OVARIAN CANCER

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OVARIAN CANCER

• Di Wen, M.D.,Ph.D

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OVARIAN TUMOURS

• Definition
• Ovarian tumors may arise at any age, but
  are commonest between 30 and 60.
• 1.Ovarian tumors are particularly liable to be or
  to become malignant.
• 2.In their early stages they are asymptomatic and
  painless.
• 3.They may grow to a large size and tend to
  undergo mechanical complications such as torsion
  and perforation.

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CARCINOMA OF THE OVARY

• Definition
• In developed countries,women have a
  lifetime risk of developing ovarian cancer of
  about 1.4,which is slightly greater than the
  risk of cervical or endometrial cancers, but well
  below the 7 average risk of breast cancer.

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CARCINOMA OF THE OVARY

• Risk Factor
• Genetic factor are sometimes involved?as
  in the Lynch Syndrome of familial breast
  colorectal and ovarian cancer.Ovulation induction
  with Clomiphene over more than year carries a
  l0-fold increased risk of ovarian cancer,
  Long-term ora1 contraceptive use reduces the
  incidence of ovarian cancers.

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CARCINOMA OF THE OVARY

• 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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CARCINOMA OF THE OVARY

• Primary Carcinoma of the Ovary
• 80 of all cases of primary carcinoma of
  the ovary arise in serous or mucinous cysts.

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CARCINOMA OF THE OVARY

• Solid Carcinoma of the Ovary
• This accounts for 10 of primary
  carcinoma. It is arise commonly bilateral but
  one tumor is usually larger than the other. The
  ovarian shape is retained for a time and there is
  a well-marked pedicle but soon the tumors become
  fixed. Secondary deposits occur in the omentum
  and ascites develops.

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CLINICAL FEATURES OF OVARIAN TUMOURS

• Symptoms due to Size
• Lack of any specific symptoms, ovarian
  tumors are often large by the time the doctor is
  consulted.

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• Menstrual function is seldom upset, and
  any irregularity is attributed to the patients
  time of life.

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• She may have noticed that her clothes are
  getting tight ant attributed this to weight gain
  or, if the abdominal swelling has coincided with
  amenorrhea she may believe herself to be
  pregnant.

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CLINICAL FEATURES OF OVARIAN TUMOURS

• Pressure Symptoms
• These are commonly increased frequency of
  micturition, gastro-intestinal symptoms and 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, due perhaps to
  interference with alimentary function.

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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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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
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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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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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TORSION of the PEDICLE

• Complications of Ovarian Tumors
• This is the commonest complication and
  may occur with any tumor except those with
  adhesions. The thin-walled veins of the pedicle
  are obstructed first while the arterial supply
  continues. As a result there is hemorrhage into
  the tumor and into the peritoneum, and if not
  treated gangrene will occur. Very rarely the
  pedicle atrophies and the tumor obtains a new
  blood supply through its adhesions to surrounding
  viscera (parasitic tumor).

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TORSION of the PEDICLE
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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

• Clinical Features
• Differential Diagnosis
• Surgical Conditions (i.e. those
  conditions commonly seen and dealt with by a
  general surgeon.)
• Acute appendicitis
• Meckels diverticulitis
• Obstruction of bowel
• Diverticulitis

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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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TORSION of the PEDICLE
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TORSION of the PEDICLE
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RUPTURE OF OVARIAN CYST
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RUPTURE OF OVARIAN CYST RUPTURE OF OVARIAN CYST
RUPTURE OF OVARIAN CYST
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RUPTURE OF OVARIAN CYST

• PSEUDOMYXOMA PERITONEI
• This rare condition occasionally but not
  inevitably follows mthe rupture of a mucinous
  cystadenoma. The epithelial cells implant on the
  peritoneum and continue to secrete a gelatinous
  pseudomucin which is not absorbed, or secretion
  is faster than absorption. The abdominal cavity
  is eventually filled with the jelly, while the
  secreting cells spread over the parietal and
  visceral peritoneum.

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RUPTURE OF OVARIAN CYST

• HYDROTHORAX
• Hydrothorax may accompany ascites due to
  any cause, or may occur as an accompaniment of a
  lung tumor. The so-called Meigs syndrome
  describes the specific condition of ascites and
  hydrothorax in conjunction with benign ovarian
  fibroma.

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• Features suggestive of malignancy
• 1.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.
• 2.Rapid growth.
• 3.Ascites.

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• Features suggestive of malignancy
• 4.Solid tumours, especially when bilateral.
• 5.Multilocular cysts with solid areas. (At least
  10 of cysts are malignant).
• 6.Pain. Pressure pain can occur with any tumor
  but referred pain suggests malignant involvement
  of nerve roots.
• 7.Tumor markers, such as CA125, may be measured
  in the blood, but a normal level does not exclude
  malignancy.

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OVARIAN TUMOURS

• 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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OVARIAN TUMOURS

• PRIMARY EPITHELIAL TUMOR
• 1.Mucinous cystadenoma or cystadencarcinoma (of.
  Cervical epithelium).
• 2.Serous cystadenoma or cystadenocarcinoma (of .
  tubal epithelium).
• 3.Endometrioma or Endometrioid carcinoma (of.
  Endometrium).
• 4.Clear cell carcinoma.
• 5.Brenner tumour.

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OVARIAN TUMOURS

• STROMATOUS TUMOURS GERM CELL TUMOURS
• .Fibroma or sarcoma.
• .Dysgerminoma.
• .Teratoma.
• .Gonadoblastoma.
• .Yolk sac tumour.
• .Carcinoid
• .Thyroid tumour Choriocarcinoma

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OVARIAN TUMOURS

• HORMONE-PRODUCING TUMORS
• Estrogen-producing
• Granulosa cell tumour.
• Thecoma.
• Androgen-prodicing
• Sertoli-Leydig cell tumour (Arrhenoblastoma).
• Hilar cell tumour.
• Lipoid cell tumour.

