Atlas of pathophysiology, 2 Edition

Part II - Disorders

Genital Diseases

Ovarian Cancer

Ovarian cancer is the fifth leading cause of cancer death among U.S. women and has the highest mortality rate of all gynecologic cancers. In women with previously treated breast cancer, metastatic ovarian cancer is more common than cancer at any other site. It may be linked to mutations in the BRCA 1 or BRCA 2 gene.

Age Alert

More than one-half of all deaths from ovarian cancer occur in women between ages 55 and 74 and about one-quarter of ovarian cancer deaths are between ages 35 and 54.

The prognosis varies with the histologic type and stage of the disease. It's generally poor because ovarian tumors produce few early signs and are usually advanced at diagnosis. With early detection and new treatments, about 45% of women with ovarian cancer survive for 5 years; however, the overall survival rate hasn't improved significantly.

Causes

Exact cause unknown

Associated factors

·   Infertility, nulliparity

·   Familial tendency

·   Ovarian dysfunction, irregular menses

·   Exposure to asbestos, talc, industrial pollutants

·   Fertility drugs

·   Diet high in saturated fat

·   Hormone replacement therapy

Pathophysiology

Primary epithelial tumors (account for 90% of all ovarian cancers) arise in the Mllerian epithelium; germ cell tumors, in the ovum itself; and sex cord tumors, in the ovarian stroma. Ovarian tumors spread rapidly intraperitoneally by local extension or surface seeding and, occasionally, through the lymphatics and the bloodstream. Generally, extraperitoneal spread travels through the diaphragm into the chest cavity, where the tumor may cause pleural effusions. Other metastasis is rare.

Signs and symptoms

·   May grow to considerable size before overt symptoms appear

Occasionally, in the early stages

·   Vague abdominal discomfort, distention

·   Mild GI discomfort (nausea, vomiting, bloating)

·   Urinary frequency, pelvic discomfort

·   Constipation

·   Vaginal bleeding

·   Weight loss

Later stages

·   Tumor rupture, torsion, or infection—pain, which, in young patients, may mimic appendicitis

·   Granulosa cell tumors—effects of estrogen excess such as bleeding between periods in premenopausal women

·   Arrhenoblastomas (seen rarely)—virilizing effects

Advanced ovarian cancer

·   Ascites

·   Postmenopausal bleeding and pain (rarely)

·   Symptoms of metastatic tumors, most commonly pleural effusion

Diagnostic test results

·   Exploratory laparotomy, including lymph node evaluation and tumor resection, is required for accurate diagnosis and staging.

·   Laboratory tumor marker studies (such as ovarian carcinoma antigen, carcinoembryonic antigen, and human chorionic gonadotropin) show abnormalities that may indicate complications.

·   Abdominal ultrasonography, computed tomography scan, or X-rays delineate tumor size.

·   Aspiration of ascitic fluid reveals atypical cells.

Treatment

·   Varying combinations of surgery, chemotherapy, and radiation

Conservative treatment for unilateral encapsulated tumor in young girl or young woman

·   Resection of the involved ovary

·   Careful follow-up, including periodic chest X-rays to rule out lung metastasis

More aggressive treatment

·   Total abdominal hysterectomy and bilateral salpingo-oophorectomy with tumor resection, omentectomy, possible appendectomy, lymphadenectomy, tissue biopsies, and peritoneal washings

If tumor has matted around other organs or involves organs that can't be resected

·   Surgically debulk tumor implants to less than 2 cm (or smaller) in greatest diameter

Chemotherapy

·   May be curative; extends survival time in most patients; largely palliative in advanced disease

·   Current standard is combination paclitaxel and platinum-based chemotherapy

P.327

OVARIAN CANCER

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Clinical Tip: Metastatic Sites for Ovarian Cancer

Ovarian cancer can metastasize to almost any site. Illustrated here are the most common sites.

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