Ovarian Ovarian tumorstumors

STAGING & MANAGEMENTSTAGING & MANAGEMENT

TREATMENT OF OVARIAN CYSTS TREATMENT OF OVARIAN CYSTS AND BENIGN TUMORSAND BENIGN TUMORS

• Ovarian cysts < 6 cms usually regress by absorption or Ovarian cysts < 6 cms usually regress by absorption or spontaneous rupture and the patient may be managed spontaneous rupture and the patient may be managed conservatively over 2 menstrual cycles with monthly conservatively over 2 menstrual cycles with monthly rectovaginal examination.rectovaginal examination.

• If regression fails to occur, assessment is indicatedIf regression fails to occur, assessment is indicated

• Diagnostic tests include laboratory blood studies and pelvic Diagnostic tests include laboratory blood studies and pelvic examination. Usually, ultrasound studies with and without blood examination. Usually, ultrasound studies with and without blood flow measurements to the involved ovary are used for diagnosis flow measurements to the involved ovary are used for diagnosis and to help determine the best therapy. and to help determine the best therapy.

• Some tumors require surgery to diagnose accurately, ruling out Some tumors require surgery to diagnose accurately, ruling out malignancy, or to treat. If one ovary must be removed, normal malignancy, or to treat. If one ovary must be removed, normal conception and childbirth is possible as long as a normal ovary conception and childbirth is possible as long as a normal ovary remains on the other side. remains on the other side.

Medication Medication

• Female hormones or clomiphene may be Female hormones or clomiphene may be prescribed. These help shrink or destroy some prescribed. These help shrink or destroy some tumors. Oral contraceptives are often used as the tumors. Oral contraceptives are often used as the first step in treatment. first step in treatment.

LAPAROSCOPYLAPAROSCOPY

• Ovarian cyst and benign tumors can also be Ovarian cyst and benign tumors can also be resected by this techniqueresected by this technique

Staging The Federation Staging The Federation Internationale de Gynecologie et Internationale de Gynecologie et

d'Obstetrique (FIGO) and the d'Obstetrique (FIGO) and the American Joint Committee on American Joint Committee on

Cancer (AJCC) have designated Cancer (AJCC) have designated staging.staging.

Stage I ovarian cancerStage I ovarian cancer• limited to the ovaries. limited to the ovaries.

– Stage IA: tumour limited to 1 ovary, the capsule Stage IA: tumour limited to 1 ovary, the capsule is intact, no tumour on ovarian surface and no is intact, no tumour on ovarian surface and no malignant cells in ascites or peritoneal malignant cells in ascites or peritoneal washings. washings.

– Stage IB: tumour limited to both ovaries, Stage IB: tumour limited to both ovaries, capsules intact, no tumour on ovarian surface capsules intact, no tumour on ovarian surface and no malignant cells in ascites or peritoneal and no malignant cells in ascites or peritoneal washings. washings.

– Stage IC: tumour is limited to 1 or both ovaries Stage IC: tumour is limited to 1 or both ovaries with any of the following: capsule ruptured, with any of the following: capsule ruptured, tumour on ovarian surface, malignant cells in tumour on ovarian surface, malignant cells in ascites or peritoneal washings.ascites or peritoneal washings.

Stage II ovarian cancerStage II ovarian cancer

• tumors involving 1 or both ovaries with pelvic tumors involving 1 or both ovaries with pelvic extension and/or implants. extension and/or implants. – Stage IIA: extension and/or implants on the Stage IIA: extension and/or implants on the

uterus and/or fallopian tubes. No malignant uterus and/or fallopian tubes. No malignant cells in ascites or peritoneal washings. cells in ascites or peritoneal washings.

– Stage IIB: extension to and/or implants on Stage IIB: extension to and/or implants on other pelvic tissues. No malignant cells in other pelvic tissues. No malignant cells in ascites or peritoneal washings. ascites or peritoneal washings.

– Stage IIC: Pelvic extension and/or implants Stage IIC: Pelvic extension and/or implants (stage IIA or stage IIB) with malignant cells (stage IIA or stage IIB) with malignant cells in ascites or peritoneal washings.in ascites or peritoneal washings.

