Ovarian cancer

ABOUT THIS CONDITION

Understanding ovarian cancer

What are the types of ovarian cancer ?

There are four different types of ovarian tumours:

• Epithelial ovarian cancer. This is the most common type of ovarian cancer. It forms in the cells that cover the outer surface of ovaries or fallopian tubes. There are different subtypes of epithelial tubo-ovarian cancer, including serous, mucinous, endometrioid, and clear cell. Most women who get this cancer are in their 50s and 60s.
• Borderline tumours of the ovaries. They originate from the surface of the ovary. These tumours are not benign, but they also don’t fully meet the criteria for ovarian cancer. 
• Germ cell tumours. These are rare tumours that form in the cells inside the ovary that produce eggs. They are most common in teenagers and young women. There are several types of germ cell tumours, including dysgerminoma, immature teratoma, and yolk sac tumor. It’s possible to preserve fertility and cure this type of cancer.
• Sex-cord stromal tumours. These are rare tumours that grow from the support cells that hold the ovaries together and make female hormones. The most common types are the granulosa cell tumour and Sertoli-Leydig cell tumour. They affect women in their 20s, 30s, 50s, and 60s. They tend to grow slowly. They also have high cure rates and may be a candidate for fertility preservation surgery. This tumour is known to recur several years after initial diagnosis. 

What are the risk factors for developing ovarian cancer?

• Advanced age (usually women> 60 years old)
• The onset of menstruation at an early age and/ or delayed menopause
• Nulliparity and infertility
• Endometriosis
• Family history of endometrial, breast or ovarian cancer, especially if the woman has a mutation in certain genes (e.g. BRCA1, BRCA2, PALB2)
• Family history of Lynch syndrome

What are the symptoms of ovarian cancer?

Many women with ovarian cancer have no symptoms until the cancer has spread beyond the ovary. Even then, it often causes vague symptoms, as these are common in women for many other conditions (e.g. irretable bowel syndrome). These symptoms can include the following:

• Abdominal swelling or bloating
• Pelvic pain or pressure
• Difficulty eating or feeling full
• Loss of appetite or unplanned weight loss or weight gain
• Tiredness and lack of energy (fatigue)
• Urinary frequency or urgency
• Changes in bowel habits, such as constipation or diarrhoea
• Back pain
• Change in menstrual periods
• Bleeding or unusual vaginal discharge after menopause

Just because you experience these symptoms does not mean you have ovarian cancer, but you should see your doctor an evaluation particularly if these symptoms are severe or persistent.

Diagnosing ovarian cancer

Diagnosing ovarian cancer starts with your doctor taking a detailed medical history. They will ask you about your health history, your symptoms, risk factors, reproductive history (such as if you've ever been pregnant), and family history of disease. You may have one or more of the following tests:

• Pelvic examination

• Transvaginal ultrasound (abdominal in case of large pelvic masses)

• CT (Computed Tomography) scan

• Tumour markers (blood test): CA-125 (mainly), CEA, CA 19-9, AFP, hCG, LDH and inhibin-B

• Biopsy

What should I do if it is suspected I have ovarian cancer?

If the examinations show an increased likelihood of ovarian cancer, the next step is to visit a Certified Gynaecological Oncologist. Seeking specialist care is ctrucial, as Gynaecological Oncologists have the knowledge, training, and experience to provide the best ovarian cancer care. 

Treating ovarian cancer

If you have ovarian cancer, you will probably have surgery to remove the tumour and, if necessary and possible, cancer that has spread. You might also have chemotherapy (medication treatment) before surgery to make the cancer easier to remove and/or post-operatively to kill cancer that was left behind or that may have spread. 

If the cancer is seemingly confined to the ovary, a staging surgery is typically performed, which aims to detect microscopic spread of cancer outside the ovary (up to 30%). If ovarian cancer has spread to the abdominal cavity, a cytoreductive surgery will be performed instead of staging surgery. The goal of cytoreductive surgery is to remove all the macroscopic visible disease.

Staging surgery

The staging surgery includes:

• Collection of the free peritoneal fluid or peritoneal lavage to investigate whether it contains cancer cells (cytological examination)
• Removal of the adnexa (fallopian tube and ovary) containing the tumour, making every effort not to rupture its capsule. The specimen is then sent for rapid biopsy (frozen section), during which the pathologist will respond in a short time if it is cancer or not. In case of undeniable malignancy, the surgery continues based upon the following:
• Removal of the uterus and cervix (total hysterectomy) and controlateral adnexa (fallopian tube and ovary).
• Systematic removal of the pelvic and para-aortic lymph nodes (up to the level of the renal vessels). For borderline tumours the systematic lymphadenectomy can be omitted.
• Omentectomy (removal of fatty apron hanging from the stomach and large bowel).
• Careful examination of peritoneal areas for any metastatic foci of the disease. In case nodules or adhesions are found that could represent metastases, it is necessary to remove them. Otherwise, random biopsies are obtained from the pelvis, the paracolic gutters and the peritoneal surface of diaphragm.
• Appendicectomy for mucinous carcinomas of the ovary. In these tumours, pelvic and para-aortic lymph node removal is not required.

