Ovarian Cancer: Symptoms, Stages & Causes

Ovarian cancer usually appears in postmenopausal women in the sixth decade of life, the risk of developing ovarian cancer is increased in women with a family history involving two or more first degree relatives

What is Ovarian Cancer?

A malignant (cancerous) tumor that develops in the tissues of the ovary. Ovary tumor can arise from any of the three types: cells germ, stromal, and epithelial, although approximately 90% of ovarian cancers arise from the ovarian epithelium (the membranous covering of the ovary)

Epithelial ovarian cancer occurs most often in women over the age of 60 (after menopause). Although tumors are typically non-cancerous or cancerous, epithelial ovarian tumors may straddle the border

Ovarian Cancer Pathology

Ovarian cancer can be divided into three main entities: epithelial ovarian carcinomas, germ cell ovarian cancer and stromal carcinomas. Most ovarian cancers (85-90%) derived from the epithelial surface of the ovary. The nomenclature takes into account cell type, tumor location and degree of malignancy, ranging from benign tumors of low malignancy to invasive carcinomas 

Low malignancy ("borderline malignancy") epithelial tumors have a much better prognosis than invasive carcinomas and are characterized by epithelial papillae with atypical cell clusters, cellular stratification, nuclear atypia and increased mitotic activity. Malignant tumors are characterized by an infiltrative destructive growth pattern with malignant cells that grow disorganized and dissect into the stromal planes. Invasive epithelial carcinomas are characterized by their histological type and degree (degree of cellular differentiation)

Ovarian Cancer Symptoms

Ovarian cancer has no specific symptoms and signs in the early stages of the disease. There may be some vague and non-specific symptoms known as odd symptoms of ovarian cancer that are often ignored. However, if any of the symptoms persist, it is essential that a doctor evaluate them immediately. Only a doctor can determine if the symptoms are an indication of early ovarian cancer; however, having two or more of the following symptoms is reason for concern

These early symptoms of ovarian cancer can include:

• Sensation of abdominal bloating

• Sensation of ovarian pain

• Menstrual disorders

• Abdominal swelling

• Unexplained weight gain

• Changes in bowel habits (Constipation or Diarrhea)

• Urinary urgency

As ovarian cancer progresses, symptoms become more specific and include: 

• Pelvic, abdominal or low back pain

• Unexplained weight loss

• Unusual vaginal bleeding

• Fatigue and not feeling well (malaise)

Signs

• Patients may feel a palpable abdominal mass

• Patients may have lymphadenopathy

• Patients may have hormonal disorders

• Patients may have signs of ascites ovarian cancer (abdominal distention, shifting, and dullness to percussion)

Ovarian Cancer Stages

The stage of ovarian cancer depends on the extent of the disease found during surgical exploration. Epithelial ovarian cancer spreads by  by peritoneal surface shedding and lymphatic dissemination. A careful and accurate staging surgical laparotomy is necessary to adequately stage the patient; Therefore, it is recommended that a gynecological-oncological surgeon perform this procedure to avoid understaging. Total abdominal hysterectomy, bilateral salpingooophorectomy and partial omentectomy are performed

A Careful examination of all serosal surfaces is performed and biopsies of all severely affected areas are taken. Ovarian capsule rupture, if present, is noted. Ascites and peritoneal washings are collected. As part of the initial surgical staging procedure, the surgeon attempts to remove as much of the tumor as possible because the amount of residual disease in patients with stage 3 ovarian cancer correlates with survival

low malignant potential (LMP) 

The tumor is borderline borderline ovarian tumor (cancerous) and slow growing

• Noninvasive ovarian epithelial neoplasms are classified as malignant neoplasms of the order line, tumors with low malignant potential or, more recently, as atypical proliferative tumors 
• These tumors can be serous, mucinous, endometrioid (endometrioid ovarian cancer) or, rarely, clear cell tumors (clear cell ovarian cancer)
• This heterogeneous subclass of tumors is identified by careful histological evaluation to detect the absence of overtly malignant characteristics 
• Clinically, these tumors are characterized by a diagnosis at a lower average age than frankly malignant tumors, an early stage at the time of diagnosis, infrequent or late relapses, and long survival even with residual or recurrent disease 
• The prognosis of atypical proliferative tumors largely depends on whether implants that are often inside or outside the primary tumor are invasive or non-invasive

Stage 1 ovarian cancer

Growth limited to the ovaries

Stage 1a: 

