Ovarian cancer is a primary, secondary or metastatic tumor lesion of the female hormone–producing sex glands – the ovaries. In the early stages, ovarian cancer is asymptomatic; there are no pathognomonic manifestations. Common forms are manifested by weakness, malaise, decreased and perversion of appetite, impaired gastrointestinal function, dysuric disorders, ascites. Diagnosis includes physical and vaginal examination, ultrasound, MRI or CT of the pelvis, laparoscopy, examination of the cancer marker CA 125. In the treatment of disease, a surgical approach is used (pangisterectomy), polychemotherapy, radiotherapy.
C56 Malignant neoplasm of the ovary
Ovarian cancer ranks seventh in the structure of general oncopathology (4-6%) and ranks third (after uterine body cancer and cervical cancer) among malignant tumors in oncogynecology. Disease most often affects women of the pre-menopausal and menopausal periods, although it is no exception among women younger than 40 years.
The problem development is considered from the standpoint of three hypotheses. It is believed that, like other ovarian tumors, pathology develops under conditions of prolonged hyperestrogenism, which increases the likelihood of tumor transformation into estrogen-sensitive gland tissue.
Another view of the genesis is based on the ideas of constant ovulation with the early onset of menarche, late menopause, a small number of pregnancies, shortening of lactation. Continuous ovulation contributes to changes in the epithelium of the ovarian stroma, thereby creating conditions for aberrant DNA damage and activation of oncogenes expression.
The genetic hypothesis identifies women with familial forms of breast and ovarian cancer among the potential risk group. According to observations, an increased risk is associated with the presence of infertility, ovarian dysfunction, endometrial hyperplasia, frequent oophoritis and adnexitis, uterine fibroids, benign tumors and ovarian cysts. The use of hormonal contraception for longer than 5 years, on the contrary, reduces the likelihood by almost half.
According to the place of origin of the initial cancer focus, primary, secondary and metastatic ovarian lesions are distinguished.
- Primary ovarian cancer develops immediately in the gland. According to their histotype, primary tumors are epithelial formations of papillary or glandular structure, less often develop from the cells of the integumentary epithelium. Primary disease is more often bilaterally localized; has a dense consistency and a bumpy surface; occurs mainly in women under 30 years of age.
- Secondary ovarian cancer. It accounts for up to 80% of clinical cases. The development of this form of cancer occurs from serous, teratoid or pseudomucinous ovarian cysts. Serous cystadenocarcinomas develop at the age of 50-60 years, mucinous – after 55-60 years. Secondary endometrioid cystadenocarcinomas occur in young women, usually suffering from infertility.
- Metastatic ovarian lesion develops as a result of the spread of tumor cells by hematogenic, implantation, lymphogenic pathways from primary foci in cancer of the stomach, breast, uterus, thyroid gland. Metastatic ovarian tumors have rapid growth and an unfavorable course, usually affect both ovaries, early disseminated along the peritoneum of the pelvis. Macroscopically, the metastatic form of ovarian cancer has a whitish color, a bumpy surface, a dense or testy consistency.
More rare types of ovarian cancer are represented by papillary cystadenoma, granulocellular, light-cell (mesonephroid) cancer, adenoblastoma, Brenner’s tumor, stromal tumors, dysgerminoma, teratocarcinoma, etc. In clinical practice, ovarian cancer is evaluated in accordance with the criteria of FIGO (stages I-IV) and TNM (prevalence of primary tumor, regional and distant metastases).
I (T1) – the prevalence of the tumor is limited to the ovaries:
- IA (T1a) – cancer of one ovary without germination of its capsule and proliferation of tumor cells on the surface of the gland
- IB (T1b) – cancer of both ovaries without germination of their capsules and proliferation of tumor cells on the surface of the glands
- IC (T1c) – cancer of one or two ovaries with germination and/or rupture of the capsule, tumor growths on the surface of the gland, the presence of atypical cells in ascitic or flushing waters
II (T2) – damage to one or both ovaries with the spread of the tumor to the pelvic structures:
- IIA (T2a) – ovarian cancer spreads or metastasizes into the fallopian tubes or uterus
- IIB (T2b) – ovarian cancer spreads to other pelvic structures
- IIC (T2c) – the tumor process is limited to pelvic lesion, the presence of atypical cells in ascitic or flushing waters
III (T3/N1) – a lesion of one or both ovaries with metastasis of ovarian cancer along the peritoneum or into regional lymph nodes:
- IIIA (T3a) – the presence of microscopically confirmed intraperitoneal metastases
- IIIB (T3b) – macroscopically determined intraperitoneal metastases up to 2 cm in diameter
- IIIC (T3c/N1) – macroscopically determined intraperitoneal metastases with a diameter of more than 2 cm or metastases to regional lymph nodes
IV (M1) – metastasis of ovarian cancer to distant organs.
