OVARIAN CANCER

1. OVARIAN OVARIAN CANCER CANCER Submitted By, Submitted By, Mariya Antony Mariya Antony 2 2nd year BSc Nursing Student STCON STCON nd year BSc Nursing Student

3. INTRODUCTION INTRODUCTION ? Cancerous epithelial tumors are called carcinomas. About 85% to 90% of malignant ovarian cancers are epithelial ovarian carcinomas. These tumor cells have several features (when looked at in the lab) that can be used to classify epithelial ovarian carcinomas into different types. The serous type is by far the most common, and can include high grade and low grade tumors. The other main types include mucinous, endometrioid, and clear cell. ● Serous carcinomas (52%) ● Clear cell carcinoma (6%) ● Mucinous carcinoma (6%) ● Endometrioid carcinoma (10% ? ? ? ?

4. ? ? ? ? ? ? It is the leading cause of gynecologic cancer deaths leading cause of gynecologic cancer deaths worldwide including India. These are difficult to detect because they are often present deep in to the pelvis. No early screening mechanism No early screening mechanism exists at the present. Tumor associated antigens Tumor associated antigens are helpful in determining follow-up after diagnosis and treatment and to evaluate recurrent disease but are not useful in early general screening.

5. DEFINITION….. DEFINITION….. ? Ovarian cancer is a a malignancy of the ovaries malignancy of the ovaries, the female sex organs that produce eggs and make the hormones estrogen and progesterone.

8. INCIDENCE. INCIDENCE.

11. Incidence Incidence ? Ovarian cancer is the eighth 18th 18th most commonly occurring cancer overall. There were nearly 300,000 new cases in 2018. The top 25 countries with the highest rates of ovarian cancer in 2018 are given in the table below. eighth most commonly occurring cancer in women and the 1rank Serbia 16.6 as per age standardised rate per 1 lakh people. ? ? One in 70 women develop ovarian One in 70 women develop ovarian cancer. cancer.

12. Statistics ? While the ovaries may be just one organ, more than 30 types of ovarian cancer exist. They’re classified by the type of cell where the cancer begins, plus the stage of the cancer. ? The most common type of ovarian cancer is epithelial tumors. More than 85 percent of ovarian cancer first develops in the cells that are lining the outer portion of the ovaries. ? Ovarian cancer ranks fifth among cancer deaths in American women. It causes more deaths than any other cancer of the female reproductive system. ? ? One in 78 women will be diagnosed with ovarian cancer in their lifetimes. Older women are more likely to be diagnosed with ovarian cancer. The average age for an ovarian cancer diagnosis is 63 years old. ? Only 15 percent of ovarian cancer cases are diagnosed in the early stage.

13. ? Women whose cancer is diagnosed in an early stage have a five-year-survival rate of 92 percent. For all types and stages of cancer, the five-year relative survival rate is 47 percent. ? In 2018, 22,240 will be diagnosed with ovarian cancer. Another 14,070 will die from this type of cancer.

14. INCIDENCE ? In women ages 35-74, ovarian cancer is the fifth leading cause of cancer-related deaths. An estimated one woman in 78 will develop ovarian cancer during her one woman in 78 will develop ovarian cancer during her lifetime. lifetime. The American Cancer Society estimates that there will be over 22,280 new cases of ovarian cancer diagnosed this year and that more than 14,240 women will die from ovarian cancer this year. ? When one is diagnosed and treated in the earliest stages, the five-year survival rate is over 90 percent. Due to ovarian cancer's non-specific symptoms and lack of early detection tests, about 20 percent of all cases are found early, meaning in stage I or II. If caught in stage III or higher, the survival rate can be as low as 28 percent. Due to the nature of the disease, each woman diagnosed with ovarian cancer has a different profile and it is impossible to provide a general prognosis.

16. EPIDEMIOLOGY AND RISK FACTORS EPIDEMIOLOGY AND RISK FACTORS.

17. ? The frequency of ovarian cancer is highest in industrialized countries and affect women of all races and ethnic backgrounds.

18. RISK FACTORS RISK FACTORS ? ? Age Age – Ovarian cancer rates are highest in women ages 55–64. Age is the strongest risk factor for ovarian cancer. It is much more common after menopause, and using hormone therapy may increase a woman's risk. This risk appears strongest in those who take estrogen therapy without progesterone for at least 5-10 years. It is not known whether taking estrogen and progesterone in combination also increases risk. Family history Family history – If women in the family have had them, particularly a mother or a sister, the risk is higher. Family history of ovarian cancer is a risk factor; a woman has a higher chance of developing it if a close relative has had ovarian, breast, or colon cancer. Inherited gene mutations, including the BRCA1 and BRCA2 mutations linked to breast cancer, are responsible for about 10% of ovarian cancers. Talk to you doctor if you have a strong family history of these cancers to determine if closer medical observation may be helpful. Genetic mutations Genetic mutations – Mutations of the BRCA1 or BRCA2 genes significantly increase a woman’s risk of ovarian cancer. ? ? ? ?