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krukenberg tumour
OVARIAN TUMOURS

• There is one well-known secondary tumour
  of the ovary, the krukenberg tumour, a secondary
  of a stomach carcinoma.

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OVARIAN TUMOURS --MUCINOUS CYSTADENOMA

• Definition
• 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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OVARIAN TUMOURS --MUCINOUS CYSTADENOMA

• signs and symptoms
• The signs and symptoms are those
  generally associated with any non-functioning
  ovarian tumor. Rupture may occur and seeding of
  the epithelium on the peritoneal surface may
  cause pseudomyxoma peritonei.

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OVARIAN TUMORS --MUCINOUS CYSTADENOCARCINOMA

• Definition
• This is only a third as common as the
  serous variety. Malignancy in a mucinous cyst is
  characterised by the formation of areas of solid
  carcinoma in the wall. The cells are columnar,
  show mitoses and tend to form glandular
  structures.

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OVARIAN TUMORS --SEROUS CYSTADENOMA

• Definition
• 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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OVARIAN TUMORS --SEROUS CYSTADENOCARCINOMA

• Definition
• 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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CARCINOMA OF THE OVARY

• 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 post-menopausal cases.

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CARCINOMA OF THE OVARY

• 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 well-differentiated adenocarcinoma, an
  adeno-acanthoma, mucinous adenocarcinoma or
  clear-celled carcinoma.

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CARCINOMA OF THE OVARY

• Clear Cell Carcinoma
• It is doubtful if this exists as a
  distinct entity. Clear cells may be seen in
  almost any variety of ovarian carcinoma, but
  occasionally a carcinoma, usually solid, consists
  almost entirely of polygonal cells with clear
  cytoplasm. It behaves in the same way as any
  other solid carcinoma and has the same prognosis.

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CARCINOMA OF THE OVARY

• Secondary Carcinoma of the Ovary
• The ovary may be the site of secondary
  deposits from growths arising in other parts of
  the genital tract. These are usually overshadowed
  by the clinical manifestations of the primary
  growth.

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CARCINOMA OF THE OVARY

• Secondary Carcinoma of the Ovary
• Ovarian metastases from extra-genital
  tumors are not uncommon. The commonest sites of
  primary growth are breast, stomach and large
  intestine.

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CARCINOMA OF THE OVARY

• 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
  Meigs syndrome.

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CARCINOMA OF THE OVARY

• GERM CELL TUMOURS
• There are four main types of gern cell
  tumour
• .Dysgerminoma
• .Tumours of tissues found in the embryo or adult
  ---- the teratomata
• .Tumours of dysgenetic gonads ---- commonly a
  gonadoblastoma
• .Tumours of extra-embryonic tissues such as
  choriocarcinoma or yolk sac tumour.

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CARCINOMA OF THE OVARY

• 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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CARCINOMA OF THE OVARY

• Yolk sac tumor
• This is a rare tumor found in children and
  young adults. It has a variable histological
  structure and is highly malignant. The main
  interest lies in the fact that it produces
  alphafetoprotein and the blood levels can be used
  as a diagnostic test and as a means of monitoring
  response to treatment.

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CARCINOMA OF THE OVARY
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CARCINOMA OF THE OVARY

• Estrogen-producing Tumors
• These belong to the granulosa-theca cell
  group and are found at all ages. They account for
  3 of all solid tumors of the ovary.

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CARCINOMA OF THE OVARY

• 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
  post-menopausal bleeding.

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CARCINOMA OF THE OVARY

• ANDOROGEN-PRODUCING TUMOURS
• Three distinct types of masculinising
  ovarian tumor are recognised a) Sertoli-Leydig
  cell tumor (Arrhenoblastoma), b) Hilar cell
  tumor, c) Lipoid cell tumor. All three cause
  amenorrhoea.

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Spread of Ovarian Cancer

• Direct
• The first spread is directly into
  neighbouring structures peritoneum, uterus,
  bladder, bowel and omentum.

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Spread of Ovarian Cancer

• 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 of Ovarian Cancer

• Blood stream
• Blood spread is usually late, to the
  liver and lungs.

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SURGICAL PROCEDURES IN OVARIAN CANCER

• General Principle
• 1.To classify the growth according to its extent
  of spread (staging) as accurately as possible.
• 2.To remove as much cancerous tissue as possible
  (surgical debulkingcyto-reductive
  treatment).

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SURGICAL TREATMENT OF OVARIAN TUMMOURS

• General Rule
• 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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TREATMENT OF OVARIAN CANCER

• General Principle
• Much attention is being directed towards
  the treatment of epithelial ovarian cancer which
  is now the most frequent cause of death from
  gynecological malignancy. The principles of
  treatment are

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TREATMENT OF OVARIAN CANCER

• General Principle
• Ovarian carcinoma is staged surgically, so
  laparotomy is an essential part of management for
  most patients.
• Surgical removal of as much malignant tissue as
  possible, even if this should call for resection
  of structures outside the normal field of the
  gynecologist.

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TREATMENT OF OVARIAN CANCER

• General Principle
• Follow-up with intensive chemotherapy, using
  various combinations of antineoplastic drugs.
  Taxanes, probably combined with platinum
  compounds, are an appropriate first choice.
• 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 IN OVARIAN CANCER

• 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 IN OVARIAN CANCER

• 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