Incidence	Approximately 1%; commonest cause of death from cancer of female genital tract
Age
Sex
Geography
Aetiology
Presentation	Loss of weight and general malaise; loss of appetite; ascites may mean that the patient's waistline is actually increasing. Pain - most commonly from complications Pressure symptoms - retention of urine, urinary frequency, sensation of lump Endocrine in some Malignancy - abdominal discomfort and bowel symptoms in metastatic intraperitoneal disease; cachexia in later stages; hydronephrosis, leg oedema from venous thrombosis
Investigations	Pelvic examination; ovaries should not be palpable in a postmenopausal woman USS abdomen/pelvis MRI of pelvis CXR for chest metastases Barium enema or IVU for bowel/urinary symptoms Differential diagnosis - in pelvis: full bladder, pregnancy, uterine fibromyomata, chronic salpingitis, faeces, pelvic kidney - in abdomen: fat, fluid, faeces, flatus, fetus, fibroids
Macro
Micro
Staging	Stage I disease limited to one or more ovaries  Stage II growth extending beyond the ovaries but confined within the pelvis Stage III growth with widespread intraperitoneal metastases   Stage IV other distant metastases/parenchymal liver involvement
Serum markers	Elevated Ca125 in epithelial tumours (but also endometriosis) CEA (carcinoembryonic antigen) in mucinous cystadenoma hCG and a-fetoprotein in functional germ cell tumours
Management	Surgical - lower midline or paramedian vertical incision - peritoneal washings for cytology immediately on entering - thorough exploration of abdomen and pelvis to determine extent of spread - pelvic and para-aortic lymph node sampling - if there are doubts about malignancy, a frozen section of the tumour can be examined - in a young woman with unilateral disease who has yet to complete her family, or unilateral germ cell tumours, unilateral salpingo-oopherectomy - in all other cases, TAH with bilateral salpingo-oopherectomy and omentectomy (omentum removed to prevent secondaries causing ascites) Chemotherapy - most patients presenting with ovarian cancer sufficiently advanced that surgery is insufficient; hence adjuvant chemotherapy is important for long term survival - epthelial ovarian cancer responds to cisplatin or carbaplatin therapy - germ cell tumours are treated using intensive combination chemotherapy Radiotherapy - rarely used for adjuvant therapy as metastases tend to be widely disseminated at presentation - however, pelvic irradiation may be used in the treatment of stage 2 disease and palliative treatment for pelvic recurrence - dysgerminomas are extremely radiosensitive Second-look
Prognosis	Epithelial tumours - 5 year survival is 15-20% Rare germ cell tumours - 5 year survival is 60-80%
Complications	Torsion - occurs in pedunculated cysts not fixed to other structures; common in dermoid cysts and fibomata Rupture - due to inadequate blood supply to part of the wall of the cyst; abdominal tenderness and rigidity, may be vomiting and shock with larger cysts. Cyst collapses and becomes impalpable. Can lead to dissemination of malignant cells within the peritoneal cavity. If the cyst is large, the patient should be given an immediate laparotomy Haemorrhage - occurs more often into malignant ovarian cysts; causes pain similar to torsion Impaction - more commonly cysts that have become adherent to pelvic peritoneum; may cause urinary retention Infection - may become involved in local infections, e.g. appendicitis Ovarian tumours diagnosed during pregnancy - most comonly corpus luteum cyst or dermoid cyst - rarely malignant; hoever, malignant cysts should be removed without delay - operations are generally deferred until the 16th week of labour if possible, as the risk of miscarriage/premature labour is highest in the first 12 weeks; also, a corpus luteum cyst may be maintaining the pregnancy by secreting progesterone - ovarian tumours are a rare cause of obstructed labour

Gynaecology

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