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Prof. Abdulhafid AbudherMBBch,DGO,MD,FABOG,FRCOG
IntroductionFifth most common cancer in womenFifth most frequent cause of cancer death1 in 70 newborn girls will develop cancer
during her lifetimeDisease of postmenopausal women and all
agesYear 2000
23000 new cases14000 deaths
Etiology Cause is unknownPredisposing factors
Repeated ovulationInfertility treatmentPCO 2.5 fold increaseUnopposed estrogen therapy
Etiology Increase risk by
High diet in saturated animal fatsAlcohol and milk (never confirmed)Exposure to talk powder
EtiologyProtective factors
Chronic anovulationMultipartyBreast feedingPregnancy -reduction 13-19% per pregnancyCOC Pills decrease by 50% for 5 years and
more of use
Over 90% develop sporadically10% of epithelial based on genetic
predispositionTurner syndrome(45,XO) dysgerminoma and
gonadoplastomaTwo first degree relatives –risk 50%
hereditaryIn two forms
Breast and ovarian syndrome (BOC) Germline mutation in BRCA1 gene on chromosome
17(28-44%) Less common BRCA2 on chromosome 13 (1/800)
Lyncy II syndrome (hereditary nonpolyposis colorectal cancer syndrome )HNPCC
HistopathologyDivided to three categories according to cell
type of originEpithelia neoplasmsGerm cell neoplasmsSex cord and stromal neoplasms
May be the site of metastatic disease Neoplasms metastatic to the ovary
1-Epithelia neoplasmsTend to occur in the sixth decade of life Derived from the ovarian surface mesothelial cells ,
six types:SerousMucinous endometroid clear cellTransitional cellundifferentiated
Account for over 60% of all ovarian neoplasmsMore than 90% of malignant ovarian tumors
Ovarian serous cystadenocarcinomaMost common 35-50% of all epithelial tumorsBilateral in 40-60%85% with extra ovarian spread at diagnosisOver 50% exceeds 15 cm, solid areas,
hemorrhage, cyst wall invasion Most poorly dfferentiated
Mucinous neoplasms10-20% of epithelial ovarian tumorSecond most common type of epithelial
ovarian carcinomaBilateral in less than 10%Average size is 16-17 cm (large) ,multilocular
,viscous mucus
Pseudomyxoma peritoneiUnusual conditionAssociated with mucinous neoplasms of ovaryProgressive accumulation of mucinous in
abdominal cavityMay be associated with appendixBenignPotentially morbid ,intestinal obstructionMortality rate approaches 50%
Endometroidal neoplasmAdenometroidal patternBilateral in 30-50%30% of patients will have endometrial
carcinoma of uterus as primary
Clear cell carcinomaCalled mesonephroid carcinoma5% of epithelial ovarian cancerSmall sizeAggressive ,hypercalcimeia ,hyperpyrexiaCystic and solid
Transitional cell carcinomaBrenner Newly describedPresent with advanced stagePoorer prognosis
Undifferentiated carcinomaAccounts for less than 10% of epithelial Absence of any distinguishing microscopic
features that permit its placement in one of the other histologic categories.
2-Germ cell neoplasmsTend to occur in second and third decade of life Better prognosisMany produce biological markersTypes:
Dysgerminoma Young females (Seminoma in male) 30-40% of germ cell tumors Unilateral in 85-90% Solid
Endometrial sinus tumor Was called yolk sac tumor Second most common germ cell tumor Occurs in 20% of cases Bilateral in less than 5% Commonly present with acute abdomen Produces AFP
Immature teratomas Malignant counterpart of mature cystic teratoma 20% of germ cell neoplasms Bilateral in less than 5% Elevated serum AFP Three germ layers Immature neuroectodermal element
Mature teratomas Common at age 20 to 30 Most common neoplasm diagnosed during pregnancy Less than 2% goes malignant after age of 40
Embryonal carcinoma Very rare in pure form HCG and AFP are usually elevated
Choriocarcinoma rare germ cell tumor unrelated to pregnancy Lower elevation HCG May cause precocious puberty, uterine bleeding or
amenorrhea
Gonadoblastoma Rare More common on the right than left ovary Occur in second decade of life Associated with presence of Y chromosome
Mixed germ cell tumors Accounts for 10% of germ cell tumor Contains two or more germ cell elements dysgerminoma and endometrial sinus tumor ocurs
together
3-Sex Cord-Stromal tumorsGranulosa cell tumor
1-2% of all ovarian neoplasmsMost common malignant tumor of sex cord-
sromalAssociated with hyperestrogenismMay cause precocious
puberty(girls) ,adenomatous hyperplasia and vaginal bleeding(postmenopausal women)
Ovarian thecoma Associated with hyperesrogenism Benign tumor
Ovarian fibroma Benign tumor Associated with Meig’s syndrome
Sertoli-stromal cell tumors Rare consist of testicular structures Occur during third decade Usually virilizing Rarely bilateral
4-Neoplasms metastatic to the ovaryAccounts for 25% of all ovarian malignancyMimic primary ovarian cancerPresent as bilateral adnexal masses25% unilateralCommon primary cancers
