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CANCER OF THE OVARY
  • Leading cause of death in gynecological cancer
  • It is thought that a genetic accident might have occurred during the normal frequent ovulation and ovarian epithelial cells.


Factors Affecting Ovarian Cancer Development

  • The risk is reduced in patients who have tubal ligations and hysterectomy
  • Oral contraceptives also reduce risks
  • Alcohol consumption and smoking do not affect the risk
  • Multiple pregnancies decrease risks, so is breastfeeding


Familial Factors: Three types of entities are described. They are:

  1. Ovarian cancer alone
  2. Ovarian and breast cancers
  3. Ovarian and colon cancers
  • Family history is the most important risk factor
  • It is associated with BRCA1 gene on chromosome 17
  • Most ovarian cancers are of epithelial origins
  • In younger patients, ovarian cancer is of germ cell origin, usually
  • There is an entity called "tumors of low malignant potential", which is usually treated with surgical resections and subsequent close observation. This tumor does not respond to chemotherapy
  • Clear cell carcinomas are aggressive in nature and should be considered as a high-grade malignancy.
  • Ovarian cancer usually spreads through the abdominal and pelvic cavities


Signs and Symptoms

  • Most patients are asymptomatic until the disease is far advanced, hence the high mortality rate attached to it
  • Abdominal pain and swelling are early complaints
  • Pelvic mass in the elderly
  • Nausea and vomiting
  • Significant weight loss
  • Constipation
  • Intestinal obstruction
  • Pedal edema


Prognostic Factors:

  • Younger age at diagnosis correlates with good prognosis
  • Residual tumor less than 1 cm after surgery
  • Extent of disease at diagnosis - prognosis is poorer if the disease at diagnosis is advanced
  • Histologic type and grade: poorer prognosis with aggressive tumors (mucinous and clear cell types)
  • Good performance status good prognosis
  • There is no good screening test or procedure that has proven to reduce ovarian cancer incidence
  • Prophylactic oophorectomy (removing both normal ovaries to prevent cancer development) ahs not proven to be of any value


Diagnosis

  • Abdomino-pelvic ultrasound
  • CA-125 (ovarian cancer tumor marker) has no significance prognostically at diagnosis
  • CA-125 level becomes more significant during the course of chemotherapy and follow-up
  • Cat Scans of the abdomen and pelvis need to be done
  • Complete blood count (CBC) with differential
  • Chest x-ray to rule out lung metastasis
  • Bone scan may be necessary


Treatment

  • Management of limited disease
    • Initial evaluation requires an exploratory laparotomy and careful inspection of the peritoneal surfaces necessary
    • Multiple peritoneal biopsies
    • Surgical cyto reduction might involve performing total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy
    • Patients are randomized to high or low risk groups depending on
      1. Positive peritoneal washings
      2. Extra cystic tumor
      3. Poorly differentiated histology
      4. Ascites
      5. Disease outside of the ovary
    • Those at high risk (one or more of the above risk factors) require more treatment with platinum-based chemotherapy
  • Management of Advanced Disease:
    • Following a cytoreductive surgery, patients need to be given platinum-based chemotherapy regimen. Current treatment involves the use of Cisplatin (7t mg/m2) and Taxol (135 mg/M2)
    • Second look laparotomy is sensitive in diagnosing recurrence, but it does not reduce the incidence of recurrence


Salvage Therapy may be given in recurrent disease

  • If the tumor was initially sensitive to platinum and recurrence was six months or greater, patient may be treated with Cisplatin again
  • If the tumor was resistant to Cisplatin or the time interval to recurrence is less than___


The following agents/drugs may be used:

  • Taxol
  • Ifosfamide
  • Adriamycin
  • Tamoxifen
  • Gemcitabine plus or minus Cisplatin may be used in both Cisplatin-sensitive and Cisplatin resistant disease
  • Topotecan
  • Monoclonal Antibody specific for CA125 is undergoing trials