Download ovarian tumors

Ovarian Cancer
DI WEN
M.D., Ph.D.,
Professor & Chairman
Department Of Obstetrics & Gynecology
Renji Hospital Affiliated to SJTU School of Medicine
General Introduction
Ovarian
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tumors are
commonest between 30
and 60.
They are particularly
liable to be or to become
malignant.
In their early stages, they
are asymptomatic and
painless.
They may grow to a
large size.
1.4% lifetime risk of
ovarian cancer
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Risk Factors
Family history
Ovarian cancer
Breast cancer
Colon cancer
Genetic factors
Older age
Caucasian
More menstrual circles during lifetime
(Ovulation induction)
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Incidence
Nearly 25% of all ovarian neoplasm are
malignant.
Approximately 80％ of them are primary
growths of the ovary.
The remainder being secondary，usually
carcinomata.
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symptoms
Lack of any specific symptoms,
ovarian tumors are often large by
the time the doctor is consulted.
Menstrual function is seldom upset,
and any irregularity is attributed to the
patient’s ‘time of life’.
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symptoms
Increased abdominal size
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symptoms
Pressure symptoms
Gastro-intestinal symptoms (Bloating)
Urge to urinate
plevic pain (a dull pain in the lower abdomen)
Very large tumors may cause respiratory
embarrassment and edema or varicosities in
the legs, and a characteristic ‘ ovarian
cachexia’ develops.
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CLINICAL FEATURES OF OVARIAN TUMOURS
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CLINICAL FEATURES OF OVARIAN TUMOURS
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CLINICAL FEATURES OF OVARIAN TUMOURS
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DIFFERENTIAL DIAGNOSIS
General Rule
An experienced examiner will
recognize an ovarian tumor mainly
because ovarian tumor is, in the
circumstances,
the
most
likely
diagnosis. All abdominal swellings
should be subjected to ultrasound and
X-ray examination.
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
ASCITES
A fluid thrill
may be elicited
from an ovarian
cyst, and ascites
and tumor may
coexist; but as a
rule the distinction
should be easily
made.
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DIFFERENTIAL DIAGNOSIS
Uterine Fibroids
A
large
midline
intramural fibroid may
be
impossible
to
distinguish from a solid
ovarian tumor until the
abdomen is opened and
an entirely different
surgical
problem
encountered.
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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Histological Classification
Most tumors arise from the ovarian
stroma and germinal epithelium. The
embryonic coelom from which that
epithelium develops also gives rise to the
Mullerian duct from which develop the
structures of the genital tract, and it is
this common origin which explains the
great variety of epithelial patterns which
are met with.
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Primary Epithelial
Tumor
Mucinous cystadenoma or cystadencarcinoma
(of. Cervical epithelium).
Serous cystadenoma or cystadenocarcinoma
(of . tubal epithelium).
Endometrioma or Endometrioid carcinoma
(of. Endometrium).
Clear cell carcinoma.
Brenner tumour.
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Ovarian Germ Cell Tumor
Fibroma or sarcoma.
.Dysgerminoma.
.Teratoma.
.Gonadoblastoma.
.Yolk sac tumour.
.Carcinoid
.Thyroid tumour Choriocarcinoma
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Gonadal Sex Cord Stromal Tumor
Estrogen-producing:
Granulosa cell tumour.
Thecoma.
Androgen-prodicing:
Sertoli-Leydig cell tumor (Arrhenoblastoma).
Hilar cell tumour.
Lipoid cell tumour.
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Krukenberg Tumor
There is one wellknown
secondary
tumour of the ovary,
the krukenberg
tumour,
secondary
of
stomach carcinoma.
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a
a
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Mucinous cystadenoma
A
unilocular
or
multilocular cyst of ovary
lined by tall columnar
epithelium resembling that
of the cervix or large
intestine. It is usually large
and may reach immense
proportions, occupying the
whole peritoneal cavity and
compressing other organs. It
may occur at any age.
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OVARIAN TUMOURS --MUCINOUS CYSTADENOMA
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SEROUS CYSTADENOMA
A unilocular or multilocular
cyst lined by epithelium similar
to the fallopian tube. They are
the most common benign
epithelial tumors and form
20% of all ovarian neoplasm.
