Ovarian Cancer - Symptoms, Diagnosis, Stages & Treatment
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Ovarian Cancer - Symptoms, Diagnosis, Stages & Treatment

Cancer cells are examined under the microscope and graded according to how similar they are to normal cells. It means that grade 1 cancer cells look like normal cells, while grade 3 cancer cells are relatively unlike normal cells. Between these two is called grade 2. The cause of ovarian cancer is not yet known. However, some risk factors have been identified that increase the risk of developing this type of cancer.

About a quarter of ovarian cancers are detected at an early stage. Detecting cancer early increases the chances of successful treatment. 9 out of 10 women treated for early-stage ovarian cancer live at least five years after their cancer diagnosis.

The risk of developing ovarian cancer in an average woman's lifetime is 1.4-1.8%. About 70% of ovarian cancers are diagnosed at stage III. The most crucial reason such a high rate of advanced-stage ovarian cancer is diagnosed is that this cancer spreads to the intra-abdominal organs in the form of implantation, primarily through the direct spread. Since there is direct spread to the intra-abdominal organs quickly, patients are diagnosed at an advanced stage.

What are the risk factors for epithelial ovarian cancers?

  • Advancing age is one of the risk factors for ovarian cancer. It often occurs after menopause. More than half of ovarian cancers occur over the age of 65.
  • Obesity is also a significant risk factor. Studies have shown that overweight women are more likely to die from ovarian cancer. This risk increases by 50 percent in extremely obese women.
  • Familial inheritance is also an essential factor—the frequency of familial ovarian cancer increases in BRCA1 and BRCA2 gene mutation carriers. Ovarian cancer is also common in people belonging to the hereditary non-polyposis colorectal cancer family. As the number of people with ovarian cancer in the family increases, the risk of the person himself increases exponentially. However, familial ovarian cancers constitute 5-10% of all ovarian cancers. In other words, the vast majority of patients come across as the first case in the family.
  • Early menstruation (early menarche) and late menopause increase the risk. With each ovulation, damage occurs on the outer surface of the ovary, and this area returns to normal with the healing process. When the tissue is damaged, and the healing process is prolonged, it is thought that carcinogenic substances disrupt this tissue, which is dividing during the healing process, plays a role in the progression to cancer.
  • The use of talcum powder for cleaning the genital area increases the risk of ovarian cancer. There is an increased risk in patients with polycystic ovary syndrome.
  • People with frequent ovarian inflammation are also at increased risk.
  • The risk is increased in people who take long-term hormone replacement therapy during menopause.
  • Not giving birth to a child and not breastfeeding increases the risk because ovulation function stops after birth and lactation periods. When this period is not experienced, there is an increase in risk.

What are the factors that reduce the risk of ovarian cancer?

  • Having more than one child,
  • Breastfeeding,
  • Having used birth control pills,
  • Removal of the uterus,
  • Not using talcum powder during or after genital cleaning,
  • To follow a diet rich in fruits and vegetables and to reduce the consumption of animal food,
  • Avoiding obesity,
  • Conscious use of vitamins,
  • Using a diet rich in vitamin A or low doses of vitamin A (retinoid or fenretinide),
  • Using beta-carotene (a vitamin found in carrots),
  • Use of vitamin C-rich diet or vitamin pills and balanced vitamin C use,
  • Ovarian cancer is less common in people who use COX-2 inhibitor drugs,
  • Diet rich in Vitamin D.

What are the Symptoms of Ovarian Cancer?

Ovarian cancer is the most insidious developing and spreading of all gynecological cancers. Therefore, it usually does not give any symptoms in the early period. Most of the cases caught in the early period are diagnosed incidentally during routine gynecological examination. Sometimes, an accidental diagnosis is made after a cyst operation is detected in patients presenting with right or left lower abdominal pain. In general, after ovarian cancer spreads to the abdomen, with the layer called the peritoneum, which covers the inside of the abdomen, the fluid called ascites accumulates in the abdomen, and the patient usually brings complaints related to the discomfort caused by the acid fluid. These complaints are generally in the form of thickening around the abdomen, old skirts and trousers being too small to close in a short time, excessive fullness in the abdomen, and gas after meals. These complaints are general complaints that can occur in many situations. So there is no specific indication. Sometimes, patients may also come because of menstrual irregularity, pain in the lower abdomen, and a feeling of downward pressure.

Is early diagnosis possible in ovarian cancer?

About 70% of ovarian cancers are diagnosed at stage III. The most crucial reason for diagnosing ovarian cancers at such a high rate is that this cancer spreads more directly into the abdomen in the form of implantation. For this reason, patients are diagnosed at an advanced stage, as there is direct spread to the intra-abdominal organs in a short time.

No screening test detects precursor lesions of ovarian cancer yet. For this purpose, many different cancer markers have been used in scientific research; however, these markers were high in 30% of the patients in the early stage, which we call stage I. Although the results obtained in screening with the use of more than one tumor marker are more successful, they have not been used routinely due to the high costs they bring.