Stage III ovarian cancerStage III ovarian cancer• tumours involving 1 or both ovaries with tumours involving 1 or both ovaries with

microscopically confirmed peritoneal implants microscopically confirmed peritoneal implants outside the pelvis. Superficial liver metastasis equals outside the pelvis. Superficial liver metastasis equals stage III.stage III.

• – Stage IIIA: microscopic peritoneal metastasis Stage IIIA: microscopic peritoneal metastasis

beyond pelvis (no macroscopic tumour). beyond pelvis (no macroscopic tumour). – Stage IIIB: macroscopic peritoneal metastasis Stage IIIB: macroscopic peritoneal metastasis

beyond pelvis less than 2 cm in greatest beyond pelvis less than 2 cm in greatest dimension. dimension.

– Stage IIIC: peritoneal metastasis beyond pelvis Stage IIIC: peritoneal metastasis beyond pelvis greater than 2 cm in greatest dimension and/or greater than 2 cm in greatest dimension and/or regional lymph node metastasis.regional lymph node metastasis.

Stage IV ovarian cancerStage IV ovarian cancer

tumours involving 1 or both ovaries with tumours involving 1 or both ovaries with distant metastasis. Parenchymal liver distant metastasis. Parenchymal liver

metastasis equals stage IV.metastasis equals stage IV.

ManagementManagement

Treatment OptionsTreatment Options • The treatment of ovarian cancers based on The treatment of ovarian cancers based on

the stage of the disease which is a the stage of the disease which is a reflection of the extent or spread of the reflection of the extent or spread of the cancer to other parts of the body.cancer to other parts of the body.

• It also depends on histologic cell It also depends on histologic cell type, and the patient's age and type, and the patient's age and overall condition.overall condition.

• There are basically three forms of There are basically three forms of treatment of ovarian cancer:treatment of ovarian cancer:– surgerysurgery – ChemotherapyChemotherapy – radiation treatmentradiation treatment, ,

GENERAL GUIDELINES:GENERAL GUIDELINES:

• Standard treatment is surgery (staging and Standard treatment is surgery (staging and optimal debulking) followed by adjuvant optimal debulking) followed by adjuvant chemotherapy in most cases. Even if optimal chemotherapy in most cases. Even if optimal surgery is not possible, removing as much tumor surgery is not possible, removing as much tumor as possible will provide significant palliation of as possible will provide significant palliation of symptoms.symptoms.

• Borderline lesions may be treated with Borderline lesions may be treated with conservative surgery conservative surgery

GENERAL GUIDELINES:GENERAL GUIDELINES:

• Germ cell tumors are treated with surgery and multi-Germ cell tumors are treated with surgery and multi-agent chemotherapy in most cases agent chemotherapy in most cases

• Advanced epithelial ovarian cancer is very sensitive Advanced epithelial ovarian cancer is very sensitive to chemotherapy with responses in the range of 70-to chemotherapy with responses in the range of 70-80% to first-line chemotherapy. The majority, 80% to first-line chemotherapy. The majority, however, relapse and ultimately die of chemotherapy-however, relapse and ultimately die of chemotherapy-resistant disease. Second-line chemotherapy to date resistant disease. Second-line chemotherapy to date is disappointing in all forms of epithelial ovarian is disappointing in all forms of epithelial ovarian cancer with virtually no chance of successful second-cancer with virtually no chance of successful second-line treatment following failure of initial regime. line treatment following failure of initial regime.

SURGERYSURGERY

Treatment of Ovarian Treatment of Ovarian Epithelial CancerEpithelial Cancer

Stage IStage I

• Generally a total abdominal hysterectomy, removal of Generally a total abdominal hysterectomy, removal of both ovaries and fallopian tubes, omentectomy, both ovaries and fallopian tubes, omentectomy, biopsy of lymph nodes and other tissues in the pelvis biopsy of lymph nodes and other tissues in the pelvis and abdomen,is done. Young women whose disease is and abdomen,is done. Young women whose disease is confined to one ovary are often treated by a unilateral confined to one ovary are often treated by a unilateral salpingo-oophorectomy without a hysterectomy and salpingo-oophorectomy without a hysterectomy and removal of the opposite ovary being performedremoval of the opposite ovary being performed

• Depending on the pathologist's interpretation of the Depending on the pathologist's interpretation of the tissue removed, there may be no further treatment if tissue removed, there may be no further treatment if the cancer is low grade, or if the tumor is high grade the cancer is low grade, or if the tumor is high grade the patient may receive combination chemotherapy. the patient may receive combination chemotherapy.

