RC, J Natl Cancer Inst 95:94, 2003
  9. AJCC Cancer Staging Manual 6th ed. Springer 2002
  10. Attanoos et al. Value of mesothelial and epithelial antibodies in distinguishing diffuse peritoneal mesothelioma in females from serous papillary carcinoma of the ovary and peritoneum. Histopathology 40:237-44, 2002 PMID: [1]
  11. Journal Watch 24(14):112, 2004 Goff BA, Mandel LS, Melancon CH, Muntz HG. Frequency of symptoms of ovarian cancer in women presenting to primary care clinics. JAMA. 2004 Jun 9;291(22):2705-12. PMID: [2]
  12. Journal Watch 24(15):117, 2004 Brinton LA, Lamb EJ, Moghissi KS, Scoccia B, Althuis MD, Mabie JE, Westhoff CL. Ovarian cancer risk after the use of ovulation-stimulating drugs. Obstet Gynecol. 2004 Jun;103(6):1194-203. PMID: [3]
  13. U.S. Preventive Services Task Force. Screening for ovarian cancer: recommendation statement. U.S. Preventive Services Task Force. Am Fam Physician. 2005 Feb 15;71(4):759-62. PMID: [4] Corresponding NGC guideline withdrawn Jan 2011
  14. Journal Watch 25(11):85, 2005 Fishman DA, Cohen L, Blank SV, Shulman L, Singh D, Bozorgi K, Tamura R, Timor-Tritsch I, Schwartz PE. The role of ultrasound evaluation in the detection of early- stage epithelial ovarian cancer. Am J Obstet Gynecol. 2005 Apr;192(4):1214-21; discussion 1221-2. PMID: [5]
  15. Internal Medicine News, July 2005, pg 5 Journal Watch 25(14):112, 2005 Mor G, Visintin I, Lai Y, Zhao H, Schwartz P, Rutherford T, Yue L, Bray-Ward P, Ward DC. Serum protein markers for early detection of ovarian cancer. Proc Natl Acad Sci U S A. 2005 May 24;102(21):7677-82. Epub 2005 May 12. PMID: &dopt=Abstract
  16. Smith LH, Morris CR, Yasmeen S, Parikh-Patel A, Cress RD, Romano PS. Ovarian cancer: Can we make the clinical diagnosis earlier? Cancer. 2005 Oct 1;104(7):1398-407. PMID: [6]
  17. Armstrong DK et al. Intraperitoneal cisplatin and paclitaxel in ovarian cancer. N Engl J Med 2006 Jan 5; 354:34-43. PMID: [7]
    - Cannistra SA. Intraperitoneal chemotherapy comes of age. N Engl J Med 2006 Jan 5; 354:77-9. PMID: [8]
  18. Internal Medicine World Report, Dec 2005 cites le-M Singh, PNAS 2005; 102:14004
  19. Aletti GD, Dowdy SC, Gostout BS, Jones MB, Stanhope CR, Wilson TO, Podratz KC, Cliby WA. Aggressive surgical effort and improved survival in advanced-stage ovarian cancer. Obstet Gynecol. 2006 Jan;107(1):77-85. PMID: [9]
  20. UpToDate 14.1 [10]
  21. Finch A, Beiner M, Lubinski J, Lynch HT, Moller P, Rosen B, Murphy J, Ghadirian P, Friedman E, Foulkes WD, Kim-Sing C, Wagner T, Tung N, Couch F, Stoppa-Lyonnet D, Ainsworth P, Daly M, Pasini B, Gershoni-Baruch R, Eng C, Olopade OI, McLennan J, Karlan B, Weitzel J, Sun P, Narod SA; Hereditary Ovarian Cancer Clinical Study Group. Salpingo-oophorectomy and the risk of ovarian, fallopian tube, and peritoneal cancers in women with a BRCA1 or BRCA2 Mutation. JAMA. 2006 Jul 12;296(2):185-92. PMID: [11]
  22. Chan JK, Kapp DS, Shin JY, Husain A, Teng NN, Berek JS, Osann K, Leiserowitz GS, Cress RD, O'malley C. Influence of the gynecologic oncologist on the survival of ovarian cancer patients. Obstet Gynecol. 2007 Jun;109(6):1342-50. PMID: [12]
  23. Collaborative Group on Epidemiological Studies of Ovarian Cancer. Ovarian cancer and oral contraceptives: Collaborative reanalysis of data from 45 epidemiological studies including 23,257 women with ovarian cancer and 87,303 controls. Lancet 2008, 371:303 PMID: [13]
