Ovarian cancer

The Function of the Ovaries and Complications Associated with Ovarian Cancer

The ovaries are paired reproductive glands located on either side of the uterus. They have two main roles: producing oocytes (eggs) and secreting sex hormones—estrogen and progesterone—that regulate the menstrual cycle, fertility, and secondary female characteristics. Diseases affecting the ovaries can disrupt hormonal balance, fertility, and reproductive health.

Ovarian cancer often goes undetected until advanced stages due to subtle early symptoms. As it progresses, complications include fluid accumulation in the abdomen (ascites), bowel or urinary obstruction, hormonal irregularities, and metastasis to the peritoneum, liver, lungs, or lymph nodes. Symptoms such as persistent bloating, pelvic pain, or vaginal bleeding are often initially attributed to benign conditions. Timely awareness and screening are vital to improving prognosis.

Categories Associated With Primary and Secondary Ovarian Tumours

Ovarian tumours are classified into primary (originating in the ovary) and secondary (metastatic) types:

Primary Ovarian Cancer:

This includes tumours emerging from ovarian tissue:

  • Epithelial Tumours: Represent ~90% of ovarian cancers:
    • High-grade serous carcinoma (most common)
    • Low-grade serous carcinoma
    • Endometrioid carcinoma
    • Clear cell carcinoma
    • Mucinous carcinoma
  • Germ Cell Tumours: Rare and occur mostly in younger women:
    • Dysgerminoma
    • Mature and immature teratoma
    • Yolk sac tumour
    • Embryonal carcinoma
  • Sex Cord–Stromal Tumours:
    • Granulosa cell tumour
    • Thecoma–fibroma group
  • Rare Tumours: Such as ovarian sarcomas or small cell carcinoma of the ovary.

Secondary (Metastatic) Ovarian Cancer:

These occur when cancers from organs like the breast, colon, or stomach spread to the ovary (e.g., Krukenberg tumours).

Risk factors include:

  • Family history (especially BRCA1/BRCA2 mutations)
  • Age (most cases occur after menopause)
  • Endometriosis
  • Use of hormone replacement therapy
  • Nulliparity or delayed childbearing
  • Obesity
  • Early menarche or late menopause

Signs And Symptoms of Ovarian Cancer

Ovarian cancer often remains clinically silent until the later stages, but may include:

  • Persistent bloating or increased abdominal girth
  • Pelvic or abdominal pressure/pain
  • Feeling full quickly or loss of appetite
  • Urinary urgency or frequency
  • Unplanned weight loss or gain
  • Fatigue
  • Changes in bowel habits
  • Irregular vaginal bleeding (especially postmenopausally)
  • Menstrual changes in premenopausal women

These signs are common and non-specific, making early recognition difficult yet crucial.

Diagnosis of Ovarian Cancer

Evaluation involves multiple steps:

Clinical History & Physical Exam:

Detailed gynecologic assessment and abdominal/pelvic examination.

Laboratory Tests:

  • CA-125: Elevated in most epithelial ovarian cancers but can also rise due to benign conditions.
  • Other markers like HE4, LDH, AFP, β-hCG are especially useful for germ cell tumours.

Imaging Studies:

  • Transvaginal/transabdominal Ultrasound: First-line imaging to evaluate masses
  • CT Scan / MRI of Abdomen & Pelvis: Assess tumour size, spread, and ascites
  • PET-CT: For evaluating metastasis

Surgical Evaluation:

  • Diagnostic Laparoscopy/Laparotomy: Direct visualisation, biopsy, and potentially staging.
  • Surgical Staging: Includes optimal tumour debulking (removal of as much tumour as possible).

Staging:

Based on the FIGO (International Federation of Gynaecology and Obstetrics) system:

  • Stage I: Cancer confined to the ovaries
  • Stage II: Pelvic extension
  • Stage III: Peritoneal implants outside the pelvis or lymph node spread
  • Stage IV: Distant metastases (e.g., liver parenchyma, lungs)

Best Treatment for Ovarian Cancer

Treatment depends on the disease stage, tumour type, and patient health. Strategies include:

A. Traditional Treatments

B. Advanced and Alternative Treatments

C. Traditional Treatment for Ovarian Cancer

1. Surgical Procedures

  • Total Hysterectomy + Bilateral Salpingo-Oophorectomy: Removal of uterus, both ovaries, and fallopian tubes.
  • Omentectomy: Removal of the omentum (common site of metastasis).
  • Debulking Surgery: Removal of visible tumour masses; optimal cytoreduction (<1 cm residual) correlates with better outcomes.
  • Fertility-Sparing Surgery: In select early-stage germ cell tumours.

2. Systemic Chemotherapy

  • Standard regimen: Carboplatin + Paclitaxel combination.
  • Administered intravenously over 3–6 cycles.
  • Side effects include hair loss, nausea, neuropathy, and bone marrow suppression.

3. External Beam Radiation Therapy

Not commonly used as primary treatment, but may be used palliatively for localised recurrences or bone metastases.

B. Advanced Treatments for Ovarian Cancer

1. Microinvasive Therapies and Surgeries

  • cryo
  • Nano

2. Targeted Therapies

  • PARP Inhibitors (e.g., olaparib, niraparib) — especially effective in BRCA-mutated tumours; used as maintenance therapy.
  • Anti-angiogenic Agents (e.g., bevacizumab) to block tumour blood supply.
  • VEGF Receptor Inhibitors (e.g., cediranib) selectively disrupt tumour vascularisation.

3. Targeted Radiation Therapy (Brachytherapy / Radioembolization)

  • An important form of cancer treatment is Brachytherapy, utilising seeds of Iodine-125 or Palladium-103. It’s not as invasive as surgery, but it is equally effective compared to other forms of treatment.

4. Immunotherapy and Biologic Agents

  • Checkpoint Inhibitors (e.g., pembrolizumab) are being explored in clinical trials for recurrent disease.
  • Adoptive T-cell Therapy and cancer vaccines are under investigation.

5. Microvascular Interventional Chemo

  • Direct infusion of chemotherapy into the peritoneal cavity increases local concentration with fewer systemic effects.

Prevention and Lifestyle Management

Preventive strategies help reduce risk and improve early detection:

  • Genetic testing for BRCA1/2 and counselling for high-risk families
  • Use of oral contraceptives (lowers risk)
  • Pregnancy and breastfeeding have protective effects
  • Regular pelvic exams and vigilance for persistent symptoms
  • Maintaining a healthy weight and a balanced diet
  • Avoiding hormone replacement therapy unless medically necessary
  • Prophylactic removal of ovaries and tubes (salpingo-oophorectomy) in at-risk women after childbearing

Prognosis and Survival Rates

The prognosis for ovarian cancer is generally linked to stage at diagnosis:

  • Stage I 5‑year survival: ~90%
  • Stage II: ~70%
  • Stage III: ~39%
  • Stage IV: ~17%

Despite aggressive disease behaviour, enhanced surgical techniques, chemotherapy regimens, and targeted maintenance therapies like PARP inhibitors have improved survival and quality of life in many patients.

Conclusion

Ovarian cancer is a challenging disease due to its silent progression and advanced-stage presentation in many patients. However, strong outcomes are achievable through early detection, comprehensive surgery, and multi-modal treatment including chemotherapy, targeted agents, and innovative approaches like HIPEC and immunotherapy. Risk assessment, preventive measures, and patient education remain essential in reducing incidence and improving survival outcomes.