http://www.gyncancer.com/ovarian-cancer.html

In addition, there are others that are very rare. The ovary is also a site for
metastasis from other cancers, especially the intestinal cancers and breast
cancer. Cancers metastatic to the ovary are referred to as Krukenberg tumors.

The germ cell tumors are of note because they commonly occur in young women;
50% are in women younger than 21 years of age. They are also of note because
these can be very aggressive and virulent cancers, which however, with
chemotherapy can be prevented from recurring. They are also noteworthy because
the teratomas have the potential to form complete adult type tissues. The
common name of a mature teratoma is "dermoid." It can contain hair, teeth,
bone and brain tissue. Often they are full of skin. They are not malignant but
very rarely can have a secondary malignancy such as a melanoma or a squamous
cell cancer of skin. Some contain thyroid tissue and can cause
hyperthyroidism. Teratoma means monster which is an apt name for these ovarian
tumors full of teeth and hair. If the tissue is immature or fetal in
appearance then they are malignant.

The specialized stromal cell tumors are rare but of interest because they can
produce hormones. Granulosa and theca cell tumors are often mixed and can
produce estrogen. If it occurs in a young girl it can produce premature sexual
development which will also stop the bones from growing and thus cause short
stature. Sertoli-Leydig cell tumors produce male hormones and will cause
defemininization then masculinization with male pattern baldness, deep voice,
excessive hair growth and enlargement of the clitoris. The specialized stromal
cell cancers are usually not aggressive cancers and usually involve only one
ovary.

The majority of ovarian cancers are the epithelial adenocarcinomas and are
what most people mean when they say ovarian cancer. Like adenocarcinomas
elsewhere they are graded and include a spectrum of disease from benign cysts
to low grade borderline cancers to grade I, II, and III cancers. These cancers
are often cystic and spread easily throughout the abdomen on all the
peritoneal surfaces. This is not surprising since their origin is the same as
that of the peritoneum. The peritoneum itself can give rise to an identical
cancer long after the ovaries have been removed.

The remainder of this article is primarily concerned with epithelial ovarian
cancers.

RISK FACTORS FOR OVARIAN CANCER

Epithelial ovarian cancers tend to be a cancer of affluent societies where
expected life spans are long. An increased risk factor, other than age, is
nulliparity or delayed childbearing. A decreased risk is seen with multiparity
and with prolonged use of birth control pills. The mechanism for this
protective effect is thought to be that the number of ovulations is reduced.
Each ovulation requires the breakage of the ovarian follicle and the repair to
the ovarian surface. Reparative processes means increased cell divisions, or
mitoses. Each mitotic event is a time of risk for a mutation to occur. There
have been some unsubstantiated claims that the use of talcum powders
contaminated with asbestos can cause ovarian cancers. Dietary factors are
difficult to determine but if present are very weak in their association. One
study has even associated yogurt with an increased risk. More recently there
has been a purported increased risk with the use of fertility drugs. The cause
of ovarian cancer is unknown.

SYMPTOMS

There are no symptoms of early ovarian cancer. Occasionally an ovarian cyst
will be detected on a routine gynecologic examination. A cyst can break and
bleed and that will also cause enough symptoms to cause the woman to seek
help. Otherwise, the cancer is usually far advanced before it is diagnosed.
The symptoms will be due to a build up of fluid in the abdomen called ascites.
Some women will present with several gallons of ascitic fluid.

Ovarian cancer spreads on the surfaces of the intestines and can cause
obstruction. Sometimes it will spread into the lining of the lung cavity
causing fluid to accumulate which can cause shortness of breath. Often there
will be a several month history of digestive problems that are not specific.
X-rays of the abdomen, upper GI studies and barium enemas will fail to find
the cancer because these tests evaluate the inside of the intestines and the
insides are always normal. The problem is on the outside of the intestines.
Only when the fluid is detected by an ultrasound test or a CT scan or a mass
is felt will the diagnosis be considered. The diagnosis is made at exploratory
surgery.

The stage is determined at surgery. If there are cancer nodules throughout the
abdomen then it is obviously a stage III cancer. If only one ovary is
apparently involved then there has to be an extensive search for microscopic
cancer on the other abdominal structures and in the lymph nodes. An early
stage is assigned only after a more advanced stage has been excluded.

