Ovarian cancer 414192 223655020 2008-07-05T02:54:47Z Arcadian 104523 mesh {{Inappropriate tone|date=December 2007}} {{DiseaseDisorder infobox | Name = Ovarian cancer | ICD10 = {{ICD10|C|56||c|51}}, {{ICD10|D|27||d|10}} | ICD9 = {{ICD9|183}}, {{ICD9|220}} | ICDO = varied | Image = | Caption = | OMIM = | OMIM_mult = | MedlinePlus = 000889 | eMedicineSubj = med | eMedicineTopic = 1698 | DiseasesDB = 9418 | MeshID = D010051 | }} '''Ovarian cancer''' is a [[malignant]] [[tumor]], of any [[histology]], arising from an [[ovary]]. ==[[Epidemiology]]== Ovarian cancer is the fifth leading cause of [[cancer]] deaths in [[women]], the leading cause of death from [[gynecology|gynecological]] malignancy, and the second most commonly diagnosed gynecologic malignancy.<ref>[http://www.merck.com/mrkshared/mmanual/section18/chapter241/241b.jspThe Merck Manual of Diagnosis and Therapy Section 18. Gynecology And Obstetrics Chapter 241. Gynecologic Neoplasms]</ref> According to the [[American Cancer Society]], there is no true test for ovarian cancer. "Several large studies are in progess to learn how best to find ovarian cancer in its earliest stage."[http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_ovarian_cancer_be_found_early_33.asp?rnav=cri] Since there is no accurate screening test, "an exploratory surgical procedure called laparotomy is generally required for the definitive diagnosis of ovarian cancer. During this procedure, cysts or other suspicious areas must be removed and biopsied. After the incision is made, the surgeon assesses the fluid and cells in the abdominal cavity. If the lesion is cancerous, the surgeon continues with a process called surgical staging to ascertain how far the cancer has spread." [http://www.ovariancancer.org/index.cfm?fuseaction=Feature.showFeature&CategoryID=7&FeatureID=134] The exact cause is usually unknown. The disease is more common in industrialized nations, with the exception of [[Japan]]. In the [[United States]], females have a 1.4% to 2.5% (1 out of 40-60 women) lifetime chance of developing ovarian cancer. Older women are at highest risk. {{Fact|date=November 2007}} More than half of the deaths from ovarian cancer occur in women between 55 and 74 years of age and approximately one quarter of ovarian cancer deaths occur in women between 35 and 54 years of age. The risk of developing ovarian cancer appears to be affected by several factors. The more children a woman has, the lower her risk of ovarian cancer. Early age at first pregnancy, older ages of final pregnancy and the use of low dose [[hormonal contraception]] have also been shown to have a protective effect. Ovarian cancer is reduced in women after [[tubal ligation]]. {{Fact|date=November 2007}} The relationship between use of oral contraceptives and ovarian cancer was shown in a summary of results of 45 case-control and prospective studies. Cumulatively these studies show a protective effect for ovarian cancers. Women who used oral contraceptives for 10 years had about a 60% reduction in risk of ovarian cancer. (risk ratio .42 with statistical significant confidence intervals given the large study size, not unexpected). This means that if 250 women took oral contraceptives for 10 years, 1 ovarian cancer would be prevented. This is by far the largest epidemiological study to date on this subject (45 studies, over 20,000 women with ovarian cancer and about 80,000 controls).