Ovarian Cancer, Fallopian Tube Cancer and Primary Peritoneal cancer.

Ovarian, fallopian tube and primary peritoneal cancer are best considered together because the clinical features, histological appearances and treatment are essentially identical. The fallopian tubes, particularly the fimbrial ends (the little finger-like projections at the end of the fallopian tubes) sit right adjacent to the ovaries, and cancer arising in this vicinity is difficult to determine whether it started in the ovaries or the fallopian tubes.

Some evidence suggests that perhaps most “ovarian cancer” has indeed arisen from the fallopian tubes. Primary peritoneal cancer relates to cancer arising from the lining of the abdominal cavity called the peritoneum.

These cancers are actually called epithelial cancers – which arise from the surface of the ovaries (and related organs), to distinguish them from less common cancer that arise from the egg cells or the stromal cells (main body) of the ovary. Since 2000, all the big international research organizations have considered epithelial cancers arising from ovary, fallopian tube or the peritoneum as essentially one entity for trial purposes.

Symptoms

Ovarian and related cancers notoriously cause few symptoms till the disease is quite advanced, and the earliest symptoms are often subtle and vague. Symptoms include:

Abdominal distension or a feeling of pressure in the abdomen
Abdominal or pelvic pain
Awareness of a mass in the belly or rising out of the pelvis
Disrupted bowel function, especially constipation
Disrupted menstrual function
Occasionally vaginal discharge or bleeding.

Risk factors

Genetic predisposition eg BRCA 1 and BRCA 2 gene mutations
Strong family history
Nulliparity
Infertility
Oral contraceptive pill, higher parity and breastfeeding – all protective against ovarian and related cancers.

Evaluation of symptoms and investigations

History and physical examination, especially pelvic examination
· Routine blood tests, FBC (blood count), ELFT (liver and kidney test)
Tumour markers including CA125, CEA, CA19-9 and on occasion HE4/ROMA. Tumour markers are proteins that can be expressed on the surface of neoplasms and if found to be elevated, may indicate cancer
Ultrasound scan
PET –CT scan (or CT scan of chest, abdomen and pelvis)

Spread

Adjacent organs – ovary, fallopian tube and pelvis
Throughout the peritoneal (abdominal) cavity
The fluid around the lungs
Pelvic and para-aortic lymph glands.
Via the blood stream to distant sites (rarely and late)

Treatment of early stage ovarian cancer

For women who have completed their family, treatment entails surgery to remove uterus, tubes and ovaries (TAHBSO) + staging. Staging refers to the removal or biopsy of places where the cancer has a propensity to spread – peritoneal surfaces, fluid around the pelvic organs, lymph nodes, omentum and the appendix. If the cancer is localized to the ovary and is of low grade (low aggressiveness), chemotherapy may not be required. Under all other circumstances, chemotherapy is administered to give optimal outcomes.

In uncommon circumstances, for women with early stage disease and wishing to retain reproductive capacity, it may be possible to retain the uterus and the other ovary, while undergoing all other aspects of the staging surgery. Chemotherapy may or may not be required and typically the reproductive organs are removed at the completion of child bearing.

Treatment of advanced stage disease

Chemotherapy

The administration of chemotherapy takes place in specialised units under the supervision of a medical oncologist. These sub-specialty trained clinicians determine the type and dose of chemotherapy, monitor and manage side effects and provide ongoing clinical review.

Follow up

Follow up of ovarian cancer is usually shared between the gynaecologic oncologist and the medical oncologist (chemotherapy doctor). Follow up is at 2 – 3 monthly intervals for the first 2 – 3 years and then pushed out to longer intervals between visits at the discretion of the treating doctors.