Ovarian cancer. Staging
Staging classification is made on the basis of surgical evaluation, and the removal of as much tumor as possible is the cornerstone of treatment. Despite the importance of surgery, some type of adjunctive treatment is almost always required. The proper surgical procedure and the appropriate choice of adjunctive therapy depend on the findings at initial exploration, the histologic type of the tumor, and the age and reproductive desires of the patient. There are few diseases encountered by the gynecologist that will demand as much knowledge and skill as the therapy of ovarian cancer.
Cancer
Staging
The FIGO staging classification scheme for ovarian cancer is outlined in the box, page 42. The staging of advanced disease (spread throughout the abdomen) may be obvious to most physicians, but it is important for a surgeon to be meticulous in the staging of early ovarian cancer. In one study it was found that one third of patients referred with stage I or stage II disease were actually found to have stage III disease when the appropriate staging operation was performed. Similar results have been reported by other researchers. Buy cheap levitra at Canadian Pharmacy
To perform a staging operation appropriately, the spread patterns of the cancer should be understood. The cancer can spread by direct infiltration of pelvic structures such as the pelvic peritoneum, bladder surface, rectal surface, fallopian tube, broad ligament, or uterus. Lymphatic spread occurs early in ovarian cancer, with nodal metastases occurring in 10-12% of patients with stage I cancer and 2025% of patients with stage II disease. In stage III and stage IV, the incidence of positive lymph nodes is 50-70%. By far, however, the most significant spread of ovarian cancer is exfoliation of clonogenic cells into the peritoneal cavity. These cells are swept up the right abdominal gutter to the diaphragm and omentum by the clockwise flow of peritoneal fluid in the abdomen. The cells implant, form tumor nodules, and in turn exfoliate more cells. The normal daily activities of the patient and normal peristalsis of the intestine result in spread of the disease throughout the abdominal cavity. Proper staging requires a generous lower and upper midline incision and meticulous exploration with multiple peritoneal and nodal biopsies.
In young patients who wish to bear children and have epithelial, germ cell, or stromal tumors confined to one ovary, conservation of the uterus and other ovary and fallopian tube is possible, provided that a full surgical staging procedure is performed. In these patients, it is particularly important to be meticulous in the evaluation of the entire abdomen.