Ovarian cancer is a relatively uncommon gynecologic cancer in the U.S.

Epidemiology

• Incidence - 40/100,000 for postmenopausal females
• Age - median age is 60 years
• Sex - exclusively female

Risk Factors

• Increased risk
  • Family history of breast or ovarian cancer
    • Genetic predisposition only identified in 5% of cases
    • Associated with BRCA-1, BRCA-2 and Lynch Syndrome II
    • Higher probability of BRCA mutations in Ashkenazi Jews
  • Nulliparity
• Decreased risk is associated with:
  • Oral contraceptive use
  • Pregnancy
  • Lactation
  • History of tubal ligation

Pathophysiology

• Malignant transformation of the epithelium of the ovarian surface
• Often spreads early to the contiguous peritoneal mesothelium
  • Spread follows the flow of peritoneal fluid

Clinical Presentation

• Symptoms are most often nonspecific, most patients present with stage III or IV disease
• Abdominal symptoms
  • Abdominal fullness, dyspepsia, early satiety, bloating, pelvic pain
• Physical findings
  • Ascites
  • Pleural effusions
  • Umbilical mass (Sister Mary Joseph nodule)
  • Ovarian mass
  • Unusual findings
    • Seborrheic keratoses (Leser-Trélat)
    • Migratory superficial thrombophlebitis (Trousseau sign)
    • Subacute cerebellar degeneration (paraneoplastic syndrome)
    • Palmar fasciitis
    • Dermatomyositis

Prevention

• In patients with known BRCA-1 or BRCA-2 mutation who have completed childbearing, bilateral salpingo-oophorectomy dramatically reduces risk for ovarian cancer
  • Small risk of primary peritoneal serous carcinoma will still exist

Diagnosis

• Laboratory testing
  • Serum marker testing may be useful in  high risk patients (see below)
• Histology
  • Surgical biopsy to determine if ovarian mass is malignant
    • Avoid percutaneous biopsy as it can cause tumor spillage into the pelvis
• Imaging studies
  • Ultrasound
    • Transvaginal ultrasonography (TVUS) followed by CT/MRI  if suspicious TVUS findings

Disease Monitoring

• CA 125
  • Recommended use
    • Early detection in hereditary syndromes (eg, BRCA-1 and BRCA-2) in conjunction with (TVUS)
    • Assessment of patient response to chemotherapy, detection of early relapse and prediction of prognosis

Disease Screening

• Biomarkers
  • CA 125
    • Recommended use for differential diagnosis of suspicious pelvic mass in postmenopausal females
    • Not recommended for:
      • Population screening
      • Initial diagnostic testing (although level >65 U/ml is suspicious for ovarian cancer)
  • BRCA-1 and BRCA-2 testing should be considered in patients with family history of ovarian cancer.
  • Other currently available markers are not useful
  • Two trials are currently ongoing which are designed to evaluate multimodality (CA125 and TVUS) screening
    • The PLCO trial in U.S. and the U.K. Collaborative Trial of Ovarian Screening
      • Both have finished enrollment and are in analysis phases

Differential Diagnosis

• Cholecystitis
• Peptic ulcer disease
• Other gastrointestinal malignancies - gastric, pancreatic, gallbladder
• Cirrhosis
• Irritable bowel disease