Brief introduction of ovarian cancer
2 English reference ovarian cancer [National Guidelines for Clinical Application of Essential Drugs: 20 12 Edition. Chemicals and biological products]
Director of Xiangya Medical Dictionary
Ovarian cancer [Xiangya Medical Dictionary]
Ovarian cancer [Xiangya Medical Dictionary]
3 Overview Ovarian cancer is one of the common tumors in female reproductive system, and its incidence ranks third after cervical cancer and uterine body cancer [1]. The mortality rate ranks first among all kinds of gynecological tumors, which poses a serious threat to women's lives [1]. Because of the complicated embryonic development, histological anatomy and endocrine function of the ovary, its tumor may be benign or malignant [1]. Because ovarian cancer is asymptomatic in the early clinical stage, it is difficult to distinguish its histological types, benign and malignant. Only 30% of tumors were found during laparotomy, and most tumors have spread to uterus, bilateral appendages, omentum and pelvic organs. Therefore, ovarian cancer is really a big problem in diagnosis and treatment [1]. Up to now, according to the statistics of clinical data at home and abroad, the five-year survival rate is only 25% ~ 30% [1].
Over the years, experts have discussed the pathological morphology, clinical occurrence and development law and treatment scheme of ovarian malignant tumor, and accumulated a lot of experience.
The pathological changes of ovarian cancer are more complicated than any organ, because: ① the ovarian tissue structure has potential pluripotency; ② During embryogenesis, the ovary is very close to the urinary system, and some mesonephric tissues will be lost to the ovary; ③ Ovary comes from embryonic reproductive ridge, which is male and female, and then differentiates. There are many classification methods of ovarian tumors, and this chapter adopts the classification based on histogenesis, which has clinical practical significance.
4. 1 Ovarian malignant tumors derived from embryonic epithelium (lumen epithelium of accessory middle kidney), such as serous adenocarcinoma, mucinous adenocarcinoma, endometrioid adenocarcinoma, mixed serous mucinous cystadenocarcinoma, fibroadenocarcinoma, malignant brenner's tumor, clear cell carcinoma of accessory middle kidney, undifferentiated (anaplastic) carcinoma, etc. Sometimes these tumors have the function of yellowing.
4.2 Ovarian malignant tumors derived from embryonic cells, such as teratoma, primary choriocarcinoma and asexual cell tumor, sometimes secrete hormones.
4.3 Malignant ovarian tumors derived from undifferentiated mesenchymal cells, such as benign tumor 1 ~ 6 sarcoma, malignant mixed mesodermal tumor, carcinosarcoma, etc.
4.4 Ovarian malignant tumors derived from sexually differentiated mesenchymal stem cells are all potential malignant tumors, also known as functional tumors, because they have the function of producing autologous hormones.
1. Feminized mesothelioma: ① granular cell tumor; ② theca cell tumor; ② Granular-follicular cell tumor.
2. Male mesothelioma: ① testicular cell tumor; ② Portal vein cell tumor.
3. Gender; Andromeda strain.
4.5 Ovarian malignant tumor, such as malignant mesonephroma occurring in the remnant mesonephros.
4.6 Ovarian malignant tumor caused by ectopic tissue and malignant residual tumor of adrenal cells.
5 Clinical manifestations of ovarian cancer Most malignant ovarian tumors have no conscious symptoms in the early stage, and the disease often progresses when symptoms appear. Due to the rapid growth of tumor, abdominal distension, abdominal mass and ascites may occur in a short time. When the tumor infiltrates surrounding tissues or compresses nerves, it can cause abdominal pain, low back pain or sciatica. If the pelvic vein is compressed, edema of lower limbs may occur, which generally does not cause menstrual disorder. If both ovaries are destroyed by cancer tissue, it will cause menstrual disorder and amenorrhea. In addition, if it is a functional tumor, it can produce corresponding symptoms of excessive estrogen or androgen. Such as: causing early dysfunctional uterine bleeding, postmenopausal bleeding or male signs. Advanced patients show obvious cachexia, such as emaciation and severe anemia. Gynecological examination shows that scattered hard nodules and masses can be touched in the posterior fornix, mostly bilateral, substantial, uneven and motionless, often accompanied by bloody ascites. Sometimes swollen lymph nodes can be touched in the groin, armpit or clavicle.
