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Ovarian cancer: Difference between revisions
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<section begin="gynaecology intro" /><section begin="oncology" />'''Ovarian cancer''' is the second most common gynaecological cancer (after endometrial), but the most common cause of gynaecological cancer death due to its poor prognosis. It has no early symptoms, it has potential to grow very large, and it has aggressive behaviour. There is no effective screening for it in the general population. The most common type is the epithelial type (90% of cases), which has the worst prognosis. It is mostly a disease of postmenopausal women in the 55 – 65 age group. The 5-year survival is 30 – 35%. 70% of cases are stage III or IV at the time of diagnosis. The only real opportunity for survival is early diagnosis with complete surgical excision. | <section begin="gynaecology intro" /><section begin="oncology" />'''Ovarian cancer''' is the second most common gynaecological cancer (after endometrial), but the most common cause of gynaecological cancer death due to its poor prognosis. It has no early symptoms, it has potential to grow very large, and it has aggressive behaviour. There is no effective screening for it in the general population. The most common type is the epithelial type (90% of cases), which has the worst prognosis. It is mostly a disease of postmenopausal women in the 55 – 65 age group. The 5-year survival is 30 – 35%. 70% of cases are stage III or IV at the time of diagnosis. The only real opportunity for survival is early diagnosis with complete surgical excision. | ||
Ovarian germ cell tumours (like teratoma) account for < 3% of ovarian cancers. They mostly affect younger women, rarely affecting those over 30. They’re most commonly benign. Most are diagnosed at an early stage and are highly curable (5-year survival > 95%). | <section begin="germ cell" />Ovarian germ cell tumours (like teratoma) account for < 3% of ovarian cancers. They mostly affect younger women, rarely affecting those over 30. They’re most commonly benign. Most are diagnosed at an early stage and are highly curable (5-year survival > 95%).<section end="germ cell" /> | ||
== Etiology == | == Etiology == | ||
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There’s nothing in particular which can distinguish borderline tumours from other tumours clinically. The diagnosis is made pathologically, after surgery.<section end="borderline" /> | There’s nothing in particular which can distinguish borderline tumours from other tumours clinically. The diagnosis is made pathologically, after surgery.<section end="borderline" /> | ||
<section begin="germ cell" /> | |||
=== Ovarian germ cell tumours === | === Ovarian germ cell tumours === | ||
Ovarian germ cell tumours are those ovarian tumour which originate from primordial germ cells in the ovary. These can develop into foetus-like structures, placenta-like structures, extraembryonal structures, or grow completely undifferentially. It’s a heterogenous group of tumours with many different types with different characteristics. | Ovarian germ cell tumours are those ovarian tumour which originate from primordial germ cells in the ovary. These can develop into foetus-like structures, placenta-like structures, extraembryonal structures, or grow completely undifferentially. It’s a heterogenous group of tumours with many different types with different characteristics. | ||
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A yolk sac tumour is a germ cell tumour which has grown into a yolk sac-like structure. They characteristically produce AFP. | A yolk sac tumour is a germ cell tumour which has grown into a yolk sac-like structure. They characteristically produce AFP. | ||
Embryonal carcinoma of the ovary is one of the most aggressive ovarian tumours. It’s very rare. | Embryonal carcinoma of the ovary is one of the most aggressive ovarian tumours. It’s very rare.<section end="germ cell" /><section begin="oncology" /> | ||
<section begin="oncology" /> | |||
=== Ovarian sex cord-stromal tumours === | === Ovarian sex cord-stromal tumours === | ||
Ovarian sex cord-stromal tumours (SCSTs) are a group of ovarian tumours. Some of them are benign, some of them are malignant. These tumours arise from sex cord cells, like Sertoli or granulosa cells, or from stromal cells, like fibroblasts and gonadal stroma. In contrast to epithelial ovarian cancers, malignant SCSTs are often diagnosed at an early stage, and so the prognosis is good. SCSTs account for < 5% of all ovarian tumours. Most types are most prevalent in postmenopausal women. The only exception is Sertoli-Leydig cell tumour, which primarily affects 30 – 40 year old women. <section end="oncology" />There are many types: | Ovarian sex cord-stromal tumours (SCSTs) are a group of ovarian tumours. Some of them are benign, some of them are malignant. These tumours arise from sex cord cells, like Sertoli or granulosa cells, or from stromal cells, like fibroblasts and gonadal stroma. In contrast to epithelial ovarian cancers, malignant SCSTs are often diagnosed at an early stage, and so the prognosis is good. SCSTs account for < 5% of all ovarian tumours. Most types are most prevalent in postmenopausal women. The only exception is Sertoli-Leydig cell tumour, which primarily affects 30 – 40 year old women. <section end="oncology" />There are many types: | ||
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Fibroma is the most common benign SCST, while granulosa cell tumour is the most common malignant SCST. | Fibroma is the most common benign SCST, while granulosa cell tumour is the most common malignant SCST. | ||
