Download OVARIAN CANCER

OVARIAN CANCER
INTRODUCTION
I.Histologic Classification
i.coelomic epithelium originating tumor
accounts for 50-70% of primal ovarian tumor , 85-90% of
ovarian malignace.developed from germinal epithelium→
primal coelomic epithelium →various muller,s epithelium
→tubal epithelium,cervical mucosa epithelium,endometrium
the coelomic epithelial tumors include
(i).serous tumor
(ii).mucinous tumor
(iii).endometrioid tumor
(iv).clear cell tumor
(v).Brenner tumor/transitional cell tumor
(vi).mixed epithelial tumor
(vii).undifferentiated carcinoma
ii.germ cell tumor
accounts for 20-40% of ovarian tumor.germ cells originate
from endogerm tissues.in the course of its origination,
transformation and development the cellular heterogeneity
may occur and form various tumors
germ cell tumors include
(i).dysgerminoma
(ii).endodermal sinus tumor
(iii).embryonic carcinoma
(iv).polyembryonic tumor
(v).choriocarcinoma
(vi).teratoma
i).immature type
ii).mature type
(a).solid teratoma
(b).cystic teratoma
a).dermoid cyst
b).malignant change of dermoid cyst
(c).monodermal and highly specialized tumors
a).struma ovarii
b).carcinoid
(vii).mixed type
iii.ovarian gonadal sex cord stromal tumor
accounts for 5% of ovarian tumor.sex cord stroma
originates from mesenchymal tissues of primal coelom
female and male differentiation
→epithelium differentiation→granulosa,
Sertolic cell tumor
functional tumor
stromal differentiation →theca cell,
Leydig cell tumor
sex cord stromal cells tumor includes
(i).granulosa cell-stromal tumor
i).granulosa cell tumor
ii).theca cell tumor,fibroma
(ii).Sertolic-Leydig cell tumor
i).androblastoma
(iii).gynandroblastoma
iv.metastasized tumor
II.High risk factors of ovarian tumors
i.hereditary and family factors
about 20-25% malignant ovarian tumors have
family history
ii.environmental factors
the mobidity of ovarian cancer is high in industry
developed countrys,this may be because of high
cholesterol diet in these countrys
iii.endocrinic factors
mobidity in less pregnant or infertile women is high(why),
functional cancers may easily complicated with mammary
andendometrial cancer
III.pathology
i.epithelial ovarian tumors
age:30-60 ;classification:benigh,borderline,malignant
borderline tumor means:
(i).serous cystadenoma
mobidity :accounts for 25%benigh tumors
macroexamination :unilateral,globular,different size,smooth
surface,cystic,thin wall and filled by clear light-yellow fluid
section : simple type,monocystic,smooth wall;papillary type,
multicystic,intracystic papilla
microscopic exanination : tumor wall is composed of fibroconnective tissues and lined by a single layer of cuboid or
columnar epithelium
borderline serous cystadenoma
macroexamination : moderate size bilateral,more extracystic
papilla
microscopic examination :thin papillary branch,epithelium≤3
layers,slight cellular atypia,nuclear mitosis<1/HP,no stroma
invasion
5 year survival rate :over 90%
serous cystadenocarcinoma
morbidity :most common malignant ovarian tumor,40-50%
macroexamination :bilateral,relatively large,semisolid,nodular
or lobular,smooth surface,gray white color,papillary
proliferation
section :multicystic,filled by papilla,brittle,bleeding,necrosis,
blurred cysticfluid
microscopic examination :obvious epithelial proliferation,
4-5layers,cuboid or columnar cancer cells,obvious
cellular atypia,stromal invasion
5 year survival rate:20-30%
(ii).mucinous cystadenoma
morbidity:20% of benign tumor
macroexamination:unilateral,round or elliptic,smooth
surface,gray white,large or giant
section:multicystic,filled by tremellose mucus,less
intracystic papilla
microscopic examination:fibroconective tissues wall,lined
a single layer of high columnar epithelium,malignant
change rate 5-10%
peritoneal myxoma:2-5% of mucinous cystadenomas may
develop,formation,histology
borderline mucinous cystadenoma
macroexamination:relative large,more unilateral,smooth
surface,multicystic
section:thick walll,solid area,tiny soft papilla
microscopic examination:epithelium≤3 layers,slight
cellular heterogeneous,large dark stained nucleus,less
mitosis,proliferated epithelium protrude into cavity and
form papilla,no stromal invasion
mucinous cystadenocarcinoma
morbidity:10% of malignant tumors
macroexamination:unilateral,large size,papillary or solid
area
section:semicystic and semisolid,blurred or bloody fluid
microscopic examination:dense gland,less stroma,glandular
