Ovarian Cancer

Ovarian Cancer

 

Ovarian cancer is a relatively uncommon gynecologic cancer in the U.S.

Epidemiology

  • Incidence – 40/100,000 for postmenopausal females
  • Age – median age is 60 years
  • Sex – exclusively female

Risk Factors

  • Increased risk
    • Family history of breast or ovarian cancer
      • Genetic predisposition only identified in 5% of cases
      • Associated with BRCA-1, BRCA-2 and Lynch Syndrome II
      • Higher probability of BRCA mutations in Ashkenazi Jews
    • Nulliparity
  • Decreased risk is associated with:
    • Oral contraceptive use
    • Pregnancy
    • Lactation
    • History of tubal ligation

Pathophysiology

  • Malignant transformation of the epithelium of the ovarian surface
  • Often spreads early to the contiguous peritoneal mesothelium
    • Spread follows the flow of peritoneal fluid

Clinical Presentation

  • Symptoms are most often nonspecific, most patients present with stage III or IV disease
  • Abdominal symptoms
    • Abdominal fullness, dyspepsia, early satiety, bloating, pelvic pain
  • Physical findings
    • Ascites
    • Pleural effusions
    • Umbilical mass (Sister Mary Joseph nodule)
    • Ovarian mass
    • Unusual findings
      • Seborrheic keratoses (Leser-Trélat)
      • Migratory superficial thrombophlebitis (Trousseau sign)
      • Subacute cerebellar degeneration (paraneoplastic syndrome)
      • Palmar fasciitis
      • Dermatomyositis

Diagnosis

  • Imaging
    • Ultrasound
      • Transvaginal ultrasonography (TVUS) followed by CT/MRI  if suspicious TVUS findings
    • Histology
      • Surgical biopsy to determine if ovarian mass is malignant
        • Avoid percutaneous biopsy as it can cause tumor spillage into the pelvis
  • Laboratory testing
    • Serum marker testing may be useful in  high risk patients (see below)

Differential Diagnosis

  • Cholecystitis
  • Peptic ulcer disease
  • Other gastrointestinal malignancies – gastric, pancreatic, gallbladder
  • Cirrhosis
  • Irritable bowel disease

Disease Monitoring

  • CA 125
    • Recommended use
      • Early detection in hereditary syndromes (eg, BRCA-1 and BRCA-2) in conjunction with (TVUS)
      • Assessment of patient response to chemotherapy, detection of early relapse and prediction of prognosis

Disease Screening

  • Biomarkers
    • CA 125
      • Recommended use for differential diagnosis of suspicious pelvic mass in postmenopausal females
      • Not recommended for:
        • Population screening
        • Initial diagnostic testing (although level >65 U/ml is suspicious for ovarian cancer)
    • BRCA-1 and BRCA-2 testing should be considered in patients with family history of ovarian cancer.
    • Other currently available markers are not useful
    • Two trials are currently ongoing which are designed to evaluate multimodality (CA125 and TVUS) screening
      • The PLCO trial in U.S. and the U.K. Collaborative Trial of Ovarian Screening
        • Both have finished enrollment and are in analysis phases

Prevention

  • In patients with known BRCA-1 or BRCA-2 mutation who have completed childbearing, bilateral salpingo-oophorectomy dramatically reduces risk for ovarian cancer
    • Small risk of primary peritoneal serous carcinoma will still exist

See Also