Archive for Ovarian Cancer

Aug
27

OVARIAN CYST-DO YOU NEED AN OPERATION?

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Management of Ovarian Cysts is primarily dependent on the type of cyst, the size of the cyst,  and how long it has been present. So when do you need to have surgery and what type of surgery will be done?

Antique Medical Illustration of Female Genitals

As mentioned in previous posts, most cysts resolve after several weeks to months. Most commonly, an ultrasound has been done to look at several factors including size, characteristics and in some cases placement.

What is an ultrasound? This is a way of visualizing a mass using sound waves which bounce off of organs and other tissues. It is performed through a transducer which is placed on top of the skin of the abdomen and it is also placed into the vagina for better visualization of the ovaries. Neither of these procedures hurt. The Radiologist is looking for the ovaries, they will evaluate and characterize this cyst as

  • cystic- there is one circular wall containing fluid only
  • biloculated- a fluid filled cyst with one thin wall
  • multiloculated- there are several walls within the cyst cavity
  • complex- contains walls, debris such as cells and blood
  • solid- contains solid elements, thick or irregular walls, these are most predictive of malignancy.

All of these factors help to determine whether watchful waiting is appropriate or whether surgery is indicated. The reasons to perform ultrasounds also include the need to determine whether a palpated mass or nodule in the pelvis is even associated with the ovary. Occasionally these masses can represent a problem with the gastrointestinal tract or with the uterus.

How do the specialist further evaluate an ovarian cyst after the ultrasound has determined it to be complex?

A CA-125 is often ordered. This is a blood test which measures a substance in the blood stream that an ovarian cancer may be producing. It is actually not intended to be a screening test as many things can cause elevations. It is used in conjunction with the ultrasound characteristics of a cyst.

Color Doppler Velocimetry studies have been looked at in terms of whether a cancer has a different blood flow than a benign cyst. This is a study where the blood is given a color image and used to evaluate the amount of blood flow to the ovary. Studies have shown there is no specific pattern differentiating ovarian cancers from cysts, therefor this is felt to be of little value.

Cyst Aspiration is a procedure where a long needle is placed through the skin of the abdomen, through all the layers of the abdomen, and then into the cyst itself. The fluid within the cyst is then drawn up through the needle, then removed and studied by pathologist. They look at the cells within the fluid as well as perform different tests on the fluid to determine whether any cancer is present. This procedure has many problems and is no longer a recommended procedure in the vast majority of cases. The main issue is that of potentially pulling cancer cells out from a cyst, through the abdominal cavity and accidentally spilling those cancer cells within the abdomen thus facilitating potential spread of a cancer that had been confined to the ovary.

When do the specialists recommend surgery?

In premenopausal women, surgery will be recommended if:

  • the cyst has not resolved within a few months
  • the cyst is enlarging over a period of roughly 6 weeks
  • a CA-124 is elevated with an enlarging cyst
  • Pain is also a reason to operate as these cysts can be quite painful as they enlarge.

In post menopausal women, indications for surgery include the above plus

  • cyst is solid or complex
  • ascites (fluid in the belly) is present-this can be a sign of cancer
  • fixed mass in the cul-de-sac

It is estimated that 15% of asymptomatic pre-menopausal women and 5% of menopausal women will have a cystic ovarian mass of greater that 2.5 cm in their life time. By characterizing a cyst through ultrasound and following it for a designated period of time, many operations can be avoided.

The type of operation often depends on the size of the cyst and the suspicion for malignancy. A small cyst, the size of a plum or less, can often be removed through a laparoscope. This is a tube which is placed through the abdominal wall, air is used to inflate the wall away from the organs in the abdominal cavity. This allows the surgeon to see and operate on the ovaries, as well as remove the cyst from the abdominal cavity. There has been tremendous advances in laparoscopic surgeries in the last several years. If the cyst is larger than this, or if there is a high degree of suspicion for malignancy, a laparotomy will be performed. This is a more invasive surgery where a larger incision into the abdominal cavity is made for better visualization of the cyst and surrounding organs.  This allows better evaluation of the potential of involvement of fallopian tubes, uterus, bowel as well as lymph nodes.

Ovarian cysts are most often benign and asymptomatic, having been found by accident. It is important to realize  that surgery is not necessary in many cases. It takes  an experienced radiologist  to evaluate these cysts through ultrasound, coupled with a gynecologic specialist who is also experienced in following ovarian cysts to determine when and if surgery is needed.

Anne Vaillancourt PAC

This is my final installation about ovarian cysts.  I would love to hear your opinions, comments and your stories about ovarian cysts and your experiences. Please leave me a comment below.