Stage IIStage II

• Treatment is almost always hysterectomy and Treatment is almost always hysterectomy and bilateral salpingo-oophorectomy as well as bilateral salpingo-oophorectomy as well as debulking of as much of the tumor as possible and debulking of as much of the tumor as possible and sampling of lymph nodes and other tissues in the sampling of lymph nodes and other tissues in the pelvis and abdomen that are suspected of pelvis and abdomen that are suspected of harboring cancer. After the surgical procedure, harboring cancer. After the surgical procedure, treatment may be one of the following: 1) treatment may be one of the following: 1) combination chemotherapy with or without combination chemotherapy with or without radiation therapy or 2) combination chemotherapy.radiation therapy or 2) combination chemotherapy.

Stage IIIStage III

• Treatment is the same as for Stage II ovarian Treatment is the same as for Stage II ovarian cancer. Following the surgical procedure, the cancer. Following the surgical procedure, the patient may either receive combination patient may either receive combination chemotherapy possibly followed by additional chemotherapy possibly followed by additional surgery to find and remove any remaining cancer.surgery to find and remove any remaining cancer.

Stage IVStage IV • CYTOREDUCTIVE SURGERY/DEBULKING:CYTOREDUCTIVE SURGERY/DEBULKING:

– surgery to remove as much of the tumor as surgery to remove as much of the tumor as possible.possible.

– Most researchers consider residual disease Most researchers consider residual disease of <1 cm to be optimal debulking surgery. of <1 cm to be optimal debulking surgery. followed by combination chemotherapyfollowed by combination chemotherapy

Trial of 146 patients with stage III and IV Trial of 146 patients with stage III and IV ovarian cancer treated with cisplatin at ovarian cancer treated with cisplatin at

Rosewell park Cancer Institute:Rosewell park Cancer Institute:SIZE OF RESIDUAL DISEASESIZE OF RESIDUAL DISEASE SURVIVALSURVIVAL

5 YEARS 5 YEARS

8 YEARS8 YEARS

<1 CM<1 CM 56%56% 42%42%

1-2 CMS1-2 CMS 19%19% 10%10%

>2 CMS>2 CMS 13%13% 8.7%8.7%

CHEMOTHERAPYCHEMOTHERAPY

• Prolongs remission and survival Prolongs remission and survival

• Also used for palliative treatment in advanced n Also used for palliative treatment in advanced n recurrent disease recurrent disease

• Administered in all cases beyond stage IaAdministered in all cases beyond stage Ia

• Earlier single agents were used, nowadays Earlier single agents were used, nowadays combination therapy is favouredcombination therapy is favoured

CHEMOTHERAPYCHEMOTHERAPY• No chemotherapeutic agent kills all cancer cells in No chemotherapeutic agent kills all cancer cells in

one treatment ,Tf treatment needs to be repeated one treatment ,Tf treatment needs to be repeated several times several times

• All agents used should be active against that All agents used should be active against that particular tumorparticular tumor

• should have different modes of action to avoid should have different modes of action to avoid drug resistance n should have differenr drug resistance n should have differenr mechanisms of toxicity.mechanisms of toxicity.

CHEMOTHERAPYCHEMOTHERAPY

• This allows each of them to be used as nearv to This allows each of them to be used as nearv to the full dose as possible.the full dose as possible.

• Drugs are given at 3 weeks intervalsDrugs are given at 3 weeks intervals

• Intraperitoneal chemotherapy is also done Intraperitoneal chemotherapy is also done

• The initial treatment of ovarian cancer is called The initial treatment of ovarian cancer is called first-line therapy.first-line therapy.

• If the cancer continues to grow with first-line If the cancer continues to grow with first-line therapy or returns after first-line therapy, therapy or returns after first-line therapy, additional treatment, called additional treatment, called second-line therapysecond-line therapy, , may be administered.may be administered.

• If the tumor continues to grow after second-line If the tumor continues to grow after second-line therapy, the next therapy is called therapy, the next therapy is called third-line third-line therapytherapy, and so on., and so on.

First-Line ChemotherapyFirst-Line Chemotherapy

• First-line chemotherapy for ovarian cancer First-line chemotherapy for ovarian cancer typically consists of two drugs given together. typically consists of two drugs given together. The combination =paclitaxel + platinum drug—The combination =paclitaxel + platinum drug—either carboplatin or cisplatin. either carboplatin or cisplatin.

• Select women may benefit from administration of Select women may benefit from administration of chemotherapy directly into the abdomen—called chemotherapy directly into the abdomen—called intraperitoneal therapy—in addition to intraperitoneal therapy—in addition to conventional intravenous administration.conventional intravenous administration.

Second-Line Second-Line ChemotherapyChemotherapy

• The choice of drugs for second-line therapy The choice of drugs for second-line therapy depends largely on which drugs were depends largely on which drugs were administered for first-line therapy and how long it administered for first-line therapy and how long it has been since the first-line therapy was stopped.has been since the first-line therapy was stopped.

• chemotherapy drugs) for the treatment of ovarian chemotherapy drugs) for the treatment of ovarian

cancer that has returned: cancer that has returned: GEMZAR (gemcitabine HCl for injection) GEMZAR (gemcitabine HCl for injection)

plus another chemotherapy, carboplatin, is plus another chemotherapy, carboplatin, is indicated ,6 months after their first-line therapy; indicated ,6 months after their first-line therapy;

Second-Line Second-Line ChemotherapyChemotherapy

• Hycamtin (topotecan HCl for injection) is indicated as Hycamtin (topotecan HCl for injection) is indicated as a single agent (one drug) for the treatment of a single agent (one drug) for the treatment of ovarian cancer upon failure of first-line therapy; ovarian cancer upon failure of first-line therapy;

• and Doxil (doxorubicin HCl liposome injection) is and Doxil (doxorubicin HCl liposome injection) is approved for use to treat women whose cancer has approved for use to treat women whose cancer has returned following first-line therapy.returned following first-line therapy.

NICE guidelines for the use of NICE guidelines for the use of chemotherapychemotherapy

– It is recommended that paclitaxel in combination It is recommended that paclitaxel in combination with a platinum-based compound or platinum-with a platinum-based compound or platinum-based therapy alone (cisplatin or carboplatin) are based therapy alone (cisplatin or carboplatin) are offered as alternatives for first-line chemotherapy offered as alternatives for first-line chemotherapy (usually following surgery) in the treatment of (usually following surgery) in the treatment of ovarian cancer. ovarian cancer.

– When relapse occurs after an initial (or When relapse occurs after an initial (or subsequent) course of first-line chemotherapy, subsequent) course of first-line chemotherapy, additional courses of treatment should be additional courses of treatment should be considered, using different treatment options. considered, using different treatment options.

NICE guidelines for the use of NICE guidelines for the use of chemotherapy chemotherapy (contd..)(contd..)

– The following definitions are used by NICE: The following definitions are used by NICE: • Platinum-sensitive ovarian cancer: disease that responds to Platinum-sensitive ovarian cancer: disease that responds to

first-line platinum-based therapy but relapses 12 months or first-line platinum-based therapy but relapses 12 months or more after completion of initial platinum-based chemotherapy. more after completion of initial platinum-based chemotherapy.

• Partially platinum-sensitive ovarian cancer: disease that Partially platinum-sensitive ovarian cancer: disease that responds to first-line platinum-based therapy but relapses responds to first-line platinum-based therapy but relapses between 6 and 12 months after completion of initial platinum-between 6 and 12 months after completion of initial platinum-based chemotherapy. based chemotherapy.

• Platinum-resistant ovarian cancer: disease that relapses within Platinum-resistant ovarian cancer: disease that relapses within 6 months of completion of initial platinum-based 6 months of completion of initial platinum-based chemotherapy.Platinum-refractory ovarian cancer: disease chemotherapy.Platinum-refractory ovarian cancer: disease that does not respond to initial platinum-based chemotherapy.that does not respond to initial platinum-based chemotherapy.

