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.
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.
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.
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.
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.
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.
Inhibin A and inhibin B are the tumor markers for sex cord-stromal tumors, mainly granulosa cell subtype.
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 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 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.
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.
In stage 2A, cancer spreads to the fallopian tube or uterus. In this figure, it has spread to the fallopian tube.
And here, it extends to the fallopian tube and the uterus.
Here it extends anteriorly to infiltrate the urinary bladder.
And here it extends posteriorly to involve the rectum.
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.
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.
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 may also present as nodular deposits in the parenchymal of the lung, or in liver or spleen.
It may also present as the involvement of inguinal lymph nodes.
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 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 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 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 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.