epithelium>3 layers,obvious cellular atypia,stromal invasion
5 year survival rate:40-50%,prognosis is better than serous
cystadenocarcinoma
(iii).endometrioid tumor
morbidity : less encountered,benign
macroexamination : more unilateral,smooth surface
microscopic examination : surface is a single layer of columnar
epithelium which very like endometrial gland epithelium,
cavity is lined by pavement epithelium
borderline:rare
endometrioid carcinoma
morbidity :10-24% of primary malignant tumor
macroexamination:more unilateral,moderate size
section:cystic or solid,papilla,bloody fluid
microscopic examination:very similar to endometrial cancer,
more adenocarcinoma or adenoacanthoma,often complicated
with endometrial carcinoma
5 year survival rate :40-50%
ii.ovarian germ cell tumors
a group of ovarian tumors originated from primal germ cells,
its morbidity is secondary to the epithelial tumors,most occurs in
childhood and adolescence,morbidity before adolescence accounts
for 60-90%,while after menopause it only accounts4%
(i).teratoma
mature teratoma :also called dermoid cyst
morbidity :the most common benign ovarian tumor,10-20%
of ovarian tumors,85-97%of germ cell tumors,over 95% of
teratoma
age :occurs at any age,mostly between 20-40
macroexamination :more unilateral,moderate size,round or
elliptic,smooth and thin walll,
section :more nuicystic,filled by lipid and hair,occasionally
tooth and bone can be seen,scolex on the wall
components :endoderm,ectoderm and mesoderm
highly specialized teratoma : monoderm,such as struma ovarii
malignant change rate :2-4%,more in postmenopause,metastasized by spreading and peritoneal implantation
prognosis :bad,5 year survival rate 15-31%
immature teratoma : malignant tumor
components :2-3germ layers,immature embryonic tissue
age:adolescence
macroexamination : more solid
malignance :dependent upon the ratio and differentiation of
immature tissue and the quantity of nervous epithelium
recurrent and metastatic rate : high,5year survival rate20%
(ii).dysgerminoma :mid malignant tumor
morbidity :5%of malignant ovarian tumors most in adolescence
and reproductive period
macroexamination :solid, more unilateral,round or elliptic,
moderate size,touching like eraser,smooth surface or lobular
section:light-brown color
microscopic examination :round or polygonal cells,lymphocyte
invasion in stroma
prognosis :very sensitive to radiotherapy,5year survival rate90%
(iii).endodermal sinus tumor :also called yolk sac tumo
morbidity : rarely encountered
age : mostly occurred in children and young women
macroexamination :unilateral,relatively large,round or elliptic
section:partially cystic,brittle tissue,bleeding and necrosis area,
gray-red or gray-yellow color
microscopic examination:endodermal sinus structure,flat or
cuboid or columnar tumor cells which produce AFP,AFP is
an important diagnostic and therapeutic marker
prognosis:average survival time is 1 year
iii.ovarian gonadal sex cord stromal tumor
accounts for 5-8%of malignant ovarian tumor
(i).granulosa-stromal cell tumor
i).granulosa cell tumor:low malignance
morbidity:3-6%of ovarian tumor,80%of sex cord stromal tumor
age:at any age,mostly between 45-55
feminization effect:secret estrogen
macroexamination:unilateral,different size ,round or elliptic,
lobular, smooth surface ,solid or partially cystic
section:brittle and soft tissue,bleeding and necrosis
microscopic examination :Call-Exner body
prognosis :better,5year survival rate over 80%
ii).theca cell tumor :benign tumor
feminization effect:secret estrogen,often coexist with granulosa
cell tumor
macroexamination : unilateral different size ,round or elliptic,
thin smooth fibrocapsule
section:solid ,gray white
microscopic examination :short spindal cells,lipid in cytoplasm
prognosis : malignant tumor is rare ,prognosis is better than
other ovarian cancer
iii).fibroma :common benign tumor
morbidity :2-5%of ovarian tumor
age : mostly in mid-aged women
macroexamination :unilateral, moderate size,smooth surface
or nodular
section:gray white,solid and hard
microscopic examination:composed of spindle cells
Meigs syndrome :accompanied with hydrothorax and ascites
(ii).Sertoli Leydig cell tumor:also called androblastoma
morbidity : rare
age : below40
macroexamination : unilateral,small,solid smooth surface
section :gray white accompanied by cystic degeneration,
bloody or serous or mucinous cystic fluid
