Ovarian Cancer – Risk Factors, Symptoms, Investigations, Staging, Treatment

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ovarian cancer

How a Patient with Ovarian Cancer Presents?

To further understand the disease in a better way, have a look at the video below where CancerBro meets Mrs. Owen who has recently being diagnosed with ovarian cancer. CancerBro asks Mrs. Owen several important questions related to her disease from early symptoms which lead her to contact an oncologist to various other risk factors related to ovary cancer.

 
To make you understand the disease better, we will meet Mrs. Owen ovarian cancer patient today. She has recently been diagnosed with cancer.
 
Mrs. Owen is a 65-year-old lady, who lives with her husband. They don’t have any children. She has recently been diagnosed with ovarian cancer. Let’s meet her.
 
Cancerbro: Hi Mrs. Owen, I am very sorry to hear about your illness. How are you feeling today?
 
Mrs. Owen: CancerBro, me and my husband were very worried when I was diagnosed with ovarian cancer, but after coming here and talking to you we are feeling a bit relaxed.
 
CancerBro: That’ great Mrs. Owen. I am always there for my patients. Can I ask you a few questions related to your disease?
 
Mrs. Owen: Yeah, sure CancerBro, why not? Please go ahead.
 
CancerBro: What were your complaints for which you consulted your doctor?
 
Mrs. Owen: I had abdominal pain, increased abdominal size and difficulty eating and feeling full for last three months. It was associated with increased urinary frequency and urgency.
 
CancerBro: When did you start having menses and when did you get married?
 
Mrs. Owen: My menses started at 11 years and I got married at 34 years of age.
 
CancerBro: When did you attain menopause? Did you take any hormone replacement therapy after menopause?
 
Mrs. Owen: I attained menopause at 56 years. Yes, I was on hormone replacement therapy after menopause.
 
CancerBro: Did anyone else in your close relatives had ovarian, breast or any other cancer?
 
Mrs. Owen: Yes, my mother had a breast cancer and my mother’s sister had ovarian cancer. I think you must have got an idea of how a patient with ovarian cancer presents and what are the risk factors for the disease.

What are the Risk Factors for Ovarian Cancer?

Early age of starting menses and late age of menopause are the risk factors for the disease.

Late age of marriage increases the risk of ovary cancer. Also, no child or late birth, after 30 to 35 years of age increases the risk of ovary cancer.

Inadequate breastfeeding also increases the risk of ovary cancer.

Intake of hormone replacement therapy after menopause increases the risk of ovary cancer and consumption of birth control pills decreases the risk.

Increasing obesity is also a risk factor, therefore, the regular physical activity may help in reducing the risk of ovary cancer.

History of breast or ovary cancer in close relatives increases the risk in other family members. So these were the ovarian cancer risk factors.

ovarian cancer risk factors infographic

What are the Symptoms and Signs of Ovarian Cancer?

A knowledge about the symptoms is required to consult the doctor at an early stage before the disease becomes very advanced.

Ovarian cancer may present with abdominal or pelvic pain, abdominal distention or bloating, difficulty in eating or feeling full quickly and increased urinary frequency or urgency.

Anyone or combination of these ovary cancer symptoms, when present in a woman is 5th to 7th decade of life, is highly suspicious for ovary cancer.

ovarian cancer symptoms infographic

What are the Investigations for Ovarian Cancer?

To confirm the diagnosis of ovary cancer, we have to do some scans and blood tests.

The first step is to do transabdominal or transvaginal ultrasound, to look for the ovary mass and the rest of the pelvic structures. CT scan of abdomen and pelvis or PET CT scan may be done if required.

Next step is to do blood tests, which will depend upon the sub-type of ovary cancer, as we have discussed previously.

ovarian cancer tumor markers infographic CA-125 is the tumor marker for epithelial ovary cancer, which is elevated most commonly. But CA-125 testing has some limitations.

It may be false negative in some cases, that is negative when there is cancer. This could be seen in subtypes other than epithelial ovary cancer. Even in some cases of an early-stage disease, it could be a false negative. Also, in the mucinous subtype of epithelial ovary cancer, it may be negative, and CA 19.9 or CEA may be elevated.

CA-125 may also be false positive, that is elevated in the absence of ovary cancer. Other cancers in which it may be false positive are breast, lung and GI cancer. The non-cancerous conditions in which it may be false positive are PID, endometriosis, pregnancy, cirrhosis, peritonitis, pleuritis and pancreatitis.

