Download ovarian malignancy

OVARIAN MALIGNANCY
 Ovarian
cancers are a clinical challenge
because the majority are asymptomatic
until late in the disease process.
 So 70% women will present with an
advanced stage at diagnosis.
 It has the highest mortality among all
the gynecological malignancies.
 About
30% of ovarian tumors in
postmenopausal women are malignant.
 Whereas only 7% in premenopausal women
are malignant.
WHO (Scully 1999)
• Epithelial tumors (benign, borderline or
malignant)
– Serous
– Mucinous
– Endometroid
– Clear cell (mesonephroid)
– Brenner
– Mixed epithelial
– Undifferentiated
– Unclassified
•
•
Sex cord stromal tumours
– Granulosa stromal cell tumour
– Androblastoma or Sertoli-Leydig cell
tumour
– Gynandroblastoma
– Unclassified
Lipid cell tumors
 Germ







cell tumours
Dysgerminoma
Endodermal sinus tumour
Embryonal cell tumour
Polyembryoma
Choriocarcinoma
Teratoma
Mixed tumours
 Gonadoblastoma
 Soft
tissue tumours not specific to ovary
 Unclassified tumours
 Metastatic tumours
Incessant ovulation :
 Nulliparity
 Early menarche
 Late menopause
 Infertility
 Regarding the relation with infertility,
ovulation-inducing drugs are supposed to be a
risk factor by resulting in multiple ovulation,
but the evidence is still not clear.
GENETIC FACTORS
Inheritance has a very important role :
 BRCA1 and BRCA2 genes are implicated
 50% risk of ovarian cancer.
 the other familial syndrome is hereditary
Nonpolyposis Colon cancer (HNPCC) or
 Lynch II syndrome
 It includes multiple adenocarcinomas, colon
cancer, ovarian, endometrial and breast
cancers.
PATHOLOGY
 Most
common epithelial tumours
 50-60% of all ovarian tumours
 Malignant epithelial tumours comprise 90% of
all ovarian tumours.
 Epithelial tumours can be
 Benign,
 Borderline
 malignant
Serous tumours commonest – 75%
Mucinous 20%
Endometroid, clear cell, and transitional
SEROUS TUMOURS
 Serous
tumours resemble the glandular
epithelium of the fallopian tubes.
 They are cystic
 Psammoma bodies are characteristic
 Papillary ingrowths may be present
 Mucinous tumours
PAPILLARY SEROUS CYST ADENO
CARCINOMA
MUSCINOUS CYST ADENOMA
 Multilocular
thin-
walled cysts
 Contain mucinous
fluid
 They are the largest
ovarian tumours
 Cells lining may
resemble endo
cervical cells
 10% bilateral
•
•
•
•
•
Pseudomyxoma peritonei is a term used to
describe the presence of mucoid material in
the abdomen and pelvis surrounded by fibrous
tissue.
It can result secondary to a ruptured
mucinous tumour of the ovary,
a well differentiated appendiceal carinoma,
any other gastrointestinal primary tumour or
a mucocele of the appendix.
Care should be taken to avoid rupture during
surgery
BORDERLINE TUMOURS
 Low
malignant potential
 10% of all epithelial tumours
 Commoner in young women between 30 and
50yrs.
Histological criteria
 Epithelial hyperplasia
 Nuclear atypia and increased mitotic activity
 Detached cell clusters
 Absence of stromal invasion
 Metastases are uncommon
 They have very good prognosis
Direct or transcoelomic spread :
• Omentum (most common)
• Posterior cul de sac
• Paracolic gutters
• Right hemidiaphragm
• Capsule of the liver
• Peritoneal surface of small and large
intestines
• Mesenteries
• Parietal peritoneum
Lymphatic spread :
 Para-aortic nodes
 Pelvic nodes
 Supraclavicular nodes
 Retroperitoneal nodes
 Para-aortic
node metastases are 20% in
stages I and II and 65% in stage IV.
Pelvic lymph nodes are seen in 30% of
stage I and II and 67% of stage III and
IV.
Haematogenous : late stages
 Lungs
 Liver (Parenchymal)
 Bone and brain (rarely)
Clinical features :
 Malignancies
are more common in
extremes of age group – younger and older
age
 Malignancy 50-60yrs
 Borderline between 30 & 50 yrs.