The most crucial point for early diagnosis is that any cystic formation more than three centimeters in diameter detected in regular gynecological examination and post-menopausal ultrasonography should be considered suspicious. On the other hand, if a cystic formation is seen in the ultrasonography performed in the premenopausal period, especially if this cyst is still present in the postmenopausal period and has some additional ultrasonographic features, it should be reviewed by a physician experienced in the diagnosis of gynecological cancer.

How is ovarian cancer diagnosed? 

The diagnosis of ovarian cancer is made only by making a diagnosis of tissue called histopathological examination. Surgical intervention is required for this diagnosis. The surgical intervention to be performed here is for both diagnostic and therapeutic purposes. During the operation, a sample is taken from the suspicious ovary and, if any, the tissues to which it has spread and sent to the histopathological examination, which we call frozen examination, during the operation. During the process, whether the tumor originates from the ovary or not, the tumor's cell type and the degree of similarity (differentiation) of the tumor to the normal tissue are determined. The surgical treatment is shaped according to the results obtained here.

Preoperative imaging methods (such as computerized tomography, positron emission tomography, ultrasonography) or determination of tumor marker levels can provide information about the extent of the disease, but they are not definitive diagnostic methods. In addition, they can never replace tissue diagnosis.

What are the stages of ovarian cancer?

Stage 1a: tumor limited to one ovary, no tumor on the outer surface of the ovary, no intra-abdominal spread, the ovary with the tumor is not ruptured (external surface continuity is intact). There is no tumor in the intra-abdominal fluid.

Stage 1b: the tumor is limited to both ovaries, there is no tumor on the outer surface of the ovaries, there is no intra-abdominal spread, the ovary with the tumor is not ruptured. There is no tumor in the intra-abdominal fluid.

Stage 1c: the tumor is limited to one or both ovaries, there is a tumor on the outer surface of the ovaries, or the ovary with the tumor is ruptured (external surface continuity is interrupted), or there are tumor cells in the intra-abdominal fluid.

Stage 2a: the tumor is limited to one or both ovaries, but the tumor has spread to the uterus (womb) or tubes. The ovary with the tumor is not ruptured; there is no tumor on the outer surface of the ovaries. There is no tumor in the intra-abdominal fluid.

Stage 2b: the tumor is limited to one or both ovaries, but the tumor has spread to other organs outside the uterus (womb) or tubes within the pelvis. The ovary with the tumor is not ruptured; there is no tumor on the outer surface of the ovaries. There is no tumor in the intra-abdominal fluid.

Stage 2c: the tumor is limited to one or both ovaries, but the tumor has spread to the uterus (womb) or tubes or other intrapelvic formations. However, the ovary with the tumor is ruptured, or there is a tumor on the outer surface of the ovaries or tumor cells in the intra-abdominal fluid.

Stage 3a: The tumor is in one or both ovaries but has spread outside the pelvis at a microscopic level. There is microscopic spread in abdominal (intra-abdominal) organs (such as intestine, omentum).

Stage 3b: The tumor is in one or both ovaries but has spread beyond the pelvis. However, the largest tumor diameter in the spread is less than two centimeters. The diameter of the metastases is less than two centimeters in the spread in the abdominal (intra-abdominal) organs (such as the intestine, omentum). Lymph nodes are negative.

Stage 3c: The tumor is in one or both ovaries, but has spread beyond the pelvis. However, the largest tumor diameter in spread is above two centimeters. In the spread to abdominal organs (such as intestine, omentum), the diameter of the metastases is larger than 2 cm or the lymph nodes are positive.

Stage 4: There is tumor spread outside the abdomen. Spread between the lung membranes or to the brain or liver or other extra-abdominal organs and formations.

How is ovarian cancer treated?

The most important point in the treatment of ovarian cancer is surgical treatment. Surgery is applied for both diagnosis and treatment purposes in patients.

Goals of surgical treatment:

1) To determine whether the tumor really originates from the ovary,

2) To determine the extent of the tumor in the abdomen,

3) To determine the type of tumor among ovarian cancers,

4) It is the application of surgery so that no tumor is left behind.

In the surgical intervention for the treatment of ovarian cancer, the surgical treatment that is determined in world standards and should be applied to all patients:

  • Surgery is started with a midline incision made from the middle of the abdomen to cover the lower and upper abdomen.
  • First, a sample is taken from the fluid accumulated in the abdomen for pathological examination. If this fluid is not available, fluid is obtained by washing the inside of the abdomen.
  • The extent of the tumor in the abdomen and lower abdomen is determined.
  • The uterus and both ovaries are removed.
  • The membrane called the omentum, which covers the inside of the abdomen, is removed.
  • Tumor spread is sought on the membrane covering the inside of the abdomen, called the peritoneum, and the areas with spread are removed.
  • All of the lymph nodes located under the peritoneum and around the great vessels are taken from the lowest point of the abdomen, from the beginning of the vessels leading to the leg. This procedure is called pelvic lymph adenectomy for the lower abdomen. The lymph nodes around the main vessels called the aorta and the inferior vena cava are also completely removed, and this procedure is called paraaortic lymph adenectomy. The upper border of the paraaortic lymphadenectomy is the starting point of the renal vessels. All lymph nodes in the mentioned areas should be removed because ovarian cancer can spread to these formations. At least 25 lymph nodes should be removed in ideal pelvic lymph adenectomy and at least 10 lymph nodes in ideal paraaortic lymph adenectomy.
  • The appendix is ​​checked and in some tumor types, the appendix is ​​removed even if there is no spread.
  • Expansions on the intestine are searched and all spreads are removed. If necessary, the part of the large or small intestine that is affected by the tumor is removed.
  • The liver and spleen area should be checked. In particular, the surface of the formation that separates the abdominal cavity and the chest cavity, called the diaphragm, located on the liver, is also checked and if any, tumors are removed.