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Aug
09

OVARIAN CANCER-TYPES AND TYPING

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You have been told you have an ovarian mass and

you have gone through the gut wrenching weeks of

Antique Medical Illustration of Female Genitals

waiting to find out what it means. You have had tests, exams, and  as well as a  biopsy and most likely surgery. You have thought about death and you have thought about life. You are now going to meet with your specialist to find out the  type of ovarian cancer you have and you ask yourself,

What does cell type mean, what is staging and why do the specialists do this?

What are my chances of beating this and what do I need to know?

Not all ovarian cancers are created equal, so what do you need to know about them? First you will be told whether this mass or lesion is a tumor or a cancer. Tumors are abnormal growths and are not necessarily malignant or able to spread and destroy tissue. Carcinomas are malignant, they spread and cause damage and destruction of healthy tissue.  The types of cancers include:

  • Epithelial Cell Cancer- most common, some are benign and some are malignant
  • Primary Peritoneal Cancer- closely related to epithelial cell ovarian carcinomas-they are malignant
  • Fallopian Tube Cancer-less common, have decent outlook for survival
  • Germ Cell Tumor- most benign, less than 2% of ovarian cancers, 90% of women survive greater than 5 years.
  • Stromal Tumor-account for 1% of ovarian cancers, 50% are found in women over 50.

Most likely you have been diagnosed with an epithelial cell tumor. This cell type accounts for most of ovarian tumors and cancers. It is important to remember that most epithelial cell tumors are benign. Different types of benign tumors include serous adenomas, mucinous adenomas, and brenner tumors. These tumors grow slowly and do not spread to other organs.

LMP tumors, or low malignant potential tumors are exactly that: tumors that grow slowly, do not grow into the ovary but spread outward, and do not invade other organs. They can be fatal however this is uncommon. They are also known as a borderline epithelial cell cancer.

Malignant epithelial ovarian cancer accounts for 85-90% of epithelial cell carcinomas. Types include serous type (most common), mucinous, endometrial, and clear cell. These tumors are capable of fast growth, spread and invasion of surrounding and distant tissues and organs. Because of this, these tumors are staged, as most tumors with malignant potential are.

What is staging?

After a diagnosis has been made, several tests are done to determine the degree of growth and invasion of the ovary, as well as whether there has been spread to lymph nodes and organs.

  • Grading classifies tumor based on appearance as compared to normal tissue on a scale of 1, 2 or 3
  • Grade 1 is well differentiated or looks like normal ovarian tissue (best prognosis), Grade 3 is poorly differentiated and has no similarity to ovarian tissue, Grade 2 is inbetween
  • Staging denotes how far the cancer has spread.
  • TNM are terms used to define grading and staging. T-extent of primary tumor, N-involvement or lack of involvement of lymph nodes, M-whether there is distant metastasis to other organs

The grading and staging of a cancer will be a major determinant of how well the cancer can be treated. It is VERY important that you be under the care of a cancer specialist (Oncologist) for any of the serious ovarian tumors and it is often advisable to see a cancer specialist for an opinion regarding best treatment for the tumors with less malignant potential. Most of the treatment algorithms ( a sort of recipe) are standardized, but diagnosis can require an experienced pathologist-a specialist who looks at the cells under the microscope. There are constant advancements on testing for different treatment options and you would want your cancer physician to be current with the most accurate testing and treatment.

A few of the top Cancer treatment centers in the US include

These centers are not all inclusive and there are many more excellent centers through out the US. The above list comes from the US News and World Report and these institutions are ranked by physician quality and peer respect, nursing care and survival rates.  Where ever you go, it is important to get recommendations from your provider as well as people you are acquainted with who may have had some experience with the medical facility you are interested in.

Negotiating the medical community with a life threatening illness is very difficult and I strongly advise that all people in this position have a trusted person who can be their advocate. You will need someone with you who can absorb all the information given to you by the experts, someone who can take notes. Your advocate should be aware of the entire treatment plan so that they can help keep the various different groups of professionals aware of aspects of your care they may not be involved in.

It is not wise to make the assumption that all health professionals involved in the many aspects of diagnosis and treatment of cancer, actually speak to each other. The good ones do, but someone you trust needs to keep your interest first and foremost and ensure that communication in intact.

OK, your turn. Ask me questions by leaving me comments below. You may also want to read my first post on Ovarian cancer.

Anne Vaillancourt

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Ovarian cancer is the 9th most common cancer women can have and is the 5th leading cause of cancer deaths in women.