Cytoreductive surgery

Cytoreductive surgery typically removes both ovaries, the uterus, and any cancer nodules found in the abdomen. Dr Tranoulis may also need to remove: 

• Part of the lining of your abdominal cavity (peritonectomy)
• Part of your small intestines or colon (colectomy)
• Your omentum—the fatty apron hanging from your intestines (omentectomy)
• Your spleen (splenectomy)
• The tail of your pancreas
• Part of the diaphragm (lining of your breathing muscle)
• Part of the liver (partial hepatectomy)
• Your gallbladder
• Part of your stomach
• Any enlarged lymph nodes

Cytoreductive surgery can be performed in the primary setting (primary cytoreductive surgery) followed by 6 cycles of adjuvant chemotherapy. The aim of the cytoreductive surgery is to remove all the visible disease, as this is associated with optimal oncological outcomes.  In some cases, the extent of the disease or the general condition of the patient (e.g. advanced age, serious health problems, poor nutrition) does not allow the above goals to be achieved without a high risk of complications. In such cases, chemotherapy (neoadjuvant chemotherpay) before surgery (interval cytoreductive surgery) is usually administered to shrink the cancer so it can be removed with less extensive surgery. For highly selected cases treated in the neoadjuvant chemotherapy setting, hyperthermic intra-peritoneal chemotherapy (HIPEC) can be administered intra-operatively after achieving complete removal of the disease, as there is evidence to suggest that it improves the oncological outcomes.

Excellence in surgical care

Dr. Tranoulis is highly experienced in the treatment of gynaecological cancers and a recognised leader in his field. International studies have demostrated that surgeons performing higher volumes of particular procedures can often offer patients better outcomes, such as shorter hospital stays and fewer complications. Studies also confirm that ovarian cancer patients initially treated by Gynaecological Oncologists specialised in Cytoreductive Surgery have improved survival rates compared to those treated by general gynaecologists or general surgeons. Dr. Tranoulis is a Certified Gynaecological Oncologist  with further sub-specialisation in Cytoreductive Surgery and HIPEC at the prestigious Basingstoke Peritoneal Malignancy Institute. 

Depending on the location and stage of your cancer, we may recommend:

• Cytoreductive surgery techniques that permit the complete removal of all cancerous tissue safely and effectively, which studies have found offers women with advanced ovarian cancer the best prognosis 
• HIPEC
• Minimally invasive robotic assisted surgery
• Comprehensive lymph node dissection to detect microscopic disease that otherwise might escape detection by imaging tests
• Fertility-sparing procedures

Hyperthermic Intra-peritoneal Chemotherapy (HIPEC)

In Cytoreductive Surgery and hyperthermic intraperitoneal chemotherapy (HIPEC), visible cancerous tumours are first removed from the abdominal cavity surgically. The cavity is then bathed with hot chemotherapy — heated to 42 degrees Celsius — to kill any microscopic cancer cells that remain. Hyperthermia augments the cytotoxicity of chemotherapy, and intra-peritoneal installation allows for delivery of much higher doses locally than are possible systemically, while minimizing toxicity.

Adjuvant chemotherapy

Chemotherapy after surgery (adjuvant) is administered to eradicate cancer cells that might have been left behind or may have spread but can’t be detected. Most women with ovarian cancer will have 6 cycles of adjuvant chemotherapy after the primary cytoreductive surgery  and they will subsequently enter a period of surveillance or maintenance therapy. In case of neoadjuvant chemotherapy administration, 2 to 3 cycles of adjuvant chemotharapy are usually administered after interval cytoreductive surgery with or without administration of HIPEC.

Surveillance

Once you’re finished with treatment, you’ll enter a period of surveillance to make sure your cancer doesn’t return, and if it does, to catch it early. Dr Tranoulis will create an individualised follow-up plan for you which includes:

• Periodic clinical examination, including gynecological examination (every 3-6 months)
• Measurement of the tumour markers in the blood (mainly CA-125)
• Screening checks. The available options include CT or MRI and PET/CT, so decisions are made based on the doctor’s judgement, changes in tumor markers and possible symptoms of the patient.

Recurrence

When cancer comes back after treatment, it’s called recurrence. Cancer can recur anywhere in your body, often in your abdominal cavity. Symptoms of recurrence are abdominal pain, bloating, nausea, or vomiting and changes in bowel or bladder habits. 

If ovarian cancer returns, you will likely have chemotherapy, either one type alone or several kinds in combination. For women who fulfill specific criteria, another operation (secondary cytoreductive surgery) may be offered followed by administration of systematic chemotherapy. Maintenance treatment can also nbe offered.

Less common treatment for recurrent ovarian cancer is hormone therapy, especially for low-garde serous carcinoma and granulosa tumours.

Coping with fear

Being told you have ovarian cancer can be scary, and you may have many questions. We are here to help you. Learning about your cancer and about the treatment options available to you can make you feel less afraid.