Ovarian Epithelial Cancer

• Ovarian epithelial cancer is a disease in which malignant (cancer) cells form in the tissue covering the ovary.
• Women who have a family history of ovarian cancer are at an increased risk of developing ovarian cancer.
• Some ovarian cancers are caused by inherited gene mutations (changes).
• Women with an increased risk of ovarian cancer may consider surgery to prevent it.
• Possible signs of ovarian cancer include pain or swelling in the abdomen.
• Tests that examine the ovaries, pelvic area, blood, and ovarian tissue are used to detect (find) and diagnose ovarian cancer.
• Certain factors affect treatment options and prognosis (chance of recovery).

Ovarian epithelial cancer is a disease in which malignant (cancer) cells form in the tissue covering the ovary.

The ovaries are a pair of organs in the female reproductive system. They are located in the pelvis, one on each side of the uterus (the hollow, pear-shaped organ where a foetus grows). Each ovary is about the size and shape of an almond. The ovaries produce eggs and female hormones (chemicals that control the way certain cells or organs function).

Ovarian epithelial cancer is one type of cancer that affects the ovary. (Refer to the treatment summaries on Ovarian Germ Cell Tumours and Ovarian Low Malignant Potential Tumours for information about other types of ovarian cancer.)

Women who have a family history of ovarian cancer are at an increased risk of developing ovarian cancer.

Women who have one first-degree relative (mother, daughter, or sister) with ovarian cancer are at an increased risk of developing ovarian cancer. This risk is higher in women who have one first-degree relative and one second-degree relative (grandmother or aunt) with ovarian cancer. This risk is even higher in women who have two or more first-degree relatives with ovarian cancer.

Some ovarian cancers are caused by inherited gene mutations (changes).

The genes in cells carry the hereditary information that is received from a person’s parents. Hereditary ovarian cancer makes up approximately 5% to 10% of all cases of ovarian cancer. Three hereditary patterns have been identified: ovarian cancer alone, ovarian and breast cancers, and ovarian and colon cancers.

Tests that can detect mutated genes have been developed. These genetic tests are sometimes done for members of families with a high risk of cancer. (Refer to the summaries on Screening for Ovarian Cancer, Prevention of Ovarian Cancer, and Genetics of Breast and Ovarian Cancer for more information.)

Women with an increased risk of ovarian cancer may consider surgery to prevent it.

Some women who have an increased risk of ovarian cancer may choose to have a prophylactic oophorectomy (the removal of healthy ovaries so that cancer cannot grow in them). It is not known if this procedure prevents ovarian cancer.

Possible signs of ovarian cancer include pain or swelling in the abdomen.

Early ovarian cancer may not cause any symptoms. When symptoms do appear, ovarian cancer is often advanced. Symptoms of ovarian cancer may include the following:

• Pain or swelling in the abdomen.
• Pain in the pelvis.
• Gastrointestinal problems, such as gas, bloating, or constipation.

These symptoms may be caused by other conditions and not by ovarian cancer. If the symptoms get worse or do not go away on their own, a doctor should be consulted so that any problem can be diagnosed and treated as early as possible. When found in its early stages, ovarian epithelial cancer can often be cured.

Women with any stage of ovarian cancer should think about taking part in a clinical trial. Information about ongoing clinical trials is available from the NCI Web site.

Tests that examine the ovaries, pelvic area, blood, and ovarian tissue are used to detect (find) and diagnose ovarian cancer.

The following tests and procedures may be used:

• Pelvic exam: An exam of the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum. The doctor or nurse inserts one or two lubricated, gloved fingers of one hand into the vagina and the other hand is placed over the lower abdomen to feel the size, shape, and position of the uterus and ovaries. A speculum is also inserted into the vagina and the doctor or nurse looks at the vagina and cervix for signs of disease. A Pap test or Pap smear of the cervix is usually done. The doctor or nurse also inserts a lubricated, gloved finger into the rectum to feel for lumps or abnormal areas.
• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
• CA 125 assay: A test that measures the level of CA 125 in the blood. CA 125 is a substance released by cells into the bloodstream. An increased CA 125 level is sometimes a sign of cancer or other condition.
• Barium enema: A series of x-rays of the lower gastrointestinal tract. A liquid that contains barium (a silver-white metallic compound) is put into the rectum. The barium coats the lower gastrointestinal tract and x-rays are taken. This procedure is also called a lower GI series.
• Intravenous pyelogram (IVP): A series of x-rays of the kidneys, ureters, and bladder to find out if cancer has spread to these organs. A contrast dye is injected into a vein. As the contrast dye moves through the kidneys, ureters, and bladder, x-rays are taken to see if there are any blockages.
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerised tomography, or computerised axial tomography.
• Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. The tissue is removed in a procedure called a laparotomy (a surgical incision made in the wall of the abdomen).