 CA-125 tumor marker infographic The tumor markers for germ cell tumor are AFP, beta HCG, and LDH.

Different sub-types of germ cell tumors have different combinations of this tumor marker elevated.

Most commonly elevated in dysgerminoma is LDH, and beta HCG may also be elevated in some cases, but AFP is never elevated in dysgerminoma.

In choriocarcinoma, beta HCG is very high and LDH may also be elevated. In endodermal sinus or yolk sack tumors, AFP is high and LDH may also be elevated.

Germ Cell Ovarian Cancer Tumor Markers [Infographic] Inhibin A and inhibin B are the tumor markers for sex cord-stromal tumors, mainly granulosa cell subtype.

ovarian cancer diagnosis infographics

What is the Staging of Ovarian Cancer?

Now, we come to the ovarian cancer staging.

Stage 1A is when the tumor is localised to one ovary with intact capsule, that is when the tumor has not spread to the surface of ovary or anywhere else.

stage IA - localised to one ovary with intact capsule Stage 1B when the tumor is localized to both the ovaries but with an intact capsule, with no spread of the tumor to the surface of ovary or anywhere else.

Stage 1B - localized to both the ovaries but with an intact capsule Stage 1C is when there is a capsule rupture either spontaneously or during surgery, with the presence of tumor cells on the surface of ovary or in ascitis fluid, but there is no extension of tumor to the adjacent structures.

Stage 1C - capsule rupture or tumor cells on the surface of ovary or in ascitis fluid To understand the stage 2 better, we will discuss the normal anatomy of the female pelvis. Imagine we are seeing from the top, on both side of the uterus are ovaries which are connected to the uterus with fallopian tube.

In front of the uterus is the urinary bladder, and these tube-like structures joining the bladder on both sides are called as ureters. This tube-like structure present behind the uterus is called as the rectum.

ovary anatomy diagram In stage 2A, cancer spreads to the fallopian tube or uterus. In this figure, it has spread to the fallopian tube.

stage 2A - cancer extentds to fallopian tube and uterus And here, it extends to the fallopian tube and the uterus.

stage 2A - cancer spreads to fallopian tube Here it extends anteriorly to infiltrate the urinary bladder.

stage 2B - infiltrates urinary bladder And here it extends posteriorly to involve the rectum.

stage 2B - tumor extends to rectum

Ovarian Cancer FIGO Staging Infographic stage 1 and 2

In stage 3, cancer extends outside the pelvis into the abdominal cavity. Let’s have a look at abdominal structures first.

This is the large intestine. And this is the liver, behind which is the stomach. And these are the lungs, which are present in the thoracic cavity, separated from the abdomen by the diaphragm.

normal anatomy of abdomen In stage 3 ovarian cancer, there may be involvement of these nodular structures present inside the abdomen, called as retroperitoneal lymph nodes.

Stage 3 may also present as surface deposits inside the abdomen, called peritoneal deposits.

stage 3, peritoneal deposits Now we come to the stage 4 ovarian cancer. It may spread to the lungs, which may present as a fluid collection around the lung, called a pleural effusion.

stage 4, metastasis to lungs Stage 4 may also present as nodular deposits in the parenchymal of the lung, or in liver or spleen.

stage 4, metastasis to lungs and liver It may also present as the involvement of inguinal lymph nodes.

ovarian cancer FIGO staging Infographic stage 3 and 4 So this was the ovarian cancer staging.

FIGO Staging for Ovarian Cancer Summary

Ovarian Cancer FIGO staging is the most commonly used staging system for the disease. FIGO stands for International Federation of Gynecology and Obstetrics.

Stage I

Stage IA – Tumor limited to one ovary/fallopian tube, with capsule intact, with no disease on ovary/fallopian tube surface. No cancer cells detected in ascites or peritoneal washings.

Stage IB – Tumor limited to both ovaries/fallopian tubes, with capsule intact, with no disease on ovary/fallopian tube surface. No cancer cells detected in ascites or peritoneal washings.

Stage IC1 – The cancer cells leak into the abdomen/pelvis during surgery (surgical spill)

Stage IC2 – Tumor present on the capsule of the ovary/fallopian tube or the capsule ruptured before surgery

Stage IC3 – The cancer cells are detected in ascites or peritoneal washings

Stage II

Stage IIA – Tumor extension/implants from ovaries/fallopian tubes to uterus.

