B26. Malignant ovarian cancer; operative treatment, chemo- and radiation therapy

See topic A11 for more information.

Management

Most patients with epithelial ovarian carcinoma are treated by surgical removal or cytoreduction followed by adjuvant chemotherapy. Borderline tumours are managed like malignant epithelial tumours.

Surgical treatment

The treatment, diagnosis, and staging of ovarian cancer is surgical, either by laparotomy or in some cases, laparoscopy. Frozen section is performed during the operation, and the information is used to help determine the diagnosis and stage of the tumour, and therefore the extent of the surgical procedure.

The standard staging procedure is total hysterectomy with bilateral salpingo-oophorectomy with pelvic and paraaortic lymph node dissection and omentectomy. Peritoneal cytology is also acquired by peritoneal washing.

The upper abdomen, peritoneal surfaces, mesenteries, and other abdominal organs are inspected visually. If metastases are evident during surgery, they’re removed as much as possible.

In cases of mucinous epithelial ovarian cancer, some experts advocate removal of the appendix, even though it appears normal visually. This is because mucinous ovarian cancer is associated with appendiceal metastasis.

In young patients with stage Ia disease or non-epithelial ovarian cancers who desire it, fertility-preserving surgery may be performed instead. This includes unilateral salpingo-oophorectomy, peritoneal washing, omentectomy, and pelvic and paraaortic lymphadenectomy.

Cytoreduction (removing as much as possible of visible lesions) may be performed in stage III and IV when complete resection is impossible.

Chemotherapy

Epithelial ovarian cancer is chemosensitive. Neoadjuvant and/or adjuvant chemotherapy is therefore widely used. Chemotherapy is mostly platinum-based, for example carboplatin + paclitaxel. It may sometimes be administered intraperitoneally.

Targeted molecular therapy

All patients with epithelial ovarian cancer should be tested for familial cancer syndromes which may cause ovarian cancer, especially familial BRCA1 and BRCA2 mutations. In cases of epithelial ovarian cancers in people with positive familial BRCA mutations, PARP inhibitors may be used as adjuvant therapy in addition to chemotherapy.

Bevacizumab (anti-VEGF) may also be used.

Radiotherapy

Radiotherapy is not part of the standard management of ovarian cancer, but it may be used on a palliative indication for recurrent or metastatic ovarian cancer.

Germ cell tumours

Ovarian germ cell tumours often occur in fertile women, and as such special measures should be taken to preserve fertility if possible, if the patient wants to. If a germ cell tumour is highly suspected, bilateral oophoerctomy may not be required, and we may opt for fertility-sparing surgery instead (unilateral salpingo-oophorectomy with preservation of the uterus).

If the contralateral ovary appears to also be affected by the tumour at the time of surgery, we may resect this tumour affection while preserving the rest of the contralateral ovary to preserve fertility. Even if the whole tumour can’t be removed during surgery, cure is likely with adjuvant chemotherapy.

Adjuvant chemotherapy cures most patients with germ cell tumours as they’re highly chemosensitive. The standard chemotherapy regimen consists of bleomycin, etoposide, and carboplatin/cisplatin (BEP).

Sex cord-stromal tumours

The treatment of malignant SCSTs is generally the same as for other ovarian cancers and includes bilateral salpingo-oophorectomy (adnexectomy) and total hysterectomy. Adjuvant chemotherapy may be used in some cases. Surgical removal of the tumour generally causes resolution of the tumours effects. In patients with Meigs syndrome, surgical removal of the fibroma leads to complete resolution of the symptoms. In patient with hormonal changes, these changes are reversed after surgery.