In 10% of cases they are
bilateral. It is uncommon to
find them large than a fetal
head.
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OVARIAN TUMORS --SEROUS CYSTADENOMA
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Serous cystadenocarcinoma
This is by far the commonest
primary carcinoma, accounting for
60% of all cases, and in over half
the cases it is bilateral. The cysts
are always of papillary type and the
epithelium burrowing through the
capsule
produces
papillary
processes on the serous surface.
Extension of the growth to the
pelvis and adjacent organs fixes the
tumor. Ascites is always present.
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Endometrioid Carcinoma of the Ovary
It is now recognized that
carcinoma of the ovary
may be of endometrial
type, sometimes arising in
endometrioma. Attacks of
pain, unusual with ovarian
cancer, are common.
Sometimes there is uterine
bleeding in postmenopausal cases.
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Endometrioid Carcinoma of the
Ovary
Usually the lesion is cystic
and chocolate brown in color.
If such a cyst ruptures
spontaneously, malignancy
should be suspected. The
histology varies as in uterine
carcinoma. It may be a welldifferentiated adenocarcinoma,
an adeno-acanthoma, mucinous
adenocarcinoma or clear-celled
carcinoma.
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Fibroma
 This is composed of
fibrous tissue and
resembles fibromata found
elsewhere. It is most
common in the elderly and
accounts for 4-5% of all
ovarian neoplasm.
 The fibroma is believed by
many to be a thecoma
which has undergone
fibrous transformation. It
is sometimes associated
with Meig’s syndrome.
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Dysgerminoma
This is the only solid
ovarian
tumor
of
characteristic appearance.
Usually ovoid with a
smooth capsule, it is of
rubbery consistency and
greyish colour. It is
commonest in younger
age groups, under 30
years as a rule, and is
often bilateral. Sometimes
it is found in cases of
intersex.
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Teratoma
Cystic teratoma or
dermoid
Solid teratoma
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Yolk Sac Tumor
 rare
Children and
young adults
highly malignant
alphafetoprotein
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Estrogen-producing Tumors
These belong to the granulosatheca cell group and are found at
all ages. They account for 3% of all
solid tumors of the ovary.
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Estrogen-producing Tumors
In childhood there is accelerated skeletal
growth and appearance of sex hair.
 5% occur in children precocious puberty.
 60% occur in child-bearing years irregular
menstruation.
 30% occur in post-menopausal women postmenopausal bleeding.
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Andorogen-producing Tumours
Three distinct types of masculinising
ovarian tumor are recognised: a) SertoliLeydig cell tumor (Arrhenoblastoma), b)
Hilar cell tumor, c) Lipoid cell tumor. All
three cause amenorrhoea.
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Spread -Direct
The first spread is directly into
neighbouring
structures
–
peritoneum, uterus, bladder, bowel
and omentum.
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Spread -Lymphatics
Ovarian drainage is to the para-aortic
glands, but sometimes to the pelvic and
even inguinal groups. Cells seeded on to
the peritoneum are drained via the
lymphatic channels on the underside of
the diaphragm into the subpleural
glands and thence to the pleura.
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Spread -Blood Stream
Blood spread is usually late, to
the liver and lungs.
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Staging of ovarian cancer
STAGE I Growth limited to ovaries
Ia Limited to one ovary. No ascites.
Ib Limited to both ovaries. No ascites.
Ic Ascites or positive peritoneal washings also present or
tumour on surface of one or both ovaries or capsule ruptured.
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Staging of ovarian cancer
 STAGE II Pelvic extension
IIa Spread to uterus/tubes
IIb Spread to other pelvic tissues
IIc IIb with ascites or positive peritoneal washings or tumour
on surface of one or bothOvarian
ovaries
or capsule ruptured.
Cancer
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Staging of ovarian cancer
 Stage III Extrapelvic intraperitoneal spread and/or retroperitoneal
or inguinal positive nodes, or superficial lover metastases.
IIIa Apparent limitation to true pelvis
IIIb Histologically proven abdominal peritoneal superficial
implants<2cm diameter.
IIIc Abdominal implants>2cm
diameter or positive
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retroperitoneal or inguinal nodes.
