Ovarian Cancer

1
Ovarian Cancer
DI WEN M.D., Ph.D.,
Professor Chairman
Department Of
Obstetrics Gynecology
Renji Hospital Affiliated to SJTU
School of Medicine
2
General Introduction

• Ovarian 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

3
Risk Factors

• Family history
• Ovarian cancer
• Breast cancer
• Colon cancer
• Genetic factors
• Older age
• Caucasian
• More menstrual circles during lifetime (Ovulation
  induction)

4
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.

5
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 patients time
  of life.

6
symptoms

• Increased abdominal size

7
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.

8
CLINICAL FEATURES OF OVARIAN TUMOURS
9
CLINICAL FEATURES OF OVARIAN TUMOURS
10
CLINICAL FEATURES OF OVARIAN TUMOURS
11
General Rule
DIFFERENTIAL DIAGNOSIS

• 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.

12
DIFFERENTIAL DIAGNOSIS
13
ASCITES
DIFFERENTIAL DIAGNOSIS

• 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.

14
Uterine Fibroids
DIFFERENTIAL DIAGNOSIS

• 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.

15
DIFFERENTIAL DIAGNOSIS
16
DIFFERENTIAL DIAGNOSIS
17
DIFFERENTIAL DIAGNOSIS
18
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.

19
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.

20
Ovarian Germ Cell Tumor

• Fibroma or sarcoma.
• .Dysgerminoma.
• .Teratoma.
• .Gonadoblastoma.
• .Yolk sac tumour.
• .Carcinoid
• .Thyroid tumour Choriocarcinoma

21
Gonadal Sex Cord Stromal Tumor

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

22
Krukenberg Tumor

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

23
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.

24
OVARIAN TUMOURS --MUCINOUS CYSTADENOMA
25
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.

26
OVARIAN TUMORS --SEROUS CYSTADENOMA
27
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.

28
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.

29
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.

30
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.

31
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.

32
Teratoma

• Cystic teratoma or dermoid
• Solid teratoma

33
Yolk Sac Tumor

• rare
• Children and young adults
• highly malignant
• alphafetoprotein

34
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.

35
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.

36
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.

37
Spread -Direct

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

38
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.

39
Spread -Blood Stream

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

40
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.

41
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 both
  ovaries or capsule ruptured.

42
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 implantslt2cm diameter.
• IIIc Abdominal implantsgt2cm diameter or positive
  retroperitoneal or inguinal nodes.

43
Staging of ovarian cancer

• Stage IV
• Distant metastases or pleural effusion with
  positive cyotlogy or parenchymal liver
  metastases.

44
Diagnosis

• Pelvic exam
• Ultrasound
• CT scan
• CA125 blood test
• SURGERY

45
TORSION of the PEDICLE

• The commonest complication
• Occur with any tumor
• Except those with adhesions

46
Clinical Features-Subacute
TORSION of the PEDICLE

• 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.

47
Clinical Features-acute
TORSION of the PEDICLE

• 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.

48
Ruptured Cyst
TORSION of the PEDICLE

• This may occur alone or in conjunction
  with torsion. Rupture is not particularly
  upsetting to the patient unless the contents are
  irritant.

49
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.

50
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.

51
Treatment

• Surgery
• Chemotherapy
• Radiation Therapy
• ? Hormonal Therapy

52
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 debulkingcyto-reductive
  treatment).

53
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.

54
SURGICAL TREATMENT OF OVARIAN TUMMOURS
55
SURGICAL TREATMENT OF OVARIAN TUMMOURS
56
SURGICAL TREATMENT OF OVARIAN TUMMOURS
57
Follow-up

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

58
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.

59
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.

60
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.

61
SURGICAL PROCEDURES IN OVARIAN CANCER
62
(No Transcript)
63
Thanks for Your Attention
DI WEN M.D., Ph.D.
Professor Chairman
Department of
Obstetrics Gynecology
Renji Hospital Affiliated to SJTU
School of Medicine

64
(No Transcript)
65
Hereditary Breast and Ovarian Cancer BRCA1
Breast cancer 50-85

• Autosomal Dominant Transmission
• Precise Risk for Male Breast Cancer Unclear
• Increased Risk for Prostate Cancer?

Second primary breast cancer 40-60
Ovarian cancer 20-60
Adapted from ASCO
66
Hereditary Breast and Ovarian Cancer BRCA2
breast cancer (50-85)
male breast cancer (6)
ovarian cancer (10-20)

• Autosomal Dominant Transmission
• Increased risk of prostate, laryngeal, melanoma
  and pancreas cancers