Breast (40%_Stomach (Krukenberg tumors)Colonendometrium
Diagnosis of ovarian CancerInsidious diseaseNon specific GIT complainsAbdominal distentionPelvic weightMenstrual abnormalities in 15%Rarely excessive estrogens or androgens
ScreeningRoutine pelvic examinationUltrasound examinationTumor markers
CA-125 antigen from fetal amniotic and coelomic epithelium
TAG 72 ,M-CSF ,OVX1
Evaluation of the patient with suspected ovarian neoplasmChild and postmenopausal women at great
risk of malignancyReproductive women is likely to have
functional cyst or endometriomaDifferential diagnosis is influenced by
Age Characteristic of the mass on pelvic
examinationRadiographic appearance
Physical ExaminationComprehensive examination
Lymph node , Sister Mary Joseph’s noduleAbdomen examinationPelvic examination
Characteristics
BenignMalignant
MobilityMobileFixed
ConsistencyCysticSolid or Firm
Bilateral/Unilateral
UnilateralBilateral
Cul-de-sacSmoothNodular
Radiographic EvaluationTrans abdominal ultrasoundTrans vaginal ultrasoundColor flow Doppler
ConsistencySimple cyst <10cm in size
Solid or cystic and solid
SeptationsSeptations <1mm in thickness
Multiple septations >3mm in size
Uni or bilateralunilateralBilateral
othersCalcification, teeth
ascites
Radiographic Evaluation,,,,Computed tomography (CT)
Pelvic organs and Retroperitoneal structuresMagnetic resonance imaging (MRI)
Nature of ovarian neoplasmX ray chestBarium enemamammogram
Laboratory EvaluationCBCSerum electrolyteshCG (pregnancy)AFP ,LDH lactate dehydrogenase (young
girls)CA-125
Surgical Treatment of Epithelial CancerSurgery is the corner stone of therapySurgical staging to
Reduce amount of disease Evaluate the extent of spread
Debulking or cytoreduvtive surgery is removalPrimary tumorAssociated metastasis disease
Intra operative differentiationBenignMalignant
SimpleUnilateralNo adhesionsSmooth surfaceIntact capsule
AdhesionsRuptureAscitesSolid areasAreas of hemorrhage or necrosisMulti loculated massBilateral
Most common location of metastases
Peritoneum 85%Omentum 70%Liver 35%Pleura 33%Lung 25%Bone 15%
Procedures in stagingSample of ascites or peritoneal washings from
Para colic gutters , pelvic and subdiaphragmatic for cytologyComplete abdominal explorationIntact removal of tumorInfracolic omentectomyBiopsies of abdominal peritoneal implantsPelvic and Para aortic lymph node biopsiesCytoreduvtive surgery to remove all visible
disease
International Federation of Gynecology&Obstetrics (FIGO) Staging Stage I. growth limited to the pelvis
Ia- One ovary Ib- both ovaries Ic- Ia or Ib and ovarian surface tumor ,rupture capsule, malignant ascites,
peritoneal cytology positive. Stage II. Extension to the pelvis
IIa- extension to the uterus or fallopian tube IIb- extension to the other pelvic tissues IIc- IIa or IIb and ovarian surface tumor ,rupture capsule, malignant ascites,
peritoneal cytology positive. Stage III.Extension to abdominal cavity
IIIa- abdominal peritoneal surfaces with microscopic metastases IIIb- tumor metastases <2cm in size IIIc- tumor metastases >2cm or metastatic disease in pelvic para aortic or
inguinal lymph nodes Stage IV. Distant metastases
Malignant pleural effusion Pulmonary parenchymal metastases Liver or splenic paranchyml metastases Metastases to thr supraclavicular lymph nodes or skin
Surgical treatment of Germ Cell NeoplasmsMost are at early stage on young womenRemoval of involved adnexiaSame complete surgical staging
Chemotherapy of epithelial cancerStage Ia and grade I, don’t need treatmentAgents ,cisplatin, carboplatin,
cyclophosphamide, paclitaxelCompination paclitaxel 175mg/m2 and
cisplatin 75mg/m2 or carboplatin for 6 cycles at 3 week intervals
Toxic effects Vomiting ,diarrhea ,alopecia, nephro and
ototoxicity and myelosuppression.
Chemotherapy of Germ Cell NeoplasmsCurableDysgerminoma most radiation sensitivePreserve future reproductive potential with
chemotherapyRegimens ,vinblastine-bleomycin-cisplatin ,
vincristin-actinomycin, D-cyclophsphomide, bleomycin-etoposide-cispltin
Complications of chemotherapyNausea vomiting alopecia
AgentToxicity
CisplatinCarboplatinCyclophosphamidePaclitaxilAltretaminEtoposideBleomycinDoxorubicin Vincristineifosfamide
Nephrotoxicity,neurotoxicity, ototoxicityThrombocytopenia, neutropeniaHemorrhagic cystitis, pulmonary fibrosisMyelosuppressionPeripheral neuropathyMyelosuppressiomPulmonary fibrosisCardiac toxicityNeurotoxicityHemorrhgic cystitis,central neurotoxicity
Radiation therapy and alternativeVery limited role in epithelial cancerDysgerminomaImmunotherapyGen therapy
prognosisRelated to
Response to chemotherapyDifferentiation of tumorGerm cell better than epithelialStage of the disease -5 year survival rate
(epithelial) Stge I -75-93% stageII- 65-74% Stage III- 23-41% Stage IV- 11%