Certain factors affect treatment options and prognosis (chance of recovery).

The prognosis (chance of recovery) and treatment options depend on the following:

• The stage of the cancer.
• The type and size of the tumour.
• The patient’s age and general health.
• Whether the cancer has just been diagnosed or has recurred (come back).

Stages of Ovarian Epithelial Cancer

Key Points for This Section

• After ovarian epithelial cancer has been diagnosed, tests are done to find out if cancer cells have spread within the ovaries or to other parts of the body.
• The following stages are used for ovarian epithelial cancer:
o Stage I
o Stage II
o Stage III
o Stage IV

After ovarian epithelial cancer has been diagnosed, tests are done to find out if cancer cells have spread within the ovaries or to other parts of the body.

The process used to find out if cancer has spread within the ovary or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment.

An operation called a laparotomy is usually done to find out the stage of the disease. A doctor must cut into the abdomen and carefully look at all the organs to see if they contain cancer. The doctor will also perform a biopsy (cut out small pieces of tissue so they can be looked at under a microscope to see whether they contain cancer). Usually the doctor will remove the cancer and organs that contain cancer during the laparotomy. (See the Treatment Options by Stage section).

The following stages are used for ovarian epithelial cancer:

Stage I

In stage I, cancer is found in one or both of the ovaries and has not spread. Stage I is divided into stage IA, stage IB, and stage IC.

• Stage IA: Cancer is found in a single ovary.
• Stage IB: Cancer is found in both ovaries.
• Stage IC: Cancer is found in one or both ovaries and one of the following is true:
o cancer is found on the outside surface of one or both ovaries; or
o the capsule (outer covering) of the tumour has ruptured (broken open); or
o cancer cells are found in the fluid of the peritoneal cavity (the body cavity that contains most of the organs in the abdomen) or in washings of the peritoneum (tissue lining the peritoneal cavity).

Stage II

In stage II, cancer is found in one or both ovaries and has spread into other areas of the pelvis. Stage II is divided into stage IIA, stage IIB, and stage IIC.

• Stage IIA: Cancer has spread to the uterus and/or the fallopian tubes (the long slender tubes through which eggs pass from the ovaries to the uterus).
• Stage IIB: Cancer has spread to other tissue within the pelvis.
• Stage IIC: Cancer has spread to the uterus and/or fallopian tubes and/or other tissue within the pelvis and cancer cells are found in the fluid of the peritoneal cavity (the body cavity that contains most of the organs in the abdomen) or in washings of the peritoneum (tissue lining the peritoneal cavity).

Stage III

In stage III, cancer is found in one or both ovaries and has spread to other parts of the abdomen. Stage III is divided into stage IIIA, stage IIIB, and stage IIIC.

• Stage IIIA: The tumour is found only in the pelvis, but cancer cells have spread to the surface of the peritoneum (tissue that lines the abdominal wall and covers most of the organs in the abdomen).
• Stage IIIB: Cancer has spread to the peritoneum but is 2 centimeters or smaller in diameter.
• Stage IIIC: Cancer has spread to the peritoneum and is larger than 2 centimeters in diameter and/or has spread to lymph nodes in the abdomen.

Cancer that has spread to the surface of the liver is also considered stage III disease.

Stage IV

In stage IV, cancer is found in one or both ovaries and has metastasized (spread) beyond the abdomen to other parts of the body. Cancer is found in the tissues of the liver.

Recurrent Ovarian Epithelial Cancer

Recurrent ovarian epithelial cancer is cancer that has recurred (come back) after it has been treated.

