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 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.

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.

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.

Evaluation of symptoms and investigations

  • History and physical examination, especially pelvic examination
  • Routine blood tests, FBC, ELFT
  • 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.

For many years the gold standard treatment for ovarian and related cancers has been to attempt to surgically remove all or as much disease as possible and then follow this with chemotherapy.  Surgery can be quite extensive including removal of uterus, tubes, ovaries, omentum and on occasion parts of the bowel, stomach, and the liver, the spleen, the lymph glands and stripping of the peritoneal lining of the abdomen that contains disease.  The goal of surgery is really to remove all visible evidence of disease.

Recent studies have shown that for patients with very advanced disease, by giving 3 cycles of chemotherapy prior to the surgery (so called neoadjuvant chemotherapy), patient’s general medical condition improves and the extent and burden of cancer reduces.  The studies show that this approach is associated with a reduction in peri-operative morbidity and mortality, an increased likelihood of removing all macroscopic disease and no reduction in overall survival from the disease.  The decision to have primary surgery or neoadjuvant chemotherapy will be determined by the treating gynaecologic oncologist based on CT scan findings and the general condition of the patient.

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.