In all but the earliest cancers there is often some cancer remaining after
surgery. This is because it spreads throughout the abdomen in little nodules,
some are only barely visible and others are too small to see. The surgical
goal is not to leave any nodule larger than 1cm which is about a quarter of an
inch. If the residual is this small or smaller then the debulking or
cytoreduction is considered to have been optimal. Sometimes this is not
possible but a maximum effort should be done to try to achieve this optimal
situation. This may require removal of a piece of intestine and even a
colostomy in some instances.

In addition to stage, the grade is also important. There is a grade designated
grade 0. This refers to an epithelial adenocarcinoma of low malignant
potential, also called a borderline cancer. These cancers tend to be indolent
and although they may be stage III, not recur for many years even without
treatment. Grade I adenocarcinomas are easily identified as being from a
glandular origin. Grade III cancers are difficult to identify as glandular;
they are also called poorly differentiated. Grade II cancers are intermediate
in appearance. Grade I cancers are expected to behave the best, grade III the
worst.

MANAGEMENT OF OVARIAN CYSTS

Any woman with an enlarged ovary is considered to have an ovarian cancer and
is operated, except those women who are found to have a simple cyst less than
10 cm in size and who are ovulatory or early pregnant. These women can be
followed conservatively and reexamined in four weeks. If the cyst is gone or
getting smaller, then it can be followed until it is gone. They had a
functional cyst. Every ovulating woman gets a cyst every cycle. This follicle
cyst is usually about 2 cm when it breaks and releases the egg. Sometimes the
follicle cyst does not break and persists and gets larger. It will eventually
break on its own, but if detected during this time a cancer will also have to
be considered. It should be allowed to go away on its own. Or, the follicle
cyst ruptures and becomes a corpus luteum cyst. This will also go away by
itself. Persistent ovarian cysts will have to be operated to exclude or
diagnose a cancer. An ultrasound test can often distinguish between a simple
cyst and a complex cyst. A simple cyst is just a fluid filled structure. A
complex cyst has internal structures or solid areas within it. A simple cyst
can be followed. A complex cyst or solid tumor should be operated.

TREATMENT OF BORDERLINE OVARIAN CANCER

There is a special category of epithelial ovarian cancers called borderline or
cancers of low malignant potential based on the microscopic appearance of the
cancer. They are expected to behave as very low grade cancers, that is, to be
very slow growing. Signs of recurrence may not develop for fifteen or twenty
years. Most will never recur. Most are stage I, but can be stage III when
diagnosed. They are usually not treated after surgery. If they recur then they
are reoperated. The treatment of advanced stage disease with residual is
controversial. The inclination is for chemotherapy; the dilemma is that it
cannot be demonstrated to work.

TREATMENT OF EPITHELIAL OVARIAN CANCER

The initial treatment is surgery which will consist of removal of the uterus,
tubes and ovaries as well as any large nodules of cancer. There are exceptions
when only one ovary is removed. This conservative surgery is indicated in the
following situation.

1. The patient has a strong desire for further childbearing and is otherwise
fertile.
2. The cancer is stage IA. Grade 0, I, or sometimes II epithelial cancer.
3. The cancer is a stage I germ cell cancer or a specialized stromal cancer.

In this situation a unilateral oophorectomy is indicated. The low grade
epithelial cancers require no further treatment, although these women are
advised to have the remaining ovary removed when childbearing is completed.
The germ cell cancers are usually on only one side. All will receive
aggressive chemotherapy and most will do well. The specialized stromal cell
cancers are usually unilateral and not aggressive cancers, so the other ovary
can be retained until no longer needed.

Otherwise, all ovarian cancer patients receive a maximal surgical effort so
that the residual is small. This will give them a better chance for a complete
response to chemotherapy. If a segment of intestine has to be removed, then
that is done. Sometimes this will result in a colostomy. If all the large
pieces of cancer can be removed then a maximum effort is indicated. All the
cancer can seldom be removed, but if no piece larger than 1-2 cm remains after
surgery then that is considered to be an optimal cytoreduction surgery. After
surgery almost all patients will require additional treatment.