Treatment Option Overview

Key Points for This Section

• There are different types of treatment for patients with ovarian epithelial cancer.
• Three kinds of standard treatment are used. These include the following:
o Surgery
o Radiation therapy
o Chemotherapy

• New types of treatment are being tested in clinical trials. These include the following:
o Biologic therapy
o High-dose chemotherapy with stem cell transplant
o Targeted therapy

There are different types of treatment for patients with ovarian epithelial cancer.

Different types of treatment are available for patients with ovarian epithelial cancer. Some treatments are standard, and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the treatment currently used as standard treatment, the new treatment may become the standard treatment.

Clinical trials are taking place in many parts of the country. Information about ongoing clinical trials is available from the NCI Web site. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

Three kinds of standard treatment are used. These include the following:

Surgery

Most patients have surgery to remove as much of the tumour as possible. Different types of surgery may include:

• Total hysterectomy: A surgical procedure to remove the uterus, including the cervix. If the uterus and cervix are taken out through the vagina, the operation is called a vaginal hysterectomy. If the uterus and cervix are taken out through a large incision (cut) in the abdomen, the operation is called a total abdominal hysterectomy. If the uterus and cervix are taken out through a small incision (cut) in the abdomen using a laparoscope, the operation is called a total laparoscopic hysterectomy.
• Unilateral salpingo-oophorectomy: A surgical procedure to remove one ovary and one fallopian tube.
• Bilateral salpingo-oophorectomy: A surgical procedure to remove both ovaries and both fallopian tubes.
• Omentectomy: A surgical procedure to remove the omentum (a piece of the tissue lining the abdominal wall).
• Lymph node biopsy: The removal of all or part of a lymph node. A pathologist views the tissue under a microscope to look for cancer cells.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Some women receive a treatment called intraperitoneal radiation therapy, in which radioactive liquid is put directly in the abdomen through a catheter.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy).

A type of regional chemotherapy used to treat ovarian cancer is intraperitoneal (IP) chemotherapy. In IP chemotherapy, the anticancer drugs are carried directly into the peritoneal cavity (the space that contains the abdominal organs) through a thin tube.

The way the chemotherapy is given depends on the type and stage of the cancer being treated.

New types of treatment are being tested in clinical trials. These include the following:

Biologic therapy

Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

High-dose chemotherapy with stem cell transplant

High-dose chemotherapy with stem cell transplant is a method of giving high doses of chemotherapy and replacing blood-forming cells destroyed by the cancer treatment. Stem cells (immature blood cells) are removed from the blood or bone marrow of the patient or a donor and are frozen and stored. After the chemotherapy is completed, the stored stem cells are thawed and given back to the patient through an infusion. These reinfused stem cells grow into (and restore) the body’s blood cells.

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells.

Treatment Options by Stage

Stage I and II Ovarian Epithelial Cancer

Treatment of stage I and stage II ovarian epithelial cancer may include the following:

• Total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy. Lymph nodes and other tissues in the pelvis and abdomen are removed and examined under the microscope to look for cancer cells.
• Total abdominal hysterectomy, unilateral salpingo-oophorectomy, and omentectomy. Lymph nodes and other tissues in the pelvis and abdomen are removed and examined under the microscope to look for cancer cells.
• A clinical trial of internal or external radiation therapy.
• A clinical trial of chemotherapy.
• A clinical trial of surgery followed by chemotherapy or watchful waiting (closely monitoring a patient's condition without giving any treatment until symptoms appear or change).
• A clinical trial of a new treatment.

Stage III and IV Ovarian Epithelial Cancer

Treatment of stage III and stage IV ovarian epithelial cancer may be surgery to remove the tumour, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy.

After surgery, treatment may include the following:

• Chemotherapy using one or more anticancer drugs, including intraperitoneal (IP) chemotherapy.
• Combination chemotherapy followed by second-look surgery (surgery performed after the initial surgery to determine whether tumour cells remain).
• A clinical trial of biologic therapy or targeted therapy.

Information about ongoing clinical trials is available from the NCI Web site.

Treatment Options for Recurrent Ovarian Epithelial Cancer

Treatment of recurrent ovarian epithelial cancer may include the following:

• Chemotherapy with or without surgery.
• A clinical trial of chemotherapy or intraperitoneal (IP) chemotherapy.
• A clinical trial of high-dose chemotherapy with stem cell transplant.
• A clinical trial of biologic therapy.