<ref>Collaborative Group on Epidemiological Studies of Ovarian Cancer. Ovarian cancer and oral contraceptives: collaborative reanalysis of data from 45 epidemiological studies including 23 257 women with ovarian cancer and 87 303 controls. Lancet 2008;371:303-14 doi:10.1016/S0140-6736(08)60167-1</ref> The link to the use of [[fertility medication]], such as [[Clomiphene citrate]], has been controversial. An analysis in [[1991]] raised the possibility that use of drugs may increase the risk of ovarian cancer. Several [[cohort]] studies and [[case-control]] studies have been conducted since then without providing conclusive evidence for such a link. <ref>{{cite journal |author=Brinton, L.A., Moghissi, K.S., Scoccia, B., Westhoff, C.L., Lamb, E.J. |title=Ovulation induction and cancer risk |journal=Fertil. Steril. |volume=83 |issue=2 |pages=261–74; quiz 525–6 |year=2005 |pmid=15705362 |doi=10.1016/j.fertnstert.2004.09.016}}</ref> It will remain a complex topic to study as the infertile population differs in [[parity (medicine)|parity]] from the "normal" population. There is good evidence that in some women genetic factors are important. Carriers of certain mutations of the [[BRCA1]] or the [[BRCA2]] [[gene]]. The BRCA1 and BRCA2 gene account for 5%-13% of ovarian cancers[http://clincancerres.aacrjournals.org/cgi/content/full/10/7/2473] and certain populations (e.g. [[Ashkenazi Jew]]ish women) are at a higher risk of both [[breast cancer]] and ovarian cancer, often at an earlier age than the general population. {{Fact|date=November 2007}} Patients with a personal history of breast cancer or a family history of breast and/or ovarian cancer, especially if at a young age, may have an elevated risk. A strong family history of [[uterine cancer]], [[colon cancer]], or other [[gastrointestinal cancer]]s may indicate the presence of a syndrome known as [[hereditary nonpolyposis colorectal cancer]] (HNPCC, also known as [[Hereditary nonpolyposis colorectal cancer|Lynch II syndrome]]), which confers a higher risk for developing ovarian cancer. Patients with strong genetic risk for ovarian cancer may consider the use of [[prophylactic]] i.e. preventative [[oophorectomy]] after completion of childbearing. {{Fact|date=November 2007}} A Swedish study, which followed more than 61,000 women for 13 years, has found a significant link between milk consumption and ovarian cancer. According to the BBC, "[Researchers] found that milk had the strongest link with ovarian cancer - those women who drank two or more glasses a day were at double the risk of those who did not consume it at all, or only in small amounts." <ref>BBC News [http://news.bbc.co.uk/2/hi/health/4051331.stm Milk link to ovarian cancer risk] [[29 November]] [[2004]]</ref> Recent studies have shown that women in sunnier countries have a lower rate of ovarian cancer, which may have some kind of connection with exposure to [[Vitamin D]]. {{Fact|date=February 2007}} Other factors that have been investigated, such as [[talc]] use, [[asbestos]] exposure, high dietary fat content, and childhood [[mumps]] infection, are controversial and have not been definitively proven. "Associations were also found between alcohol consumption and cancers of the ovary and prostate, but only for 50 g and 100 g a day."<ref>[http://www.jr2.ox.ac.uk/bandolier/booth/hliving/alccan.html Alcohol consumption and cancer risk]</ref> ==Classification== [[Image:Mature cystic teratoma of ovary.jpg|right|thumb|80px|A germ cell tumor of the ovary, discovered during a [[Caesarean section|C-section]]; this is a 4 cm [[teratoma]]]] Ovarian cancer is classified according to the [[histology]] of the tumor, obtained in a [[pathology]] report. Histology dictates many aspects of clinical treatment, management, and [[prognosis]]. *[[Surface epithelial-stromal tumour]], also known as '''ovarian epithelial carcinoma''', is the most common type of ovarian cancer. It includes [[serous tumour]], [[endometrioid tumor]] and [[mucinous]] [[cystadenocarcinoma]]. *[[Sex cord-stromal tumour|Sex cord-stromal tumor]], including [[estrogen]]-producing [[granulosa cell tumor]] and '''virilizing''' [[Sertoli-Leydig cell tumor]] or [[arrhenoblastoma]], accounts for 8% of ovarian cancers. *[[Germ cell tumor]] accounts for approximately 30% of ovarian tumors but only 5% of ovarian cancers.