INCIDENCE AND EPIDEMIOLOGY
Annually in the United States, about 22,530 new cases are found and 13,980 women die of ovarian cancer. Incidence begins to rise in the fifth decade, peaking in the eighth decade. Risk is increased in nulliparous women and reduced by pregnancy (risk decreased about 10% per pregnancy) and oral contraceptives. About 5% of cases are familial.
Mutations in BRCA-1 and BRCA-2 predispose women to both breast and ovarian cancer. Cytogenetic analysis of epithelial ovarian cancers that are not familial often reveals complex karyotypic abnormalities, including structural lesions on chromosomes 1 and 11 and loss of heterozygosity for loci on chromosomes 3q, 6q, 11q, 13q, and 17. C-myc, H-ras, K-ras, and HER2/neu are often mutated or overexpressed. Unlike in colon cancer, a stepwise pathway to ovarian carcinoma is not apparent. Ovarian cancers may also occur in the setting of Lynch syndrome, inherited nonpolyposis colorectal cancer, due to mutations in the genes that repair DNA mismatches. The subset of women with endometrioid histology often have a mutation in ARID1A, a DNA repair complex component.
No benefit has been seen from screening women of average risk. Hereditary ovarian cancer accounts for 10% of all cases. Women with BRCA-1 or -2 mutations should consider prophylactic bilateral salpingo-oophorectomy by age 40.
Most pts present with abdominal pain, bloating, urinary symptoms, and weight gain indicative of disease spread beyond the true pelvis. Localized ovarian cancer is usually asymptomatic and detected on routine pelvic examination as a palpable nontender adnexal mass. Most ovarian masses detected incidentally in ovulating women are ovarian cysts that resolve over one to three menstrual cycles. Adnexal masses in postmenopausal women are more often pathologic and should be surgically removed. CA-125 serum levels are ≥35 U/mL in 80–85% of women with ovarian cancer, but other conditions may also cause elevations.
Half of ovarian tumors are benign, one-third are malignant, and the rest are tumors of low malignant potential. These borderline lesions have cytologic features of malignancy but do not invade. Malignant epithelial tumors may be of five different types: serous (50%), mucinous (25%), endometrioid (15%), clear cell (5%), and Brenner tumors (1%, derived from urothelial or transitional epithelium). The remaining 4% of ovarian tumors are stromal or germ cell tumors, which are managed like testicular cancer in men (Chap. 73). Histologic grade is an important prognostic factor for the epithelial varieties.
Extent of disease is ascertained by a surgical procedure that permits visual and manual inspection of all peritoneal surfaces and the diaphragm. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, partial omentectomy, pelvic and paraaortic lymph node sampling, and peritoneal washings ...