• Growth limited to one ovary, no ascites containing malignant cells of tumors
• No external superficial tumor, capsule intact

Stage 1b: 

• Growth limited to both ovaries, no ascites containing malignant cells, or no ascites ovarian cancer
• No external superficial tumor, capsule intact

Stage 1c: 

• Stage 1a or 1b tumor but with tumor on the surface of one or both ovaries, or with the capsule ruptured, either with ascites present containing malignant cells or with positive peritoneal washings

Stage 2 ovarian cancer

Growth involving one, or both ovaries with pelvic extension

Stage 2a: 

• Extension or metastasis to the uterus or fallopian tubes

Stage 2b: 

• Extension to other pelvic tissues

Stage 2c: 

• Stage 2a or 2b tumor but with tumor on the surface of one or both ovaries, or with capsule(s) ruptured, either with ascites present containing malignant cells or with positive peritoneal washings

Stage 3 ovarian cancer

Cancer affecting one or both ovaries with peritoneal implants outside the pelvis and / or positive retroperitoneal or inguinal nodes

Superficial liver metastases equal to stage 3. The ovarian tumor is limited to the true pelvis, but with histologically proven malignant extension to the small bowel or omentum

Stage 3a: 

• Tumor very limited to the true pelvis with negative lymph nodes, but with microscopic histologically confirmed seeding of the abdominal peritoneal surface

Stage 3b: 

• Tumor of one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces, none greater than 2 cm in diameter. Nodes negative

Stage 3c: 

• Abdominal implants greater than 2 cm in diameter, or positive retroperitoneal or inguinal lymph nodes, or both

Stage 4 ovarian cancer

Growth one or both ovaries with distant metastases

• If there is a pleural effusion, there must be positive cytologic test results to assign a stage 4 case. Hepatic parenchymal metastasis is equivalent to stage 4

Ovarian Cancer Causes

The causes of ovarian cancer are unclear, but several factors are known to increase a woman's chances of developing the disease. These are called risk factors. Although there appear to be hormonal correlations 

Women who carry at least one pregnancy to delivery, breastfeed, or have a tubal ligation or total hysterectomy (surgery to remove the uterus and cervix) for reasons other than cancer appear significantly less likely to develop ovarian cancer. Lifestyle factors, such as dietary fat content and exercise frequency, are also related to ovarian cancer risk, with a much lower risk in women who eat a low-fat diet and exercise daily (minimum of 30 to 60 minutes). Smoking cigarettes increases the risk of ovarian cancer, as is the case with many cancers

Ovarian Cancer Risk Factors

Risk factors for ovarian cancer include:

• Old age: the incidence of the disease increases with age

Half of all cases are diagnosed after age 60

• Family history: especially among first degree relatives (mother, daughter, sister). Women who also have a close relative with the disease increase the risk threefold. Also, if a woman has had breast cancer, she has an increased risk of ovarian cancer

• α BRCA1 or BRCA2 mutation: Women who carry the BRCA-1/BRCA-2 GENE mutations have especially high risk, though not the certainty, to develop ovarian cancer. Some women who have such high risk choose prophylactic oophorectomy (surgery to remove the ovaries) when they reach the end of their childbearing years or menopause as a means for reducing their risk

• A personal history of breast, uterine

• No history of pregnancy: Pregnancy gives a break from ovulation and estrogen exposure for nine months. Therefore, multiple pregnancies appear to actually reduce the risk of ovarian cancer. Likewise, because oral contraceptives suppress ovulation and reduce estrogen exposure, women taking birth control pills have a lower incidence of the disease

• Obesity or  High-fat diet: Being overweight is associated with an increased risk of ovarian cancer

• Estrogen hormone replacement therapy (HRT): A study has shown that long-term use in high doses may increase a woman's risk of developing ovarian tumors

• Early menarche: Menstruating early (before age 12)

• Late menopause: experiencing menopause late seem to put women at greater risk of ovarian cancer. It is believed that the longer a woman ovulates, the greater the risk of ovarian cancer (some researchers believe the cause is estrogen exposure during monthly cycles). Since ovulation occurs only during the childbearing years, the longer you have your menstruates, the greater the risk

• Regularity and duration of the menstrual cycle: Women with short or irregular menstrual cycles lengths are at greater risk

• Endometriosis: Women who have endometriosis may have an increased risk of ovarian cancer

• Lynch II syndrome (hereditary non-polyposis colorectal cancer)