- Seventy-five percent of ovarian carcinomas are epithelial in origin; these include serous cystadenocarcinoma and mucinous, endometrioid, and clear cell tumors. Germ cell tumors make up fewer than 5% of all cancerous ovarian tumors, but in women under 20 years of age, they account for 65% of diagnosed ovarian cancers.

Causes and Incidence The etiology has not been established, but an increasing incidence among nulliparous women suggests that uninterrupted ovulation is a predisposing factor. Other risk factors include a family history of the disease; a high-fat, low-fiber, vitamin A–deficient diet; and occupational exposure to asbestos and talc. Ovarian cancer is the sixth most common form of cancer in women and the fourth leading cause of death from cancer, and the incidence is rising. Ovarian cancer is most common in Western industrialized nations among older white women of NorthernEuropean descent.

Disease Process Ovarian cancer begins in the various tissues of the ovary and then spreads by direct extension and lymphatics to the regional nodes in the pelvis and paraaortic region and to the abdominal and pelvic peritoneum. Metastasis is commonly to the liver and lungs.

Symptoms Symptoms of early disease are often absent or mild and associated with other common problems. They include such things as vague abdominal discomfort, dyspepsia, bloating, flatulence, and digestive disturbances. Later stage signs and symptoms include ascites, abdominal and pelvic pain, abdominal and pelvic masses, persistent gastrointestinal symptoms, urinary complaints, and menstrual irregularities.

Potential Complications The prognosis is good with diagnosis at an early stage. However, because early ovarian cancer is typically asymptomatic, the chances of prompt diagnosis are slim. Complications include intestinal obstruction, ascites, and cachexia.

Diagnostic Tests An enlarged ovary on manual examination is often the first diagnostic sign. A definitive diagnosis is made by biopsy through laparoscopy. Tumor marker CA-125 is being evaluated as a diagnostic tool. It is predictive in only about 50% of early cases but may prove useful for tracking treatment progress.

Treatments

Surgery
Salpingo-oophorectomy with or without hysterectomy is the primary treatment.

Drugs
Systemic chemotherapy as adjuvant to surgery.

General
Radiation therapy as adjuvant to surgery.

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- Tumors arise from the exocrine glands (95%) and the endocrine glands (5%) in the pancreas. Ductal adenocarcinomas constitute 80% of all pancreatic tumors. Other histologic types include squamous cell and giant cell carcinomas, sarcomas, plasmacytomas, and lymphomas.

Causes and Incidence Cigarette smoking is strongly linked to the development of cancer of the pancreas. Other possible predisposing factors include excessive consumption of caffeine, ethanol abuse, high-fat diets, and occupational exposure to solvents and petrochemicals. More than 28,000 cases of pancreatic cancer are diagnosed each year in the United States, and it is the fourth leading cause of cancer death. Men are 1 1/2 to 2 times as susceptible as women.

Disease Process Most tumors begin in the head of the exocrine gland, obstruct the bile duct, and extend to the duodenum, intestines, and spine. Spread occurs to the regional lymph nodes, and common metastatic sites include the liver and lungs.

Symptoms Symptoms occur late in the disease and include anorexia; weight loss; flatulence; bloating; constipation; upper abdominal pain, which radiates to the back and abates in a fetal position; jaundice; and thrombophlebitis.

Potential Complications The prognosis is extremely poor, with a 3% long-term survival rate. Complications include diabetes and alterations in mental status.

Diagnostic Tests Ultrasound, computed tomography scans, and endoscopic retrograde pancreatography are used to locate masses and to assist in staging of the tumor. The definitive diagnosis is made by needle or tissue biopsy.

Treatments

Surgery
Pancreatectomy or Whipple procedure; bypass of obstructions for palliation.

Drugs
Chemotherapy has not been effective to date.

General
Radiation limits tumor progression but does little for survival rate.

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- Adenocarcinomas account for most prostate cancers. The rest are transitional cell, squamous cell, endometrioid, or sarcomatous cancers. (Also see Cancer.)

Causes and Incidence The cause is unknown but appears to be related to endogenous hormones. Prostate cancer is the most commonly diagnosed cancer in men in the United States, with more than 165,000 cases reported annually. It is the third leading cause of cancer deaths in men and strikes those over age 50 most frequently (more than 85% are over age 65). The incidence and mortality rate are higher in black men.

Disease Process Adenocarcinomas usually begin in the lower posterior prostate and grow slowly to encompass the entire gland. The tumor spreads directly to the bladder and levator ani muscles and, via the lymphatic system, throughout the pelvis. Metastasis occurs through the bloodstream to the bones, liver, lungs, and kidneys.

Symptoms Early signs mimic benign prostatic hypertrophy; they include difficulty initiating and stopping the urinary stream, frequency and pain on urination, and a weak urinary stream.

Potential Complications The prognosis is good with tumors that have not metastasized (more than 70%), and even with metastasized disease, treatment may achieve long-term palliation. Complications of advanced disease include thrombosis, pulmonary emboli, retrograde ejaculation, and impotence.

Diagnostic Tests Palpable nodules on digital rectal examination and an elevated prostate-specific antigen offer suspicions of tumor. A needle biopsy is the definitive follow-up.

Treatments

Surgery
Prostatectomy for localized tumor; transurethral resection when the bladder is involved; bilateral orchiectomy for metastatic disease.

