Malignant tumors of the ovaries

The primary cancer is called malignant tumors, primarily affecting the ovary. Secondary ovarian cancer (cystadenocarcinoma) occurs most often in relation to malignant tumors of this organ. It develops more often in serous, less often mucinous cystadenomas. The secondary lesions of the ovaries include endometrioid cystadenocarcinoma, which often develops in young women suffering from primary infertility.

[1], [2], [3], [4]

Epidemiology

The incidence ranges from 3.1 cases per 100,000 women in Japan to 21 cases per 100,000 women in Sweden. Worldwide, more than 200,000 women fall ill on ovarian cancer every year, and about 100,000 die from this disease. Epithelial cancer is more common in white women in the industrialized countries of northern and western Europe and North America and less often in India and Asia.

[5], [6], [7], [8]

Risk factors

• violation of the menstrual cycle: early menarche, early (up to 45 years) or late (after 55 years) menopause, uterine bleeding;
• reproductive function (infertility);
• uterine myoma;
• genital endometriosis;
• hyperplastic processes of the endometrium;
• surgery for tumors of the internal genitalia with the abandonment of one or both ovaries;
• diseases of the mammary glands (mastopathy, fibroadenomatosis).

[9], [10]

Pathogenesis

The clinical course of malignant tumors of the ovaries is characterized by aggressiveness, a short period of tumor duplication and the universal character of metastasis. Regional for the ovaries are the iliac, lateral sacral, paraaortic and inguinal lymph nodes. The implantation path of the spread of distant metastases predominates - into the parietal and visceral peritoneum, pleura, carcinomatous ascites and hydrothorax. Lymphogenous metastases (to paraaortal and iliac collectors) are noted in 30-35% of primary patients. Hematogenous metastases in the lungs and liver are never isolated. They are often determined against a background of extensive implantation and lymphogenous dissemination.

[11], [12], [13], [14], [15], [16]

Symptoms of the malignant tumors of the ovaries

Malignant tumors of the ovaries are characterized by the following signs: abdominal pain (pulling, persistent, increasing, sudden, paroxysmal, etc.), changes in general condition (fatigue, weakness, dry mouth, etc.), weight loss, increase abdomen, changes in menstrual function, the appearance of acyclic bleeding from the genital tract, etc.

Stages

At present, the classification of malignant tumors of the ovaries using the TNM system is used in oncology:

T - primary tumor.

• T0 - primary tumor is not detected.
• T1 - the tumor is confined to the ovaries.
  • T1A - the tumor is limited to one ovary, there is no ascites.
  • T1B - the tumor is limited to two ovaries, there is no ascites.
  • T1C - the tumor is limited to one or two ovaries, ascites or in the wash from the abdominal cavity there are malignant cells.
• T2 - a tumor affects one or both ovaries with spreading on the parameter.
  • T2A is a tumor with proliferation and / or metastases to the uterus and / or one or both tubes, but without involvement of the visceral peritoneum and without ascites.
  • Т2В - the tumor extends to other tissues and / or affects the visceral peritoneum, but without ascites.
  • T2C - the tumor extends to the uterus and / or one or both tubes, and / or to other pelvic tissues. Ascites.
• TK - a tumor affects one or both of the ovaries, spreads to the small intestine or omentum, is confined to the small pelvis or there are intraperitoneal metastases outside the small pelvis or in the lymph nodes of the retroperitoneal space.

N - regional lymph nodes.

• N0 - there are no signs of regional lymph node involvement.
• N1 - there is regional lymph node involvement.
• NX - insufficient data to assess the condition of regional lymph nodes.

M - distant metastases.

• M0 - no signs of distant metastases.
• Ml - there are distant metastases.
• MX - insufficient data to determine distant metastases.

In practice, the classification of ovarian cancer is applied depending on the stage of the tumor process, which is determined on the basis of clinical examination and during the operation.

I stage - the tumor is confined to the ovaries:

• 1a stage - the tumor is oganiched with one ovary, no ascites;
• Stage 16 - the tumor is confined to both ovaries;
• 1c stage - the tumor is limited to one or both ovaries, but in the presence of obvious ascites or atypical cells are determined in the washings.

