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Ovarian Cancer - Causes, Sign & Symptoms, Diagnosis And Treatment

After cancer of the lung, breast, and colon, primary ovarian cancer ranks as the most common cause of cancer deaths among American women. In women with previously treated breast cancer, metastatic ovarian cancer is more common than cancer at any other site.

The prognosis vades with the histologic type and stage 6r the disease but is generally poor because ovarian tumors produce few early signs and are usually advanced at diagnosis. Although about 40% of women with ovarian cancer survive for 5 years, the overall survival rate hasn't improved significantly.

Three main types of ovarian cancer exist:

• Primary epithelial tumors account for 90% of all ovarian cancers and include serous cystoadenocarcinoma, mucinous cystoadenocarcinoma, and endometrioid and mesonephric malignancies. Serous cystoadenocarcinoma is the most common type and accounts for 50% of all cases.
• Germ cell tumors include endodermal sinus malignancies, embryonal carcinoma (a rare ovarian cancer that appears in children), immature teratomas, and dysgerminoma.
• Sex cord (stromal) tumors include granulosa cell tumors (which produce estrogen and may have feminizing effects), granulosatheca cell tumors, and the rare arrhenoblastomas (which produce androgen and have virilizing effects)

Causes of ovarian cancer

Exactly what causes ovarian cancer isn't known, but its incidence is noticeably higher in women of upper socioeconomic levels between the ages of20 and 54. However, it can occur during childhood. Other contributing factors include age at menopause; infertility; celibacy; high-fat diet; exposure to asbestos, talc, and industrial pollutants; nulliparity; familial tendency; and history of breast or uterine cancer.

Primary epithelial tumors arise in the miillerian epithelium; germ cell tumors, in the ovum itself; and sex cord tumors, in the ovarian stroma (the ovary's supporting framework).

Ovarian tumors spread rapidly intraperitoneally by local extension or surface seeding and, occasionally, through the lymphatics and the bloodstream. Generally, extraperitoneal spread is through the diaphragm into the chest cavity, which may cause pleural effusions. Other types of metastasis are rare.

Signs and symptoms

Typically, symptoms vary with the size of the tumor. Occasionally, in the early stages, ovarian cancer causes vague abdominal discomfort, dyspepsia, and other mild Gl disturbances. As it progresses, it causes urinary frequency, constipation, pelvic discomfort, abdominal distention, and weight loss.

Tumor rupture, torsion, or infection may cause pain, which, in young patients, may mimic appendicitis. Granulosa cell tumors have feminizing effects (such as bleeding between periods in premenopausal women); conversely, arrhenoblastomas have virilizing effects. Advanced ovarian cancer causes ascites, rarely postmenopausal bleeding and pain, and symptoms relating to metastatic sites (most often pleural effusions.

Diagnosis of mastitis and breast engorgement

• abdominal ultrasonography, computed tomography scan, or X-ray (may delineate tumor size)
• complete blood count, blood chemistries, and electrocardiography
• excretory urography for information on renal function and possible urinary tract anomalies or obstruction
• chest X-ray for distant metastasis and pleural effusions
• barium enema (especially in patients with GI symptoms) to reveal obstruction and size of tumor
• lymphangiography to show lymph node involvement
• mammography to rule out primary breast cancer
• liver function studies or a liver scan in patients with ascites
• ascites fluid aspiration for identification of typical cells by cytology
• laboratory tumor marker studies, such as ovarian carcinoma antigen, care inoembryonic antigen, and human chorionic gonadotropin.

Treatment of mastitis and breast engorgement

Depending on the stage of the disease and the patient's age, treatment of ovarian cancer requires varying combinations of surgery, chemotherapy and, in some cases, radiation.

Conservative treatment

Occasionally, in girls or young women with a unilateral encapsulated tumor who wish to maintain fertility, the following conservative approach may be appropriate:

• resection of the involved ovary
• biopsies of the omentum and the uninvolved ovary
• peritoneal washings for cytologic examination of pelvic fluid
• careful follow-up, including periodic chest X-rays to rule out lung metastasis

Aggressive treatment

Ovarian cancer usually requires more aggressive treatment, including total abdominal hysterectomy and bilateral salpingo-oophorectomy with tumor resection, omentectomy, appendectomy, lymph node biopsies with lymphadenectomy, tissue biopsies, and peritoneal washings.

Complete tumor resection is impossible if the tumor has matted around other organs or if it involves organs that can't be resected. Bilateral salpingo­oophorectomy in a prepubertal girl necessitates hormone replacement therapy, beginning at puberty, to induce the development of secondary sex characteristics.

Chemotherapeutic drugs useful in ovarian cancer include melphalan, chlorambucil, thiotepa, methotrexate, cyclophosphamide, doxorubicin, vincristine, vinblastine, dactinomycin, bleomycin, paclitaxel, and cisplatin. These drugs are usually given in combination and they may be administered intraperitoneally.

Radiation therapy is generally not used for ovarian cancer because the resulting myelosuppression would limit the effectiveness of chemotherapy.

Other treatments

Radioisotopes have been used as adjuvant therapy, but they cause small­bowel obstructions and stenosis.

In addition, I. V. administration of biological response modifiers - inter­ leukin-2, interferon, and monoclonal antibodies - is currently being investigated.

Special considerations If the patient has mastitis:

Because the treatment of ovarian cancer varies widely, so must the care of the patient.

Before surgery:

• Thoroughly explain all preoperative ests, the expected course of treatment, and surgical and postoperative procedures.
• In premenopausal women, explain that bilateral oophorectomy artificially induces early menopause, so they may experience hot flashes, headaches, palpitations, insomnia, depression, and excessive perspiration.

After surgery:

• Monitor vital signs frequently, and check I. V. fluids often. Monitor intake and output, while maintaining good catheter care. Check the dressing regularly for excessive drainage or bleeding, and watch for signs of infection.
• Provide abdominal support, and watch for abdominal distention. Encourage coughing and deep breathing. Reposition the patient often, and encourage her to walk shortly after surgery.
• Monitor and treat adverse effects of radiation and chemotherapy.

CLINICAL TIP If the patient is receiving immunotherapy, watch for flu like symptoms that may last 12 to 24 hours after drug administration. Give aspirin or acetaminophen for fever. Keep the patient well covered with blankets, and provide warm liquids to relieve chills. Administer an antiemetic as needed.

• Enlist the help of a social worker, chaplain, and other members of the health care team for additional supportive care.

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