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Staging of ovarian cancer
Stage IV
Distant metastases
or pleural effusion
with
positive
cyotlogy
or
parenchymal liver
metastases.
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Diagnosis
Pelvic exam
Ultrasound
CT scan
CA125 blood test
SURGERY
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TORSION of the PEDICLE
 The commonest
complication
 Occur with any
tumor
 Except those
with adhesions
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TORSION of the PEDICLE
Clinical Features-Subacute
The patient complains of recurrent
abdominal pain which passes off as the
pedicle untwists. There is a rise in pulse
and temperature during the bleeding;
And over a period anemia develops.
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TORSION of the PEDICLE
Clinical Features-acute
The signs and symptoms are those of an
acute abdominal condition. The problem
becomes one of differential diagnosis to
exclude those conditions in which laparotomy
is not needed and laparoscopy may be useful.
Pain tends to be intense and
continuous.
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TORSION of the PEDICLE
Ruptured Cyst
This may occur alone or in conjunction with
torsion. Rupture is not particularly upsetting to the
patient unless the contents are irritant.
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Suggestive of Malignancy
Age. If the patient is over 50 the chance of
malignancy is over 50% as opposed to less
than 15% in premenopausal women.
Tumors in childhood are usually malignant.
Rapid growth.
Ascites.
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Suggestive of Malignancy
Solid tumours, especially when bilateral.
Multilocular cysts with solid areas. (At least
10% of cysts are malignant).
Pain. Pressure pain can occur with any tumor;
But referred pain suggests malignant
involvement of nerve roots.
Tumor markers, such as CA125, may be
measured in the blood, but a normal level does
not exclude malignancy.
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Treatment
 Surgery
 Chemotherapy
 Radiation Therapy
 ? Hormonal Therapy
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Surgical Procedures
To classify the growth according to its
extent of spread (staging) as accurately as
possible.
To remove as much cancerous tissue as
possible
(‘surgical
reductive treatment’).
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debulking’;’cyto-
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Surgical Procedures
Benign ovarian over 10 cm in diameter
must be removed, but clinical and
ultrasonically diagnosed cysts under 10 cm
(the size of a lemon) in women under 35
years may be reviewed in a few months if
there is no suspicion of malignancy. A
follicular or luteral cyst may resolve
spontaneously.
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SURGICAL TREATMENT OF OVARIAN TUMMOURS
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SURGICAL TREATMENT OF OVARIAN TUMMOURS
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SURGICAL TREATMENT OF OVARIAN TUMMOURS
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Follow-up
Follow-up with intensive
chemotherapy,
using
various
combinations of antineoplastic
drugs. Taxanes, probably combined
with platinum compounds, are an
appropriate first choice.
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Second Look
A ‘second look’ laparotomy or laparoscopy
operation (SLO), to determine the actual
effectiveness of the chemotherapy and to
decide whether it should be stopped does not
affect prognosis, so should only be performed
with informed consent in clinical trials.
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Surgical Procedures -Incision
A vertical incision which can
be extended is essential to allow a
full inspection. Reduction of a
cyst by tapping and extraction
through a suprapubic incision is
not acceptable practice.
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Surgical Procedures - Cytology
Before handling the tumour, take
specimens of ascitic fluid or peritoneal
saline washings for cytological
examination, and a cytology smear
from the underside of the diaphragm.
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SURGICAL PROCEDURES IN OVARIAN CANCER
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Thanks for Your Attention
DI WEN
M.D., Ph.D.
Professor & Chairman
Department of Obstetrics & Gynecology
Renji Hospital Affiliated to SJTU School of Medicine
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Hereditary Breast and Ovarian
Cancer: BRCA1
Breast cancer 50%-85%
• Autosomal Dominant Transmission
Second primary breast cancer 40%-60%
• Precise Risk for Male Breast Cancer Unclear
Ovarian cancer 20%-60%
• Increased Risk for Prostate Cancer?
Adapted from ASCO
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Hereditary Breast and Ovarian
Cancer: BRCA2
breast cancer
(50%-85%)
male breast cancer
ovarian cancer
(6%)
(10%-20%)
• Autosomal Dominant Transmission
• Increased risk of prostate, laryngeal,
melanoma and pancreas cancers
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