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Diagnosis and treatment of epithelial ovarian cancer

Ovarian cancer accounts for about 25% of all malignant tumors of the female genital tract. However, there are more deaths from this cancer each year in the United States as endometrial cancer and cervical cancer combined. The risk of spontaneous ovarian cancer is about 1.7%. 15,520 deaths due to epithelial ovarian cancer are expected in 2008. The average age at diagnosis is 60. There has been a significant improvement in the survival rate five years for patients with ovarian cancer. It’s probably a combination of better tumor debulking surgeries and better chemotherapeutic options.

Most patients with this type of ovarian cancer have no signs or symptoms until the disease spreads to the upper abdomen. 70% of patients present with advanced disease. Symptoms of ovarian cancer at an early stage may include nonspecific pelvic discomfort, urinary frequency and constipation that are caused by a massive expansion of the pelvis. At an advanced stage, patients experience abdominal pain, bloating, anorexia, nausea and constipation.

The best tumor marker for ovarian cancer is CA 125. lower elevations in CA 125 can also be seen in endometriosis, benign tumors, fibroids in pregnancy and postpartum. In addition, moderate elevation of CA 125 can be seen in another adnocarcinoma such as breast cancer and endometrial cancer. The sensitivity of CA 125 is 70% to 80% and the specificity is 98.6% to 99.4%. However, in the average-risk population with a low prevalence of ovarian cancer, the false positive may be too high.

The National Cancer Institute recommends screening for ovarian cancer in women with known genetic syndromes associated with the disease and for women with a strong family history. Routine screening of women without a family history of ovarian cancer is not recommended. The known genetic syndromes include hereditary breast cancer and ovarian syndrome associated with BRCA1, BRCA2 and hereditary nonpolyposis colorectal cancer (HNPCC) syndrome. The absolute risk of ovarian cancer in the presence of either BRCA 1 or BRCA 2 mutation ranges from 16% to 60%. For patients with HNPCC syndrome, the risk of ovarian cancer life is 9% to 12%.

Epithelial cancer accounts for approximately 90% of ovarian cancers. Most common histologies are serous, mucinous, endometrioid, transitiona and clear cell types. The germ cell tumors include disgerminoma, endodermal sinus tumor, embryonal carcinoma and teratoma with malignant primary choriocarcinoma. Tumor stromal tumors include granular or Sertoli Leydig tumor.

At initial presentation, surgery is used for confirmation and staging of cancer. Stage I disease is limited to one or both ovaries. Phase II involves one or both ovaries with extension to the pelvic viscera. Stage III is associated with implants in the pelvic wall or abdominal serosal surface of the intestine or liver or intestine involves the omentum. Stage IV involves distant metastases. The 5-year survival for stage IA and grade 1 or 2 histology is over 90%. For stage I disease and high-risk stage II disease, survival at 5 years is 80%. For patients with stage III disease after optimal cytoreduction, the 5-year survival is 20% to 30%. This reduces to less than 10% for stage III patients with optimal cytoreduction and stage IV disease.

Cancer stage I ovarian cancer with good prognostic features can be treated with surgery alone. For women at high risk, early stage cancer (stage I grade 3 or stage II disease), adjuvant chemotherapy with platinum-based display a 11% improvement in survival agents improves progression-free 8% overall survival. For stage III and IV disease, the current standard includes maximum to try followed by chemotherapy with platinum-based agents debulking.

An optimal reduction is important in the treatment of ovarian cancer. Retrospective data have shown that survival is better for women receiving chemotherapy with the presence of low-volume disease. In the environment in which they can not achieve optimal debulking, another approach is for the patient to receive chemotherapy in front. For patients who had a partial response to neoadjuvant chemotherapy, it may be appropriate to attempt surgical removal of macroscopic disease at the time.

As for the standard chemotherapy for advanced cancer care type ovarian, studies have shown that the combination of paclitaxel / cisplatin combination exceeds cyclophosphamide / cisplatin. Subsequent studies showed that the carboplatin / paclitaxel is at least as effective as cisplatin / paclitaxel.

Intraperitoneal chemotherapy is an attractive approach for the treatment of a disease largely confined to the peritoneal space. GOG 172 was a phase III clinical trials have shown that this regional approach resulted in progression-free survival and increased overall survival compared with single intravenous approach. The disadvantage of this approach includes local toxicity, and requiring the installation of intraperitoneal catheter.

Due to the high rate of recurrence in patients with advanced ovarian cancer if consolidation chemotherapy can improve time to progression and overall survival was examined in a phase III trial comparing 3 and 12 cycles of taxol. The progression-free survival favored the arm cycle 12. However, overall survival was not different between the two groups. Therefore, the oncologist should discuss with the patient and allow them to decide whether the improved progression-free survival justifies toxicities including peripheral neuropathy and alopecia.

For many patients with advanced ovarian cancer responded to initial treatment, the disease falls at a later time. The treatment of patients with refractory disease or recurrent disease should be individualized. For people with free treatment long distance, can be reused many similar drugs. There are also a number of medications a single agent activity in ovarian cancer. These include altretamine, bevacizumab, docetaxel, etoposide, gemcitabine, liposomal doxorubicin, paclitaxel, tamoxifen, topotecan, and vinorelbine.

Radiation therapy may also play a role in the palliative treatment of some patients with recurrent ovarian cancer. Symptoms such as pain massive growth or metastasis pelvic bone can be a palliative treatment. Rarely can develop brain metastases can also be treated with radiation.

The best treatment of ovarian cancer requires a team approach between primary care, gynecologic oncology surgeon, medical oncologists and radiation oncologists. Since many chemotherapeutic agents available and understand the biology of epithelial ovarian cancer, we hope to improve overall survival and quality of life of our patients.

Gigi P. Chen, MD, received his training in medical oncology and hematology at the University of California, Davis. She now practices at Diablo Valley Hematology-Oncology Center for Research and Treatment of Cancer in California in Pleasant Hill, California. The facility specializes in comprehensive and advanced treatment of all forms of cancer through clinical trials, chemotherapy, biological therapy, diagnostic imaging, and radiation. She is on the medical staff at John Muir Medical Center in Walnut Creek and both Concord and Regional Medical Center in San Ramon.

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