6 Diagnosis of ovarian cancer 6. 1 Symptoms and signs are often unconscious in the early stage, and the disease often progresses when symptoms appear [1]. Due to the rapid growth of tumor, abdominal distension, abdominal mass and ascites may occur in a short time [1]. When the tumor infiltrates surrounding tissues or compresses nerves, it can cause abdominal pain, low back pain or sciatica [1]. If pelvic vein is compressed, edema of lower limbs may occur, and if both ovaries are destroyed by cancer tissue, menstrual disorder and amenorrhea may be caused [1]. In addition, if it is a functional tumor, the corresponding symptoms may be caused by excessive estrogen or androgen [1]. The advanced patients have obvious cachexia such as emaciation and severe anemia [1]. Gynecological examination shows that scattered hard nodules and masses can be touched in the posterior fornix, mostly bilateral, substantial, uneven and motionless, often accompanied by bloody ascites [1]. Sometimes swollen lymph nodes can be touched in groin, armpit or clavicle [1].
6.2 Auxiliary examination 6.2. 1 Ultrasound examination can determine the size, location, shape, internal structure and source of the tumor, and its diagnostic coincidence rate can reach 90%[ 1].
6.2.2 Cytological examination of abdominal cavity or posterior fornix puncture and intraoperative cytological examination of ascites or peritoneal lavage fluid are helpful for the diagnosis, differential diagnosis and staging of ovarian malignant tumors [1].
6.2.3 Laparoscopy can directly peep into pelvic and abdominal organs, determine whether there are tumors and specific conditions of tumors, and whether there are metastatic foci and sites, which is of diagnostic value in combination with biopsy and pathological examination [1].
6.2.4 Tumor markers can increase carcinoembryonic antigen (CEA), carbohydrate antigen CA 125, alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG)[ 1].
6.2.5 Radiodiagnostic abdominal plain film examination can show the teeth and bones of mature ovarian teratoma [1].
6.2.6 Computed tomography (CT) and magnetic resonance imaging (MRI) can clearly show the image of the tumor, whether there is metastasis in various organs and pelvic lymph nodes, and play a certain role in the diagnosis, staging, observation of the changes of residual tumors and whether there is tumor recurrence during follow-up [1].
6.3 Early diagnosis Because there are no typical symptoms and signs in the early stage of ovarian malignant tumor, it is still extremely important to inquire about the medical history in detail, and make a careful physical examination and gynecological examination. If there are suspicious clinical conditions, early diagnosis should be made with the help of modern imaging examination and systemic tumor marker examination. The so-called suspicious circumstances may be long-term ovarian insufficiency, long-term unexplained symptoms of digestive tract or urinary tract, * * * ovarian enlargement or postmenopausal touching of the ovary, and the originally suspected ovarian tumor rapidly enlarged, fixed and hardened.
6.4 If adnexal masses can be achieved in the early stage of localization diagnosis, combined with imaging examination, localization diagnosis is not difficult. However, in some cases, the primary tumor metastasized outside the ovary at an early age, resulting in small nodules scattered in the pelvic cavity. At this time, we should choose some special examination methods to assist diagnosis (qualitative), rather than relying solely on follow-up and follow-up.
6.5 Qualitative diagnosis Although diagnostic techniques are changing with each passing day, smear examination of posterior fornix effusion, puncture fluid examination of hysterorectal depression and cytological examination of ascites are still simple, easy and rapid basic examinations. For suspicious cases, laparoscopy and histological examination can make a definite diagnosis immediately. Imaging examination, especially * * ultrasound scanning, is helpful to make a qualitative diagnosis of the boundary (diffusion range) and internal structure (nature) of early ovarian malignant tumor. Endocrine examination is helpful for the diagnosis of ovarian gonadal stromal tumors and some ovarian cancers with ectopic endocrine syndrome. Serum tumor markers such as CA 125, CEA, SONA and SGA are highly sensitive to ovarian malignant tumors, but their specificity is poor. Therefore, it is impossible to judge their types by immunological detection. Combined detection of multiple tumor markers, such as simultaneous detection of CA 125, CEA, ferritin and tissue polypeptide antigen (TPA), can improve the reliability of qualitative diagnosis.
7 Diseases that need to be differentiated from ovarian cancer. Ovarian cancer needs to be differentiated from ovarian cysts and benign tumors, and laparotomy is needed [1].
8 treatment plan for ovarian cancer 8. 1 treatment principle: surgical treatment is the main treatment for ovarian malignant tumor, supplemented by comprehensive treatment such as radiotherapy and chemotherapy.
8.2 Surgery is not only the most effective treatment method, but also the necessary means to determine the diagnosis and staging [1]. Early ovarian cancer surgery can be performed simultaneously with tumor resection and definite staging [1]. In principle, the scope of operation includes total hysterectomy and double appendectomy, omentum resection, pelvic and abdominal aortic lymph node dissection [1]. For advanced cancer, cytoreductive surgery was performed. For young people who have fertility requirements and meet the requirements, conservative surgery is feasible to preserve fertility function [1].
First of all, detailed exploration should be done during the operation, including peritoneal lavage, palpation of pelvic and abdominal organs and pelvic and retroperitoneal lymph nodes, and multi-point biopsy of diaphragm, peritoneum and omentum, so as to accurately stage the tumor. Surgical methods are divided into radical surgery and conservative surgery to preserve reproductive function. The scope of thorough operation includes bilateral appendages, uterus, omentum, appendectomy and pelvic and retroperitoneal lymph node dissection. For patients with extensive pelvic tumor implantation and metastasis, it is advocated to do tumor cell reduction as much as possible. Williams et al reported that the complete remission rate of postoperative chemotherapy was 83% in patients with clean surgical resection, 59% in patients with basic resection (residual tumor diameter < 2 cm) and 42% in patients with partial resection (tumor diameter > 2 cm). Therefore, although malignant germ cell tumor is sensitive to combined chemotherapy, it is still the key to successful treatment to remove the tumor as much as possible during operation.
8.3 Chemotherapy Due to the early spread of ovarian tumors, most cases can't identify the focus during surgery, and the effect and application of radiotherapy are limited. Therefore, systemic chemotherapy is an important adjuvant treatment. The tumor of some advanced patients can shrink after chemotherapy, which creates favorable conditions for reoperation.
Chemotherapy is the main adjuvant treatment for ovarian cancer, which can not only relieve the disease, but also completely eliminate the cancer focus and obviously prolong the survival period [1]. Chemotherapy is mostly used to kill residual lesions and cancer cells that are difficult to remove after surgery [1]. Except for some malignant tumors and borderline tumors of stage ⅰa and ⅰb, other patients should be given postoperative adjuvant chemotherapy [1]. Most ovarian cancers are sensitive to chemotherapy [1].
There is no unified chemotherapy scheme for the treatment of ovarian malignant tumor so far. The principles are as follows: ① it is better to use large doses intermittently and small doses continuously; The former means that each course of treatment is about 1 week, and the interval is about 3 ~ 4 weeks, which can not only achieve effective anti-tumor effect, but also help the body to eliminate toxicity and restore immune function. ② The curative effect of combined chemotherapy is better than that of single chemotherapy: modern times tend to adopt combined chemotherapy, but it should be noted that the toxic reaction of combined chemotherapy is more serious. ③ According to the drug sensitivity test, selecting sensitive chemotherapy drugs can prolong the survival time of patients. ④ Make different chemotherapy schemes according to the tissue type.
TP (paclitaxel, carboplatin or cisplatin) is commonly used for epithelial cancer, BEP (bleomycin, etoposide and cisplatin) and VPB (vincristine+cisplatin+bleomycin) are used for germ cell tumors and specific gonadal interstitial cell tumors [1].
8.3. 1 Advanced ovarian cancer is mainly treated with platinum-containing chemotherapy [1]. Platinum (carboplatin or cisplatin) combined with paclitaxel is the standard treatment for ovarian epithelial cancer [1]. Can be intravenous drip or intraperitoneal injection [1].
Intravenous infusion: paclitaxel, 135 ~ 175 mg/m2 (administered before carboplatin or cisplatin); Carboplatin, AUC 5 ~ 6 mg/(ml min) [1]. Once every 3 weeks for 6-8 cycles [1].
Intraperitoneal chemotherapy: this scheme is suitable for patients with residual lesions under microscope after cytoreductive surgery [1]. Compared with intravenous chemotherapy, intraperitoneal chemotherapy can significantly prolong the progression-free period and overall survival [1]. Because of the side effects of drugs, such as abdominal pain, gastrointestinal reaction, fatigue, hematological toxicity and neuropathy, most patients can't fully tolerate six cycles of intraperitoneal chemotherapy [1].
8.3.2 Chemotherapeutic drugs that can be considered after the failure of first-line treatment in second-line treatment are adriamycin, topotecan, gemcitabine and carboplatin, oral etoposide (daily 100mg, continuous 14 days, every 2 1 day as a cycle) and hexamethylmelamine [1] In most cases, single drug therapy is as effective as combination therapy, and the effective rate is 15% ~ 25% [1]. The effective rate of tamoxifen for these patients is 10% ~ 20% [1]. Bevacizumab is an anti-angiogenesis monoclonal antibody, which has been applied to epithelial ovarian cancer alone or in combination with cytotoxic chemotherapy drugs [1].
8.3.3 Palliative treatment of advanced ovarian cancer: cytoreductive surgery, palliative radiotherapy and salvage chemotherapy. Patients with intestinal obstruction were given positive symptomatic nutritional support and psychological counseling [1]. Due to abdominal metastasis and ascites, patients may have abdominal distension and pain. Analgesia and anti-anxiety treatment were performed according to the degree of cancer pain [1].
8.3.4 Chemotherapy scheme for epithelial cancer and sex cord stromal tumor (1)PAC scheme:
On the first day, 400mg of CTX (cyclophosphamide) was injected intravenously.
Intravenous injection of adriamycin 40mg the next day.
DDP (cisplatin)? On the third day, 80 mg was injected intraperitoneally.
(2)CFP regimen: intravenous injection of CTX 400mg on the first day.
On the second day after operation, 5FU (fluorouracil) l50mg was injected intraperitoneally.
DDP (cisplatin)? On the third day, 80 mg was injected intraperitoneally.
(3) Cleaner production scheme:
CXR 200 mg was injected intravenously for 5 days.
DDP (cisplatin) 40mg intravenous drip for 5 days.
(4)CHFP scheme:
5FU (fluorouracil) 1000mg intravenous drip, 1 day or day 8.
Intravenous infusion of DDP (cisplatin) 40mg on day/kloc-0 and day 8.
CTX (cyclophosphamide) l00mg was taken orally twice a day, on the 2nd-7th day and the 9th-16th day.
8.3.5 Chemotherapy scheme for germ cell tumors and sarcomas (1)VAC scheme: intravenous VCR 2mg on day 1.
ACD 300ug intravenous drip for 2 ~ 6 days.
Intravenous injection of CTX 300 mg for 2 ~ 6 days.
(2)FAC scheme:
5Fu (fluorouracil) 1000mg was given intravenously for 5 days.
ACD 300ug intravenous drip for 5 days.
Intravenous injection of CTX (cyclophosphamide) 300 mg for 5 days.
(3)PVB scheme:
1 day after intravenous injection of VLB 20mg (or VCR2mg).
The next day, BLM 30 mg was injected into muscle or abdominal cavity.
DDP (cisplatin) 20 ~ 30 mg intravenous drip or intraperitoneal injection 1 ~ 5 days.