Stage IIB – Tumor extension/implants from ovaries/fallopian tubes to bladder, sigmoid colon, rectum, or other pelvic tissues.

Stage III

Stage IIIA1 – Tumor involves one or both ovaries/fallopian tubes or primary peritoneal cancer with spread to retroperitoneal lymph nodes only.

Stage IIIA2 – Tumor involves one or both ovaries/fallopian tubes with microscopic peritoneal deposits with/without spread to retroperitoneal lymph nodes.

Stage IIIB – Tumor involves one or both ovaries/fallopian tubes with macroscopic peritoneal deposits (</=2 cm) with/without spread to retroperitoneal lymph nodes.

Stage IIIC – Tumor involves one or both ovaries/fallopian tubes with macroscopic peritoneal deposits (>2 cm) with/without spread to retroperitoneal lymph nodes. The cancer cells might have invaded the capsule of the liver or the spleen without parenchymal involvement.

Stage IV

Stage IVA – Tumor spread to the fluid in pleural cavity (pleural effusion) with positive cytology.

Stage IVB – Tumor spread to the spleen/liver parenchyma, to the lymph nodes other than the retroperitoneal lymph nodes, and/or to other organs outside the abdomen such as the lungs, bones, etc.

What is the Treatment of Ovarian Cancer?

Now we will discuss the ovary cancer treatment. Surgery and chemotherapy are the main treatment modalities for ovarian cancer.
 
First, we have to decide whether the patient is a candidate for fertility preservation surgery in which only one side ovary is removed, and the other one with a uterus is left behind. It is an option in early stage epithelial ovary tumors and sex cord-stromal tumors when the tumor is limited to one ovary. And maybe considered in the most of the cases of low grade or borderline ovary tumors and germ cell tumors of the ovary.
 
First, we have to ask the patient whether her family is complete or she wants more children. If she wants more children and is will for it, fertility preservation surgery may be done.
 

Ovary Cancer - Fertility Preservation Surgery CancerBro, that means it is best for a patient like me who has a germ cell tumor at a very young age, when I am not even married.

 
Absolutely, but the final decision will be taken by the oncologist after assessing your disease in detail.
 
Now, let’s discuss the treatment further. In most cases, the surgery which we do for ovary tumors is known as cytoreductive surgery. It may be called as primary cytoreductive surgery or interval debulking surgery, depending upon whether we are giving chemotherapy before or after surgery. If the surgery is done when there is a relapse of the disease after the patient has completed treatment previously, it is known as secondary cytoreductive surgery.
 

CancerBro, how is it decided whether to do surgery first or give chemotherapy first?

It is decided by the oncologist after assessing the condition of the patient and seeing the scans. If the disease appears upfront resectable on the scans, and the performance status of the patient is good as assessed by the oncologist, we can proceed directly with the surgery.
 
When surgery is done first before chemotherapy, it is called as primary cytoreductive surgery. Sometimes, the disease may not be upfront resectable, or the performance status of the patient may be poor. In either of these conditions, the surgery might not be possible upfront. In these cases, interval debulking surgery is preferred in which chemotherapy is given first, and then the decision for surgery is depending upon the response to chemotherapy.
 

ovarian cancer treatment infographic CancerBro, is chemotherapy required in all the cases after primary cytoreductive surgery?

No, it depends upon the stage and the subtype of the tumor. In some early stage and low-grade tumors, chemotherapy is required after surgery.

Preferred treatment approaches for different stages of ovarian cancer

Stage I

In case of Stage I epithelial ovarian cancer, upfront cytoreductive surgery is generally preferred. Chemotherapy may be added after surgery depending upon stage (IA/IB/IC), grade, and other factors.

Stage II

In case of Stage II epithelial ovarian cancer, cytoreductive surgery followed by chemotherapy may be done in most cases.

Stage III

In case of Stage III epithelial ovarian cancer, chemotherapy may be given before or after surgery. If the performance status of patient is poor or the disease is not upfront resectable, chemotherapy may be given before surgery, otherwise after surgery.

Stage IV

In case of Stage IV epithelial ovarian cancer, chemotherapy is considered as the first-line treatment. Surgery may also be employed after chemotherapy depending on response. Other palliative treatment may be used to relieve the symptoms of advanced disease.

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