virilism effect :secret androgen
prognosis :10-30% is malignant ,5year survival rate 70-90%
iv.ovarian metastatic tumor:all of the cancers in the human body
can metastasize to the ovary,the common primary
origination is at breast,intestine,stomach,reproductive tract,
urinary tract and other organs
morbidity:5-10%of ovarian tumor
Krukenberg tumor :a special metastatic adenocarcinoma,its
primary origination is in the gastrointestinal tract
macroexamination:bilateral,renal shape, no adhesion,often
accompanied by ascites
section:solid
microscopic examination:signet-ring cell which produce mucus
prognosis:very bad
• IV.Metastatic Path
•
•
•
•
•
•
•
•
•
•
•
•
i.metastatic character:there is subclinical metastasis on
omentum,peritoneum,retroperitoneal LN and diaphragm
although the tumor is localized from its apparence
ii.metastatic path:
(i).directly spreading:this is the chief metastatic path.the
tumor cells may directly invade the capsule,involve
the neighbour organs and extensively implant on the
peritoneum and omentum
(ii).lymphetic vessels metastasis:this is an important
metastatic way which includes
i).spread along the ovarian blood vessels and is metastasized
to para-aortic LN through ovarian lymphetic vessels
•
•
•
•
•
•
•
•
•
•
ii).from ovarian hilus lymphetic vessels to internal and
external iliac LN,and then from the common iliac LN
to para-aortic LN
iii).along the round ligament enters the external iliac and
inguinal LN.diaphragm is the place to which the cancer
is easily metastasized,especially the right diaphragm is
the most easily invaded because of its dense lymphetic
plexus
(iii).blood metastasis is very rare.but at very late stage it may
metastasize to the liver and lung
• V.Histologic grades
•
•
•
•
•
•
•
•
the WHO standards of histologic grading is chiefly
according to the histologic structure and cellular
differentiation.
Grade I:means the cell is well differentiated
Grade II:means moderate differenation
Grade III:means undifferenation
the effects of histologic grade on the prognosis is
more important than that of the histologic types
• VI.Clinical stage:the FIGO(1986) clinical stage is
•
adopted
• stage I
• Ia
•
tumor is localized in the ovary
tumor is localized in one ovary,the capsule is integrated,
no tumor on ovary surface,no ascites
• Ib
•
tumors are localized in bilateral ovarys,integrated capsule
no tumor on surface,no ascites
• Ic
•
•
•
based on Ia or Ib,there is tumor on the surface(unilateral
or bilateral);or capsule is ruptured;or there is malignant
cells in ascites ;or the abdominal cavity irrigating fluid
is positive
• Stage II unilateral or bilateral ovarian tumor with pelvic
•
metastasis
• IIa
spread to uterus and (or)fallopian tube
• IIb
spread to other tissues in pelvis
• IIc
•
•
•
based on the IIa or IIb, there is implantation on
unilateral or bilateral ovarian surface;or the capsule is
ruptured;or the ascites contains malignant cells;or the
abdominal cavity irrigating fluid is positive
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Stage III unilateral or bilateral ovarian tumor.there is
extrapelvic peritoneal implantation and (or) the
retroperitoneal or inguinal LN is positive,liver
surface metastasis is stage III
IIIa
macroexamination shows that the tumor is located in the true pelvis,LN is negative but there is
microscopic peritoneal implantation
IIIb
unilateral or bilateral ovarian tumor,there is
peritoneal surface implantation and its diameter
is<2cm, LN is negative
IIIc
the peritoneal surface implantation is>2cm and
(or) retroperitoneal or inguinal LN is positive
stageIV unilateral or bilateral ovarian tumor with telemetastasis,
hydrothorax contains cancer cells,and there is liver
parenchyma metastasis
VII.Clinical Manifestation
i.benign ovarian tumor
(i).at early stage
(ii).when tumor is moderate size
(iii).when tumor is large enough to occupy the full pelvis
or abdominal cavity
ii.malignant ovarian tumor
(i).at early stage
(ii).once there are symptoms
(iii).the severity of the symptoms depends ouon
i).the tumor size,location and whether there is neighbour
tissues or organs invasion
ii).the histologic type of the tumor
iii).whether there is complication
(iv).at late stage
i).symptoms
ii).body signs
VIII.Diagnosis
i.cytologic examination
ii.B-Ultrasound
iii.radiodiagnosis:
(i).abdominal plain film
(ii).intravenous pyelography,barium meal,barium double
contrast radiography or mammary soft tissue X-ray