The aim of surgical treatment is to complete the surgery so that no tumor remains in the abdomen and to complete the steps we have mentioned above. After surgical treatment, chemotherapy is administered to all patients, except for patients with early stage (stage 1 and 2). Currently, paclitaxel and platinum-containing chemotherapy are the most common chemotherapy, with a total of six cycles.

In order to reduce the prevalence of the tumor before surgical treatment, chemotherapy application without surgery has come to the fore in recent years. The aim of this treatment approach, known as neo-adjuvant chemotherapy, is to reduce the common tumor burden and to reduce the degree of bowel removal to be performed. In fact, this treatment approach should only be applied to patients whose tumors are so widespread that surgical treatment cannot be applied in the first place.

Many studies have shown that the ideal treatment is to apply complete surgical staging to the patient in the first place. The success of preoperative chemotherapy and subsequent surgery is never as good as surgery and subsequent chemotherapy. On the other hand, if the extent of the patient's tumor is very advanced and surgical treatment cannot be applied, then the neo-adjuvant chemotherapy approach may be beneficial. If it is decided to apply preoperative chemotherapy, this chemotherapy should not exceed three cycles. It has been scientifically proven that applying more chemotherapy does not contribute positively to the results of patients.

Is it possible to preserve fertility after surgery?

Although ovarian cancer is a disease that is usually seen after menopause, it can sometimes be seen in patients who are in the fertile period and have never given birth to a child. Regardless of the patient's age; The extent of the disease in all epithelial ovarian cancers should be determined exactly.

In patients who want to preserve fertility and fertility, if there is no spread to the abdomen, if the contralateral ovary is not involved by the tumor, if the histological type of the tumor (the type of tumor determined from the tissue piece taken during the surgery) is suitable for fertility preservation, fertility-sparing treatment can be applied. For this type of surgery, the patient's ovary with tumor involvement is removed; The membrane called the omentum and the retroperitoneal lymph nodes are removed without removing the intact ovary and uterus on the opposite side. In addition, even if there are no foci of spread of the tumor on the peritoneal membrane, at least 10 random biopsies from different regions are taken for pathological examination. Only then can the true extent of the tumor and the extent of the disease be determined. If the surgery is not performed properly, the patient's true tumor extent will not be known and the result of starting with incomplete information can be disastrous. Among early stage patients, fertility is preserved in stage Ia grade 1, 2 stage Ib grade 1 cases. Since fertility-preserving treatment is very risky in advanced stages, its application is not a standard approach.

The most important point to remember is that fertility-sparing surgery should only be performed after detailed information in patients who want to absolutely preserve their fertility and accept the risk of tumor recurrence in the remaining ovarian or intra-abdominal organs caused by this type of treatment. This approach is not a standard treatment.

How can I protect myself from ovarian cancer?

  • Regular health checks should be done by going to a gynecologist. Discuss this information with your doctor, especially if you have a family history of ovarian cancer.
  • Use birth control pills. Because the risk is reduced in people who have used these drugs for years.
  • See your physician for tubal ligation or hysterectomy. Tubal ligation after child desire is completed can reduce the risk of ovarian cancer. Removal of the uterus (hysterectomy) can likewise reduce the risk. However, these surgical procedures should not be performed only for the risk of ovarian cancer, but should be performed for a valid medical reason.
  • Breastfeed your baby. Having one or more children and breastfeeding for one or more years can reduce the risk. Although these methods reduce the risk to a small extent, they do not provide complete protection. It is not recommended to have children just to reduce the risk of ovarian cancer. Remember that birth control pills have a much greater risk-reducing effect.
  • Eat healthy. Many studies have shown that this cancer is less common in women who eat a diet rich in vegetables. The American Cancer Society recommends a diet rich in plant origin and variety. Make sure to consume at least five servings of vegetables and fruits a day. Eat limited amounts of red meat, especially if it is high in fat.
  • Consult your physician for genetic testing. If you have a family history of ovarian cancer, consider genetic counseling and, if appropriate, genetic testing. Discuss the benefits and potential drawbacks of testing with your physician before requesting the test. Genetic testing indicates whether a woman has certain genetic changes that increase her risk for ovarian cancer. While it is a great relief to learn that she does not carry the genetic change, knowing that she does carry this change can be quite stressful. However, this information can be useful in developing methods for cancer prevention.

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