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11-SEPTEMBER-2008 12:20:15 - Ovarian cancer The tone or style of this article or section may not be appropriate for . Specific concerns may be found on the talk page. See 's guide to writing better articles for suggestions. December 2007 Ovarian cancer Classification and external resources ICD-10 C56., D27. ICD-9 183, 220 ICD-O: varied DiseasesDB 9418 MedlinePlus 000889 eMedicine med/1698 MeSH D010051 Ovarian cancer is a malignant tumor, of any histology, arising from an ovary. Contents 1 Epidemiology 2 Classification 3 Symptoms 3.1 Studies on the accuracy of symptoms 4 Ovarian Cancer Symptoms Consensus Statement 5 Diagnosis 6 Staging 7 Treatment 8 Prognosis 9 Complications 10 See also 11 References 12 External links Epidemiology Ovarian cancer is the fifth leading cause of cancer deaths in women, the leading cause of death from gynecological malignancy, and the second most commonly diagnosed gynecologic malignancy.1 According to the American Cancer Society, there is no true test for ovarian cancer. Several large studies are in progress to learn how best to find ovarian cancer in its earliest stage.1 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. 2 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.citation needed 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.citation needed 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.2 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. 3 It will remain a complex topic to study as the infertile population differs in 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 cancers3 and certain populations e.g. Ashkenazi Jewish women are at a higher risk of both breast cancer and ovarian cancer, often at an earlier age than the general population.citation needed 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 cancers may indicate the presence of a syndrome known as herary nonpolyposis colorectal cancer HNPCC, also known as 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.citation needed 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. 4 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.citation needed 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.5 Classification A germ cell tumor of the ovary, discovered during a C-section; this is a 4 cm teratoma A germ cell tumor of the ovary, discovered during a 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 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.citation needed 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 cancercitation needed. 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.citation needed 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.6 The smaller, second study found that women with ovarian cancer had pelvic/abdominal pain, increased abdominal size/bloating, and difficulty eating/feeling full.7 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 of 57% for early-stage disease and 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.8 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.citation needed Diagnosis Ovarian cancer at its early stagesI/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.citation needed 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 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 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 This article may require cleanup to meet 's quality standards. Please improve this article if you can. 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.citation needed 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.9 Chemotherapy has been a general standard of care for ovarian cancer for decades, although with highly variable protocols.10 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.citation needed Patients in this clinical trialcitation needed 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.11 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%.citation needed If a diagnosis is made early in the disease, five-year survival rates can reach 90% to 98%.citation needed Germ cell tumors 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.citation needed 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 ^ Merck Manual of Diagnosis and Therapy Section 18. Gynecology And Obstetrics Chapter 241. Gynecologic Neoplasms ^ 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/S0140-67360860167-1 ^ Brinton, L.A., Moghissi, K.S., Scoccia, B., Westhoff, C.L., Lamb, E.J. 2005. Ovulation induction and cancer risk. Fertil. Steril. 