The interval of each course of treatment in the above scheme is generally 3 ~ 4 weeks, depending on the patient's physique, reaction degree, hemogram and liver and kidney function. Take the medicine for at least 4 ~ 6 courses. For patients with advanced or insensitive tumors, the course of chemotherapy is more, usually 8 ~ 1 year, and it is reduced to 3 ~ 4 courses in the second year.
8.4 Radiosensitivity of radioimmunotherapy for ovarian malignant tumors varies greatly. Endodermal sinus tumor, immature teratoma and embryonic carcinoma are the least sensitive, epithelial ovarian cancer and granular cell carcinoma are moderately sensitive, and asexual cell tumor is the most sensitive. Postoperative radiotherapy can be used to control it. Because of the early abdominal metastasis of ovarian cancer, the irradiation range includes abdominal cavity and pelvic cavity. The liver and kidney areas should be protected to avoid radiation damage. The radiation dose in the whole abdominal cavity is 3000 ~ 5000 cgy/6 ~ 8 weeks.
Internal irradiation refers to intraperitoneal injection of limb gold (198AU) or phosphorus (32P), which can make the surface of abdominal cavity reach a dose that is difficult to reach by external irradiation. Because of its limited penetration, it can be used to treat abdominal superficial metastasis, residual tumor under microscope or ruptured tumor during operation, so as to improve the five-year survival rate. The disadvantage is that there must be no adhesion in the abdominal cavity, so that radioactive isotopes can be evenly distributed, otherwise it will cause intestinal damage and serious consequences. Generally, the amount of 198AU is 120 ~ 150 mCurie, and 32P is 10 ~ 20 mCurie.
8.5 immunotherapy The purpose of immunotherapy is to improve immune function [1]. Interferon, interleukin -2 and thymosin are commonly used in clinic [1].
The prevention of ovarian cancer focuses on the early detection of tumors. Early patients, whether benign or malignant, often have no obvious symptoms, and benign tumors may become malignant, so regular general surveys should be conducted. In order to find ovarian malignant tumor early, we should pay attention to the following points:
(1) All ovarian solid masses or cysts larger than 6cm should be surgically removed immediately.
(2) Ovarian masses in premenopausal and postmenopausal women should be considered as tumors. Women of childbearing age have small adnexal cystic masses. Those who do not shrink within 2 months are considered as tumors, and those who increase during the observation period are operated at any time.
(3) Pelvic inflammatory mass, especially suspected pelvic tuberculosis or endometriosis, which cannot be ruled out after treatment, should be explored by surgery.
(4) If endometrial adenomatous hyperplasia or endometrial adenocarcinoma is found after menopause, we should pay attention to whether there is a tumor in the ovary and perform surgical treatment in time.
(5) During pelvic surgery, we should carefully check whether the bilateral ovaries are diseased. In addition to the indications of ovarian diseases, if the patient is over 45 years old and needs hysterectomy due to uterine diseases, it is recommended to remove both appendages at the same time.
10 Prognosis of ovarian cancer The prognosis of ovarian cancer is poor and the 5-year survival rate is low. Long-term regular follow-up after treatment, including gynecological examination, B-ultrasound and imaging examination, tumor markers [1].
Up to now, according to the statistics of clinical data at home and abroad, the five-year survival rate of ovarian cancer is only 25% ~ 30% [1].
The prognosis of ovarian malignant tumor is related to clinical stage, pathological grade, tumor type and treatment method. The more late, the worse the effect. According to the follow-up statistics of 4892 cases admitted to 45 hospitals around the world, the 5-year survival rate of stage Ia was 72%, stage IIA was 52%, stage III was 1 1%, and stage IV was 5%.
In stage I cancer, when the tumor is confined in the cyst, the five-year survival rate can reach 90%. The worse the differentiation degree of tumor cells, the worse the therapeutic effect. The therapeutic effect of low potential malignant tumor is obviously better than that of epithelial cancer. Embryonic cancer has the worst prognosis in ovarian cancer, while asexual cell tumor has a better prognosis because of its sensitivity to radiation. In addition, untimely or improper treatment will also adversely affect the treatment effect.
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