NICE guidelines for the use of NICE guidelines for the use of chemotherapy chemotherapy (contd…)(contd…)

– Paclitaxel in combination with a platinum-based compound Paclitaxel in combination with a platinum-based compound (carboplatin or cisplatin) is recommended as an option for the (carboplatin or cisplatin) is recommended as an option for the second-line (or subsequent) treatment of women with second-line (or subsequent) treatment of women with platinum-sensitive or partially platinum-sensitive advanced platinum-sensitive or partially platinum-sensitive advanced ovarian cancer, except in women who are allergic to ovarian cancer, except in women who are allergic to platinum-based compounds. platinum-based compounds.

– Single-agent paclitaxel is recommended as an option for the Single-agent paclitaxel is recommended as an option for the second-line (or subsequent) treatment of women with second-line (or subsequent) treatment of women with platinum-refractory or platinum-resistant advanced ovarian platinum-refractory or platinum-resistant advanced ovarian cancer, and for women who are allergic to platinum-based cancer, and for women who are allergic to platinum-based compounds. compounds.

– PLDH (pegylated liposomal doxorubicin hydrochloride) is PLDH (pegylated liposomal doxorubicin hydrochloride) is recommended as an option for the second-line (or recommended as an option for the second-line (or subsequent) treatment of women with partially platinum-subsequent) treatment of women with partially platinum-sensitive, platinum-resistant or platinum-refractory advanced sensitive, platinum-resistant or platinum-refractory advanced ovarian cancer, and for women who are allergic to platinum-ovarian cancer, and for women who are allergic to platinum-based compounds. based compounds.

NICE guidelines for the use of NICE guidelines for the use of chemotherapychemotherapy (contd….) (contd….)

Topotecan is recommended as an option for Topotecan is recommended as an option for second-line (or subsequent) treatment only for second-line (or subsequent) treatment only for those women with platinum-refractory or those women with platinum-refractory or platinum-resistant advanced ovarian cancer, platinum-resistant advanced ovarian cancer, or those who are allergic to platinum-based or those who are allergic to platinum-based compounds, for whom PLDH and single-agent compounds, for whom PLDH and single-agent paclitaxel are considered inappropriate. paclitaxel are considered inappropriate.

REGIMENS IN OVARIAN CANCERREGIMENS IN OVARIAN CANCER

REGIMENREGIMEN DOSEDOSE

CPCP CISPLATIN CISPLATIN PACLITAXELPACLITAXEL

75 mg/sq.m75 mg/sq.m135-175mg/sq.m135-175mg/sq.m

CTCT CARBOPLATINCARBOPLATINPACITAXELPACITAXEL

AUC=5AUC=5135-175mg/sq.m135-175mg/sq.m

DCDC CISPLATINCISPLATINCYCLOPHOSPHAMIDECYCLOPHOSPHAMIDE

75mg/sq.m75mg/sq.m750mg/sq.m750mg/sq.m

CAPCAP CYCLOPHOSPHAMIDECYCLOPHOSPHAMIDEDOXORUBICINDOXORUBICINCISPLATINCISPLATIN

600mg/sq.m600mg/sq.m50mg/sq.m50mg/sq.m75mg/sq.m75mg/sq.m

BEPBEP BLEOMYCINBLEOMYCINETOPOSIDEETOPOSIDECISPLATINCISPLATIN

10mg/sq.m x 3 days10mg/sq.m x 3 days20mg/sq.m x 5days20mg/sq.m x 5days100mg/sq.m100mg/sq.m

REGIMEN FOR NON-EPITHELIAL REGIMEN FOR NON-EPITHELIAL TUMORSTUMORS

VACVAC VincistreneVincistrene

VBCVBC

BEPBEP

SIDE EFFECTSSIDE EFFECTS

While chemotherapy drugs kill cancer cells, they While chemotherapy drugs kill cancer cells, they also damage some normal cells, causing side also damage some normal cells, causing side effects. These side effects will depend on the type effects. These side effects will depend on the type of drugs given, the amount taken, and how long of drugs given, the amount taken, and how long treatment lasts. Temporary side effects might treatment lasts. Temporary side effects might include the following: include the following:

• nausea and vomiting nausea and vomiting • loss of appetite loss of appetite • hair loss hair loss • hand and foot rashes hand and foot rashes • kidney or nerve damage kidney or nerve damage • mouth sores mouth sores

• an increased chance of infection (from a shortage an increased chance of infection (from a shortage of white blood cells) of white blood cells)

• bleeding or bruising after minor cuts (from a bleeding or bruising after minor cuts (from a shortage of platelets) shortage of platelets)

• tiredness (from low red blood cell counts) tiredness (from low red blood cell counts)

RADIOTHERAPY:RADIOTHERAPY:

• Now, has a very small role since platinum based Now, has a very small role since platinum based protocols and paclitaxel have improved the protocols and paclitaxel have improved the median survival.median survival.