  24. Morch LS Hormone Therapy and Ovarian Cancer JAMA. 2009;302(3):298-305. <PubMed> PMID: [14] <Internet> [15]
  25. Buys SS et al Effect of Screening on Ovarian Cancer Mortality JAMA. 2011;305(22):2295-2303 <PubMed> PMID: [16] <Internet> [17]
  26. Yang D et al. Association of BRCA1 and BRCA2 mutations with survival, chemotherapy sensitivity, and gene mutator phenotype in patients with ovarian cancer. JAMA 2011 Oct 12; 306:1557. PMID: [18]
  27. van Nagell JR Jr et al. Long-term survival of women with epithelial ovarian cancer detected by ultrasonographic screening. Obstet Gynecol 2011 Dec; 118:1212. PMID: [19]
    - Jacobs I and Menon U. Can ovarian cancer screening save lives? The question remains unanswered. Obstet Gynecol 2011 Dec; 118:1209. PMID: [20]
  28. Hippisley-Cox J and Coupland C. Identifying women with suspected ovarian cancer in primary care: Derivation and validation of algorithm. BMJ 2012 Jan 4; 344:d8009. <PubMed> PMID: [21] <Internet> [22]
  29. Pearce CL et al Association between endometriosis and risk of histological subtypes of ovarian cancer: a pooled analysis of case—control studies The Lancet Oncology, Early Online Publication, 22 February 2012 <PubMed> PMID: [23] <Internet> [24]
    - Gourley C Link between endometriosis and ovarian-cancer subtypes The Lancet Oncology, Early Online Publication, 22 February 2012 <PubMed> PMID: [25] <Internet> [26]
  30. U.S. Preventive Services Task Force Screening for Ovarian Cancer: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement DRAFT [27]
    - U.S. Preventive Services Task Force Screening for Ovarian Cancer Evidence Update for the U.S. Preventive Services Task Force Reaffirmation Recommendation Statement [28]
  31. Ovarian Germ Cell Tumors (PDQ): Treatment [29]
    - Ovarian Cancer: NIH Institute and Center Resources [30]
  32. National Guideline Clearinghouse
    - Ovarian cancer screening. American College of Radiology ngc-guideline: [31]
    - Staging and follow-up of ovarian cancer. American College of Radiology ngc-guideline: [32]
    - Guidance on the use of paclitaxel in the treatment of ovarian cancer. National Institute for Health and Clinical Excellence ngc-guideline: [33]
    - Diagnostic imaging in the assessment of metastatic and recurrent ovarian cancer. (Program in Evidence-based Care) ngc-guideline: [34]
    - Use of systemic therapy in women with recurrent ovarian cancer - development, methods and clinical practice guideline. Society of Gynecologic Oncologists of Canada ngc-guideline: [35]
    - Risk assessment and genetic counseling for hereditary breast and ovarian cancer: recommendations of the National Society of Genetic Counselors. National Society of Genetic Counselors ngc-guideline: [36]
    - Hereditary breast and ovarian cancer syndrome. American College of Obstetricians and Gynecologists ngc-guideline: [37]
    - PET imaging in ovarian cancer: recommendations. Program in Evidence-based Care ngc-guideline: [38]
    - Part I. Ovarian Cancer: Screening Guideline Syntheses, recommendations from ACR, SIGN, USPSTF, & UMHS [39]
    - Ovarian carcinoma. Association of Comprehensive Cancer Centres ngc-guideline: [40]
    - Ovarian cancer. The recognition and initial management of ovarian cancer. National Collaborating Centre for Cancer. National Institute for Health and Clinical Excellence (NICE) ngc-guideline: [41]

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