Drugs
Hormone therapy for palliation.

General
Radiation as a primary treatment alternative to surgery and for palliation; counseling for changes in sexual functioning.

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- Skin cancers can be divided into two groups: melanomas and nonmelanomas. Three distinct types of nevi (moles) give rise to melanomas: common acquired, dysplastic, and congenital melanocytic; they produce four types of melanoma: superficial spreading (70%), nodular (15%), lentigomaligna (less than 10%), and acrolentiginous (less than 5%). Nonmelanomas are typically either basal cell or squamous cell in origin.

Causes and Incidence Environmental factors such as ultraviolet radiation and chronic sun exposure are strongly linked to the development of skin cancer. Long-term x-ray exposure and occupational exposure to radium, arsenic, coal tar, and creosote are also risk factors. Genetic risk factors such as a fair complexion, light hair, and difficulty tanning play a role, as does family history.
Skin cancer is the most common of all malignancies. An estimated 600,000 cases are diagnosed annually in the United States alone. Most are nonmelanomas, but more than 32,000 are melanomas, and the incidence of melanoma is increasing by 4% a year. Fair-skinned individuals over 40 years of age who live near the equator and have a history of long-term sun exposure are at highest risk.

Disease Process Basal cell carcinomas vary considerably in appearance but usually begin as a small, shiny, flesh-colored nodule on the skin. The carcinoma enlarges slowly and develops a pearly border with telangiectases on the surface. It often bleeds, crusts, and then rebleeds in a chronic cycle. It rarely metastasizes but does invade adjacent tissue structures. Squamous cell carcinomas are usually scaly and crusty or nodular, warty, and raised and often develop in keratotic tissue or old scars. They eventually ulcerate and invade the underlying tissue. They rarely metastasize, but when they do, the lungs are the most common site. Malignant melanomas arise from a mole that begins to show changes in size, color, shape, and consistency. They begin by growing on the epidermis and then invade the dermis and subcutaneous tissues. Once this occurs, the tumor metastasizes fairly rapidly through the vascular and lymphatic systems. Common metastatic sites include the bones, brain, liver, and lungs.

Symptoms A skin lesion that does not go away and that grows larger over time or a mole that changes appearance is a possible sign, as are itchiness, scaling, oozing, bleeding from a mole or lesion, and changes in sensation.

Potential Complications The prognosis is excellent with intervention, particularly with nonmelanoma carcinomas, because metastasis is rare. The long-term prognosis for melanomas is tied to the thickness of the tumor at the time of diagnosis. Tumors over 3 mm deep carry a survival rate of less than 50%. Metastasized disease reduces the survival rate dramatically. Common complications include scarring and disfigurement at the site of tumor removal.

Diagnostic Tests Tissue biopsy and a histologic examination form the base for definitive diagnosis.

Treatments

Surgery
Excision is the treatment of choice for melanoma; excision, cryosurgery, electrodesiccation and curettage, and Mohs chemosurgery are used for nonmelanomas.

Drugs
Topical chemotherapeutic agents to treat premalignant actinic keratosis; interferon to treat recurrent or advanced basal cell carcinoma; hyperthermic regional perfusions in combination with surgery to treat melanomas.

General
Radiation in combination with surgery for extensive nonmelanomas; radiation may be used instead of surgery in elderly patients or to treat nonmelanomatous lesions of the nose, eyelids, or lips (melanomas are radioresistant); prevention education about sun exposure and use of sun screens and protective clothing when in the sun.

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- Most malignant lesions of the stomach are adenocarcinomas (95%). The rest are lymphomas and leiomyosarcomas.

Causes and Incidence The cause of stomach cancer is unknown but is thought to be related to dietary factors connected to food preservation and preparation. Gastritis, gastric atrophy, and genetic factors are believed to be predisposing factors. The incidence varies worldwide. Stomach cancer is the most common malignancy in Japan, and the incidence is extremely high in Iceland and Chile. The number of cases has declined significantly in western Europe and the United States. About 23,000 new cases are seen in the United States each year. The incidence is higher in men (2:1 ratio), in individuals 50 to 70 years of age, and in people of lower socioeconomic status.

Disease Process Cancer cells usually begin to grow in the distal end of the stomach in the lesser curvature. The cells form a tumor that spreads along the mucosa, eventually invading and moving through the stomach wall. The tumor then spreads directly to surrounding structures such as the spleen, esophagus, pancreas, colon, duodenum, and peritoneum. The cancer is also spread via the lymphatics to regional nodes and via the bloodstream to the liver.

Symptoms No specific symptoms appear in the early stages. Most people have generalized gastrointestinal (GI) complaints such as indigestion, burping, and fullness after eating. Later signs may include vomiting, dysphagia, anorexia, weight loss, and back pain.

Potential Complications The prognosis for long-term survival is poor (16%), primarily because most cases are diagnosed after metastasis has occurred. Complications include malnutrition and GI obstruction.

Diagnostic Tests Double-contrast x-ray studies of the stomach can delineate suspicious lesions. The definitive diagnosis is made by endoscopy with brush biopsy.

Treatments

Surgery
Excision of the tumor and regional lymph nodes; subtotal or total gastric resection or gastrectomy for resection for cure, depending on tumor location; gastroenterostomy for palliation.

Drugs
Systemic chemotherapy to treat advanced metastatic disease.

General
Radiation for palliation of GI obstruction.

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