• -However it can be used as a palliative treatment -However it can be used as a palliative treatment for metastatic bone or brain lesions or of localized for metastatic bone or brain lesions or of localized recurrence to alleviate the pain.recurrence to alleviate the pain.

• Also used in recurrent germ cell tumors especially Also used in recurrent germ cell tumors especially dysgerminomas dysgerminomas which is very radiosensitive.which is very radiosensitive.

• Radioactive isotopes of gold-Au198 and Radioactive isotopes of gold-Au198 and phosphorus-P32 have been used intraperitoneally phosphorus-P32 have been used intraperitoneally along with external radiotherapy.along with external radiotherapy.

• However there’s no improvement in survival rate.However there’s no improvement in survival rate.

• High incidence of bowel complications have been High incidence of bowel complications have been noted.noted.

Recurrent Ovarian Recurrent Ovarian Epithelial CancerEpithelial Cancer

• Detection of Recurrent DiseaseDetection of Recurrent Disease

• Second-Look SurgerySecond-Look Surgery

Second-Look SurgerySecond-Look Surgery • The use of second-look surgery can help diagnose The use of second-look surgery can help diagnose

and manage ovarian cancer.and manage ovarian cancer.

• evidence of enhanced survival after this procedure evidence of enhanced survival after this procedure is lacking.is lacking.

• It is defined as re-exploration n patients with It is defined as re-exploration n patients with advanced stage III and stage IV ovarian cancer’ advanced stage III and stage IV ovarian cancer’ after a standard course of chemotherapy have no after a standard course of chemotherapy have no clinical, biochemical, ro radiologic evidence of clinical, biochemical, ro radiologic evidence of disease disease

The findings of second-look surgery The findings of second-look surgery are:are:

• microscopically positive (grossly negative, but microscopically positive (grossly negative, but microscopically positive) microscopically positive)

• macroscopically positive (grossly and macroscopically positive (grossly and pathologically positive)pathologically positive)

Treatment of Recurrent Treatment of Recurrent CancerCancer

• Patients who develop recurrent cancer despite Patients who develop recurrent cancer despite surgery and primary chemotherapy, and will be surgery and primary chemotherapy, and will be givengiven salvage chemotherapy salvage chemotherapy, may be placed , may be placed into one of three groups (A-C): into one of three groups (A-C):

GROUP AGROUP A

• are patients resistant to primary therapy and are patients resistant to primary therapy and have shown tumor growth during treatment. This have shown tumor growth during treatment. This persisting tumor is considered to be refractory i.e. persisting tumor is considered to be refractory i.e. have absolute platinum-resistance. Secondary have absolute platinum-resistance. Secondary non-cross resistant chemotherapies or biological non-cross resistant chemotherapies or biological therapies should be considered. therapies should be considered.

GROUP BGROUP B

• are patients who respond well to initial are patients who respond well to initial chemotherapy, but develop recurrent cancer chemotherapy, but develop recurrent cancer within months after the end of primary care. This within months after the end of primary care. This group with relatively platinum resistant tumor has group with relatively platinum resistant tumor has an intermediate prognosis. an intermediate prognosis.