II stage - a tumor affects one or both ovaries with spreading to the pelvic region:

• IIa stage - spread and / or metastasis on the surface of the uterus and / or fallopian tubes;
• IIb stage - spread to other tissues of the pelvis, including peritoneum and uterus;
• K IIb stage - spread as with IIa or II6, but there is obvious ascites or atypical cells are determined in the washings.

Stage III - spread to one or both of the ovaries with peritoneal metastases outside the pelvis and / or metastases in the retroperitoneal lymph nodes:

• IIIa stage - microscopic metastases along the peritoneum;
• IIIb stage - macrometastasis per peritoneum less than or equal to 2 cm;
• IIIv stage - metastases on the peritoneum more than 2 cm and / or metastases in the regional lymph nodes and omentum.

IV stage - spread to one or both ovaries with distant metastases (distant lymph nodes, liver, navel, pleura). Ascites.

[17], [18]

Diagnostics of the malignant tumors of the ovaries

Age of the patient, on which depend : the incidence of various tumors, the progression of the disease and the prognosis of treatment.

The profession of the patient, especially associated with the impact of unfavorable production factors and environmental factors, may be a risk factor for the development of tumor processes.

General examination: skin coloring, weight loss, swelling of the legs, abdominal enlargement, peripheral lymph nodes, palpation of the abdomen (size, tenderness, mobility, consistency of the tumor, presence of ascites).

Gynecological examination and vaginal and rectal examination : the condition of the cervix and uterine body, the presence of a tumor in the appendages, its size, consistency, connection with surrounding organs, the state of recto-vaginal septum, Douglas space and parameters.

[19], [20], [21]

Additional research methods

Ultrasound of the pelvic organs, computer and magnetic resonance imaging, puncture of the Douglas space followed by cytological examination of flushing, diagnostic laparoscopy (laparotomy) with express biopsy and taking smear-prints, to clarify the histotype of the tumor, and revision of the abdominal cavity organs (in malignant tumors the degree of spread of the process is revealed).

To clarify the status of adjacent organs and features of tumor topography, we show irrigoscopy, excretory urography, fibrogastroscopy, chest X-ray, etc.

Immunological methods of early diagnosis of ovarian cancer - the detection of tumor markers CA-125 (with serous and low-grade adenocarcinoma), CA-119 (with mucinous cystadenocarcinoma and endometrioid cystadenocaryinoma), glycoprotein hormone (with granulosa-cell and mucinous ovarian cancer).

[22], [23], [24], [25]

Treatment of the malignant tumors of the ovaries

Basic principles of treatment of patients with various ovarian tumors

Benign tumors - In the reproductive age (up to 45 years) - removal of the appendages of the uterus on the side of the lesion. When bilateral tumors in young women - resection of the tumor with possible preservation of ovarian tissue. In pre- and postmenopause - supra-vulgar amputation or extirpation of the uterus with appendages.

Malignant tumors - In the 1st and 2nd stages - treatment is started with surgery (extirpation of the uterus with appendages and the omission of the large omentum), after which chemotherapy is performed. In stage III and IV, treatment is initiated with polychemotherapy, then cytoreductive surgery is performed (maximum possible removal of tumor masses and metastases, supravaginal amputation or extirpation of the uterus with appendages, removal of the large omentum and metastatic nodes). In the future, repeated courses of polychemotherapy.

Borderline tumors - Extirpation of the uterus with appendages and omentectomy is indicated. In young women, an organ-saving operation is possible (removal of the tumor and resection of the large omentum), which is supplemented by several courses of adjuvant polychemotherapy (especially with the germination of the tumor capsule or the presence of implantation metastases).

Currently, comprehensive treatment of patients with malignant ovarian tumors is considered adequate: a combination of surgery with polychemotherapy and (or) remote irradiation of the pelvis and abdominal cavity. In most cases, treatment is preferable to begin with surgery. In ascites and hydrothorax, it is possible to administer platinum preparations to the abdominal or pleural cavity. Polychemotherapy includes several antitumor drugs with different mechanisms of action. In the postoperative period, polychemotherapy is performed after receiving the results of a histological examination of the removed organs.

