The ovarian cancer is a disease in which malignant tumor cells causing the forming tissue of the ovaries or fallopian tubes and grow abnormally and multiply , forming a tumor. The ovaries, which are part of the female reproductive system, are located in the pelvis, one on each side of the uterus. They are about the size and shape of an almond, and are responsible for secreting the eggs and female sex hormones.

The cancer ovarian is the leading cause of cancer death in the reproductive female, although not the most frequent (the 5th); and the sixth cause of death from cancer in women. In Spain, more than 3,500 new cases are diagnosed each year, according to 2019 data from the Spanish Society of Medical Oncology (SEOM).

This cancer is suffered by one in 70 women, it occurs more frequently in postmenopause –between 65 and 80 years of age– and the prognosis, as in all cancers, is worse the greater the stage (degree of development disease) of the same. In this case, when the tumor is detected, the stage is already advanced (in 70% of patients), and the tumor has usually spread outside the ovaries, which is why it has so much mortality.

If the cancer is found and treated before it spreads outside the ovary, the 5-year survival rate is between 80 and 92%, compared to 35-40% in more advanced stages. However, only 15% of all cases of ovarian cancer are detected at this early stage. That is why the early diagnosis of this tumor is so important, since it allows improving the prognosis, which, on the other hand, is getting better and better thanks to the advances that are taking place in medical treatment and surgery related to the control of this disease.

It is also very important the psychological support that the patient receives when she is diagnosed and, in general, throughout the treatment, since it will help her to better face this process.

Causes of ovarian cancer

The causes of ovarian cancer are not known , although it has been observed that there are a number of factors that predispose a woman to developing this type of cancer, while other factors decrease the risk of developing the disease.

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Ovarian Cancer Risk Factors

Theory of unceasing ovulation: the trauma-rupture that occurs during each ovulation in order for the egg to leave the ovary can be a stimulus for the development of ovarian cancer. For this reason, women without offspring are at a higher risk, since gestation supposes an ovulatory rest period, and those who have not been pregnant will have suffered a greater number of ovulations.
Genetic : appears more frequently in those women with a family history of ovarian cancer. 30% of ovarian cancers have been shown to express high levels of certain genetic mutations.
Age : the older, the higher the risk.

Protective factors of ovarian cancer

Polycystic ovary syndrome (PCOS) , as this condition prevents ovulation from occurring in women affected by this disorder.
Oral contraceptives; taking hormonal contraceptives prevents ovulation.
The tubal ligation and hysterectomy, cause a decrease of ovulation to the altered vascularization of the area.
Pregnancies.

Types of ovarian cancer

When we talk about ovarian cancer, different types of tumors can be distinguished. Some of the most common are listed below:

Epithelial tumors

They make up the majority of ovarian tumors, up to 75% (including benign and malignant) and 90% of malignant ones. This definition includes a set of tumors derived from the epithelium of the ovary (tissue that covers it), and the most common are:

Serous (60-80%): Cystadenoma, cystadenocarcinoma. They are the most frequent, and are usually bilateral. Globally they malignant 3 times more than mucinous.
Mucinous (25%): Cystadenoma, cystadenocarcinoma. They are usually benign, and can grow to a large size.
Endometroids (20%): (endometrioma, carcinoma). Most are malignant, and are sometimes associated with endometrial adenocarcinoma.

Germ

They constitute 25% of the total, but they are 60% of the tumors that appear in young women, and they usually produce abdominal pain and bloating .

Mature cystic teratoma is the most common (90%) and is benign, however, the rest of the tumors in this group are malignant. The most prominent are:
Benign cystic teratoma or dermoid cyst : It is very common and usually benign. In its composition, tissues such as sebaceous, sweat glands, hair … predominate.
Dysgerminoma : it is the most frequent malignant tumor in this group, and the most frequent malignant in patients younger than 30 years.

Sexual cord-stromal tumors

It is the least frequent group, and constitutes 5% of ovarian tumors.

Of granulosa: they are more frequent in postmenopausal women, and produce estrogens (female hormone), therefore they may present symptoms early due to increased estrogens, such as absence of menstruation or, conversely, heavy bleeding, increased thickness of the endometrium … By manifesting symptoms early, they are diagnosed in less advanced stages, which improves the prognosis.
From the theca-fibroma : they are usually benign, and approximately half produce estrogens and / or androgens (mainly male hormone), which can facilitate early diagnosis, as in the case of tumors derived from granulosa.
Androblastoma : they are normally benign, and they reproduce testicular elements, therefore half of these tumors can produce androgens, and this can lead to symptoms such as: acne, increased size of the clitoris, decreased menstrual bleeding …, that is, signs of virilization, and for this reason they constitute the first cause of virilization of ovarian origin.

Ovarian cancer symptoms

The symptoms of ovarian cancer are not usually specific, but are common to other less serious pathologies, for example the digestive system, so it is common for the diagnosis to come when the tumor is already at an advanced stage.