The whole abdomen needs to be treated. Sometimes this can be accomplished by
radiation. This is not a popular treatment in this country because of the
possible major side effects and because chemotherapy seems to work as well.
Another way to radiate the abdomen is to instill a radioactive substance into
the abdomen. The radioactive isotope of phosphorus, called P-32, is used. This
is a one time instillation and the entire abdominal contents receive a dose of
several thousand RADs to a depth of several millimeters. It is used only when
good distribution is assured and only microscopic amounts of cancer are
present.

Chemotherapy consists of receiving the drugs soon after surgery and it is
repeated every 3 or 4 weeks if all is going well. There are usually six
courses of treatment. How do you know if it is working? If there is any
measurable cancer, then you can tell if it is getting bigger or smaller. If
there was ascites initially which has not recurred then that is good evidence
of success. If the Ca-125 was elevated and reverts to normal then that is
evidence of a good response. If the Ca-125 rises or the ascites returns or a
new cancer is detected then that indicates failure of the chemotherapy.

http://www.gyncancer.com/ovarian-cancer.html#whattodo
Most patients with advanced ovarian cancer will do well initially, but most
will not be cured. For these women and their families there will be a
prolonged course of alternating hope and fear as results of treatment are
awaited and new treatments tried. Some of these treatments will result in a
complete remission of the cancer. Few remissions will be lasting. Some
patients will receive investigational drugs administered through nationwide
studies.

When ovarian cancer persists, in spite of several different treatment
regimens, a decision should be made as to what the overall goals will be. Cure
is seldom a realistic goal, but if that is what is decided then you should
probably seek an entirely different approach such as a highly investigational
method. These would be available only at major cancer treatment centers.

If cure is not a realistic goal, then neither may be longevity. If longevity
is not a goal, then you can stop worrying about the cancer and devote your
emotional energy and resources to the more important problems of daily living.
You are going to live with this cancer. You may die as a consequence of this
cancer. BUT, YOU ARE NOT DEAD YET. There are still things for you to do. There
are still things that your doctor needs to do for you. There are still things
your family and friends need to do for you. And, there are still things you
need to do for yourself.

Each day will require provision for comfort and function. Each day will be an
opportunity to say good-bye to those you need to say good-bye to. Each day
will be an opportunity to resolve past conflicts and reconcile yourself with
your religious beliefs. Each day will be a free day. You can do with it as you
wish.

How do you decide when to stop treatment? Ovarian cancer is different from
other cancers. It is usually diagnosed in an advanced stage, but responds well
to initial treatment. About 15% will even be cured. Most other cancers that
are diagnosed at advanced stages are essentially untreatable. By contrast,
breast cancer is usually diagnosed at an early stage, but is unpredictable and
can recur several times over many years. For the ovarian cancer patient both
the initial fear and the initial hope are both justified. Most will do well
initially, but most will do poorly in the long run.

Since the initial treatment has such a high response rate it is justified to
think that treating the recurrences will do as well. The dilemma is that as
new active drugs are developed they are rapidly used as initial treatment,
leaving few choices for the recurrences. The odds of achieving a complete
response for a recurrence following first line treatment are only about 5%.
The duration of this complete response is usually less than 6 months. The
possibility of cure is unknown, but is probably only a percentage point at
most. The odds of cure if the second line treatment does not work are too low
to calculate.

How do you decide when to stop treatment? It depends on how you ask the
question. If the question asked is:

"Is there any possibility that this cancer can be cured?"

Then the answer is "Probably not, but if there is any possibility that it can
be cured then it will require more surgery and chemotherapy or some other
treatment. Whatever the possibility, it is potentially more than zero, which
is the outcome if nothing is done."  With this approach the decision is
usually to agree to more treatment.

If the question asked is:
"Is there any known treatment that will cure this cancer?"
Then the answer is "No and any more treatment is futile."

At this point the decisions are based more on personality and philosophy than
medicine.

The decision not to try more treatment does not mean being abandoned by your
doctors. You may need even more medical care in an attempt to solve or
palliate some of the effects of the cancer. Now is also the time to make
contact with a Hospice organization if there is one available. Hospice can
help you stay at home and coordinate care with your doctors.

The decision to not take more cancer treatment does not mean to choose death
but rather to choose life, for however long it is to be, free of the burden of
chemotherapy etc.