New Vision University School of Medicine,

Tbilisi, Georgia

Ovarian Cancer

Submitted by:
Mohammad Thabet

The course:
Oncology and Palliative Therapy

Fall Semester – 2022

 Ovarian cancer

- Epidemiology:
• Ovarian cancer is ranked as the seventh most common cancer and the fifth fatal cancer
among women population.
• Every woman has a percentage of 1.6% for developing ovarian cancer during her life.
• Only 15% of all diagnosed cancer cases are detected at early stages.

-Types of ovarian cancer:

There are three types of ovarian cancer; Epithelial, Germ cell and Sex cord and Stromal
tumours.
1) Epithelial ovarian cancer:
- It is the most common with a percentage of 90% of all ovarian cancers.
- It is the fourth leading cause in cancer deaths among women and has the highest
mortality rate among the female reproductive system cancers.
- It originates from the ovarian epithelium.
- 50% of epithelial tumours are benign, 33% are malignant and 16% are border lined.
- The most common types of epithelial tumours are: serous, mucinous, endometrioid,
clear and transitional cell tumours.
-
-Risk factors:
• Risk increases with aging, especially when around the age of menopause.
• Family history of ovarian cancer, fallopian tube cancer, peritoneal cancer or premenopausal
breast cancer.
• Personal history of premenopausal breast cancer or endometriosis.
• Infertility.
• Family history of colon and endometrial cancers.
• Genetic risk factors: Women who carry disease specific alleles for BRCA1 and BRCA2 are
at significantly higher risk of epithelial ovarian cancer.
• Ethnicity: Ashkenazi Jewish heritage.
• Smoking.
• Obesity.
• Hormone replacement therapy.
-Protective factors:
• Multiparty.
• Oral contraceptives.
• Breastfeeding.

- Clinical presentation (Signs and Symptoms):

Ovarian cancer was called the “silent killer”. However, recent theories have shown that the
term is not true as the following symptoms are possibly to appear. These symptoms include:
• Bloating.
• Pelvic or abdominal discomfort.
• Difficulty eating or feeling early satiety.
• Urinary or bowel symptoms.

-Symptoms such as: fatigue, indigestion, back pain, pain with intercourse, constipation and
menstrual irregularities are not helpful in detecting ovarian cancer because they can be found
among women who are not developing ovarian cancer.
-Signs include the increase of abdominal girth because of the ascites.

-Initial evaluation and diagnosis:

When a woman complains of certain symptoms, a pelvic exam which includes a rectovaginal
exam and a generalized physical examination should be performed:
• If the exam is abnormal:
**transvaginal or pelvic ultrasound should be done to evaluate the ovaries.
**CT scan to look for other organs.
If the results are normal, wait 2 to 3 weeks and re-asses the resolving of symptoms. If not,
then a transvaginal or pelvic ultrasound should be performed. If an abnormality of the ovaries
is found:
**Additional radiographic studies, such as a CT scan or an MRI should be done.
**Blood test for the tumour marker (CA 125); 80% of women with advanced-stage epithelial
ovarian cancer is detected to have elevated level, but this can occur for other reasons.
-Staging and prognosis:

Staging helps to determine to which extent the cancer is spreading in the body and what is the
best treatment plan:

• Stage I:
The cancer is found in one or both ovaries. Cancer cells also may be found on the surface of
the ovaries or in fluid collected from the abdomen. The prognosis of this stage is 90-95% of
5- years’ survival.
• Stage II:
The cancer has spread from one or both ovaries to other pelvic tissues, such as the fallopian
tubes or uterus. Cancer cells may also be found in fluid collected from the abdomen. The
prognosis of this stage is 70-80% of 5-years survival.
• Stage III:
The cancer has spread outside the pelvis or nearby lymph nodes. Most commonly the cancer
spreads to the omentum, diaphragm, intestine and the liver. The prognosis of this stage is 20-
50% of 5-years survival.

• Stage IV:
The cancer has spread to tissues outside the abdomen and pelvis. The most common site for
the spread is in the space around the lungs. Additionally, inside the liver or spleen. The
prognosis of this stage is poor with 1-5% of 5-years survival.