Symptoms of ovarian cancer
The manifestations of ovarian cancer are variable, which is explained by the variety of morphological forms of the disease. In localized forms of ovarian cancer, symptoms are usually absent. In young women, disease can clinically manifest with a sudden pain syndrome caused by twisting of the tumor leg or perforation of its capsule.
Activation of the manifestations of ovarian cancer develops as the tumor process spreads. There is an increase in malaise, weakness, fatigue, subfebrility; deterioration of appetite, gastrointestinal function (flatulence, nausea, constipation); the appearance of dysuric phenomena.
When the peritoneum is affected, ascites develops; in the case of metastases to the lungs, tumor pleurisy develops. In the later stages, cardiovascular and respiratory insufficiency increases, edema of the lower extremities develops, thrombosis. Metastases in ovarian cancer, as a rule, are detected in the liver, lungs, bones.
Hormonal-active epithelial formations are found among malignant ovarian tumors. Granulocellular form is a feminizing tumor that promotes premature puberty of girls and the resumption of uterine bleeding in menopausal patients. A masculinizing tumor – adrenoblastoma, on the contrary, leads to hirsutism, figure changes, breast reduction, and the cessation of menstruation.
The complex of methods for the diagnosis of ovarian cancer includes physical, gynecological, instrumental examination. Recognition of ascites and tumors can be performed already during palpation of the abdomen.
- Gynecological examination, although it allows you to identify the presence of one- or two-sided ovarian formation, but does not give a clear idea of the degree of its goodness. With the help of rectovaginal examination, the invasion of ovarian cancer into the parametrium and pararectal tissue is determined.
- Visualization methods. With the help of transvaginal echography (ultrasound), MRI and CT of the pelvis, a volumetric formation of irregular shape without a clear capsule with lumpy contours and unequal internal structure is revealed; its size and degree of prevalence are estimated.
- Diagnostic laparoscopy for ovarian cancer is necessary for biopsy and determination of tumor histotype, collection of peritoneal effusion or flushes for cytological examination. In some cases, ascitic fluid can be obtained by puncture of the posterior vaginal arch.
If ovarian cancer is suspected, a study of tumor-associated markers in serum (CA-19.9, CA-125, etc.) is shown. To exclude the primary focus or metastases of ovarian cancer in distant organs, mammography, stomach and lung radiography, irrigoscopy; ultrasound of the abdominal cavity, ultrasound of the pleural cavity, ultrasound of the thyroid gland; FGDS, rectoromanoscopy, cystoscopy, chromocystoscopy.
The issue of choosing therapeutic tactics is solved taking into account the stage of the process, the morphological structure of the tumor, the potential sensitivity of this histiotype to chemotherapeutic and radiation effects, aggravating somatic and age factors. In the treatment of ovarian cancer, a surgical approach (pangisterectomy) is combined with polychemotherapy and radiotherapy.
Surgical treatment of localized disease (I-II art.) consists in the removal of the uterus with adnexectomy and resection of the large omentum. In weakened or elderly patients, supravaginal amputation of the uterus with appendages and subtotal resection of the large omentum is possible. During the operation, an intraoperative revision of the paraaortic lymph nodes with their urgent intraoperative histological examination is mandatory. In the III-IV stage of this pathology, cytoreductive intervention is performed, aimed at maximum removal of tumor masses before chemotherapy. In inoperable processes, they are limited to biopsy of tumor tissue.
Polychemotherapy can be carried out at the preoperative, postoperative stage or be an independent treatment for a widespread malignant process. Polychemotherapy (with platinum preparations, chloroethylamines, taxanes) allows to achieve suppression of mitosis and proliferation of tumor cells. Side effects of cytostatics are nausea, vomiting, neuro- and nephrotoxicity, inhibition of hematopoietic function. Radiation therapy for ovarian cancer has little effectiveness.
Prognosis and prevention
Long-term survival in ovarian cancer is due to the stage of the disease, the morphological structure of the tumor and its differentiation. Depending on the histotype of the tumor, the five-year survival threshold is overcome by 60-90% of patients with I-st. ovarian cancer, 40-50% – with II-st., 11% – with III-st.; 5% – with IV-st. Serous and mucinous ovarian cancer are more favorable in terms of prognosis; less – mesonephroid, undifferentiated, etc.
In the postoperative period after radical hysterectomy (pangisterectomy), patients require systematic observation by an oncogynecologist, prevention of the development of post-castration syndrome. In the prevention of ovarian cancer, a significant role is assigned to the timely detection of benign tumors of the glands, oncoprophylactic examinations, and reduction of the impact of adverse factors.