ovarian cancer : Treatment Options by Stage and Type of Tumor

Stage 1 - Epithelial Cancer
Several options exist for limited, Stage 1 epithelial cancer, which occurs in approximately 15% of women (see also Types of Ovarian Cancer)

Surgery should be performed in women who have finished childbearing. This includes total hysterectomy, complete removal of the uterus; bilateral salpingo-oophorectomy, removal of the fallopian tubes and ovaries; omentectomy, removal of the fatty tissue that covers the bowels; and lymphadenectomy, removal of one or more lymph nodes.

Modified ("conservative") surgery - surgery that leaves tumor-free reproductive organs intact - may be conducted in women who still wish to still have children if (1) the tumor is confined (usually not serous or endometriotic in type, which tend to be bilateral tumors), and (2) wedge biopsy of the opposite ovary shows no evidence for disease involvement. Such a procedure carries an increased risk of relapse; therefore, total hysterectomy and salpingo-oophorectomy should be performed immediately after childbearing is complete.

The role of adjuvant, or additional, treatment in patients with early epithelial ovarian cancer remains controversial. Yet results from a patient's histopathology report may suggest additional care, such as:

radiotherapy plus chemotherapy;
combination chemotherapy; or
participation in a clinical trial that evaluates immediate versus delayed chemotherapy.
Some studies suggest that systemic (whole body) chemotherapy may be less hazardous than radiotherapy, especially after the patient's abdominal lymph nodes have been removed (see also Chemotherapy and Radiotherapy). Although radiotherapy can decrease the rate of cancer relapse in the pelvis, relapse rates are unchanged in intra-abdominal areas and distant sites, and overall survival is unaffected.

Stage 1 - Germ Cell Tumor
Germ cell tumors, which arise from cells that normally form the eggs, usually are benign and tend to occur in women younger than age 30. If the germ cell tumor is a dysgerminoma (the most widespread germ cell tumor, representing nearly half of all cases), initial treatment begins with surgery to remove the tumorous ovary and the corresponding fallopian tube on the same side - known as unilateral salpingo-oophorectomy.

Adjuvant therapy for such patients may involve follow-up radiotherapy, or chemotherapy, if the woman wants to bear children in the future.

If the germ cell tumor is a nondysgerminoma (e.g., an embryonal carcinoma, immature teratoma, choriocarcinoma, polyembryoma, or mixed germ cell tumor), treatment includes surgery (unilateral salpingo-oophorectomy) to remove the tumorous ovary and the corresponding fallopian tube on the same side, with or without follow-up chemotherapy, or participation in a clinical trial of new chemotherapeutic drug combinations.

The only patients who generally do not require systemic therapy are women with Stage 1A, Grade 1 immature teratoma.

Sex-Cord Stromal Tumor (All Stages)
Because of the extreme rarity of sex-cord stromal tumors and because of their variable biologic behavior, no standard therapy exists for these tumors (see also Types of Ovarian Cancer). For example, granulosa cell tumors often respond well to therapy in younger women, whereas the same tumors may be more aggressive and difficult to manage in women over 40. But the cornerstone of most treatments is surgery to remove as much of the tumor as possible.

Many Sertoli-Leydig cell tumors appear on one side only, so if the patient is young and has early-stage disease (e.g., Stage 1A), the physician may recommend modified surgery to remove only the tumorous ovary and fallopian tube on the same side (unilateral salpingo-oophorectomy).

By contrast, older patients or those with advanced-stage or bilateral disease may benefit from more extensive surgery, including total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, lymphadenectomy, and tumor debulking.

If the stromal cell tumor is malignant, metastatic, and/or if the tumor tends to recur (e.g., granulosa cell tumors recur after 5 or 10 years in many patients), combination chemotherapy also may be beneficial, especially platinum-based combinations, such as cisplatin/vinblastine/bleomycin (PVB).

There are few findings concerning the usefulness of radiotherapy for sex-cord stromal tumors. Ongoing studies suggest that hormonal therapy (with progestins, estrogens, gonadotropin-releasing analogs, etc.) may have a future role in the management of sex-cord stromal tumors; however, to date, the findings are inconclusive.

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Stage 2 - Epithelial Cancer
The first form of treatment for Stage 2 epithelial cancer is surgery, including total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, lymphadenectomy, and tumor debulking.

After surgery, follow-up therapy may include combination chemotherapy with/without radiotherapy, or participation in a clinical trial that evaluates new chemotherapeutic drugs or drug combinations.

Note: In order to evaluate the benefits and disadvantages of chemotherapy, some researchers have divided Stage 1 and Stage 2 epithelial cancer patients into "favorable" and "unfavorable" groups. The favorable group has ovarian cancer with the following characteristics:
growth that is limited to one or both ovaries
an intact ovarian capsule (outer wall)
no evidence of tumor on the outer surface of the ovary
no evidence of tumor cells in pelvic washings
low grade (well-differentiated or moderately well-differentiated) type
The unfavorable group is identified by:

tumors with surface involvement
a ruptured capsule
evidence of tumor cells in pelvic washings
high grade (poorly differentiated) type
Study findings suggest that the favorable group is not helped by the administration of chemotherapy. By contrast, the unfavorable group may benefit from some form of post-operative therapy; however, the exact protocol for such therapy remains to be established. Therefore, systemic chemotherapy should be considered for patients who have a 25% or greater chance of relapse.

Stage 2 - Germ Cell Tumor
If the germ cell tumor is a dysgerminoma (the most widespread germ cell tumor, representing nearly half of all cases), treatment may start with surgery, including total hysterectomy and bilateral salpingo-oophorectomy, followed by radiotherapy.

However, if the patient's cancer is limited to one ovary and its corresponding fallopian tube, and if she wants to bear children in the future, modified surgery may be performed to remove only the cancerous ovary and fallopian tube on the same side (unilateral salpingo-oophorectomy), followed by chemotherapy.

If the germ cell tumor is another, nondysgerminomatous variety, treatment will begin with surgery, including total hysterectomy, bilateral salpingo-oophorectomy, and tumor debulking, or modified surgery (unilateral salpingo-oophorectomy). Surgery is followed by chemotherapy, and/or follow-up surgery to remove as much remaining cancerous tissue as possible.

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