Standard schemes for polychemotherapy of ovarian cancer

The scheme	Composition, course
SR	Cisplatin - 75 mg / m 2 and iklofosfan 750 mg / m 2 intravenously every 3 weeks, 6 courses
CAP	Cisplatin - 50 mg / m 2, doxorubicin 50 mg / m 2 and iklofosfan 500 mg / m intravenously every 3 weeks, 6 courses
Taxanes	Paclitaxel - 135 mg / m 2 /24 hours, cisplatin 75 mg / m 2 intravenously every 3 weeks for 6 courses.

Most drugs have side effects associated with oppression of bone marrow hematopoiesis and development of leukopenia, thrombocytopenia, the maximum of which occurs at the end of the 2nd week after the course. In this regard, it is necessary to monitor blood levels and stop treatment with antitumor drugs with a drop in the number of leukocytes below 3 x 10 ⁶ / l and platelets - below 1 x 10 ⁶ / l.

The tolerability of the patient's preparations and the severity of the reactions that arise in the course of their use are also of considerable importance. In particular, the use of cyclophosphamide causes nausea, vomiting, alopecia, sometimes pain in muscles and bones, headache, in rare cases, toxic hepatitis, cystitis.

At the stage of chemotherapy, it is necessary to strive to achieve complete regression of the disease (disappearance of all manifestations of the disease, normalization of the level of CA-125), and then consolidate the effect by carrying out 2-3 additional courses. When partial regression is achieved, chemotherapy should be continued until the stabilization of the process, estimated by the size of residual tumor masses and the size of tumor markers, is noted during the last two courses of treatment. In these cases, in most patients, the number of treatment courses is from 6 to 12, but not less than 6.

To determine the dose of chemotherapy drugs, the body area (in m ² ) is calculated . On average, with an increase of 160 cm and a body weight of 60 kg, the body area is 1.6 m ², with an increase of 170 cm and a weight of 70 kg - 1.7 m ².

Currently, radiotherapy is not an independent method for treating patients with ovarian tumors and is recommended as one of the stages of combined treatment in the postoperative period. Postoperative radiotherapy is indicated for patients with I and II clinical stages, and also at stage III after cytoreductive surgical procedures that reduce the volume of tumor masses in the abdominal cavity. The bowl is used remote gamma-therapy on the abdominal cavity at a dose of 22.5-25 grams with additional irradiation of the pelvis (up to 45 grams). At these stages postoperative irradiation is supplemented with "preventive" chemotherapy for 2-3 years. Radiation therapy of patients with malignant ovarian tumors of the IV clinical stage remains an unresolved problem, since the presence of large tumor masses and (or) effusion in the serous cavities is considered as a contraindication to radiation treatment. In such patients, the choice of additional treatment methods should be decided in favor of chemotherapy.

According to the International Federation of Obstetricians and Gynecologists (RGO), the 5-year survival rates for all stages of ovarian cancer do not exceed 30-35%, the 5-year survival rate at stage I is 60-70%; II - 40-50%; III - 10-15%; IV stages - 2-7%.

Prevention

1. Periodic examinations (2 times a year) with the use of pelvic ultrasonography (once a year) for women with risk factors for ovarian cancer: menstrual and reproductive disorders, uterine fibroids, benign ovarian cysts, chronic inflammatory diseases of the uterine appendages, etc.
2. Correction of anovulation and hyperstimulation of ovulation with the help of steroid contraception (primary prevention of ovarian cancer).
3. Modern diagnostics of benign and borderline ovarian tumors and their surgical treatment (secondary prevention of ovarian cancer).

[26], [27], [28], [29], [30], [31]

Forecast

5-year survival (rounded to the nearest whole number) for epithelial ovarian cancer according to FIGO stages is as follows:

• Stage IA - 87%
• Stage IB - 71%
• Stage IC - 79%
• Stage IIA - 67%
• Stage IIB - 55%
• Stage IIC - 57%
• Stage IIIA - 41%
• Stage IIIB - 25%
• Stage IIIC - 23%
• IV stage - 11%

In general, the survival rate is about 46%

[32], [33], [34], [35], [36]