 Younger age group germ cell tumours are
more common
 Older age group epithelial tumours
Symptoms :
 Majority of epithelial ovarian tumours are
asymptomatic
 They are diagnosed in late stages
 Abdominal distension and pain
 Feeling of a lump in the abdomen
 Dyspepsia,
 Bloating
 Abdominal
discomfort
 Loss of appetite and loss of weight
 Pressure symptoms like urinary frequency,
retention or constipation
 Abnormal uterine bleeding or postmenopausal
bleeding in feminising tumour
Advanced stage symptoms may be due to
 ascites
 Omental deposits
 Bowel – altered bowel habits
 Pulmonary metastases – cough and
haemoptysis
Signs
 General examination
 Cachexia
 Supraclavicular lymph nodes
 Breast lumps
 Thyroid nodules
 Pleural effusion
Abdominal examination :
 Mass in the pelvis or abdomen
 Bilateral tumours
 Boders vague and ill-defined
 Hard or varying consistency
 Fixity or restricted mobility
 Ascites
 Hepatomegaly
 Other abdominal masses suggestive of lymph
node metastases
Bimanual examination :
 Hard
fixed mass
 Uterus may be felt separate
 Nodules in the cul de sac due to secondary
deposits
Differential diagnosis :
 Benign
ovarian tumour
 Gastrointestinal problems like colonic cancer
and stomach cancer (history of altered bowel
habits, bleeding per rectum and other
gastrointestinal symptoms should warrant a
search for the same) and diverticulitis
 Lymphoma (presence of other lymph node
enlargement is suggestive)
 Retroperitoneal
sarcoma
 Pedunculated fibroids
 Pelvic inflammatory disease
 Endometriosis
 Pelvic kidney
 Functional cysts
Investigations :
 Routine investigation like blood count,
urine routine
 RFT, LFT
 Tumour markers
 Chest X-ray
 Ultrasound scan
 Colonoscopy
 Gastroscopy
 Barium
enema / barium swallow
 Pap smear
 Endometrial biopsy
 Intravenous pyelogram
 CT and MRI
TAS followed by TVS done
Ultrasound features of malignancy
 Solid or echogenic areas
 Multilocularity
 Thick and fronded septations
 Bilaterality
 Papillary
projections
 Doppler may show increased vascularity
 Ascites
 It also detects liver parenchymal
metastases
 Enclarged pelvic and para-aortic nodes
 Detects hydroureter and hydronephrosis
CT and MRI
 They
detect the extend of invasion, lymph
node involvement, retroperitonial or
omental involvement
 So that surgery can be planned
Tumour markers :
 CA 125 levels are useful in differentiating
malignant from benign neolplasms.
 Useful tumour marker in epithelial
ovarian cancer
 More useful in postmenopausal woman
 The cut off value is 30 U/mL
 The test has a sensitivity of 81% and a
specificity of 75%
 Above 95 U/mL is taken as significant
 RMI is calculated from CA 125 level
 Age and ultrasound
 Premenopausal
women in endometriosis
and pelvic tuberculosis CA 125 level may
be raised.
 More than 200 U/mL indicate malignancy
TUMOUR MARKERS IN OVARIAN CANCER
Tumour type
Serum marker
Epithelial ovarian cancer
CA 125
Mucinous cystadenocarcinoma
CEA and CA 19-9
Serious and mucinous
OCCA and OCA
Endodermal sinus tumour
AFP
Choriocarcinoma
hCG
Enbryonal cell carcinoma
hCG and AFP
Dysgerminoma
PLAP, LDH
Granulosa cell tumour
Inhibin
Screening :
 At the present moment screening with ultrasound
is only indicated in high risk women.
 High risk women need to undergo genetic
screening, use of oral contraceptives for
chemoprophylaxis and can be offered prophylactic
oophorectomy
STAGING
 Ovarian epithelial tumours are staged according
to the FIGO system
 Essentially a surgical staging
 Histological and cytological finding also taken in
account
FIGO STAGING FOR CARCINOMA OVARY
Stage Growth limited to ovaries
I
Ia Growth limited to one ovary, no ascites, no
tumour on external surface; capsule intact
Ib Growth limited to both ovaries
No ascites; no tumour on external surface;
capsule intact
Ic Tumour either stage Ia or Ib but with
tumour on the surface of one or both ovaries;
or with capsule ruptured; or with ascites
present containing malignant cells or with
positive peritoneal washings.