19. COND…. ? ? First pregnancy after age 35 First pregnancy after age 35 – Women who have never conceived and carried a pregnancy or have done so after 35 may have increased risk. ? ? Fertility drugs and hormone treatments Fertility drugs and hormone treatments – The continuous use of estrogen after menopause can place a woman at additional risk. A high no of ovulations increases the chance that a tumor suppressor gene called p53 is muted. ? ? Obesity  Obesity – If you have a body mass index (BMI) of 30 or higher, you may be at increased risk of ovarian cancer. Obesity is also a risk factor for ovarian cancer; obese women have both a higher risk of developing ovarian cancer and higher death rates from this cancer than non-obese women. The risk seems to correlate with weight, so the heaviest women have the highest risk. ? ? ? ? History of infertility History of infertility History of dysmenorrhea History of dysmenorrhea

21. PATHOPHYSIOLOGY PATHOPHYSIOLOGY

23. Clinical manifestations ACS (American Cancer Society) ? ? ? ? Bloating Pelvic or abdominal (belly) pain Trouble eating or feeling full quickly Urinary symptoms such as urgency (always feeling like you have to go) or frequency (having to go often) Fatigue (extreme tiredness) Upset stomach Back pain and leg pain Pain during sex Increased abdominal girth. ? ? ? ? ?

24. ? ? Constipation Changes in a woman's period, such as heavier bleeding than normal or irregular bleeding ? Abdominal (belly) swelling with weight loss ? ? ? Increased waist size Ovarian cancer is often silent, but Ovarian cancer is often silent, but enlargement of abdomen from enlargement of abdomen from accumulation of fluid is a common accumulation of fluid is a common sign sign

26. Types Types ? Although ovarian cancer is categorized into more than 30 different types, most are identified based on the name of the cell in which the cancer originated. Cancerous ovarian tumors develop most commonly in the epithelial cells, which make up the outer layer of the ovary; the germ cells, which form eggs; or in the stromal cells, which produce and release hormones. ? ? ? ? Types include: 1.Ovarian epithelial cancer 2.Germ cell tumors 3.Sex cord-stromal tumors

27. 1.Ovarian epithelial cancer ? Although most epithelial ovarian tumors are benign, cancerous epithelial tumors, or epithelial ovarian carcinomas, account for 85 percent to 90 percent of ovarian cancers. They are often referred to by their subtype: mucinous, endometrioid, clear cell and undifferentiated. They commonly spread to the lining and organs of the pelvis and abdomen first before spreading elsewhere, such as to the lungs and liver. They also may spread to the brain, bones and skin. Ovarian low malignant potential tumors are an ovarian epithelial subtype that occurs when abnormal cells form in the tissue covering the ovary. ? ❑ ❑ ❑ ? ?

28. ? They are so named because the tumors have a low likelihood of turning into cancer. But in rare instances, the abnormal cells become malignant, and when they do, these tumors tend to grow slowly and affect younger women. They also do not typically spread beyond the ovary, and they usually respond well to treatment . ? Two other types of cancer are similar to epithelial ovarian cancer: primary peritoneal carcinoma and fallopian tube cancer peritoneal carcinoma and fallopian tube cancer, both of which closely resemble epithelial ovarian cancer and are often treated with the same approaches and techniques primary

29. ▪ ▪ develops in the lining of the pelvis and abdomen. ▪ ▪ Fallopian tube cancer Fallopian tube cancer starts in the fallopian tubes. Primary peritoneal carcinoma : Primary peritoneal carcinoma : Both are rare.

30. Epithelial tumors are again classified in to: ? Benign epithelial ovarian tumors ? Tumors of low malignant potential ? Malignant epithelial ovarian tumor

32. 2.Germ cell tumors ? Tumors may appear in the germ cells, or egg-producing cells, of the ovaries. Most of these tumors are benign. Cancerous germ cell tumors make up less than 2 percent of ovarian cancers. Teens and women in their 20s are more likely to have this type of ovarian cancer. ? ? ? Less than 2% of cases are germ cell tumors. 9 out of 10 patients survive atleast 5 years after diagnosis Ovarian germ cell tumors are divided into the following subtypes:

34. ? ? These (immature). Immature teratomas are rare. Their cells commonly contain different types of tissue, such as hair, muscle and bone. ? ? Dysgerminoma Dysgerminoma ovarian germ cell cancer is rare, but it’s the most common germ cell ovarian cancer. Dysgerminomas don’t typically grow or spread quickly. They may also occur in other parts of the body, such as the central nervous system. ? ? Endodermal sinus tumor (yolk sac tumor) Endodermal sinus tumor (yolk sac tumor) are extremely rare. Choriocarcinomas may start in either the placenta during pregnancy, which are more common, or in the ovaries. Teratomas Teratomas These are germ cell tumors that are either benign (mature) or cancerous