(iii).CT
(iv).laparoscopy
(v).tumor marker
i).CA-125
ii).AFP
iii).HCG
iv).sexual hormone
IX.Differential Diagnosis
* *i.differential diagnosis between the benign and
malignant ovarian tumor
Differential contents
History
Body sign
General condition
B-Ultrasound
benign tumor
long clinical course
and gradually enlarge
often unilateral,movable,
cystic,smooth surface
no ascites
malignant tumor
short clinical course and
rapidly enlarge
often bilateral,fixed solid
or semisolid,rough surface,
bloody ascites with cancer
cells
better
cachexia is gradually developed
dark fluid echo area,there echo group or points exist
may be intracystic diaph- in the dark fluid area tumor
ragm,tumor outline is
outline is not clear
clear
ii.differential diagnosis of benign ovarian tumor
i.ovarian tumor like condition:may disappear within 2 month
ii.tubo-ovarian cyst
iii.uterine myoma
iv.pregnant uterus
v.large quantity ascites
iii. differential diagnosis of malignant ovarian tumor
i.endometriosis:symptoms,body signs,B-Ultrasound and laparoscopy
ii.pelvic connective tissues inflammation:history,symptoms,and
body signs,B-Ultrasound
iii.TB peritonitis:history,general symptoms,body signs, B-Ultrasound
and gastrointestinal X-ray
iv.extra-reproductive tract tumors: B-Ultrasound,Barium meal and
intravenous pyelography
v.metastatic ovarian tumor:generally no primary tumor history
X.Complications of ovarian tumor
i.pediculotorsion:common gynecologic acute abdomen
(i).mechanism
(ii).components of the pedicle
(iii).pathologic change
(iv).typical symptoms
(v).body signs
(vi).management
ii.tumor rupture:accounts for about 3% of ovarian tumor
(i).traumatic and spontaneous rupture
(ii).symptoms depends on the length of rupture,the
quantity and
the quality of the cystic fluid flowing into abdominal
cavity
(iii).body signs
(iv).management
iii.infection:rarely encountered
(i).cause of the infection
(ii).clinical manifestation
(iii).management
iv.malignant change
(i).at early stage of malignant change
(ii).suspicious manifestation
(iii).management principle of ovarian tumor
XI.Prevention
i.prevention of high risk factors : suggesting high protein
and vitamin A diet and avoiding high cholesterol diet
ii.popularizing the regular examination and treatment
iii.early diagnosis and treatment
XII.Treatment of ovarian tumor
i.benign ovarian tumor:once the diagnosis is confirmed
operation should be performed
(i).young patient with unilateral tumor
bilateral tumor
(ii).perimenopausal patient with benign ovarian tumor
(iii).manipualtion principle of operation
ii.malignant tumor:the treating principle is chiefly by
operation and the chemotherapy and radiotherapy is as
the accessory treatment
(i).operation:operation play the key role for the treatment
especially the first time of operation
i).probe during operation
ii).operating range:(a).for stage Ia or Ib
(b).for stage Ic or over Ic
(c).cytoreductive operation
iii).the indications of reserving contralateral ovary
(a).stage Ia,well differentiated
(b).borderline or low malignant tumor
(c).no tumor is found in the contralateral ovary
(d).has the condition of closely postoperative follow up
(ii).chemotherapy
chemotherapy is a chief accessory therapy.malignant
ovarian tumor is relatively sensitive to the chemotherapy,
the chemotherapy has certain effect even if the tumor has
extensively metastasized
the chemotherapy may be either for the prevention of
recurrence or for the postoperative treatment in the patient
whose tumor can not be thoroughly removed
for late stage patient who does not fit for the operation,the
chemotherapy can shrink the tumor and create the condition
for afterwards operation
(iii).radiotherapy:the accessory treatment for the operation
and chemotherapy
dysgerminoma is very sensitive to the radiotherapy,
granulosa cell tumor is moderate sensitive to the
radiotherapy
epithelial ovarian cancer also has certain sensitivity
to the radiotherapy
XIII.Prognosis:
prognosis is associated with the clinical stage,
histologic type,age and treating methods among
which the clinical stage is the most important
XIV.follow up
i.time of follow up:once a time within 1 year after
operation;once every 3 month in the second year after
operation;once every 6 month in the third year and once a
year over 3 years after operation
ii.contents:symptoms body signs ,pelvic and general examination
B-ultrasound,CT,MRI and tumor marker