It is difficult to diagnose early, which can make it one of the more dismal gynecologic cancers a woman can have. Research is ongoing on methods of early diagnosis and detection, as well as trying it identify risk factors to aid in prevention.

STATISTICS:

  • The American Cancer Society predicts that in 2010, 21,880 women will receive a new diagnosis of ovarian cancer and there will be 13, 850 deaths from ovarian cancer.
  • These statistics are close to past years stats on diagnosis and death, although the rate of ovarian cancer has been declining slightly.
  • 93% of women diagnosed in early stages of ovarian cancer live 5 yrs or more, however, only 19% of women with ovarian cancer are diagnosed in the early stages.
  • Lifetime risk of developing ovarian cancer  is 1 in 71, lifetime risk of dying from ovarian cancer is 1 in 95
  • 50% of women diagnosed with ovarian cancer are over 60, risk is higher in white women over African American women.
  • 3 in 4 women diagnosed with ovarian cancer survive at least 1 year, 46 % survive 5 years; women younger than 65 fair better than older women.

SYMPTOMS OF OVARIAN CANCER: many of the symptoms listed below can be present for completely normal or benign reasons, their presence does not ensure an ovarian cancer. Experts suggest however, that if many of these symptoms are new, unexplained, present daily or almost daily, last more than a few weeks; that evaluation is needed.

  • Bloating, upset stomach, early satiety or difficulty eating a full meal, and constipation
  • pelvic and/or abdominal pain, as well as back pain, pelvic or abdominal pain during intercourse
  • Changes in menstrual pattern and especially post menopausal bleeding
  • urinary frequency or a change in the pattern of urination, urgency to urinate
  • unusual or unexplained fatigue

WHAT ARE RISKS OF OVARIAN CANCER?

  • AGE: as mentioned above, incidence increases with age
  • OBESITY: studies suggest a BMI of over 30 increases risk and death from ovarian cancer, although this has not been proven. Likewise, studies have suggested a diet low in fat and high in vegetables has shown a lower rate of ovarian cancer
  • CERTAIN DRUGS: the use of fertility drugs for over 1 year especially if pregnancy was not achieved is associated with a higher incidence of low malignant potential tumors. These are tumors of the epithelial cell type which tend to grow slowly.  Use of androgens (Donazol) has suggested a higher risk in a small study, however a larger study did not confirm this. Use of HRT, especially estrogen alone for more that 5-10 years has been associated with a higher rate of ovarian cancer.
  • FAMILY HISTORY: 10% of ovarian cancers are from the genetic mutation on BRCA1 and BRCA2, many causes of epithelial ovarian cancers, which are the most common, are caused by inherited gene mutations and therefor identifiable through genetic testing. This is recommended for a family history of breast, colon and ovarian cancer even if on father’s side of the family.
  • PRIOR BREAST CANCER: many of the same risk factors for breast cancer also exist for ovarian cancer, primarily the  gene mutations mentioned above ; and possibly use of HRT. The presence of a prior cancer suggests a problem with DNA replication.

Other factors that have been looked at are use of talcum powder, use of analgesics, smoking and alcohol consumption. The use of talcum powder applied to the genital region, as well as  sanitary napkins containing talcum powder; has been suggested as one possible cause of ovarian cancer. It is speculated that talcum powder used more than 20 years ago contained trace amounts of asbestos, which is a known carcinogen. The FDA has required all talcum powder to be asbestos free, and there is no association with use of corn starch containing personal hygiene powders with increased risk of ovarian cancer. Studies have failed to demonstrate and increased risk of ovarian cancer with use of aspirin, acetaminophen  products, alcohol or smoking.

How can a woman reduce her risk of getting ovarian cancer? There is not a lot of data to give concrete answers but studies doe suggest that the following strategies can be considered:

  • Use of oral contraceptives for 5 years or more seems to reduce risk by 50% over non users of birth control pills. Likewise, risks goes down with each pregnancy as well as breast feeding. This is most likely associated with lack of ovulation, or continued activity within the ovary month to month.
  • Gynecologic surgery such as bilateral tubal ligation and hysterectomy is also associated with lower risk, exact reasons are unknown. These tests should only be done for valid, medical reasons.
  • Genetic counseling is very important if there is a family history of cancer including the BRCA gene mutation. this is  a complicated issue, but can identify women at risk and allow them to take recommended surgical action.

It is most important to see your medical provider for any new signs and symptoms of ovarian cancer, even if there is not a family history of cancer. Long term survival is best when this particular cancer is diagnosed  and treated in the early stages. Regular exams and good dialogue with a medical provider you trust is key, tell your provider everything you are feeling even if it seems trivial!

Anne Vaillancourt

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