-Treatment Decisions:
• Surgery:
It is the first step in treating ovarian cancer. Most procedures are performed using a
procedure called a laparotomy:
-Early stage ovarian cancer can be treated by laparoscopic surgery.
-Laparoscopic surgery sometimes can also be performed in women with advanced ovarian
cancer.
**If ovarian cancer is found and histopathology released:
1) Primary ovarian tumour:
- Salpingo-oophorectomy: both ovaries and fallopian tubes are removed.
- Hysterectomy: the uterus is removed.
- Staging procedure: including omentectomy, lymph node removal.
2) Bulky intra-abdominal disease:
-Debulking: removal of any additional visible disease as much as possible If the cancer has
spread, including removal of portions of the small or large intestine and removal of tumour
from the liver, diaphragm, and pelvis
-For staging: the omentum is removed with nearby lymph nodes and multiple small samples
of pelvic and abdominal tissues.

**For early “stage I” cancer and still want to get pregnant, it may be possible to only remove
one ovary and fallopian tube.

• Chemotherapy:
-It is the drugs that kill cancer cells.
-It is usually given intravenously.
-Chemotherapy is usually given in cycles.
- Most women with ovarian cancer receive chemotherapy for about 6 months following their
surgery.
-In some cases, it may be better to continue chemotherapy for a longer period of time to
reduce the chance of the recurrence.
-There is another way to deliver chemotherapy, called intraperitoneal (IP) chemotherapy.
With IP chemotherapy, the medications are injected directly into the abdominal cavity.
-Intraperitoneal chemotherapy is recommended for women with stage III ovarian cancer. -
Recent studies have shown that while IP chemotherapy has the longer survival rate.
-More than 15% response to gemcitabine, topotecan, liposomal doxorubicin and
bevacizumab.
-Around 10% of ovarian cancer are HER2/neu positive with a good respond to trastuzumab.

•Radiation:
It is not used as the first line treatment but in case of tumour recurrence in ovarian cancers.

•Hormonal therapy:
A few types of ovarian cancer need hormones to grow. In these cases, hormonal therapy may
be a treatment option.
This therapy works by blocking the action of the hormones as a way of preventing ovarian
cancer cells from getting the hormones they may need to grow.
It is usually taken as a pill but can be given as a shot.

-Follow up after treatment:

In general, women are followed up with:
-Exams (including a pelvic exam): every 3 to 4 months for 3 years, and then every 6 months.
-Blood tests: CA 125 level.
-Imaging studies: x-rays, CT scans, or MRIs once any symptoms are developed.

2) Germ cell cancer:

- It is uncommon form of ovarian cancer with 5% of ovarian cancers.
- Usually developed in adolescents and young-aged females.
- It could be benign, including: teratomas or dermoid cyst.
or
malignant, including: immature teratomas, dysgerminomas, choriocarcinoma and yolk sac
malignancies.
-Usually, it is unilateral.

-Clinical presentation:
** Palpable abdominal or pelvic masses.
** Acute abdominal pain due to ovarian torsion or haemorrhage.
** Precocious puberty when in young girls.

-Diagnosis:
** Elevated level of HCG (human chorionic gonadotropin) in:
-Embryonal carcinoma, dysgerminoma and choriocarcinoma.
** Elevated AFP (Alpha fetoprotein) in:
-Yolk sac tumour.

-Treatment:
** Unilateral oophorectomy or salpingo-oophorectomy is the typical treatment.
** If pelvic or para-aortic lymph nodes are enlarged, should be resected due to suspected
metastatic tumour.
** Chemotherapy for malignant germ cell tumour.

3) Sex cord and Stromal cell cancer:

-It is a rare type.
-Presents as unilateral solid mass, abdominal pain due to torsion or haemorrhage, signs and
symptoms due to hormonal secretion:
**Estrogen producing tumour: breast tenderness, precocious pseudo puberty,
menometrorrhagia, oligomenorrhea or amenorrhea in premenopausal girls and abnormal
vaginal bleeding in postmenopausal women.
-Diagnosed by elevated level of Mullerian Inhibiting Substance (MIS), Inhibin and AFP in
Sertoli-Leydig tumours.
-Treated mainly by surgery as most tumours are confined to the ovary. Chemotherapy also is
effective.