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Ovarian Cancer, Fallopian Tube Cancer, and Primary Peritoneal Cancer

Chapter 17 – Gynaecological Cancer in the Senior Patient

For staging of ovarian and primary peritoneal cancer, the FIGO 1988 staging system is used, while for fallopian tube cancer, the 1991 system is used. The majority of women (70%) are diagnosed in an advanced stage (III/IV). The five-year survival for these stages is <50%.

Staging of Ovarian Cancer

Stage I: Growth limited to the ovaries

  • IA Growth limited to one ovary; no ascites present containing malignant cells. No tumour on the external surface; capsule intact.
  • IB Growth limited to both ovaries; no ascites present containing malignant cells. No tumour on the external surfaces; capsules intact.
  • IC Tumour either stage IA or IB, but with tumour on the surface of one or both ovaries or with capsule ruptured or with ascites present containing malignant cells or with positive peritoneal washings.

Stage II: Growth involving one or both ovaries with pelvic extension

  • IIA Extension and/or metastases to the uterus and/or tubes.
  • IIB Extension to other pelvic tissues.
  • IIC Tumour either stage IIA or IIB, but with tumour on the surface of one or both ovaries or   with capsule(s) ruptured or with ascites present containing malignant cells or with positive peritoneal washings.

Stage III: Tumour involving one or both ovaries with histologically confirmed peritoneal implants outside implants outside the pelvis and/or positive regional lymph nodes. Superficial liver metastases equals stage III disease. Tumour is limited to the true pelvis, but with histologically proven malignant extension to small bowel or omentum

  • IIIA Tumour grossly limited to the true pelvis, with negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces or histologically proven extension to the small bowel or mesentery.
  • IIIB Tumour of one or both ovaries with histologically confirmed implants, peritoneal metastasis of abdominal peritoneal surfaces, not exceeding 2.0 cm in diameter; nodes are negative.
  • IIIC Peritoneal metastasis beyond the pelvis >2.0 cm in diameter and/ or positive regional lymph nodes.

Stage IV: Growth involving one or both ovaries with distant metastases. If pleural effusion is present, there must be positive cytology to allot a case to stage IV. Parenchymal liver metastasis equals stage IV disease

Staging of the Cancer of the Fallopian Tube

Stage 0: Carcinoma in situ (limited to tubal mucosa)

Stage I: Growth limited to the fallopian tubes

  • IA Growth is limited to one tube, with extension into the submucosa and/or and/or muscularis but not penetrating the serosal surface; no ascites.
  • IB Growth is limited to both tubes, with extension into the submucosa and/or muscularis but not penetrating the serosal surface; no ascites.
  • IC Tumour either stage IA of IB, but with tumour extension through or into the tubal serosa or with ascites present containing malignant cells or without positive peritoneal washings.

Stage II: Growth involving one or both fallopian tubes with pelvic extension

  • IIA Extension and/or metastasis to the uterus and/or ovaries.
  • IIB Extension to other pelvic tissues.
  • IIC Tumour either stage IIA of IIB and with ascites present containing malignant cells or with positive peritoneal washings.

Stage III: Tumour involves one or both fallopian tubes, with peritoneal implants outside the pelvis and/or positive regional lymph nodes. Superficial liver metastasis equals stage III disease. Tumour appears limited to the true pelvis, but with histologically proven malignant extension to the small bowel or omentum

  • IIIA Tumour is grossly limited to the true pelvis, with negative nodes, but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces.
  • IIIB Tumour involving one or both tubes, with histologically confirmed implants of abdominal peritoneal surfaces, none exceeding 2.0 cm in diameter. Lymph nodes are negative.
  • IIIC Abdominal implants >2.0 cm in diameter and/or positive retroperitoneal or inguinal nodes.

Stage IV: Growth involving one or both fallopian tubes with distant metastases. If pleural effusion is present, there must be positive cytology to categorised as stage IV disease. Parenchymal liver metastases equals stage IV disease

Treatment

Borderline Tumours
The treatment should only consist of a surgical resection of the tumour and implants. There is no role for lymphadenectomy or adjuvant chemo- or radiotherapy.

Invasive Ovarian and Peritoneal Cancers
Patients with invasive cancers should have a meticulous surgical staging. The staging includes an EN bloc resection of the ovarian tumour and the other ovary, hysterectomy, pelvic and para-aortic lymphadenectomy, omentectomy, aspiration of free fluid or peritoneal washings, and systematic exploration of the lower and upper abdomen with removal of all adhesions or suspicious lesions. In mucinous tumours, an appendectomy should also be performed.

The goal of surgery is the removal of all visible lesions (optimal debulking or cytoreductive surgery to obtain no visible residual disease). If this cannot be achieved, the value of surgery is minimal. When the preoperative evaluation indicates that the patient cannot be optimally debulked because of extensive disease or when the patient is in a poor surgical condition, one should opt for neo-adjuvant chemotherapy. In case of a response allowing optimal surgery, interval debulking surgery should be performed. Sometimes palliative surgery is performed to improve the quality of life.

Adjuvant chemotherapy should be given to all patients with stage IA (grades II and III), IB (grade II and III), IC, II, III, and IV. The combination of carboplatin with paclitaxel is the first choice. It can be administrated intravenously or, in selected patients, intraperitoneally (paclitaxel and cisplatin).

Relapse of Ovarian and Peritoneal Cancers
The majority of patients will relapse. The time to relapse is important for determining treatment. If the disease relapses six months or more after completion of first-line therapy, the disease is considered to be platinum-sensitive and platinum-based chemotherapy can be used again. If the disease relapses within six months, other drugs should be used. These other drugs include single-agent or combination therapy of liposomal doxorubicin, gemcitabine and topotecan.  Alternatively, one can opt for tamoxifen (hormonal therapy) or bevacizumab (Monoclonal antibody therapy). Secondary cytoreductive surgery should only be performed in select cases with resectable disease before initiating chemotherapy.

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