In addition, the symptoms appear when the disease has been suffered for a long time and, being similar to those caused by digestive pathology, they can be erroneously treated for a time, in many cases with antacids.

The most common symptoms of ovarian cancer are:

Abdominal swelling .
Abdominal pain.
Irregular vaginal bleeding, which appears outside the menstrual period.
Constipation , gas , strong urination.
Nausea and vomiting
Loss of appetite
Unexplained decrease or increase in weight.
Back pain.
Constitutional syndrome (tiredness, weight loss …) in tumors with great growth and that are in advanced stages.

Complications may appear such as: ascites (fluid accumulation in the abdominal cavity), torsion, rupture, intestinal obstruction, spread of cancer to other organs, infection …

The definitive diagnosis of ovarian cancer is established by studying the affected tissues, but the clinical history, imaging techniques and serum markers guide (very faithfully in some cases) the diagnosis.

Imaging techniques

Doppler vaginal ultrasound

It is the most effective imaging technique in the diagnosis of ovarian cancer, and allows evaluating whether a detected mass is solid or a fluid-filled cyst.

Malignancy is suspected when the ultrasound detects, among others, any of the following characteristics:

Bilateral location.
Solid and cystic appearance.
Presence of thick partitions, solid parts inside.
Size greater than 10 cm in women of childbearing age, or greater than 5 cm in postmenopausal women.
Presence of ascites (fluid in the abdomen).
Detection of new vascular formations.

Computed tomography

Its main utility is to determine if ovarian cancer has spread to other organs. It also serves to check the size of the tumor and if the lymph nodes are enlarged.

Magnetic resonance

The images obtained with this technique are more complete than those obtained with computed tomography, in terms of defining the lesions and evaluating the spread of the tumor.

Chest x-ray

The chest radiograph may be for the expert an alternative option to the CT scan to check for a spread of epithelial ovarian cancer to the lungs and chest cavity.

Tumor markers

Tumor markers (substances secreted by the tumor) that have been associated with ovarian cancer are:

Ca 125: it can be elevated in up to 80% of ovarian tumors, but it can be associated with benign processes, such as pregnancy, for which reason it is usually more specific in postmenopausal patients.
CEA (carcinoembryonic antigen): it is raised less frequently, but it is in almost 70% of cases of mucinous cancer.
Alphafetoprotein: it is associated with endodermal sinus tumor, because it increases in up to 95% of patients, although it can also increase in teratomas and dysgerminomas.
Inhibin: increases in granulosa and mucinous tumors.
CA19.9: Mainly elevated in mucinous tumors.
HCG: it rises in 95-100% of embryonal carcinomas, which also have an increased alphafetoprotein in 70%. HCG is also increased in choriocarcinoma.
SCC (squamous cell growth antigen): increases in immature teratomas.

Sex cord tumors also secrete hormones, as seen above, that aid in their diagnosis; thus, granulosa and teak cell tumors produce estrogens; those of Sertoli and Leydig cells secrete testosterone , and ginandroblastomas secrete estrogens and androgens.

Early diagnosis of ovarian cancer: screening

In women with first-degree relatives affected by ovarian cancer or breast cancer, it is recommended (although there is no scientific evidence of the usefulness of this screening) ultrasound and measurement of Ca 125 annually, to rule out possible family syndromes that include cancer ovary.

Ovarian Cancer Treatment

The treatment of ovarian cancer is usually approached using various techniques. The choice of one or the other will depend on the type and size of the tumor, the stage in which it is located, the involvement of the lymph nodes, and the possibility that the cancer has spread outside the abdominal cavity:

Surgery

The basic or choice treatment for early stage ovarian cancer is surgical, and usually involves radical surgery, in which the uterus and ovaries are removed, the peritoneum is explored (and biopsies are taken for suspicious lesions) , the nodes in the area are removed, and it may even be necessary to remove intestinal segments, in order to eliminate all possible locations of the tumor.

In young patients who wish to have offspring, more conservative surgery can be performed in some cases, which would be completed later, after the wishes of the offspring are fulfilled.

In advanced stages, as much of the tumor is removed as possible so that what remains can be treated after surgery with chemotherapy.

If there is no surgery option, it is treated with chemotherapy.

Chemotherapy

It is used depending on the stages and the success of the surgery, as adjuvant therapy to eliminate possible malignant cells that have survived the operation. The number of cycles of treatment the ovarian cancer patient will receive will depend on the stage of her illness she is in. In this type of cancer, chemotherapy can be administered in the vein (intravenous or IV) or in the belly (intraperitoneal or IP). See more about chemotherapy

Experts have recently incorporated anti- angiogenic therapy with a monoclonal antibody to VEGF into chemotherapy treatment that significantly improves the prognosis of ovarian cancer.