{{Fact|date=July 2007}} It tends to occur in young women and girls. The prognosis depends on the specific histology of germ cell tumor, but overall is favorable. * '''Mixed''' tumors, containing elements of more than one of the above classes of tumor histology. Ovarian cancer can also be a '''secondary cancer''', the result of [[metastasis]] from a primary cancer elsewhere in the body. Common primary cancers are [[breast cancer]] and [[gastrointestinal cancer]] (in which case the ovarian cancer is a [[Krukenberg cancer]] {{Fact|date=November 2007}}). Surface epithelial-stromal tumor can originate in the [[peritoneum]] (the lining of the abdominal cavity), in which case the ovarian cancer is secondary to [[primary peritoneal cancer]], but treatment is basically the same as for primary surface epithelial-stromal tumor involving the peritoneum. {{Fact|date=November 2007}} ==Symptoms== ===Studies on the accuracy of symptoms=== Two [[case-control]] studies, both subject to results being inflated by [[spectrum bias]], have been reported. The first found that women with ovarian cancer had symptoms of increased abdominal size, bloating, urge to pass urine and pelvic pain.<ref name="pmid15187051">{{cite journal |author=Goff BA, Mandel LS, Melancon CH, Muntz HG |title=Frequency of symptoms of ovarian cancer in women presenting to primary care clinics |journal=JAMA |volume=291 |issue=22 |pages=2705–12 |year=2004 |pmid=15187051 |doi=10.1001/jama.291.22.2705}}</ref> The smaller, second study found that women with ovarian cancer had pelvic/abdominal pain, increased abdominal size/bloating, and difficulty eating/feeling full.<ref name="pmid17154394">{{cite journal |author=Goff BA, Mandel LS, Drescher CW, ''et al'' |title=Development of an ovarian cancer symptom index: possibilities for earlier detection |journal=Cancer |volume=109 |issue=2 |pages=221–7 |year=2007 |pmid=17154394 |doi=10.1002/cncr.22371}}</ref> The latter study created a symptom index that was considered positive if any of the six (6) symptoms "occurred >12 times per month but were present for <1 year".They reported a [[sensitivity (tests)|sensitivity]] of 57% for early-stage disease and [[specificity (tests)|specificity]] 87% to 90%. ==Ovarian Cancer Symptoms Consensus Statement== In 2007, the Gynecologic Cancer Foundation, Society of Gynecologic Oncologists and American Cancer Society originated the following consensus statement regarding the symptoms of ovarian cancer.<ref>{{cite web |url=http://www.sgo.org/publications/OvarianCancerSymptoms.pdf |title=Ovarian Cancer Symptoms Consensus Statement |accessdate=2007-07-19 |format=pdf |work=}}</ref> Ovarian cancer is called a “silent killer” because symptoms were not thought to develop until the disease had advanced and the chance of cure or remission poor. However, the following symptoms are much more likely to occur in women with ovarian cancer than women in the general population. These symptoms include: *Bloating *Pelvic or abdominal pain *Difficulty eating or feeling full quickly *Urinary symptoms (urgency or frequency) Women with ovarian cancer report that symptoms are persistent and represent a change from normal for their bodies. The frequency and/or number of such symptoms are key factors in the diagnosis of ovarian cancer. Several studies show that even early stage ovarian cancer can produce these symptoms. Women who have these symptoms almost daily for more than a few weeks should see their doctor, preferably a gynecologist. Prompt medical evaluation may lead to detection at the earliest possible stage of the disease. Early stage diagnosis is associated with an improved prognosis. Several other symptoms have been commonly reported by women with ovarian cancer. These symptoms include fatigue, indigestion, back pain, pain with intercourse, constipation and menstrual irregularities. However, these other symptoms are not as useful in identifying ovarian cancer because they are also found in equal frequency in women in the general population who do not have ovarian cancer. {{Fact|date=November 2007}} ==Diagnosis== Ovarian cancer at its early stages(I/II) is difficult to diagnose