Pathophysiology

The three current theories are the incessant ovulation hypothesis, the pituitary gonado-tropin hypothesis, and the chronic inflammatory processes hypothesis. The incessant ovulation hypothesis proposes that the pathogenesis of ovarian cancer is connected to continual ovulation. Ovulation is considered a "hostile" event to the ovary perhaps with not enough time for adequate repair. Each time ovulation occurs, the ovary epithelium is disrupted and cell damage occurs. Thus, repeated ovulations may lead to a greater number of repairs of the ovarian epithelium and increase the possibility of aberrant repairs, mutation, and carcinogenesis.28-30 The pituitary gonadotropin hypothesis associates the disease with elevations in gonadotropin and estrogen levels.2 This leads to an increase in the number of follicles and therefore an increased risk of malignant changes. Finally, the chronic inflammatory processes may be involved with various environmental carcinogens to cause cancer.2,1

The three major pathologic categories of ovarian tumors include sex-cord stromal, germ cell, and epithelial. About 85% to 90% of ovarian cancers are of epithelial origin. Epithelial ovarian tumors are composed of cells that cover the surface of the ovary such as serous, mucinous, endometrioid, clear cell, and poorly differentiated adenocarcinomas. Germ cell tumors involve the precursors of ova with the most common type being dysgerminoma, which are most commonly diagnosed in women under the age of 40 and generally have a better prognosis. Sex-cord stromal tumors are indolent tumors that produce excess estrogen and androgens but also have a better overall prognosis. Although the histologic type of the tumor is not a significant prognostic factor, it is important to know the histopathologic grade. Undifferentiated tu mors are associated with a poorer prognosis than those lesions that are considered to be well or moderately differentiated.

Clinical Presentation and Diagnosis of Ovarian Cancer

General

» Ovarian cancer has often been denoted as the "silent killer " because of the nonspecific signs and symptoms. By the time symptoms become unrelenting and bothersome, patients most likely have advanced stage disease.

Symptoms

Patients may experience episodes or persistent symptoms such as abdominal pain, constipation or diarrhea, flatulence, urinary frequency, or incontinence.

Signs

The degree of abdominal swelling secondary to fluid accumulation may present like "pregnant abdomen" and irregular vaginal bleeding.

Laboratory Test

• Cancer antigen-125 (CA-125). The normal level is less than 35 units/mL (35 kil-ounits/L). Note: this test is associated with a lack of specificity. CA-125 can be elevated in a number of other states such as different phases of the menstrual cycle, endometriosis, and nongynecologic cancers.

• NOTE: It is important to rule out other cancers associated with the abdominal cavity.

• Carcinoembryonic antigen (CEA). CEA is marker for colon cancer. Normal value is less than 3 ng/mL (3 mcg/L).

• CA-19-9 is a marker for many GI tumors such as cholangiocarcinomas. Chemistries With Liver Function Tests (LFTs)

• LFTs and serum creatinine might be suggestive of extent of disease. Majority of this information is needed to determine if patient is a surgical candidate. Laboratories should be within normal limits.

• Abnormalities in CBC are not associated with ovarian cancer; however, this information is needed to determine if patient is a surgical candidate. Laboratories should be within normal limits.

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