83 2: 261-74; quiz 525-6. doi:10.1016/j.fertnstert.2004.09.016. PMID 15705362. ^ BBC News Milk link to ovarian cancer risk 29 November 2004 ^ Alcohol consumption and cancer risk ^ Goff BA, Mandel LS, Melancon CH, Muntz HG 2004. Frequency of symptoms of ovarian cancer in women presenting to primary care clinics. JAMA 291 22: 2705-12. doi:10.1001/jama.291.22.2705. PMID 15187051. ^ Goff BA, Mandel LS, Drescher CW, et al 2007. Development of an ovarian cancer symptom index: possibilities for earlier detection. Cancer 109 2: 221-7. doi:10.1002/cncr.22371. PMID 17154394. ^ Ovarian Cancer Symptoms Consensus Statement pdf. Retrieved on 2007-07-19. ^ Ehrlich, P.F., Teitelbaum, D.H., Hirschl, R.B., Rescorla, F. 2007. Excision of large cystic ovarian tumors: combining minimal invasive surgery techniques and cancer surgery--the best of both worlds. J. Pediatr. Surg. 42 5: 890-3. doi:10.1016/j.jpedsurg.2006.12.069. PMID 17502206. ^ McGuire WP, Markman M December 2003. Primary ovarian cancer chemotherapy: current standards of care. Br. J. Cancer 89 Suppl 3: S3-8. doi:10.1038/sj.bjc.6601494. PMID 14661040. ^ Swart AM, Burdett S, Ledermann J, Mook P, Parmar MK April 2008. Why i.p. therapy cannot yet be considered as a standard of care for the first-line treatment of ovarian cancer: a systematic review. Ann. Oncol. 19 4: 688-95. doi:10.1093/annonc/mdm518. PMID 18006894. External links Ovarian cancer at the Open Directory Project National Ovarian Cancer Coalition Ovarian Cancer National Alliance Bald Is Beautiful -- ovarian cancer resource for inspiration/information v d e Tumors: urogenital neoplasia - genital neoplasia C51-C63/D25-29, 179-187/218-222 Female Ovaries Surface epithelial-stromal tumor, Luteoma, Meigs syndrome, Krukenberg tumor, Teratoma, Clear cell adenocarcinoma, Endometrioid tumor, Fibroma Fallopian tube Primary fallopian tube cancer, Adenomatoid tumor Uterus Uterus Uterine sarcoma, Leiomyosarcoma Endometrium Endometrioid tumor Cervix SCC, Cervical intraepithelial neoplasia Vagina Vagina SCC, Botryoid rhabdomyosarcoma, Adenocarcinoma/Clear cell adenocarcinoma Vulva Vulva Papillary hidradenoma, Extramammary Paget's disease Male Testicles Seminoma - Endodermal sinus tumor Prostate Prostate - Transitional cell carcinoma - Prostatic intraepithelial neoplasia Penis Penis Extramammary Paget's disease Male/female Sex cord-stromal tumour Sertoli-Leydig cell tumour, Thecoma, Granulosa cell tumour - Germ cell tumor - Gonadoblastoma - Brenner tumour - Embryonal carcinoma See also noncongenital, congenital v d e Epithelial neoplasms ICD-O 8010-8799 Papilloma/carcinoma 8010-8139 Small cell carcinoma - Verrucous carcinoma - Squamous cell carcinoma - Basal cell carcinoma - Transitional cell carcinoma - Inverted papilloma Adenomas/adenocarcinomas 8140-8429 Linitis plastica pancreas Insulinoma, Glucagonoma, Gastrinoma, VIPoma, Somatostatinoma - Neuroendocrine tumors Cholangiocarcinoma - Hepatocellular adenoma/Hepatocellular carcinoma - Adenoid cystic carcinoma - Familial adenomatous polyposis - Prolactinoma - Oncocytoma - Hurthle cell - Clear cell adenoma/adenocarcinoma - Renal cell carcinoma - Multiple endocrine neoplasia - Endometrioid tumor - Apudoma - Klatskin tumor - Carcinoid - Cylindroma Adrenocortical adenoma/Adrenocortical carcinoma Papillary hidradenoma Adnexal And Skin appendage 8390-8429 sweat gland Hidrocystoma, Syringoma Cystic, Mucinous And Serous 8440-8499 Mucoepidermoid carcinoma - Cystadenoma/Cystadenocarcinoma/Pseudomyxoma peritonei - Signet ring cell carcinoma/Krukenberg tumor Ductal, Lobular And Medullary 8500-8549 Ductal carcinoma - Comedocarcinoma - Paget's disease of the breast/Extramammary Paget's disease Acinar cell 8550-8559 Acinic cell carcinoma Complex epithelial 8560-8589 Warthin's tumor - Thymoma Gonadal 8590-8679 Sex cord-stromal tumour: Thecoma - Granulosa cell tumour - Luteoma - Sertoli-Leydig cell tumour Paragangliomas And Glomus tumors 8680-8719 Paraganglioma - Pheochromocytoma - Glomus tumor Nevi and melanomas 8720-8799 Melanocytic nevus - Dysplastic nevus - Halo nevus Nodular melanoma - Lentigo maligna melanoma - Superficial spreading melanoma - Acral lentiginous melanoma Retrieved from http://en..org/wiki/Ovarian_cancer Categories: Gynecology | Oncology | Types of cancer | Herary cancersHidden categories: All articles needing style ing | articles needing style ing from December 2007 | All articles with statements | Articles with statements since November 2007 | Articles with statements since February 2007 | Articles with statements since July 2007 | Cleanup from January 2008 | All pages needing cleanup | Articles with statements since May 2008 Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages العربية Bosanski Deutsch Français Frysk Nederlands ‪Norsk bokmÃ¥l‬ Polski РуÑ?Ñ?кий Suomi Tiếng Việt ä¸æ–‡ This page was last modified on 2 September 2008, at 19
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