until it spreads and advances to later stages (III/IV). This is due to the fact that most of the common symptoms are non-specific. When an ovarian malignancy is included in the list of diagnostic possibilities, a limited number of laboratory tests are indicated. A complete blood count (CBC) and serum electrolyte test should be obtained in all patients. The serum [[BHCG]] level should be measured in any female in whom pregnancy is a possibility. In addition, serum [[alpha-fetoprotein]] (AFP) and lactate dehydrogenase (LDH) should be measured in young girls and adolescents with suspected ovarian tumors because the younger the patient, the greater the likelihood of a malignant germ cell tumor. A blood test called [[CA-125]] is useful in differential diagnosis and in follow up of the disease, but it has not been shown to be an effective method to screen for early-stage ovarian cancer due to its unacceptable low sensitivity and specificity. However, this is the only available, widely-used marker currently. Current research is looking at ways to combine tumor markers [[proteomics]] along with other indicators of disease (i.e. radiology and/or symptoms) to improve accuracy. The challenge in such an approach is that the very low population prevalence of ovarian cancer means that even testing with very high sensitivity and specificity will still lead to a number of false positive results (i.e. performing surgical procedures in which cancer is not found intra-operatively). However, the contributions of [[proteomics]] are still in the early stages and require further refining. Current studies on proteomics mark the beginning of a paradigm shift towards individually tailored therapy.{{Fact|date=November 2007}} A pelvic examination and imaging including CT scan and trans-vaginal ultrasound are essential. Physical examination may reveal increased abdominal girth and/or [[ascites]] (fluid within the abdominal cavity). Pelvic examination may reveal an ovarian or abdominal mass. The pelvic examination can include a rectovaginal component for better palpation of the ovaries. For very young patients, [[magnetic resonance imaging]] may be preferred to rectal and vaginal examination. ==Staging== Ovarian cancer staging is by the [[International Federation of Gynecology and Obstetrics|FIGO]] staging system and uses information obtained after surgery, which can include a total abdominal [[hysterectomy]], removal of (usually) both ovaries and fallopian tubes, (usually) the [[omentum]], and pelvic (peritoneal) washings for [[cytology]]. The [[AJCC]] stage is the same as the FIGO stage. *Stage I - limited to one or both ovaries **IA - involves one ovary; [[Capsule (anatomy)|capsule]] intact; no tumor on ovarian surface; no malignant cells in [[ascites]] or peritoneal washings **IB - involves both ovaries; capsule intact; no tumor on ovarian surface; negative washings **IC - tumor limited to ovaries with any of the following: capsule ruptured, tumor on ovarian surface, positive washings *Stage II - pelvic extension or implants **IIA - extension or implants onto uterus or fallopian tube; negative washings **IIB - extension or implants onto other pelvic structures; negative washings **IIC - pelvic extension or implants with positive peritoneal washings *Stage III - microscopic peritoneal implants outside of the pelvis; or limited to the pelvis with extension to the small bowel or omentum **IIIA - microscopic peritoneal metastases beyond pelvis **IIIB - macroscopic peritoneal metastases beyond pelvis less than 2 cm in size **IIIC - peritoneal metastases beyond pelvis > 2 cm or lymph node metastases *Stage IV - distant metastases to the liver or outside the peritoneal cavity Para-aortic lymph node metastases are considered regional lymph nodes (Stage IIIC). ==Treatment== {{Cleanup|date=January 2008}} Surgical treatment may be sufficient for malignant tumors that are well-differentiated and confined to the ovary. Addition of chemotherapy may be required for more aggressive tumors that are confined to the ovary. For patients with advanced disease a combination of surgical reduction with a combination chemotherapy regimen is standard. Borderline tumors, even following spread outside of the ovary, are managed well with surgery, and chemotherapy is not seen as useful. [[Surgery]] is the preferred treatment and is frequently necessary to obtain a tissue specimen for differential [[diagnosis]] via its [[histology]]. Surgery performed by a specialist in [[gynecologic oncology]] usually results in an improved result.{{Fact|date=November 2007}} Improved survival is attributed to more accurate staging of the disease and a higher rate of aggressive surgical excision of tumor in the abdomen by gynecologic oncologists as opposed to general gynecologists and general surgeons. The type of surgery depends upon how widespread the cancer is when diagnosed (the cancer stage), as well as the presumed type and grade of cancer. The surgeon may remove one (unilateral oophorectomy) or both ovaries (bilateral oophorectomy), the fallopian tubes (salpingectomy), and the uterus (hysterectomy). For some very early tumors (stage 1, low grade or low-risk disease), only the involved ovary and fallopian tube will be removed (called a "unilateral salpingo-oophorectomy," USO), especially in young females who wish to preserve their fertility. In advanced [[malignancy]], where complete resection is not feasible, as much tumor as possible is removed (debulking surgery). In cases where this type of surgery is successful (i.e. < 1 cm in diameter of tumor is left behind ["optimal debulking"]), the prognosis is improved compared to patients where large tumor masses (> 1 cm in diameter) are left behind. [[Minimally invasive]] surgical techniques may facilitate the safe removal of very large (greater than 10 cm) tumors with fewer complications of surgery.<ref>{{cite journal | author = Ehrlich, P.F., Teitelbaum, D.H., Hirschl, R.B., Rescorla, F. | title = Excision of large cystic ovarian tumors: combining minimal invasive surgery techniques and cancer surgery--the best of both worlds | journal = J. Pediatr. Surg. | volume = 42 | issue = 5 | pages = 890–3 | year = 2007 | pmid = 17502206 | doi = 10.1016/j.jpedsurg.2006.12.069 }}</ref> [[Chemotherapy]] has been a general [[standard of care]] for ovarian cancer for decades, although with highly variable protocols.<ref name="pmid14661040">{{cite journal | author = McGuire WP, Markman M | title = Primary ovarian cancer chemotherapy: current standards of care | journal = Br. J. Cancer | volume = 89 Suppl 3 | issue = | pages = S3–8 | year = 2003 | month = December | pmid = 14661040 | doi = 10.1038/sj.bjc.6601494 }}</ref> Chemotherapy is used after surgery to treat any residual disease, if appropriate. This depends on the [[histology]] of the tumor; some kinds of tumor (particularly [[teratoma]]) are not sensitive to chemotherapy. In some cases, there may be reason to perform chemotherapy first, followed by surgery. Currently for Stage IIIC ovarian adenocarcinomas after optimal debulking, median time for survival is statistically significantly longer for patient receiving '''intraperitoneal''' (IP) chemotherapy.{{Fact|date=May 2008}} Patients in this clinical trial{{Fact|date=May 2008}} did report less compliance with IP chemotherapy, and fewer than half of the patients received all six cycles of IP chemotherapy. Despite this high "drop-out" rate, the group as a whole (including the patients that didn't complete IP chemotherapy treatment) survived longer on average than patients who received intravenous chemotherapy alone. Some specialists believe the toxicities and other complications of IP chemotherapy will be unnecessary with improved IV chemotherapy drugs currently being developed. Although IP chemotherapy has been recommended as a [[standard of care]] for the first-line treatment of ovarian cancer, the basis for this recommendation has been challenged.