GROUP CGROUP C

• are patients who showed a good response to are patients who showed a good response to primary chemotherapy, and did not develop primary chemotherapy, and did not develop recurrent cancer for more than 6 months after the recurrent cancer for more than 6 months after the end of primary treatment. This group with end of primary treatment. This group with platinum-sensitive tumor shows the best platinum-sensitive tumor shows the best responses to re-treatment with a platinum-responses to re-treatment with a platinum-containing regimen. containing regimen.

prognosisprognosis• Overall 5-year survival in ovarian epithelial carcinoma is low Overall 5-year survival in ovarian epithelial carcinoma is low

because of the preponderance of late-stage disease at because of the preponderance of late-stage disease at diagnosis. diagnosis. – Stage I and II: 80-100% Stage I and II: 80-100% – Stage III: 15-20% Stage III: 15-20% – Stage IV: 5% Stage IV: 5%

• Patients under 50 in all stages have considerably better 5-Patients under 50 in all stages have considerably better 5-year survival than older patients (40% compared to 15%) year survival than older patients (40% compared to 15%)

• Dysgerminomas treated by surgery and radiation have an Dysgerminomas treated by surgery and radiation have an excellent cure rate in both early and late-stage disease excellent cure rate in both early and late-stage disease

• Endodermal sinus tumour has poor prognosis. Endodermal sinus tumour has poor prognosis.

preventionprevention• Diet: a high-fat diet may play a role in the Diet: a high-fat diet may play a role in the

aetiology of ovarian cancer. aetiology of ovarian cancer. • Oral contraceptives appear to reduce the Oral contraceptives appear to reduce the

risk of ovarian cancer for up to 10 years risk of ovarian cancer for up to 10 years following cessation of use. This protective following cessation of use. This protective effect appears to apply to patients with effect appears to apply to patients with BRCA mutations as well. BRCA mutations as well.

• Patients who have used fertility drugs Patients who have used fertility drugs should be counselled as to their possible should be counselled as to their possible increase in risk of ovarian cancer. increase in risk of ovarian cancer.

TREATMENT OF BENIGN TREATMENT OF BENIGN TUMORSTUMORS

• Diagnostic tests include laboratory blood studies and pelvic Diagnostic tests include laboratory blood studies and pelvic examination. Usually, ultrasound studies with and without examination. Usually, ultrasound studies with and without blood flow measurements to the involved ovary are used for blood flow measurements to the involved ovary are used for diagnosis and to help determine the best therapy. diagnosis and to help determine the best therapy. Laparoscopy is required in some cases, and rarely, a CT scan Laparoscopy is required in some cases, and rarely, a CT scan or MRI may be recommended. or MRI may be recommended.

• Treatment may not be necessary, except to have regular Treatment may not be necessary, except to have regular pelvic examinations so the tumor's growth can be monitored. pelvic examinations so the tumor's growth can be monitored.

• Some tumors require surgery to diagnose accurately, ruling Some tumors require surgery to diagnose accurately, ruling out malignancy, or to treat. If one ovary must be removed, out malignancy, or to treat. If one ovary must be removed, normal conception and childbirth is possible as long as a normal conception and childbirth is possible as long as a normal ovary remains on the other side. normal ovary remains on the other side.

TREATMENT OF BENIGN TREATMENT OF BENIGN TUMORSTUMORS

• Germ cell tumors are treated with surgery and Germ cell tumors are treated with surgery and multi-agent chemotherapy in most cases multi-agent chemotherapy in most cases

• Advanced epithelial ovarian cancer is very Advanced epithelial ovarian cancer is very sensitive to chemotherapy with responses in the sensitive to chemotherapy with responses in the range of 70-80% to first-line chemotherapy. The range of 70-80% to first-line chemotherapy. The majority, however, relapse and ultimately die of majority, however, relapse and ultimately die of chemotherapy-resistant disease. chemotherapy-resistant disease.

Treatment of Sensitive Treatment of Sensitive CancerCancer

• Patients with recurrent chemotherapy-sensitive disease are Patients with recurrent chemotherapy-sensitive disease are usually treated again with primary chemotherapy usually usually treated again with primary chemotherapy usually carboplatin/paclitaxel, but toxicity must also be taken into carboplatin/paclitaxel, but toxicity must also be taken into consideration.consideration.

• If carboplatin or cisplatin was used alone for primary If carboplatin or cisplatin was used alone for primary therapy, taxol should be considered for salvage therapy, taxol should be considered for salvage chemotherapy.chemotherapy.

• For low-volume disease, intraperitoneal chemo- or For low-volume disease, intraperitoneal chemo- or radiotherapy can be considered. These patients are also radiotherapy can be considered. These patients are also candidates for trials of high dose chemotherapy with candidates for trials of high dose chemotherapy with autologous bone marrow support. autologous bone marrow support.