'Silent' epithelial malignancy of the ovary/fallopian tube — vague abdominal symptoms; late diagnosis is the rule.
Also known as: ovarian cancer, epithelial ovarian cancer, fallopian tube cancer, primary peritoneal cancer, BRCA
Overview
Heterogeneous malignancy of the ovary, fallopian tube, or peritoneum. Epithelial subtypes (~90%) include high-grade serous (most common and aggressive), endometrioid, clear cell, mucinous, and low-grade serous. Non-epithelial tumors include germ cell (younger patients) and sex cord-stromal tumors. Most 'ovarian cancers' actually originate from the distal fallopian tube fimbriae.
Epidemiology
Fifth leading cause of cancer death in US women; ~20,000 new cases/year, ~13,000 deaths. Lifetime risk ~1.3% in general population; ~40% with BRCA1, ~15-25% with BRCA2. Median age at diagnosis ~63.
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High-grade serous carcinomas arise from serous tubal intraepithelial carcinoma (STIC) in fallopian tube fimbriae, with early peritoneal dissemination explaining late stage at diagnosis. TP53 mutations are nearly universal in HGSC. BRCA1/2 mutations impair homologous recombination DNA repair — confer hereditary risk and PARP inhibitor sensitivity.
Clinical presentation
Symptoms
Vague abdominal/pelvic discomfort, bloating
Early satiety, decreased appetite
Urinary urgency or frequency
Constipation or change in bowel habits
Symptoms persistent (>2 weeks) and new (within 12 months) — should prompt evaluation
GI malignancy with ovarian metastasis (Krukenberg) — Bilateral ovarian masses with signet-ring cells from gastric primary; EGD/colonoscopy
Primary peritoneal carcinomatosis — Diffuse peritoneal disease without primary ovarian mass
Ascites from cirrhosis or heart failure — Hepatic stigmata, cardiac history; SAAG calculation
Diagnostic workup
Diagnostic criteria
USPSTF 2018: Screening for ovarian cancer in asymptomatic average-risk women NOT recommended (Grade D). Genetic counseling/testing for women with personal or family history suggestive of BRCA/Lynch. FIGO 2014 staging: I (confined to ovaries/tubes), II (pelvic extension), III (peritoneal beyond pelvis ± nodes), IV (distant).
Labs
CA-125 — useful for postmenopausal women (better specificity); less reliable premenopausal due to other causes of elevation
CEA, CA 19-9 if mucinous tumor suspected or to evaluate GI primary
CBC, BMP, LFTs
Genetic testing — BRCA1/BRCA2 and broader hereditary cancer panel recommended for ALL women with epithelial ovarian, fallopian tube, or primary peritoneal cancer
BRCA1: risk-reducing salpingo-oophorectomy by age 35-40 after childbearing
BRCA2: by age 40-45
Lynch syndrome: discuss after childbearing complete
Opportunistic salpingectomy at time of benign gyn surgery for average-risk women (ACOG recommends)
Germ cell tumors
Fertility-sparing unilateral salpingo-oophorectomy + staging often appropriate
BEP chemotherapy (bleomycin, etoposide, cisplatin) for most
Excellent cure rates
Complications
Bowel obstruction (peritoneal spread) — common in advanced disease
Malignant ascites, pleural effusion
Chemo toxicity (neuropathy, alopecia, cytopenias)
VTE — increased risk
Recurrence (~70% of advanced-stage cases)
Premature menopause from BSO
PANCE pearls
Screening with CA-125 and TVUS does NOT reduce mortality in average-risk women — not recommended (UKCTOCS and PLCO trials).
All women with epithelial ovarian, fallopian tube, or peritoneal cancer should be referred for genetic counseling and BRCA/HRD testing — affects family screening and PARP inhibitor eligibility.
The 'ovarian cancer triad' of bloating, early satiety, and urinary symptoms persisting >2 weeks warrants pelvic exam, TVUS, and CA-125.
Most ovarian cancers (~70%) present at advanced stage (III-IV) because of vague early symptoms — 5-year survival ~30%.
Krukenberg tumor: bilateral ovarian metastases with signet-ring cells from a GI primary (usually gastric) — always evaluate GI tract if histology suspicious.
Opportunistic salpingectomy during benign gyn surgery reduces future ovarian cancer risk and is now recommended by ACOG.
Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants.