Treatment Guidelines for Ovarian Cancer

(2022 Edition)

I. Overview

In China, the annual incidence rate of ovarian cancer ranks 3rd in female reproductive system tumors, after cervical cancer and uterine body malignant tumors, and is increasing year by year. The rate of death is the highest among malignant tumors of female reproductive tract, which is a serious threat to women’s health. The most common type of ovarian malignancy is epithelial carcinoma, which accounts for about 80% of ovarian malignancies, followed by malignant germ cell tumors and interstitial tumors of the sex cords, each accounting for about 80% of ovarian malignancies. family:Times New Roman”>10% and 5%, and this guideline focuses on ovarian epithelial carcinoma and malignant germ cell tumors. The incidence of fallopian tube cancer and primary peritoneal cancer is low, and their biological behavior is similar to that of ovarian epithelial cancer, so the principles of diagnosis and treatment can be referred to the guidelines for ovarian epithelial cancer. For clinical cases not covered by this guideline, the physician in charge is advised to give reasonable individualized treatment according to the patient’s condition and encourage participation in clinical trials.

II. Diagnostic Techniques and Applications

(A) Screening methods and high-risk groups.

The ovaries are deep in the pelvic cavity, and ovarian lesions in their early stages often have no specific clinical symptoms; by the time they are seen for symptoms, 70% of patients are already in advanced stages. span>70% of patients are already in advanced stage. Therefore, early diagnosis of ovarian cancer is of great importance. However, the available data from general population studies show that both glycogen antigen (carbohydrate antigen, The results of screening with 125, transvaginal ultrasound alone, or a combination of the two are not satisfactory. The screening methods for the general population need to be further explored.

Epidemiologic statistics suggest that the lifetime risk of ovarian cancer in the general population is only 1.5 times higher than that of the general population. family:Times New Roman”>1%. There are about 20 known genetic susceptibility genes associated with ovarian cancer, including breast cancer susceptibility genes (breast cancer susceptibility gene, BRCA) had the most significant effect. The cumulative lifetime risk of ovarian cancer for BRCA1 and BRCA2 germline mutation carriers was 3.5 and 3.5, respectively. span style=”font-family:Times New Roman”>54% and 23%, respectively, and are at high risk for ovarian cancer. For BRCA1/2 germline mutation carriers, the recommended starting point is 30 to 35 years of age for regular combined pelvic examination, blood CA125 and transvaginal ultrasound screening. Screening for BRCA1/2 germline mutations can be performed with peripheral blood or saliva specimens by second-generation sequencing. The detection of these two mutations not only helps to identify individuals at risk for ovarian cancer, but also has prognostic and therapeutic implications for patients with ovarian cancer (see the section on targeted therapies for details). In addition, women with Lynch syndrome and Leigh-Fraumeni syndrome are at high risk for ovarian malignancy and require testing for ATM, ATM, ATM, and ATM. family:Times New Roman”>RAD51C, RAD51D, RAD51D, MLH1 , MSH2 , and

MSH6, PSM2, EPCAM, STK11 and others. In cases where there is a clear family history, but it is not possible to determine which genetic syndrome is present, genetic-related polygenic testing may be considered. The results of the test should be consulted with the appropriate physician for guidance on risk, screening methods, and diagnosis and treatment.

(ii) Clinical presentation.

Symptoms

Ovarian epithelial cancer is mostly seen in postmenopausal women. Because the ovaries are deep in the pelvis, early symptoms of ovarian epithelial carcinoma are not obvious and often non-specific, making early diagnosis difficult. In the late stage, the symptoms are mainly due to enlargement of the mass or fluid accumulation in the pelvic and abdominal cavities, including discomfort in the lower abdomen, abdominal distension, and loss of appetite, etc. Some patients show rapid increase in abdominal circumference in a short period of time, accompanied by weakness and weight loss. The symptoms of increased frequency of urination and defecation may also occur due to mass compression. The patient may have shortness of breath and difficulty lying down if a pleural effusion is present.

Ovarian malignant germ cell tumors are common in young women. The symptoms of acute abdomen may appear due to tumor torsion or tumor rupture. About 60% to 70% of patients are in the early stage when they are seen.

Signs

Clinical examination may reveal a pelvic mass or a nodule in the rectal sink of the uterus. The epithelial carcinoma is mostly bilateral, cystic or solid, and the nodes are uneven and mostly adherent to the surrounding area. If there is lymph node metastasis, enlarged lymph nodes can be found in the groin and supraclavicular region. Malignant germ cell tumors 95% or more are unilateral. The abdomen is positive for mobile turbid tones on examination in the presence of massive ascites.

(iii) Ancillary tests.

Tumor marker examination

Blood CA125, human epithelial protein , human epithelial protein span style=”font-family:Times New Roman”>4 (human epididymis protein 4, HE4) is the most valuable tumor marker used in ovarian epithelial cancer for adjuvant diagnosis, efficacy monitoring, and recurrence monitoring.

CA125: the most commonly used tumor marker for ovarian cancer, especially the tumor marker of choice for plasma cancer. The positive rate of CA125 is related to the tumor stage and histological type, and is significantly higher in patients with advanced stage, plasma carcinoma than in early stage and non-plasma carcinoma. span style=”font-family:Times New Roman”>43.5%~ of early-stage ovarian cancer patients. span>65.7%, and the positivity rate for advanced ovarian cancer was about 84.1%~92.4%). One study found thatCA125 is of higher value in the postmenopausal population, and in the postmenopausal populationThe sensitivity of CA125 in the diagnosis of ovarian cancer (79.1%79.1%~90.7%) and specificity (79.1%< ～ 89.8%) were better than premenopausal population (sensitivity 69.8%~ 87.5% span style=”font-family:Arial”>, specificity63.3%~ 85.7%) . After surgical procedure or chemotherapy.

87% to 94% of ovarian cancer cases have a good correlation between blood CA125 concentration and disease progression, which can indicate tumor progression or regression. It has been suggested that after satisfactory tumor reduction, 7 days CA125 can decrease to the initial level of CA125. style=”font-family:Times New Roman”>75% or less.
HE4:HE4is nearly 10 years of clinical use, its diagnostic specificity for ovarian cancer (about ) is very high. family:Times New Roman”>90% –95% ) higher than CA125(76.6%~86.5%< (). HE4 levels are not affected by the menstrual cycle and menopausal status, and are specific for the diagnosis of ovarian cancer in premenopausal people

(88.4% to 96.8%) outperformed CA125 (63.3%~85.7%).
ROMA Index:ROMA Index is an index that will CA125 and A model to assess the serum concentration of HE4 in combination with the patient’s menopausal status, whose value depends on CA125,HE4serum concentrations, hormones and menopausal status. status. The study showed that

shows that in premenopausal patients, the sensitivity of the ROMA index for diagnosing ovarian cancer averaged 76.0% ( 70.2% to 81.0% ), with specificity of about 85.1%

(80.4% to 88.8%) 88.8%), and in postmenopausal patients, the sensitivity was about

90.6% (87.4% to 93.0%), with specificity of about 79.4% (73.7% ~

84.2%).

Other: markers associated with ovarian malignant germ cell tumors include: alpha-fetoprotein (alpha-fetal protein, AFP, elevated in yolk sac tumors, embryonal carcinomas and immature teratomas; human chorionic gonadotropin (β- human chorionic gonadotrophic hormone, β-hCG), elevated in non-pregnant choriocarcinoma of the ovary; neuron-specific enolase

(neuron-specific enolase, NSE), elevated in immature teratomas or tumors with neuroendocrine differentiation; lactate dehydrogenase (lactic acid dehydrogenase, LDH), elevated in asexual cell tumors; CA19-9, elevated in asexual cell tumors; CA19-9 span>, elevated commonly in immature or mature teratomas.

Other ovarian epithelial tumor markers include: CA199, elevated in mucinous ovarian cancer or certain junctional tumors, or in metastatic ovarian cancer of the gastrointestinal tract Carcinoembryonic antigen (carcinoembryonic antigen, CEA), elevated is commonly seen in gastrointestinal metastatic ovarian cancer.

When the nature of the ovarian tumor is not clear, a combination of these tumor markers can be used for initial determination and differentiation.
- Imaging
The main imaging methods for ovarian cancer include ultrasonography (transvaginal or transabdominal ultrasound), CT, MRI and so on, which can clarify the tumor morphology, invasion range, and the extent of the tumor.

With the help of qualitative diagnosis, gastrointestinal imaging, intravenous urography and chest mortem can be performed accordingly if adjacent organs are suspected to be invaded and distant metastasis is present. font-family:Times New Roman”>CT and so on. The combination of these imaging methods allows for preoperative clinical staging, postoperative follow-up, and post-treatment monitoring of ovarian cancer.

Ultrasound: Ultrasound is the first choice for ovarian cancer screening, which can identify the presence of occupying lesions in the ovary and determine the benignity and malignancy of the tumor. It can clarify the presence of occupying lesions in the ovary and determine the benign and malignant nature of the tumor. The morphologic features of the tumor are the main criteria for identifying benign and malignant ovarian tumors by ultrasound.

Transvaginal sonography (transvaginal sonography, transvaginal sonography, transvaginal sonography. “font-family:Times New Roman”>TVS) has a probe close to the ovary, high image resolution, and is not disturbed by obesity or intestinal gas, and has higher sensitivity and specificity for the diagnosis of ovarian cancer. Transrectal ultrasound can be used in women without a history of sexual intercourse. Transabdominal ultrasound is an important complement to vaginal ultrasound, as it is not possible to obtain a complete view of the tumor if it is too large. In addition, transabdominal ultrasound can assess the invasion of surrounding organs, retroperitoneal lymph node metastases, and abdominal implant metastases, such as the presence of ureteral dilatation, ascites, and peritoneal implants in ovarian cancer.

Color Doppler is useful for differentiating benign from malignant ovarian tumors, which exhibit higher peak flow velocities and lower flow resistance indices than benign tumors. Ultrasonography can be used to visualize the internal blood supply of the tumor, especially the microvasculature, which is better than Doppler, and is useful for differential diagnosis and efficacy evaluation, especially for the evaluation of the efficacy of molecularly targeted drugs such as anti-angiogenic drugs. In addition, ultrasound microbubble contrast can be used to mediate targeted drugs and gene therapy.

Ultrasound is used for regular follow-up after treatment, and its cheapness and lack of radiation are its greatest advantages, focusing on the presence of metastases in the liver and spleen, hydronephrosis in both kidneys, and peritoneum.

implantation, ascites, new lesions in and around the vaginal stump, paravalvular lymphatic cysts and their progression, paravalvular, retroperitoneal lymph nodes, supraclavicular and inguinal lymph nodes. The lymph nodes of the iliac vessels, retroperitoneal lymph nodes, supraclavicular and inguinal lymph nodes were examined. In addition, in elderly or severely ill patients, cardiac ultrasound is required to detect cardiac function and vascular ultrasound to detect complications such as deep silent artery thrombosis, and ultrasonography can help distinguish tumor thrombosis from thrombosis.

For ultrasound interventions, ultrasound-guided puncture can be used to obtain a cytologic or pathologic diagnosis in patients in whom satisfactory tumor reduction is not expected or in whom the patient is too frail to tolerate major surgery. The puncture site can be chosen from the pelvic tumor, thickened greater omentum, and peritoneum. In addition, in cases of significant pelvic floor peritoneal thickening, transvaginal or rectal ultrasound-guided biopsy may be performed. However, it should be noted that for isolated ovarian tumors without clear metastases on comprehensive preoperative imaging, especially in suspected early-stage ovarian cancer, puncture biopsy should be selected with caution to avoid medical tumor dissemination due to puncture_..

AbdominopelvicCT:abdominopelvic CT is the most commonly used test for ovarian cancer, allowing observation of microscopic fat and calcifications within the lesion, and aiding in the detection of tumors of ovarian genital cell origin;CT The scan is fast and can be performed simultaneously on both the abdomen and pelvis with a single breath hold, which is valuable for evaluating the extent of the tumor and peritoneal metastasis and can assist in clinical staging. Enhanced scanning should be performed if there is no contraindication to contrast. CT images of the primary epithelial ovarian cancer show irregular or lobulated cystic tumors in the pelvis or lower abdomen with variable wall and intracapsular septa. The cystic wall and intracapsular septa vary in thickness, and may be accompanied by nodular or papillary protrusions; the solid part has irregular morphology and heterogeneous density, and enhancement scan shows heterogeneous enhancement. Ascites and peritoneal and omental metastases are common in ovarian cancer,CT

Imaging may show flattened, pancake-like soft tissue masses in the omental area with uneven density and irregular margins. It is unevenly dense, with irregular margins and poorly defined. Peritoneal metastases may appear as irregular soft tissue nodules and masses on the surface of the abdominal cavity, liver, spleen, colon, and other organs. However, CT is less sensitive in early-stage ovarian cancer and in those without significant changes in ovarian morphology.

Pelvic Pelvic MRI : high resolution of soft tissue, its multi-parameter, dynamic enhancement scan can show the nature of tissue components and hemodynamic characteristics of the lesion, and has the advantage of observation of fat, bleeding and other components, and its accuracy of identifying benign and malignant ovarian tumors can reach . The accuracy of identifying benign and malignant ovarian tumors can reach 83%~91%;MRI helps to determine the origin of the pelvic mass and aids CT in the preoperative staging of ovarian cancer. The MRI imaging characteristics of the primary focus of ovarian cancer are similar to those of CT is similar, with cystic solid masses, irregular cystic walls and compartments, papillary nodules and inhomogeneous enhancement as the main features, but MRI MRI is similar. Roman”>MRI scans are limited in scope and sensitive to motion-induced displacement, and therefore less effective in patients with peritoneal metastases and massive ascites than CT, which can be used as an abdominopelvic CT CTis a useful complement to Pelvic dynamic enhancement MRI delayed phase combined with diffusion-weighted imaging can assist in the preoperative evaluation of patients undergoing primary tumor reduction; combined with Clinical serum tumor markers CA125 testing can be used to evaluate postoperative recurrence of ovarian cancer.

(4 ) Single-photon emission computed tomography (single photon emission computed tomography, SPECT): SPECT whole-body bone imaging is useful for the diagnosis of bone metastases from ovarian cancer, and when whole-body bone imaging suggests suspicious bone metastases, tomographic fusion imaging or MRI, CT, etc. for further verification.

(5) Positron Emission computerized tomography (positron emission tomography-computed tomography, PET-CT): PET-CT is an advanced functional imaging tool that can reflect the metabolic status of the lesion before treatment PET-CT imaging helps to differentiate benign from malignant ovarian cancer and helps to detect occult metastases for more accurate staging; PET-CT synchronous enhancement CT scanning facilitates the detection of small lesions. However, PET-CT is still more expensive and is not recommended as a routine test. It is mainly used in cases where the diagnostic staging is unclear on routine imaging and has the potential to influence treatment options, evaluate efficacy after treatment, or determine the extent of metastasis after recurrence. According to the National Comprehensive Cancer Network (National Comprehensive Cancer Network, NCCN) guidelines, the use of PET-CT may be recommended in the following cases if clinically deemed necessary: (i) when benign or malignant pelvic masses are difficult to differentiate; (ii) for follow-up monitoring after the end of treatment for tumors of epithelial origin of the ovary; (iii) for malignant germ cell tumors and malignant interstitial sex cord tumors with typical symptoms, abnormal findings on physical examination or elevated tumor markers during follow-up; ④ I stage 2, 3 levels and II to IV stage immature teratomas, embryonal tumors of any stage, yolk sac tumors of any stage, and II to II to IV stage immature teratomas, embryonal tumors of any stage, yolk sac tumors of any stage, and family:Times New Roman”>stage IV asexual cell tumors after chemotherapy for follow-up monitoring.

Cytology and histopathology

Most ovarian malignancies are associated with abdominal or pleural effusions, and cytology of abdominal or pleural effusions can reveal cancer cells.

Histopathology is the gold standard for diagnosis. For patients with high clinical suspicion of advanced ovarian cancer, laparoscopic exploratory biopsy can not only obtain tissue specimens, but also provide a better understanding of the patient’s condition.

The histopathology is the gold standard for diagnosis of patients with high clinical suspicion of advanced ovarian cancer.

Gastroenteroscopy

Patients with pelvic masses need to be excluded from gastrointestinal primary tumors with ovarian metastases, especially in relatively young patients with significant elevation of serum CEA to rule out gastrointestinal metastases.

Laparoscopy

As a minimally invasive procedure, laparoscopic exploration biopsy is feasible for some patients with pelvic masses and ascites who need to exclude pelvic inflammatory masses or tuberculous peritonitis, avoiding unnecessary open surgery. Abdominopelvic exploration can also be used to determine whether satisfactory tumor reduction surgery can be achieved (see Treatment section for details).

III.

When pelvic masses are found clinically, they need to be differentiated from the following diseases.

(a) Endometriosis.

This disease can also form pelvic masses with elevated serum CA125. However, this disease is common in women of childbearing age, who may have secondary, progressive dysmenorrhea and infertility. Blood CA125 is often mildly to moderately elevated and may be accompanied by palpable nodules in the pelvic floor and sacral ligaments on examination.

(ii) Inflammatory pelvic masses.

Pelvic inflammatory disease can also form cystic or solid masses, similar to ovarian cancer, most often with a blood CA125 rise. elevation. Patients with pelvic inflammatory masses often have a history of abortion, IUD placement or removal, postpartum infection, or pelvic inflammatory disease.

The main clinical manifestations are fever, lower abdominal pain, and significant tenderness on bimanual examination, and the mass shrinks after effective anti-inflammatory treatment, CA125 decreased.

(iii) Benign ovarian tumor.

Benign tumors often occur unilaterally with good mobility, smooth surface, and intact envelope. Patients are in good general condition and CA125 is normal or only mildly elevated. The imaging usually shows a smooth-walled cystic or solid mass, usually without significant abdominopelvic fluid.

(iv) Pelvic and abdominal tuberculosis.

Patients often have a history of tuberculosis and infertility, and may have symptoms such as wasting, low-grade fever, and night sweats. When peritoneal TB is combined with ascites, it can be combined with elevated CA125. In some cases, the diagnosis is difficult to make clinically, and laparoscopy can be considered when cytologic examination of ascites fails to detect malignant cells, making a definitive diagnosis difficult.

(v) Metastatic carcinoma of the ovary.

Metastatic tumors of the gastrointestinal tract and breast can metastasize to the ovary. The metastatic ovarian tumors often present as bilateral solid or cystic masses. Ovarian metastases from gastric cancer are also referred to as Kuchenberg’s tumor. The differential diagnosis is based on clinical history, imaging, pathology, and immunohistochemical staining.

4. Pathologic classification and surgical pathologic staging

Histopathological histological examination is the gold standard for ovarian cancer diagnosis. The main pathological types of ovarian epithelial carcinoma are: plasmacytoma (70% to 80%), endometrioid carcinoma (80%), and endometrial carcinoma (80%). span style=”font-family:Times New Roman”>10%), clear cell carcinoma (10%), mucinous carcinoma (3%), and other rare pathological types (Table 1). Among them, plasmacytoma is the most common and is classified as low-grade serous carcinoma (low-grade serous

low-grade serous carcinoma, low-grade serous carcinoma, and low-grade serous carcinoma. carcinoma, LGSC) and high-grade plasmacytoma (high-grade serous carcinoma, HGSC). At the genetic level, LGSC has high-frequency KRAS and KRAS and BRAF mutations, but rare TP53 mutations; HGSC is characterized by a high degree of genetic instability and TP53 mutations in almost all cases. LGSC usually occurs bilaterally and has a variety of structural patterns microscopically, including single cells and irregularly shaped nests of small cells infiltrating the interstitium haphazardly, micropapillae or, less commonly, large papillae, and peripherally separated hyaline spaces; the different infiltration patterns often coexist. Many LGSC have a coexisting junctional plasmacytoma/ atypical proliferative plasmacytoma component. In contrast to HGSC, necrosis is almost never detected, sand granules are common, and nuclear division activity is low (usually <3/ 10HPF). HGSC are usually composed of solid cell clumps with lacunar-like lacunae. There are often papillary, glandular, and sieve-like areas, and necrosis is common, with large, deeply stained and pleomorphic nuclei, often with large odd-shaped or multinucleated nuclei. Nucleoli are usually distinct and may be large and eosinophilic. Nuclei are numerous and often have atypical nuclear schizophrenia. The number of granules varies. The three main types of ovarian germ cell tumors are yolk cystic tumors, asexual cell tumors, and teratomas, as well as some tumors of monodermal origin (Table 1). The various histologic types of ovarian epithelial cancer differ in pathogenesis, immunophenotype, mutated genes, and prognosis (Table 2).

The pathology report emphasizes standardization and standardization. It should include tumor size, growth pattern, pathologic staging, degree of differentiation, choroidal emboli, extent of metastasis, and whether the ovarian surface or the plasma surface of the fallopian tube is invaded in early-stage cancer, as well as immunohistochemistry and molecular pathology. In addition, there is an additional link to the ovarian

Targeted therapies, biological behavior, and prognosis of ovarian cancer are also available for clinical reference.

The establishment and application of modern molecular biology-based tests such as genomics, proteomics, and metabolic enzymology will identify molecular markers with greater specificity and sensitivity and may help predict tumor response, metastatic tendency, and prognosis. The results of this study will be presented in the following sections.

Table 1 Histologic types of ovarian epithelial carcinoma/germ cell tumors

< tr style="height: 46px">

Tumor type	ICD-O coding
Plasmacytosis
Benign
Plasmacytoid cystadenoma >	8441/0
Plasmacytoid adenofibroma	Plasmacytoid adenofibroma	9014/0
Plasmacytoid surface papilloma	8461/0
Junctionality
Junctional plasmacytoma	8442/1
Junctional plasmacytoma–micro papillary subtype	8460/2
Malignant

Low-grade plasmacytoma	8460/3
High-grade plasmacytoma	8461/3
< strong>Mucinous tumors
Benign<
Mucinous cystadenoma	8470/0

< td>

Junctional endometrioid tumor

Mucinous adenofibroma Junctional	< span style="font-family:Times New Roman; font-size:12pt">9015/0
junctional mucinous neoplasm	8472/1
malignant
Mucinous carcinoma	8480/3
Endometrioid tumors
Benign
Endometrioid cystadenoma	8380/0
Endometrioid adenofibroma	8381/0
Junctionality
8380/1
malignant
endometrioid carcinoma	8380/3
Clear cell tumors
Benign
clear cell cystadenoma	Benign	8443/0
clear cell adenofibroma	8313 /0
Junctionality
Junctional clear cell neoplasm	8313/1
malignant
clear cell carcinoma Brenner< span style="font-family:Microsoft JhengHei">Tumor	8310/3
benign

Malignant

td>

8323/3

BrennerTumor Junctional	< span style="font-family:Times New Roman; font-size:12pt">9000/0
Junctional Brenner Tumor	9000/1<
Malignant

Malignant Brennertumor		9000/3
pulp– Mucinous tumor
Benign<
Benign< span style="font-family:Times New Roman">–Mucinous cystadenoma	8474/0
Pulp–Mucinous adenofibroma	9014/0
Junctionality
	Junctional Pulp–mucinous tumors Other types of cancer	8474/1
Middle renal duct-like carcinoma	9111/3
Dedifferentiated and undifferentiated carcinoma	8020/3
Carcinosarcoma	8980/3
Mixed cancer
Tumors of mesenchymal origin
Intimal mesenchymal-derived tumors
Low-grade endometrioid mesenchymal sarcoma	8931/3
High-grade endometrioid mesenchymal sarcoma	8930/3
Mixed epithelial–mesenchymal tumor
Adenosarcoma	8933/3
Carcinosarcoma	8980/3

Cellular tumors

Germ cell tumors
Asexual cell tumors	9060/3
Yolk sac tumor	< span style="font-family:Times New Roman; font-size:12pt">9071/3
embryonal carcinoma	9070/3
Non-pregnant choriocarcinoma	9100/3
Mature Teratoma	9080/0
immature teratoma	9080/3 >
Mixed germ cell tumors	9085/3
< span style="font-family:Arial; font-size:12pt">Mixed germ cell tumors	Monodermal teratomas and bodies originating from cortical cysts
Cellular tumors

Ovarian goiter, benign	9090/0
Ovarian goiter, malignant	9090/3
Carcinoid	8240/3
Neuroectodermal Tumors	9084/3
monodermal teratoma	9080/0
Origin of somatic malignancies of teratoma	9084/3

Table 2 Common immunohistochemical markers and mutated genes for each subtype of ovarian epithelial carcinoma

Common immunohistochemical markers of common mutated genes
High-grade plasmacytoid carcinoma
P53 mutant type
TP53WT1+BRCA1/2Pax8+Ki67 Highly expressed low-grade plasmacytomaWT1+BRAFPax8+KRASp53 Wild-type Ki67 Lowly expressed endometrioid carcinomaER+PTENPax8+CTNNB-1(beta-catenin)Vimentin+WT1-p53 Wild-type clear cell carcinomaHNF beta+KRASWT1-PTENPIK3CAER-mucinous carcinoma CK7+KRASCdx2+CK20+PR-WT1-
The International Federation of Gynecology and Obstetrics (FIGO) 2013 revised surgical pathology staging system (Table 3) was used for ovarian epithelial carcinoma, fallopian tube carcinoma, primary peritoneal carcinoma, and other types of ovarian malignancies.
Table 3 FIGO 2013 Staging for ovarian epithelial, fallopian tube, and peritoneal cancer
FIGO
I Tumor confined to one or both ovaries/fallopian tubes
I A Tumor confined to one ovary/fallopian tube
The envelope is intact and the surface of ovary and fallopian tube is free of tumor ascites or abdominal irrigation fluid
ⅠB Tumor is confined to both ovaries/fallopian tubes
The envelope is intact, and there is no tumor ascites on the surface of ovaries and fallopian tubes or no tumor cells in the abdominal irrigation fluid
ⅠC Tumor confined to one or both ovaries/fallopian tubes and combined with the following features
ⅠC1 Intraoperative rupture of tumor
ⅠC2 Preoperative rupture of tumor or tumor located on the surface of ovary and fallopian tube
ⅠC3 Malignant tumor cells in ascites or peritoneal washings
Ⅱ Unilateral or bilateral ovarian/fallopian tube cancer or primary peritoneal cancer with intrapelvic tumor invasion
IIA Tumor invasion or implantation in uterus/fallopian tube/ovary
IIB Tumor invasion or implantation in other pelvic organs
III Ovarian/fallopian tube/primary peritoneal cancer with pathologically confirmed extra-pelvic abdominal metastasis and/or retroperitoneal (pelvic and/or para-abdominal aortic) lymph node metastasis
IIIA
IIIA1 pathologically confirmed lymph node metastasis only
IIIA1i Metastases ≤ 10 mm in maximum diameter

ⅢA1ii Maximum diameter of metastatic foci>10mm
IIIA2 Microscopically visible extra-pelvic peritoneal metastasis
ⅢB Extrapelvic peritoneal metastasis with maximum diameter ≤2cm visible to the naked eye
ⅢC Extrapelvic peritoneal metastases visible to the naked eye with a maximum diameter of >2cm (including hepatosplenic peritoneal metastases without parenchymal involvement)
IV
ⅣA pleural effusion with positive cytology
ⅣB hepatosplenic parenchymal metastasis
extra-abdominal organ metastases (including inguinal lymph nodes and lymph nodes beyond the pelvic abdomen)
Tumor invasion through the entire intestinal wall
V. Treatment
Surgery and chemotherapy are the mainstay of treatment for ovarian malignancies. A very small number of patients can be cured by surgery alone, but the vast majority of patients need surgery combined with chemotherapy and other comprehensive treatments. In recent years, with the advancement of drug therapy, more and more molecularly targeted drugs have been approved for the treatment of ovarian cancer.
(i) Surgery.
Surgery is important in the initial treatment of ovarian malignant tumors. The purpose of surgery is to remove the tumor, clarify the diagnosis, accurately stage the tumor, determine the prognosis, and guide the treatment.
Initial surgery for ovarian cancer includes comprehensive staging surgery and tumor cytoreductive surgery. Patients who are clinically judged to be in early stage should undergo full staging surgery to clarify
The final stage should be determined. Patients with intermediate to advanced stage should undergo tumor cytoreduction. If preoperative suspicion of malignancy is present, open surgery is recommended. The use of laparoscopic surgery for full staging of early-stage ovarian cancer has been reported in recent years, but remains controversial. The main use of laparoscopy in advanced ovarian cancer is to make a definitive diagnosis and to assist in determining whether satisfactory tumor reduction is possible.
Full-stage surgery

For patients with clinical stage I ovarian malignancy. The aim is to remove the tumor, stage the full surgical pathology, and evaluate the prognosis and develop a chemotherapy plan based on this. Surgical steps: (1) A longitudinal incision is made in the lower abdomen, and after entering the abdominal cavity, ascites is first taken for cytological examination. If there is no ascites, the abdominopelvic cavity is flushed with saline and the flushing fluid is taken for cytologic examination. (2) The internal organs of the abdominopelvic cavity, including all mural peritoneal surfaces, are carefully explored comprehensively. In addition to biopsy of suspicious areas, biopsy of the peritoneal regurgitation of the bladder, the rectal recess of the uterus, the peritoneum of the bilateral paracolic sulcus, and the subdiaphragmatic peritoneum (subdiaphragmatic cytology can also be performed using cytoscrapers) should be performed. The primary tumor, if confined to the ovary, should be carefully examined for peritoneal integrity.

(3) Total uterus and both ovaries and fallopian tubes are removed, and the greater omentum and any visually suspicious lesions are removed under the transverse colon. The tumor was removed as completely as possible to avoid rupture. The pelvic funnel ligament on the side where the tumor is located should be removed by high ligation. (4) Appendicectomy should be performed for visually suspicious appendiceal surface or tumor involvement of the tissues. Since primary mucinous carcinoma of the ovary is uncommon, patients with mucinous tumors of the ovary must have a thorough evaluation of the gastrointestinal tract, including the appendix, to rule out a gastrointestinal origin. (5) Bilateral pelvic lymph nodes and abdominal para-aortic lymph nodes

Barotomy, resection of the para-aortic lymph nodes with the upper border at least to the level of the inferior mesenteric artery and aiming for the level of the renal vein.

Surgery for preservation of reproductive function

If the patient is young and requires preservation of fertility, for I A or I A or stage IC ovarian epithelial carcinoma, unilateral adnexal resection + with full staging is feasible, preserving the healthy adnexa and uterus. Intraoperatively, the swelling needs to be diagnosed by cryopathology and clinically evaluated. For patients clinically judged to be stage IB, bilateral adnexal resection + with full staging and preservation of the uterus is indicated. Unilateral adnexal resection + with preservation of the healthy adnexa and uterus is possible for interstitial and junctional tumors. Malignant germ cell tumors of any stage with fertility requirements can be preserved if the uterus and contralateral ovary are normal. In patients with malignant germ cell tumors, pelvic and para-aortic lymph node dissection may not be indicated on imaging and intraoperative exploration without signs of lymph node metastasis. Stage I clear cell carcinoma is highly malignant and fertility should be preserved with caution.

The development of technologies such as egg freezing and assisted reproduction have made it possible for patients with ovarian malignancies to undergo bilateral ovarian resection to have offspring.

Tumor cell ablation

For patients with intermediate to advanced disease who have been evaluated preoperatively or intraoperatively for extra-ovarian metastases. The goal of surgery is to maximize the removal of all visible tumors, reduce tumor load, improve chemotherapy efficacy, and improve prognosis. If satisfactory tumor reduction (residual tumor ≤1 cm) is possible after gynecologic examination and imaging, the patient can be operated directly, which is called primary tumor cytoreduction. If satisfactory tumor reduction is judged to be difficult to achieve or if the patient is too old and frail to tolerate surgery, then

After obtaining a cytologic or histologic pathologic diagnosis, neoadjuvant chemotherapy 2 to 4 cycles, usually no more than 4 cycles. If the tumor can be satisfactorily reduced by chemotherapy before surgery, or if the tumor remains large after the initial reduction, the tumor can be operated after chemotherapy for 2 to 3 The procedure is called interval (intermediate) tumor cell reduction if the procedure is performed after > one treatment. Surgical steps: (1 A longitudinal incision is made in the lower abdomen to fully investigate the tumor in the pelvis and abdominal cavity. (2) Excision of the entire uterus, the greater omentum of both adnexa, and all tumors visible to the naked eye. (3) Resection of any enlarged or suspiciously involved lymph nodes that can be removed. If the extra-pelvic tumor lesion is ≤2 cm systematic bilateral pelvic and para-aortic lymph node dissection is performed, the extent of resection is the same as in the full staging procedure. (4) The principles of appendectomy are the same as for full staging exploration. (5) To achieve satisfactory reduction, a portion of the intestinal canal, appendix, spleen, gallbladder, part of the liver, part of the stomach, part of the bladder, tail of the pancreas, ureter, and removal of the diaphragm and other parts of the peritoneum can be removed depending on the location of the metastases.

Laparoscopic Exploration

Laparoscopic exploration has the following advantages in the evaluation of satisfactory resection of advanced ovarian cancer: (1) magnification of the anatomy of the pelvic and abdominal cavities, better visualization of metastases in the upper abdomen, liver surface, diaphragm, uterine bladder trap and uterine rectal trap under direct vision; (2) avoidance of unnecessary open tumor reduction surgery in patients who cannot achieve satisfactory resection (3) for patients who are not suitable for surgical tumor reduction, it is less traumatic and has faster recovery than dissection, and does not delay the time for patients to receive neoadjuvant chemotherapy. However, there is no uniform opinion at home and abroad on the criteria for determining whether abdominopelvic exploration is satisfactory for tumor reduction, and further research is needed. In addition, laparoscopy

Exploration is costly and carries a potential risk of metastasis from the puncture site, which limits its clinical use to some extent.

Reduction of tumor

Re-reduction of tumor cells in patients who have undergone initial or interval reduction and have relapsed after chemotherapy. The indication for surgery is for platinum-sensitive relapses, i.e., those with an interval of > 6 months between the end of first-line chemotherapy and relapse, and where complete resection of the relapsed lesion is expected to result in no visual residual tumor. It is important to evaluate patients for re-reduction because it differs from initial tumor cytoreduction in that only patients with R0 resection may benefit from re-reduction. The procedure is based on the location of the recurrent foci, with a longitudinal incision in the lower abdomen in the case of pelvic floor recurrence and a curved incision in the right quadrant in the case of partial hepatectomy; all tumors visible to the naked eye can be removed, as well as part of the intestinal canal, appendix, spleen, gallbladder, part of the liver, part of the stomach, part of the bladder, tail of the pancreas, ureter, and removal of the diaphragm and other parts of the peritoneum as needed.

Adjunctive palliative surgery

For patients with advanced ovarian cancer undergoing palliative care, the following adjuvant procedures are available if necessary: thoracic or abdominal puncture and drainage for combined thoracoabdominal fluid; ureteral stenting or nephrostomy for tumor compression or invasion of the ureter leading to hydronephrosis; ureteral stenting or nephrostomy for tumor invasion of the intestine. If the tumor invades the intestine and leads to bowel perforation, consider proximal fistula; if the pelvic floor tumor compresses or invades the rectum and leads to bowel difficulty or rectovaginal fistula, consider colostomy.

Reducing Risky Fallopian Tube–Ovariectomy

Recommended BRCA1/2 Germline mutation carriers undergoing risk-reducing oophorectomy after completing childbirth – ovariectomy (risk reducing salpingo- oopherectomy, RRSO). With reference to foreign sources and guidelines, the recommended age for BRCA1 germline mutation carriers to undergo RRSO is between 35 to 40 years. Given that BRCA2 germline mutation carriers develop ovarian cancer at a later age than BRCA1 germline mutation carriers 8 to 10 years, 10 years, BRCA2 germline mutation carriers can be delayed to RRSO 40 years and 40 years to 40 years. span>to 45 years. The protective effect of bilateral salpingo-oophorectomy in BRCA1/2 germline mutation carriers remains controversial, and RRSO also reduces the risk of breast cancer in premenopausal women. Therefore, bilateral salpingo-oophorectomy only should be performed with caution. RRSO has several considerations: laparoscopic surgery is possible; pelvic irrigation fluid cytology is performed after entering the abdominal cavity; the fallopian tubes should be removed intact from the umbilical end to the intramural segment; if the ovaries or tubes are adherent to the surrounding peritoneum, the adherent If the ovary or fallopian tube is adherent to the surrounding peritoneum, the adherent peritoneum should be removed; all of the excised ovary and fallopian tube should be taken for pathologic evaluation to avoid missing the presence of occult cancer.

(ii) Chemotherapy.

Chemotherapy is the mainstay of treatment for ovarian epithelial cancer and plays an important role in the adjuvant and recurrent treatment of ovarian cancer.

First-line chemotherapy

After full staging surgery determined to be ⅠA or Stage IB patients with low-grade plasmacytoma or G1 endometrioid carcinoma may be observed postoperatively, A or IB stage /G2 patients with endometrioid carcinoma can be observed after surgery or chemotherapy. The rest of the patients should receive adjuvant

Assisted chemotherapy, Stage I patients span>stage I patients 3 to 6 cycles of chemotherapy (Phase I HGSC recommended chemotherapy 6 cycle), II to IV stage patients are recommended 6 cycles of chemotherapy, and there is no evidence that more cycles of first-line chemotherapy improve the prognosis of patients. The option of abdominal chemotherapy may be considered for patients with satisfactory decompensated stage II to stage III.

First-line chemotherapy includes postoperative adjuvant chemotherapy and neoadjuvant chemotherapy. Neoadjuvant chemotherapy is preferred to paclitaxel combined with carboplatin, and studies have also investigated the use of antivascular agents such as bevacizumab in neoadjuvant therapy. family:Times New Roman”>6 weeks before surgery, bevacizumab should be discontinued. The postoperative adjuvant chemotherapy regimen is a combination of paclitaxel /platinum or doxorubicin liposomal /carboplatin.

IIAdjuvant chemotherapy regimens available for postoperative patients in stage I.

①Paclitaxel 175mg/m2, intravenous drip 3 hours, area under the curve of carboplatin concentration –time ( area under the concentration-time curve, AUC (>) 5 to 6, intravenous drip 1 hour for the first 1 day and repeated every 3 weeks for a total of 1. span style=”font-family:Times New Roman”>3 to 6 cycles.

②Carboplatin AUC 5 combined with doxorubicin liposomal 30 mg/m2 intravenously, repeated every 4 weeks, for a total of 3 to 6 cycles.

③Docetaxel 60 to 75 mg/m2 , intravenous drip 1 hour, carboplatin AUC 5 to 6, intravenous drip 1 hour on day 1 and repeated every 3 weeks for a total of 6 cycles.

The above 3 regimens have comparable efficacy but inconsistent side effect profiles, and the appropriate regimen should be selected based on the patient’s adverse effect profile. The appropriate regimen should be selected based on patient adverse effects. It is recommended that Stage I HGSC patients receive 6 cycles of chemotherapy.

IItoIVAdjuvant chemotherapy regimens available for postoperative patients in stage.

① Paclitaxel 175mg/m2, intravenous drip 3 hours, carboplatin AUC 5 to 6, IV drip 1 hour, first 1hour, first 1 day, repeated every 3 weeks for a total of 6 cycles.

②Dose-intensive regimen: paclitaxel 80mg/m2 IV doses 1 hour, first 1, 8, 15 days, carboplatin 5 days, and 5 days days. Roman”>AUC 5 to 6, intravenous drip 1 hour, first 1 day, repeated every 3 weeks for a total of 6 cycles.

③Paclitaxel weekly 60mg/m2, intravenous drip 1 hour, carboplatin Weekly

AUC 2, IV drip 30 minutes for a total of 18 weeks (for elderly, frail, and difficult-to-treat patients).

to tolerate a 3 week chemotherapy regimen).

④ Docetaxel 60 to 75 mg/m2 , intravenous drip 1 hour, carboplatin AUC 5 to 6, intravenous 1 hour, carboplatin 1 hour on day 1 and repeated every 3 weeks for a total of 6 cycles.

⑤Carboplatin AUC 5 combined with doxorubicin liposomal 30 mg/m2 intravenously, repeated every 4 weeks for a total of 6 cycles.

⑥Paclitaxel 175mg/m2, intravenous drip 3 hours, carboplatin AUC 5 to 6, intravenous drip 1 hour, bevacizumab 7.5 mg/kg , intravenous drip 30 to

90 minutes on day 1 day, repeated every 3 weeks for a total of 5 to 6 cycles, after which Bevar

zumab monotherapy was continued for 12 cycles.

⑦ Paclitaxel 175mg/m2, intravenous drip 3 hours, carboplatin AUC 6, intravenous drip 1 hour on day 1. Repeat every 3 weeks for a total of 6 cycles of bevacizumab 7.5 mg/kg intravenously for 30 to 90 minutes, repeated every 3 cycles, maintained for 12 cycles after the end of chemotherapy, or from the first 12 cycles. span style=”font-family:Times New Roman”>2 cycles on day 1.

Valizumab 15mg/kg intravenously 30 to 90 minutes every 3 repeated for a total of 22 cycles.

For satisfactory subtraction of tumorsII～IIIStage IIIPatients can also choose intravenous/abdominal combination chemotherapy regimens 135mg/m2, intravenous 3 hour or24 hour, the first >1day, Cisplatin 75～100mg/m2 Intraperitoneal injection, first 2days.

Paclitaxel 60mg/m2 intraperitoneal injection on day 8 and repeated every 3 weeks for a total of 6 cycles. The intravenous /abdominal regimen has a higher and more severe incidence of leukopenia, infection, malaise, nephrotoxicity, abdominal pain, and neurotoxicity, with the risk of catheter-related complications, and a significant number of patients failing to complete 6 cycles of intravenous /abdominal combination chemotherapy. Therefore, care should be taken to select the right patient to receive intravenous /abdominal chemotherapy. Attention to hydration before and after cisplatin intraperitoneal chemotherapy may prevent nephrotoxicity. If patients receiving intravenous /abdominal chemotherapy cannot tolerate it, they can be switched to intravenous chemotherapy.

Chemotherapy regimens for ovarian germ cell tumors include bleomycin + etoposide

+ cisplatin ( bleomycin + etoposide + cisplatinum (BEP), paclitaxel + platinum, etoposide + carboplatin, etc. The recommended first-line chemotherapy regimen is BEP, bleomycin 15 mg, first 1 to 3 days intravenously (lifetime dose not to exceed 400mg), etoposide daily 100mg/m2, and the first 1 to 5 days, cisplatin daily

20mg/m2, the first 1 to 5 days, intravenously, every 3 days. Roman”>3 weekly repeats. Except for stage IA/IB anaplastic cell tumors, stage IA embryonal carcinoma or yolk sac tumors and Stage IA stage /G1 immature teratoma, except for all patients who require chemotherapy. Postoperative chemotherapy for stage I patients 3 to 4 cycles, stage II and above advanced patients should be treated according to tumor residual 4 cycles. Roman”>4 to 6 cycles; or patients with positive serum tumor markers before chemotherapy may be treated with 2 cycles after the markers turn negative. Roman”>2 to 3 cycles. Pulmonary function should be performed regularly with bleomycin.

energy testing as bleomycin can cause pulmonary fibrosis. The BEP regimen or paclitaxel in combination with carboplatin chemotherapy is an option for malignant ovarian interstitial cord tumors.

Second-line chemotherapy

Second-line chemotherapy is used after recurrence of ovarian cancer or for those who have progressed in first-line chemotherapy. The time interval between the last chemotherapy and recurrence is the main factor affecting the effect of second-line treatment. Accordingly, recurrent tumors are classified into 2 categories: (1) platinum-resistant recurrences: tumors that are ineffective in platinum-based first-line therapy (platinum-refractory type), or chemotherapy that is effective but without a chemotherapy interval <6 months relapse (platinum-resistant type); (2) platinum-sensitive relapse: tumors that are effective on platinum-based first-line chemotherapy without a chemotherapy interval ≥6 months relapse.

In cases of platinum-sensitive relapse, the first step is to determine whether re-reduction is appropriate, and if surgery is not appropriate or platinum-containing combination chemotherapy is still required after re-reduction, the options include: carboplatin / paclitaxel 3 week regimen, carboplatin / docetaxel, carboplatin / gemcitabine, carboplatin/ doxorubicin liposome, cisplatin/ gemcitabine, carboplatin / albumin-bound paclitaxel, etc., with an efficiency of 30% to 80%. All of the above chemotherapy regimens can be considered in combination with bevacizumab. The choice of 5- fluorouracil/formyltetrahydrofolate / for mucinous carcinoma family:Times New Roman”>oxaliplatin or capecitabine/oxaliplatin regimens.

In cases of platinum-resistant relapse, rechemotherapy is less effective and the goal of treatment should be more about the patient’s quality of life and prolonging survival. Patients with relapsed resistance should be encouraged to participate in clinical trials. For platinum-resistant relapses, non-platinum monotherapies (doxorubicin liposomes, docetaxel, albumin-bound paclitaxel, oral etoposide, gemcitabine, paclitaxel peri-therapy, topotecan) ± bevacizumab are preferred, with an efficiency of 10% to 25%. Other drugs that may be effective include six

Methotrexate, capecitabine, isocyclophosphamide, irinotecan, oxaliplatin, pemetrexed, and vincristine.

(iii) Targeted therapy.

Polyadenosine diphosphate ribose polymerase inhibitors

The main processes of DNA damage repair in humans are 2 species, one is poly(adenosine diphosphate) ribose polymerase [poly(ADP-ribose) polymerase, PARP] involved in damage repair after DNA single-strand breaks, and the other is homologous recombination repair involving BRCA1/2. These two repair mechanisms ensure the smooth replication of genetic material and cell division. When one of these two repair processes is impaired, the other can compensate. On the other hand, if both DNA damage repair capabilities are inhibited, apoptosis may be promoted. Based on the above theory, the presence of impaired homologous recombination repair in tumors with BRCA1/2 mutations and the application of PARP Inhibitors that inhibit damage repair of single-strand breaks promote tumor cell apoptosis and exert stronger antitumor effects. The main PARP inhibitors that have been marketed in China are olaparib, niraparib, fluazoparib, and parmiparib.

Olaparib was the first PARP inhibitor to be used in the clinic and is currently

Approved indications in China include Advanced ovarian cancer with BRCA1/2 mutations in which first-line chemotherapy is effective ( Maintenance therapy after complete or partial remission, maintenance therapy after effective chemotherapy for platinum-sensitive recurrent ovarian cancer. Niraparib is another oral PARP inhibitor that is currently approved in China for maintenance therapy after complete or partial remission with first-line chemotherapy or platinum-sensitive relapse chemotherapy for ovarian cancer, regardless of PARP. -family:Times New Roman”>BRCA1/2 mutation status. Our self-developed PARP

The two approved indications for the inhibitor fluazopalli are germline BRCA1/2 mutation in platinum-sensitive recurrent ovarian cancer after second-line chemotherapy and maintenance therapy after effective chemotherapy for platinum-sensitive recurrent ovarian cancer. Parmiparib is also an independently developed PARP inhibitor in China, currently approved for germline BRCA1/2 >mutations in recurrent ovarian cancer previously treated with second-line chemotherapy or higher. The common adverse effects of various PARP inhibitors include anemia, leukopenia, thrombocytopenia, nausea, vomiting and fatigue, which should be taken seriously in clinical practice and promptly identified and managed. In addition to carboxylesterase, several PARP inhibitors are metabolized by hepatic cytochromes and should be avoided in conjunction with inducers and inhibitors of hepatic cytochromes, and patients should be informed of these precautions before taking the drug.

Anti-angiogenic drugs

Bevacizumab is valuable as one of the anti-angiogenic agents in the first-line treatment of ovarian cancer, platinum-sensitive relapse, and platinum-resistant relapse. Bevacizumab is used concurrently with chemotherapy during chemotherapy and, if effective, as a single agent for maintenance therapy after the end of chemotherapy. In both first-line and relapse treatment, chemotherapy in combination with bevacizumab helps prolong progression-free survival compared to chemotherapy alone. Bevacizumab can also be used in combination with olaparib in patients with BRCA1/2 mutations and HRD positive ovarian cancer Maintenance therapy after effective first-line chemotherapy + bevacizumab treatment. Bevacizumab has been shown to have a high risk of hypertension and proteinuria, which are clinically manageable with symptomatic management, but serious adverse reactions such as gastrointestinal perforation should be a concern, and the risk of gastrointestinal perforation is higher before administration.

Bevacizumab is not recommended for patients with high risk of GI perforation (intestinal involvement, intestinal obstruction due to combined tumors, etc.). The domestic anti-angiogenic drugs include apatinib mesylate, an oral small molecule tyrosine kinase inhibitor, which was shown to be superior to chemotherapy alone in combination with doxorubicin liposomes in a phase II clinical study of platinum-resistant relapsed ovarian cancer.

(iv) Immunotherapy.

Immunotherapy has shown promising results in a variety of solid tumors, mainly involving immune checkpoint inhibitors (PD-1/PD-L1 inhibitors), tumor vaccines, and peripatetic cellular immunotherapy. There are several Phase I I clinical studies on immune checkpoint inhibitors in platinum-resistant recurrent ovarian cancer showing The objective remission rate was about 10%. Its efficacy was improved when combined with antivascular agents or PARP inhibitors, but these were small studies and need to be further validated. Immune checkpoint inhibitors in combination with chemotherapy have been investigated in randomized controlled studies in both first-line and recurrent treatment of ovarian cancer, showing that the addition of immune checkpoint inhibitors to chemotherapy did not improve outcomes in a full population of ovarian cancer not screened for biomarkers. The more studied immunotherapeutic agents such as pablizumab, atezumab, and avelumab. They are different from chemotherapy in terms of side effects, which are more often manifested as immune organ function impairment. Immunotherapy opens up new directions in the treatment of ovarian cancer, but there is still a need to explore effective efficacy-related biomarkers that can help identify the population that can benefit from this class of drugs.

(v) Radiotherapy.

Ovarian epithelial cancer is moderately sensitive to radiation therapy, but because of the biology of ovarian cancer, the tendency to develop extensive pelvic and abdominal metastases, the availability of effective chemotherapeutic agents, and the recent and long-term complications of pelvic and abdominal radiotherapy, radiotherapy is largely no longer used for ovarian cancer. Therefore, radiotherapy is basically no longer used for postoperative adjuvant treatment of ovarian cancer. Even for asexual cell tumors that are sensitive to radiotherapy, chemotherapy is the main adjuvant treatment after surgery. Currently, radiotherapy is only used for palliative treatment of some recurrent ovarian cancers. For tumors that are limited, such as retroperitoneal or mediastinal lymph node metastases that are difficult to remove surgically and for which chemotherapy is not effective, intensity-modulated radiation therapy can be considered.

(vi) Hormone therapy.

For relapsed patients who cannot tolerate chemotherapy or for whom chemotherapy is ineffective, consider treatment with tamoxifen, aromatase inhibitors (letrozole, anastrozole, etc.), highly potent progestins, and gonadotropic agents. 10%.

(vii) Traditional Chinese medicine treatment.

Therapeutic effects of TCM can be used throughout all stages of treatment for ovarian cancer patients, helping to accelerate recovery, enhance the efficacy of radiotherapy, reduce adverse effects, prolong survival, and improve survival quality. Weakness of the internal organs and imbalance of the internal organs and ducts are the primary etiology of ovarian cancer, and the main treatment principle is to regulate the internal organs and ducts, and to support the positive and eliminate the evil. The patient’s condition is different from the patient’s own, and the patient’s treatment plan is individualized through evidence-based treatment.

6. Prognosis

The overall prognosis for ovarian epithelial cancer is poor due to the difficulty of early diagnosis and the lack of effective treatment for drug-resistant recurrent ovarian cancer. The effectiveness of first-line platinum-based chemotherapy in combination with paclitaxel for ovarian epithelial cancer is 80%, of which more than half achieve complete tumor remission, but even in patients who achieve complete remission, 50% to 70% recurred, with an average recurrence time of 16. span>to 18 months. Stage I patients have a 5 year survival rate of 90%, phase II about 80%, Stage III/IV patients have a 5 year survival rate of only 30% and 30% to 40%, and most patients die of tumor recurrence and drug resistance. The use of PARP inhibitors in the treatment of ovarian cancer is expected to improve the prognosis, with data to be confirmed by long-term follow-up. The 5 year survival rate for ovarian malignant germ cell tumors is 96% in early stages and approximately 96% in advanced and recurrent patients. style=”font-family:Times New Roman”>60%. 90% of recurrences occur within 2 years postoperatively, but treatment outcomes remain good after recurrence.

Factors affecting the prognosis of patients with ovarian malignancy include age, tumor stage, histologic type of tumor, degree of differentiation, and size of residual lesions after tumor cytoreductive surgery.

VII.

The first 1 to 1 after the end of treatment. family:Times New Roman”>2 years and every 3 months; after that 1 review every 3 years; after that 3 to 6 years. New Roman”>6 monthly; 1 time; yearly after 5 years 1 time.

Ask the patient about any discomfort at the time of review. Most patients lack typical symptoms at the time of recurrence, and gynecologic examinations are useful for early detection of recurrence in the vaginal stump and pelvis. Serum tumor markers should be monitored regularly, and any markers found to be elevated at the time of initial diagnosis should be reviewed. New Roman”>CA19-9, CEA, etc. Review of AFP and LDH for asexual cell tumors is noted. Imaging in ovarian malignancies

is indispensable in the follow-up surveillance of ovarian malignancies. Commonly used tests are: chest X ray, ultrasound, CT, CT, MRI, bone scan, PET-CT etc. Ovarian cancer recurrence in the pelvic and abdominal cavity is most common, and abdominopelvic ultrasonography can be the imaging test of choice. span style=”font-family:Times New Roman”>MRI or PET-CT. Chest CT is the recommended first choice for patients with suspected pulmonary metastases.

Attachments

Ovarian Cancer Treatment Guidelines (2022 Edition) Development and Validation Expert Group

(in surname stroke order)

Team leader: Wu Lingying

Members: Wang Chen, Kong Beihua, Lu Zhaohui, Liu Ziling, Jiang Xinqing, Li Li, Li Ning, Li Guiling, Yang Hongying, Ying Jianming, Lang Jinghe, Gao Yunong, Cao Dongyan, Cui Heng, Lu Xin