Ovarian Cancer

In Australia, ovarian cancer is a common gynaecological cancer with more than 1600 women newly diagnosed every year. We distinguish several types:

1. Epithelial ovarian cancer (EOC): Approx 85% of all ovarian cancers are epithelial. Typically EOC is a disease of postmenopausal women. These cancers require surgery and most patients will require chemotherapy postoperatively. Approx 16 to 18% of these cancers are hereditary.
2. Non-epithelial ovarian cancer: Thee cancers account for approx 5% of all ovarian cancers. Typically they develop in very young women. Surgery is essential but often only one ovary needs to be removed and fertility can be preserved. Sometimes chemotherapy is required and these cancers carry a very good prognosis.
3. Borderline tumours are tumours in between malignant and benign. They carry a very good prognosis but surgery is required. Chemotherapy is not effective. Sometimes young women are affected and fertility can be preserved in the majority of women. Borderline tumours are not inherited.

In contrast to most other malignant tumours a diagnosis (benign or malignant) will not be available before surgery. I discourage radiologists to drain pelvic masses for the aim to establish a diagnosis because of the enormous risk of tumour cell dissemination during such a procedure. Therefore surgery not only aims to treat the condition but also needs to establish a diagnosis before a treatment can commence.

Certain tools are available to estimate the risk of malignancy, and these tools include medical imaging (CT scan and ultrasound) and tumour markers (CA125, CA19.9, CEA, HE4). Depending on this risk assessment I will recommend one of the following:

1. Very low risk of malignancy (less than 1%): I recommend a repeat ultrasound (ideally transvaginally) and tumour marker test in 2 to 3 months
2. Low to medium risk of malignancy: surgical exploration may be useful. I would prefer a laparoscopic (key hole) approach.
3. High risk of malignancy: surgery is ideally performed through an open abdominal incision. A laparoscopic approach is reasonable if the tumour is far advanced and it needs to be determined if surgery should be the first choice of treatment.

Treatment

Surgery for ovarian cancer will typically remove the uterus, tubes and the ovaries. In most instances, a frozen section examination will be performed by the pathologist while the patient is under general anaesthesia. The pathologist will inform me about the extent of the disease within the uterus while the patient is asleep. Sometimes frozen section is inconclusive because only a limited number of sections can be done and examined in the short time provided. Depending on the pathologist’s preliminary report, the operation is continued to either i. Determine the extent of the disease (pelvic and/or aortic lymph node dissection, omentectomy (fatty pad arising from the outer line of the stomach) or ii. To remove as much cancer tissue as technically possible.

Almost all patients will require chemotherapy postoperatively. Patients who had tumour limited to one ovary only (all lymph nodes and omentum are cancer free; no free floating cancer cells in the abdomen) and who had negative tumour markers prior to surgery do not benefit from chemotherapy. Their prognosis is so good – it cannot be improved further by any other means.

Chemotherapy can be given in one of two ways. It can be given through a drip or through an intraperitoneal port that can be implanted at surgery. Generally survival is modestly better in the port group but the side effects of chemotherapy are significantly worse. I will help you come to a decision together with your medical oncologist who I will refer you to.

In some cases where patients are unable to tolerate surgery for medical reasons, chemotherapy needs to be considered as an alternative to surgery. In such cases, I will refer you to a medical oncologist who will give you 2 or 3 cycles of neoadjuvant chemotherapy and then we will re-evaluate if the patient is fit for surgery then. Ideally, the patient should be tumour-free at least once (either after upfront surgery or after surgery between chemotherapy cycles).

Surgery for suspected advanced ovarian cancer should not be performed in regional hospitals. These patients benefit from surgery is a big centre because of the availability of specialised services (nursing) and medical specialities if required. For patients with suspected advanced ovarian cancer, bowel preparation is required. Patients are require to fast at least 6 hours prior to surgery. Please stop smoking before the operation as it makes your postoperative management much easier. Before surgery, I will make arrangements for your admission to the intensive care unit (ICU) for monitoring.

When you wake up from general anaesthesia there will be some lines running in and out of you for support. A drip will give you the necessary fluids and a catheter will drain the urine from your bladder. An oxygen mask will supply oxygen to the respiratory system. A drain may collect body fluid from the inside of the abdomen. These lines will be removed once I am happy that your body functions have returned to normal, which is usually after a few hours or days.