<ref name="pmid18006894">{{cite journal | author = Swart AM, Burdett S, Ledermann J, Mook P, Parmar MK | title = Why i.p. therapy cannot yet be considered as a standard of care for the first-line treatment of ovarian cancer: a systematic review | journal = Ann. Oncol. | volume = 19 | issue = 4 | pages = 688–95 | year = 2008 | month = April | pmid = 18006894 | doi = 10.1093/annonc/mdm518 | url = http://annonc.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18006894 }}</ref> [[Radiation therapy]] is not effective for advanced stages because when vital organs are in the radiation field, a high dose cannot be safely delivered. ==Prognosis== Ovarian cancer usually has a poor [[prognosis]]. It is disproportionately deadly because it lacks any clear early detection or screening test, meaning that most cases are not diagnosed until they have reached advanced stages. More than 60% of patients presenting with this cancer already have stage III or stage IV cancer, when it has already spread beyond the ovaries. Ovarian cancers shed cells into the naturally occurring fluid within the abdominal cavity. These cells can implant on other abdominal (peritoneal) structures, included the [[uterus]], [[urinary bladder]], [[bowel]] and the lining of the bowel wall ([[omentum]]). These cells can begin forming new tumor growths before cancer is even suspected. More than 50% of women with ovarian cancer are diagnosed in the advanced stages of the disease because no cost-effective screening test for ovarian cancer exists. The 5 year survival rate for all stages is only 35% to 38%. {{Fact|date=November 2007}} If a diagnosis is made early in the disease, five-year survival rates can reach 90% to 98%. {{Fact|date=November 2007}} [[Germ cell tumor]]s of the ovary have a much better prognosis than other ovarian cancers, in part because they tend to grow rapidly to a very large size, hence they are detected sooner.{{Fact|date=November 2007}} ==Complications== * Spread of the cancer to other organs * Progressive function loss of various organs * [[Ascites]] (fluid in the abdomen) * Intestinal obstructions These cells can implant on other abdominal (peritoneal) structures, including the uterus, urinary bladder, bowel, lining of the bowel wall (omentum) and, less frequently, to the lungs. ==See also== * [[List of women who have battled ovarian cancer]] * [[Germ cell tumor]] * [[Desmoplastic small round cell tumor]] * [[Ovarian cyst]] ==References== {{reflist}} <!-- more orphans * Christian J, Thomas H: Ovarian cancer chemotherapy. Cancer Treat Rev 2001;27:99. * Runnebaum IB, Stickeler E: Epidemiological and molecular aspects of ovarian cancer risk. J Cancer Res Clin Oncol 2001;127:73. * Angeles A. Alvarez, Daniel L. Clarke-Pearson [http://www.health.am/cr/more/germ-cell-malignancies/ Germ Cell Malignancies - Nonepithelial Ovarian Cancer] *[http://www.health.am/gyneco/more/germ-cell-tumors/ Germ Cell Tumors - Ovarian Masses in Adolescent Girls] * Alvarez, Angeles A., Clarke-Pearson, Daniel L. [http://www.health.am/cr/ovarian-cancer/ Ovarian Cancer for patients] * Schrecengost A. "Ovarian mass--benign or malignant?" AORN J. 2002 Nov;76(5):792-802, 805-6; quiz 807-10. PMID 12463079 * Jonathan S. Berek, MD Robert C. Bast Jr, MD [http://www.health.am/cr/ovarian-cancer-pro/ Ovarian Cancer] [professionals] --> ==External links== *{{DMOZ|Health/Conditions_and_Diseases/Cancer/Gynecologic/Ovarian}} * [http://cancer.ucsd.edu/deafinfo/asl_ovarian.asp Moores UCSD Cancer Center Ovarian Cancer Video in ASL] {{Urogenital neoplasia}} {{Tumor histology}} [[Category:Gynecology]] [[Category:Oncology]] [[Category:Types of cancer]] [[Category:Hereditary cancers]] [[ar:سرطان المبيض]] [[bs:Rak jajnika]] [[de:Ovarialkarzinom]] [[fr:Cancer de l'ovaire]] [[fy:Aaistokkanker]] [[nl:Ovariumcarcinoom]] [[no:Eggstokkreft]] [[pl:Rak jajnika]] [[ru:Злокачественные новообразования яичников]] [[fi:Munasarjasyöpä]] [[vi:Ung thư buồng trứng]] [[zh:卵巢癌]]