B26. Malignant ovarian cancer; operative treatment, chemo- and radiation therapy
Most patients with epithelial ovarian carcinoma are treated by surgical removal or cytoreduction followed by adjuvant chemotherapy.
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.
Chemotherapy
Neoadjuvant or adjuvant chemotherapy may be 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.