Ovarian Malignancies

December 14, 2007

"The Bad" continued the discussion of what's normal and abnormal for the ovary. In this final segment I've left the worst for last.

Malignancy is ugly because I think anything that interrupts someone's life, either by surgery or another anti-cancer regimen, or by death, is the antithesis of all we seek in this life. Something within you that you have no control over--that grows to its own fruitless end at your beautiful life's expense--is ugly indeed.

 

The great irony is that all mammalian life exists because of the ovaries, yet we pay the price with the deadliest of malignancies from these two small organs.

There are whole books dedicated to the varied isolated aspects of ovarian malignancy, and I don't look to explain it all here. But there are basics that can be understood which, if nothing else, will impress the reader that there is a wide range of survivability when it comes to ovarian cancer. There are malignant tumors that can be cured by simply excising them, even leaving the rest of the pelvic organs so as to spare childbearing ability. But there are also those ovarian tumors in which the likelihood of death is almost 100% by the time it's discovered for the very first time. This is pretty scary stuff, and once again I remind a woman to just keep up with her routine appointments, for that is the most likely time--and therefore the earliest time--of incidental discovery and the best chance of surviving.

The ovary, in my opinion, is a very weird organ. It's cells have the ability to transform into many other types of body tissues, almost as if it has the secret of life itself stored in hidden genetic files. For this reason, these cells are sometimes called "totipotent." It uses its chameleon secrets to metamorphose it's cells into malignant uterine-type cells (womb-like), cervical-type cells (mouth of the womb), glandular cells (like in the fallopian tube or bowel), and even truly bizarre malignant conversions to brain, lung, and bone grown within it. Some types can even make the pregnancy hormone, hCG, giving a very confusing positive pregnancy test. Ovarian tumors can grow wildly and rapidly spread, and for this reason, once discovered, the race is on.

Besides routine physical exams which can pick up a tumor before it has turned malignant or begun to spread, there are also blood tests that serve as tumor "markers," like the CA-125. These tests are not always accurate, but only add to suspicions already there from ultrasound or physical exam. They can help a gynecologist gain some perspective in his or her medical intuition. Pelvic ultrasound can pick up suspicions before anything is caught in a physical exam, and the battle between fiscal responsibility and patient advocacy rages on, the routine use of ultrasound still not justified bottom-line-wise for well-woman visits. Regardless, a strong family history of ovarian cancer should prompt a woman to invest in a yearly ultrasound herself if her insurance won't pay for one.

The likelihood of a woman developing a malignancy of the ovary is anywhere from 1 in 70 to 1 in 100, over an expected life span. This means if you were to wax fatalistically in the check-out line at Wal-Mart, you'd realize that there are a handful of woman walking the aisles with ovarian cancer who don't even know it.

 

"Attention, Wal-Mart shoppers: Keep up with your routine appointments to the gynecologist."

Risk Factors for Ovarian Cancer:

  • Early onsent of periods ("menarche")
  • Late menopause
  • Never having been pregnant
  • Positive family history of ovarian, breast, uterine (?), or colon cancer
  • BRCA1 or BRCA2 gene mutation

Symptoms of ovarian cancer can include weight loss (as in all cancers, but usually later on), fatigue, and the particularly incriminating abdominal bloating and nausea. Slight fluid in the lungs can send a woman to her internist before seeking gynecology as the culprit.

There is such a thing called the "uterine-ovarian-breast axis," which is a concept that suggests that if you've had a cancer of one of these types, you're more prone to developing a malignancy of one of the other types. Whether this "axis" extends to the family history and how far is still being studied, but since the conversion of normal cells to malignant ones ultimately underscores the body's immunologic inability to fend off such transformations, the family gene is implicated-and with it the family tendency to undergo dangerous transformations.

A malignancy, and even the pre-malignancy in the ovary, requires surgery. In fact, staging the disease-that is, describing the extent of the disease--is a surgical protocol. While staging, best advantage is made of the surgery by removing as much tumor as possible. This attitude of wanting to remove as much tumor as one can is called "surgery of maximum effort." In advanced cases, the most desired result from surgery is to leave no tumor implant that is more than a centimeter--what is called "successful debulking of tumor." With "seeding" of the tumor all over the abdomen, it is often impossible to get every last bit of it, but if all that are left are implants--even very many of them--that are all less than a centimeter large, then this will make the disease much more sensitive to the follow-up chemotherapy. In surgery, lymph nodes and other abdominal organs are inspected and/or sampled, and from this staging technique different post-operative therapies are instituted, for different stages require different treatments.

There are numerous types of ovarian cancer, thanks to the body's ability to act like different types of tissue when going dreadfully wrong. The most common types of tumors are thought to originate from the covering over the ovary-the same stuff that coats the inside of the entire abdominal cavity. This cellophane-like layer is called the peritoneum. Even if the ovaries had been removed years earlier, it's not unheard of for a woman to develop ovarian cancer originating from this tissue elsewhere in the abdomen!

Evaluating Your Risk

Ovarian malignancy can be a chase-your-own-tail fight for survival, and the key to surviving it is a combination of early detection and surgery of maximum effort. Newer chemotherapy agents are being developed all of the time to increase the chances of cure, but for now, cancer of the ovary remains as one of the deadliest tumors.

One of the best-kept secrets is a common little pill that can provide substantial protection from ovarian cancer: The Birth Control Pill!

The longer a woman is using birth control pills, the more the risk of ovarian cancer is reduced--even in those women with a strong family history of ovarian cancer. And this protection may last for 20 years after stopping the pill. (A new hormone replacement therapy, called FemHRT, is the first different formulation for post-menopausal estrogen replacement to come along in quite a while. It is based on the ingredients of the birth control pill, so it will be interesting to see if this ends up providing the same protection well into the menopausal years.) This protection also applies to endometrial cancer (cancer of the uterus, not the cervix.)

And so ends this series on the ovary: "The Good, the Bad, and the Ugly." In medicine, we've come a long way in addressing this disease, and have a long way yet to go. One day we'll have fool-proof tumor markers for the earliest of detection, guaranteed genetic screens for those at risk, and cures for this and other cancers as well. One day there won't be a single woman in Wal-Mart with cancer.

One day.

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