<section begin="oncology" /><section begin="gynaecology intro" /> | <section begin="oncology" /><section begin="gynaecology intro" /><section begin="germ cell" /> | ||
== Clinical features == | == Clinical features == | ||
Ovarian cancer is characteristically asymptomatic until the late stages, which is part of the reason for the poor prognosis. | Ovarian cancer is characteristically asymptomatic until the late stages, which is part of the reason for the poor prognosis. | ||
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** Haemorrhage – abdominal pain and haemorrhagic shock | ** Haemorrhage – abdominal pain and haemorrhagic shock | ||
Some present with an asymptomatic adnexal mass which is discovered on bimanual examination or on ultrasound. Germ cell tumours grow quickly and therefore often cause pelvic pain or symptoms of bladder or bowel compression.<section end="oncology" /><section end="gynaecology intro" /> | Some present with an asymptomatic adnexal mass which is discovered on bimanual examination or on ultrasound. Germ cell tumours grow quickly and therefore often cause pelvic pain or symptoms of bladder or bowel compression.<section end="oncology" /><section end="gynaecology intro" /><section end="germ cell" /> | ||
=== Features of SCSTs === | === Features of SCSTs === | ||
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Sertoli-Leydig cell tumours produce androgens, which may cause virilisation, hirsutism, acne, etc. | Sertoli-Leydig cell tumours produce androgens, which may cause virilisation, hirsutism, acne, etc. | ||
<section begin="oncology" /><section begin="gynaecology intro" /> | <section begin="oncology" /><section begin="gynaecology intro" /><section begin="germ cell" /> | ||
== Diagnosis and evaluation == | == Diagnosis and evaluation == | ||
Physical examination should be performed for an adnexal mass as well as inguinal and cervical lymphadenopathy. Ultrasound (usually transvaginal) of the adnexal mass can reveal features suspicious for malignancy (solid mass, irregularity, papillary structures, etc.) and ascites. Chest, abdominal, and pelvic CT or MRI are used to look for ascites and disease spread. [[FNAB]] is never performed as it may cause spreading. | Physical examination should be performed for an adnexal mass as well as inguinal and cervical lymphadenopathy. Ultrasound (usually transvaginal) of the adnexal mass can reveal features suspicious for malignancy (solid mass, irregularity, papillary structures, etc.) and ascites. Chest, abdominal, and pelvic CT or MRI are used to look for ascites and disease spread. [[FNAB]] is never performed as it may cause spreading. | ||
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The definite diagnosis of ovarian cancer, as well as determination of its histological type, requires histology. Biopsy causes tumour seeding and is not performed. All cases of suspected ovarian cancer undergo complete surgical staging, involving total hysterectomy with bilateral salpingo-oophorectomy with pelvic and paraaortic lymph node dissection and omentectomy. Peritoneal cytology is also acquired by peritoneal washing. Only after histological evaluation of these samples can the diagnosis be made. | The definite diagnosis of ovarian cancer, as well as determination of its histological type, requires histology. Biopsy causes tumour seeding and is not performed. All cases of suspected ovarian cancer undergo complete surgical staging, involving total hysterectomy with bilateral salpingo-oophorectomy with pelvic and paraaortic lymph node dissection and omentectomy. Peritoneal cytology is also acquired by peritoneal washing. Only after histological evaluation of these samples can the diagnosis be made. | ||
It’s important to distinguish germ cell tumours from other ovarian tumours during the diagnostic evaluation, as the treatment is different. Germ cell tumours are more often solid on ultrasound than epithelial tumours. Because germ cell tumours frequently are bilateral, both sides must be examined (bilateral examination is performed routinely in all cases anyway). If germ cell tumour is suspected in a young girl, we may perform karyotyping (as the probability of intersex disorder is high). Ovarian germ cell tumours often produce tumour markers, especially hCG, AFP, and lactate dehydrogenase (LDH).<section end="gynaecology intro" /> | It’s important to distinguish germ cell tumours from other ovarian tumours during the diagnostic evaluation, as the treatment is different. Germ cell tumours are more often solid on ultrasound than epithelial tumours. Because germ cell tumours frequently are bilateral, both sides must be examined (bilateral examination is performed routinely in all cases anyway). If germ cell tumour is suspected in a young girl, we may perform karyotyping (as the probability of intersex disorder is high). Ovarian germ cell tumours often produce tumour markers, especially hCG, AFP, and lactate dehydrogenase (LDH).<section end="gynaecology intro" /><section end="germ cell" /> | ||
=== Tumour markers of malignant ovarian cancer === | === Tumour markers of malignant ovarian cancer === | ||
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=== Germ cell tumours === | === 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). | <section begin="germ cell" />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. | 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). | 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).<section end="germ cell" /> | ||
=== Sex cord-stromal tumours === | === Sex cord-stromal tumours === | ||