Ovarian Cancer

Ovarian Cancer Basics - Ovary's Enemies

• Types: Epithelial (most common, ~90%; serous, mucinous, endometrioid, clear cell), Germ cell (younger patients), Sex-cord stromal.
• Epidemiology:
  • Peak incidence: 50-70 years.
  • Highest mortality among gynecologic cancers.
• Risk Factors (↑ Risk):
  • Age (postmenopausal).
  • Nulliparity, infertility, uninterrupted ovulation.
  • Early menarche (<12 yrs), late menopause (>55 yrs).
  • Family Hx: BRCA1/BRCA2 mutations, Lynch syndrome (HNPCC).
  • Personal Hx of breast, colon, or endometrial cancer.
  • Endometriosis.
• Protective Factors (↓ Risk):
  • Multiparity.
  • Oral Contraceptive Pills (OCPs) use (≥5 years ↓ risk by ~50%).
  • Breastfeeding.
  • Tubal ligation, salpingectomy, hysterectomy.

⭐ BRCA1 mutation carriers have a ~40-50% lifetime risk of ovarian cancer; BRCA2 carriers ~15-25%.

Pathology & Staging - Rogue Cell Roundup

• Pathological Types:
  • Epithelial (~90%): Serous (MC), Mucinous, Endometrioid, Clear Cell.
  • Germ Cell (younger): Dysgerminoma, Yolk Sac (↑AFP), Teratoma.
  • Sex Cord-Stromal: Granulosa (↑estrogen, Call-Exner), Fibroma (Meigs' syndrome).
• FIGO Staging (Simplified):
  • Stage I: Limited to ovaries
    • IA: One ovary
    • IB: Both ovaries
    • IC: Rupture/surface tumor/positive cytology
  • Stage II: Pelvic extension
    • IIA: Uterus/fallopian tubes
    • IIB: Other pelvic tissues
  • Stage III: Peritoneal implants outside pelvis / regional LN+
    • IIIC: Macroscopic peritoneal mets >2 cm
  • Stage IV: Distant metastases
    • IVA: Pleural effusion (positive cytology)
    • IVB: Parenchymal/extra-abdominal mets

⭐ CA-125: key marker for epithelial ovarian cancer; monitors treatment response/recurrence, not for screening.

Clinical Features & Diagnosis - Silent Signs Search

• Symptoms (Often Vague - "Silent Killer"):

  • Abdominal bloating/distension, pelvic/abdominal pain.
  • Early satiety, changes in bowel habits (constipation/diarrhea).
  • Urinary urgency/frequency.
  • 📌 Mnemonic BEAT: Bloating, Eating difficulty (early satiety), Abdominal/pelvic pain, Trouble with bladder.

• Signs: Palpable adnexal mass (often bilateral), ascites, pleural effusion, weight loss.

• Diagnostic Approach:

  • Pelvic Exam: Bimanual exam to assess adnexa.
  • Imaging:
    • Transvaginal Ultrasound (TVS): Initial modality of choice; assesses mass characteristics (cystic, solid, septations, papillary projections).
    • CT Abdomen/Pelvis (with contrast): For staging, detecting metastases.
  • Tumor Markers:
    • CA-125: Elevated in ~80% epithelial ovarian cancer (EOC). Thresholds: >35 U/mL (postmenopausal), >200 U/mL (premenopausal) concerning. Not specific.
    • HE4 (Human Epididymis Protein 4): More specific than CA-125, especially premenopausal.
    • ROMA (Risk of Ovarian Malignancy Algorithm): Combines CA-125, HE4, menopausal status.
    • Germ cell tumors: AFP, β-hCG, LDH.
    • Sex cord-stromal tumors: Inhibin A & B, AMH.
  • Biopsy: Definitive diagnosis; usually obtained during surgical staging (laparotomy/laparoscopy). Image-guided biopsy for advanced/recurrent disease.

⭐ CA-125 is the most commonly used tumor marker for epithelial ovarian cancer; however, it can be elevated in numerous benign conditions (e.g., endometriosis, fibroids, PID, pregnancy) and other malignancies, limiting its specificity as a screening tool, especially in premenopausal women. Its primary utility is in monitoring treatment response and detecting recurrence in diagnosed cases.

Management & Prognosis - Battle Plan & Beyond

• Core Strategy: Surgery & Chemotherapy are cornerstones.
  • Surgery: Comprehensive staging & maximal cytoreduction (aim R0: no visible disease).
  • Chemo: Carboplatin + Paclitaxel (IV/IP). Neoadjuvant (NACT) for advanced/unresectable.
• Targeted Therapy:
  • PARP inhibitors (e.g., Olaparib): For BRCAm/HRD+ or platinum-sensitive recurrence.
  • Bevacizumab (anti-VEGF): With chemo & as maintenance.
• Recurrence: Platinum-sensitive vs. resistant dictates therapy.
• Prognosis: Stage, grade, residual disease critical. CA-125 for monitoring.
  • 5-yr survival: Stage I >90%; Stage III ~30-40%; Stage IV <20%.
• Follow-up: Regular exams, CA-125, imaging as indicated.

⭐ Optimal cytoreduction to R0 (no macroscopic residual disease) is the most crucial modifiable prognostic factor in advanced ovarian cancer.

High‑Yield Points - ⚡ Biggest Takeaways

• Epithelial tumors (esp. serous cystadenocarcinoma) are most common.
• Key risk: BRCA1/2 mutations; Protective: OCPs, multiparity.
• Often presents late with vague abdominal symptoms, ascites.
• CA-125 for monitoring response, not for general screening.
• Management: Surgical staging/cytoreduction + platinum-based chemotherapy.
• Germ cell tumors (younger patients): Dysgerminoma (LDH), Yolk sac (AFP).
• Granulosa cell tumors: Estrogenic, Call-Exner bodies, inhibin_A & B_