The final histopathological report may take a few days. It forms the basis for the decision if any further treatment (e.g., chemotherapy) is required. If chemotherapy is required I will bring you in contact with a qualified medical oncologist.

Surgery always carries risks. Before surgery, I do everything to minimise these risks. I give antibiotics before the skin incision in order to avoid skin and other infections. Commencing prior to surgery I give calf compression stockings in order to prevent the formation of blood clots in the legs. At surgery sterile handling of instruments further reduces the risk of infectious complications. However, there are some immanent risks of surgery for uterine cancer:

• Laparoscopic surgery may need to be converted to open surgery through the opening of the abdomen. This risk is approximately 1% to 2%. The vast majority of all laparoscopic procedures proceed laparoscopically.
• Medical and anaesthetic risks associated with general anaesthetic, with epidural analgesia or with postoperative pain control do exist. In patients with pre-existing medical conditions these risks are slightly higher.
• There is a risk of injury to pelvic organs, such as the bowel, the bladder, the ureters, blood vessels and nerves. These injuries usually get repaired during surgery. However, in an exceedingly small proportion of patients these injuries can unfortunately not be recognised during surgery or injuries may even develop after surgery. Then another operation is required to repair those defects. Injury to big blood vessels may result in the need of blood transfusion. Injury of nerves is common in patients who require removal of lymph nodes in the pelvis. In that case, patients will experience some numbness of the skin around the upper thigh.
• Lymph oedema: Lymphatic fluid usually drains from the legs via the lymph glands in the pelvis and the aorta back into the blood circulation. When lymph glands have to be removed, some fluid may accumulate in the legs (lymph oedema). The risk of lymph oedema is around 20% in patients who had to have a lymph node dissection. Patients with lymphoedema require lymph drainage.

Other possible complications include ...

• Infections to the bladder, the abdominal wound, the lungs with resulting temperatures and septicaemia
• Thromboembolic complications (formation of blood clots) in the legs that can even travel to the lungs and cause life-threatening emboli. This risk is very small because of our efforts to minimise them.
• A vaginal discharge that can even be blood-stained is very common for up to 6 weeks. 
• Shoulder tip pain is common after laparoscopic surgery. It is caused by the CO2 gas that s needed for the surgery. It normally lasts only for a day but painkillers are not effective.
• Changes in bowel habits are not uncommon for a couple of months post surgery. I recommend regulation of the bowels with natural substances such as yoghurt, prune juice and natural fibre. 

You need to stay in hospital for one or two days if the procedure was done laparoscopically or 6 to 8 days if a laparotomy (opening of the abdomen) was necessary. I recommend you have a good break for the two to four weeks. Especially I recommend avoiding intercourse, vaginal tampons and full baths and other factors that could disrupt wound healing or facilitate an infection.  

Please notify me immediately if your condition becomes worse after you have been discharged from hospital.

Follow-Up

After surgery, you should be seen regularly for follow-up for 5 years. These examinations will always include pelvic examinations and tumour marker (blood) tests. I recommend PET/CT scans only if needed. After five years, the risk of a recurrence becomes very low.  Should you experience any bleeding or pain, please do not hesitate and contact my office straight away.

Outcomes

Cancers of all types and stages may recur. Recurrence may be local or in the pelvis or at distant sites (abdomen, lungs). Treatment of recurrent ovarian cancer depends on the type of cancer (epithelial, non-epithelial, borderline), the time interval between the first diagnosis of cancer and the recurrence (the longer the better) and the distribution of disease (how many spots of cancer and their localisation).

Survival rates for Epithelial Ovarian cancer depends on its stage. Survival for stage 1 ranges between 75% and 95% at five years. Survival for stage 3 or 4 ovarian cancer depends on how successful surgery has been and how much tumour had to be left behind after surgery but also depends on the response of the cancer to chemotherapy. Unfortunately we have no means to predict if an individual patient will respond to chemotherapy or not.

Survival of patients with non-epithelial ovarian cancer is generally excellent. Most of these tumours require only the removal of one ovary, which allows us to preserve fertility in these very young women.  While chemotherapy may be required, periods will return.

Survival of patients with borderline tumours is above 90% in patients with stage 1 disease. Patients with elevated CA125 tumour markers will need to attend to a strict follow up regimen. Patients with stage 1 borderline tumours and low CA125 will only need to be seen if problems develop down the track.