36. 3.Sex –cord stromal tumors 3.Sex –cord stromal tumors ? ? Rare, making up about 1 percent of ovarian cancers. They develop from the stroma tissue cells that produce the female hormones estrogen and progesterone. Because sex-cord stromal tumors make an overabundant supply of estrogen, they often cause abnormal vaginal bleeding. ? ? Sudden severe abdominal pain. This occurs if tumor starts to bleed. More than half are found in women greater than 50 yrs but about 5% seen in young girls. ? Subtypes of sex cord-stromal tumors include granulosa cell tumors, granulosa- theca tumors and Sertoli-Leydig tumors.

38. Less common types. ? Ovarian cancer is rare, accounting for about 3 percent of cancers among women. While the most common types of ovarian cancer are epithelial, germ cell and stromal tumors, some of the rarer types of ovarian cancer occur more than others. These include: ? ? Unlike their carcinoma counterparts, ovarian sarcoma tumors develop in the connective tissues of ovarian cells. Their most common subtypes are carcinosarcomas, adenosarcomas, leiomyosarcomas and fibrosarcomas. ? ? Kruk Enberg tumors: Kruk Enberg tumors: A Krukenberg tumor is cancer that spreads to the ovaries from other organs, typically from the gastrointestinal tract. Gynecologic oncologists usually treat Krukenberg tumors in collaboration with the medical oncologist and other members of the care team treating the patient’s original cancer. Ovarian sarcoma: Ovarian sarcoma:

39. Kruk Enberg tumors and ovarian sarcoma Kruk Enberg tumors and ovarian sarcoma

40. ? ? Ovarian cysts are fluid-filled sacs that develop inside the ovary. They’re common during ovulation and often go away on their own without treatment. Although most ovarian cysts are benign, some may develop into cancer. Ovarian cysts: Ovarian cysts:

41. ❑ Recurrent ovarian cancer ? Recurrent or relapsed ovarian cancer occurs when malignant cells reappear after cancer treatments such as surgery or chemotherapy have been completed for a period of time. When ovarian cancer recurs, it is not re-staged. Recurrent ovarian cancer may return at its original location, or it may be found somewhere else in the body. ? Ovarian cancer typically recurs when a small number of cancer cells survive the treatment process but are not detected on tests. After treatment, these cancer cells may grow into tumors. ? The signs of recurrent ovarian cancer may vary from patient to patient. Because ovarian cancer often recurs in the abdomen and pelvis, near the bladder and the intestines, gastrointestinal and urinary symptoms typically develop.

43. Signs and symptoms of ovarian cancer recurrence may include: ? ? ? ? ? ? ? ? ? Persistent abdominal bloating, indigestion or nausea Changes in appetite, typically a loss of appetite or feeling full sooner Pressure in the pelvis or lower back Urge to urinate more frequently Changes in bowel movements Increased abdominal girth Lethargy, fatigue or lack of energy Abdominal pain or swelling Elevated levels of the protein CA-125

44. ? According to the Ovarian Cancer National Alliance, most patients diagnosed with ovarian cancer develop a recurrence. The cancer recurrence rate varies by patient, but the risk increases with the cancer’s stage at the time it was originally diagnosed (the more advanced the stage, the higher the risk).

45. How is the stage determined? How is the stage determined? ? The 2 systems used for staging ovarian cancer, the FIGO Gynecology and Obstetrics) system  Gynecology and Obstetrics) system and the AJCC Cancer) TNM staging system  Cancer) TNM staging system are basically the same. They both use 3 factors to stage (classify) this cancer : The extent (size) of the t tumor (T):  tube?  Has the cancer reached nearby pelvic organs like the uterus or bladder? The spread to nearby lymph n nodes (N):  (N): Has the cancer spread to the lymph nodes in the pelvis or around the aorta (the main artery that runs from the heart down along the back of the abdomen and pelvis)? Also called para-aortic lymph nodes. The spread (m metastasis) to distant sites (M):  (M): Has the cancer spread to fluid around the lungs (malignant pleural effusion) or to distant organs such as the liver or bones? FIGO   (International Federation of (International Federation of  AJCC (American Joint Committee on American Joint Committee on ? ? (T): Has the cancer spread outside the ovary or fallopian ? ?

46. FIGO CLASSIFICATION

47. TNM TNM CLASSIFICATION..

50. Stages of ovarian cancer.. Stages of ovarian cancer.. ? ❖ ❖ ❖ The stage of ovarian cancer is determined by three factors: the tumor’s size whether or not the tumor has invaded tissues into the ovary or nearby tissues whether or not the cancer has spread to other areas of the body