Stage Growth involving one or both ovaries
II with pelvic extension
IIa Extension and/or metastases to the
uterus or tubes
IIb Extension to other pelvic tissues
IIc Tumour either stage IIa or IIb but with
tumour on surface of one or both ovaries;
or with capsule ruptured; or with ascites
present containing malignant cells; or
with positive peritoneal washings
Stage Growth involving one or both ovaries with peritoneal
III implants outside the pelvis or positive retroperitoneal
or inguinal nodes. Superficial liver metastases
equals stage III. Tumour is limited to the true pelvis,
but with histologically proven malignant extension to
small bowel or omentum
IIIa Tumour grossly limited to the true pelvis with
negative nodes but with histologically confirmed
microscopic seeding of abdominal peritoneal surfaces
IIIb Tumour with histologically confirmed implants on
abdominal peritoneal surfaces, none exceeding 2cm in
diameter. Nodes are negative.
IIIc Abdominal implants greater than 2cm in diameter or
positive retroperitoneal or inguinal nodes
Stage
IV
Growth involving one or both
ovaries with distant metastases. If
pleural effusion is present there
must be positive cytology to allot a
case to stage IV. Parenchymal liver
metastases equals stage IV
Management
 Staging
laparotomy
 Ascites or peritoneal washings (50-100ml
saline) taken cytology
 Washing from cul de sac, paracolic gutter
and beneath hemidiaphragm
 Exploration of the abdomen and pelvis in
a clockwise manner from the caecum
cephalad
 Any
suspicious areas should be biopsied
 Diaphragm can be sampled either by biopsy
or by scraping
 Infracolic omentectomy
 Retroperitoneal space dissection to evaluate
the pelvic and para-aortic nodes
 Enlarged nodes must be submitted for frozen
section
 If there are no metastases a pelvic
lymphadenectomy must be performed.
 Careful documentation of the operative
findings
Surgery :
 Stage I & II total hysterectomy, bilateral
salpingo-oophorectomy and infracolic
omentectomy
 After a thorough surgical staging must be
performed.
 In advanced cases maximal cytoreductive
surgery must be attempted.
 Fertility sparing surgery – rarely there is
also a place for conservative surgery in stage
Ia grade-I in those younger women who
mare anxious to conceive
 They
should be under regular follow up
 After childbearing is completed
 Definitive surgery is done
 High risk cases surgery followed by
adjuvant chemotherapy with carboplatin
and paclitaxel for 3-6 cycles is desirable.
Advanced disease :
 Maximal cytoreductive or debulking surgery
 Residual disease should be less than 1cm.
 The surgery typically consists of a total abdominal
hysterectomy,
 Bilateral salpingo-oophorectomy and omentectomy
 In addition it may include resection of any
metastatic lesions from the peritoneal surfaces or
intestines
 Sometimes resection of part of the bladder or
removal of the sigmoid and rectum may be
necessary.
 If optimal cytoreduction has been achieved,
chemotherapy for 6-8 cycles is usually given.
 Interval
cytoreductive surgery
 Second look surgery
 Postoperative management of advanced
disease
 Intravenous carboplatin and paclitaxel
every 3 weeks for 6-8 cycles
 Intraperitoneal cisplatin and paclitaxel is
an acceptable alternative to intravenous
route.
Neoadjuvant chemotherapy :
 Advanced disease preoperative
chemotherapy for about 3 cycles followed
by cytoreductive surgery.
 After cytoreductive surgery chemotherapy
followed
 This is useful in patients with massive
ascites and pleural effusions
Immunotherapy :
 Cytokines have been used such as
interferons and interleukin – 2 in
combination with chemotherapy as secondline therapy.
Survival rates :
 The survival rates in each stage depend on
the grade of the tumour
 Stage I
76-93%
 Stage II 60-74%
 Stage III 23-41%
 Stage IV 11%