Ovarian tumours

1
??? ???? ?????? ??????

• Ovarian tumours
• By Dr.
  Sallama kamel

2
Introduction

• Ovarian cancer is the second most common
  gynecological malignancy and the major cause of
  death from a gynecological cancer.
• Unfortunately survival from ovarian cancer remain
  poor (38) , due in part to the late presentation
  of the disease.
• Prompte identification and appropriate
• treatment of cancer of the ovary are essential if
  
• the survival rates are to be optimal.

3

• -Although differentiating malignant from
• benign disease is critical in optimizing
• management for the individual case,
• -Non invasive diagnosis continues to be elusive

4
Histopathology and classification of ovarian
tumors

• A cyst or amass in the ovary could be
• Functional cysts -Follicular
  cyst.
• 
  -corpus Luteal cyst.
• 
  -Theca lutien cysts
• 
  -endometriosis cyst
• Primary T. -Epithelial
  cell T.
• 
  -Germ cell T.
• 
  -Sex cord T.
• Secondary T. - Breast , colon,
  stomach

5

• Epithelial tumours Germ cell T.
  Sex cord T.
• -Serous tumours.
  -Dysgerminoma
  -Granulosa cell .
• -Mucinous tumours.
  -Teratoma(benign and malign)
  -Thecoma
• -Endometroid tumours. -Yolk sac
  tumor -Sertoli-
  leydig cell.
• -Clear cell tumours.
  -Choriocarcinoma
  -Gynandroblastoma
• -Brenner tumours.
  -Embryonal carcinoma
  -Fibroma
• -Mixed epithelial tumours.
• -Undifferentiated tumours

6

• Physiological cyst
• -They are simply large versions of the cysts that
  forms in the ovary during the normal ovarian
  cycle.
• -Most are asymptomatic and found incidentally on
  pelvic examination or ultrasound.
• -They are most common in young women.
• -They may be a complication of induction of
  ovulation.
• -They also occur in women with trophoblastic
  disease.

7

• Follicular cysts
• ?it result from the non-rupture of a dominant
  follicle or the failure of atresia in a
  non-dominant follicle.
• ?They are lined by Granulosa cells and contain
  clear fluid.
• ?It can persist for several menstrual cycles and
  may achieve a diameter of up to 10cm.
• ?Small cysts are more likely to resolve
  spontaneously but may require intervention if
  symptoms develop or if they do not resolve after
  8-16 weeks.
• ?Occasionally they may continue to produce
  oestrogen, causing menstrual disturbances and
  endometrial hyperplasia.

8
Simple follicular cyst
9
Luteal cysts

• ?Less common than follicular cyst.
• ?Are more likely to present with intra-peritoneal
  bleeding.
• ?They may also rupture.
• ?This is usually happens on day 20-26 of the
  cycle.
• ?They should not called Luteal cyst unless they
  are more than 3cm. In size.
• Theca-lutein and granulosa lutein cysts.
• -These occurs in association with hydatidiform
  moles or Choriocarcinoma.
• -They are caused by high output of gonadotrophin
  from the chorion,and may reach a size of 10cm
• -After treatment or removal of the abnormal
  chorion the cyst resolves.
• -Similar cysts may formed if excessive doses of
  gonadotrophins or of clomiphines are given to
  induce ovulation causing hyper-stimulation
  syndrome.

10
Epithelial tumours

• -These tumours arise from the ovarian surface
  epithelium.
• -So they arise from the Coelomic epithelium
  overlying the embryonic gonadal ridge.
• Since the epithelial covering of the ovary
  and the mullerian
• duct ( from which the tubal, endometrial and
  cervical
• epithelium are derived ) are both from coelomic
  epithelium ,
• comparable metaplastic transformation into
  different types of
• epithelium is possible.
• -So the cells may differentiate to endocervical
  cells giving rise to mucinous cystadenoma.
• -Differentiation into endometrial cells give rise
  to Endometrioid tumour.
• -Differentiation to tubal epithelium give rise to
  serous cystadenoma.
• -Differentiation along uro-epithelium give rise
  to Brenner tumour.
• They are most common in women over 40 years old.

11
1.Serous cystadenoma

• -These are the most common epithelial tumours
  with a range from benign to the highly malignant
  .
• -The benign form are called benign serous cyst.
• -It is unilocular cyst with papilliferous
  processes on the inner surface and occasionally
  on the outer surface.
• -The lining epithelium is cuboidal or columnar
  and may be ciliated.
• -The cyst contain thin serous fluid.
• -They are usually smaller than the mucinous
  tumour.
• -They are often bilateral
• -They occur most commonly in late reproductive
  and early postmenopausal life.

12
The malignant form called Serous papilliferous
carcinoma

• -This is the commonest primary ovarian carcinoma.
• -It is bilateral in 50.
• -The growth often penetrates the capsule and
  project on the external surface with
  dissemination of the cells into the peritoneal
  cavity giving multiple seedling metastases and
  ascites.
• -The cyst contains many papillary processes which
  have proliferated so much that they almost fill
  the cavity and there may be exophytic papillary
  growth on the surface.
• -The lining cells are multilayer and may invade
  normal tissues.

13
Ovarian carcinoma
14
2.Mucinous cystadenoma

• -The 2nd most common epithelial tumour.
• -They are large, unilateral , multilocular cysts
  with smooth inner surface.
• -The lining epithelium is columnar
  mucous-secreting cells.
• -The cyst contain thick glutinous fluid.
• -A rare complication is pseudomyxoma peritonei,
• when there is shedding of cells on the surface of
  the
• peritoneum and grow there and continue to secrete
  mucin
• so the abdominal and pelvic cavities are slowly
  filled with a
• gelatinous mass of mucin , causing matting
  together and
• consequent obstruction of the bowel loops.
• -A similar condition may occur after rupture of a
  mucocele of the appendix and the two may
  co-exist, raising the possibility of a metastasis
  from an ovarian primary.

15
Mucinous cystadenoma
16
Malignant mucinous cyst (Mucinous carcinoma)

• -Constitute 10 of ovarian cancers.
• -On histological examination, 5 of mucinous
  cysts found to be malignant.
• Epithelial tumours of borderline malignancy
• - mean that the tumour carry some of the features
  of malignancy( e.g. multilayering of cells and
  nuclear atypia).
• -But there is no stromal invasion.
• -20 of epithelial tumours are of borderline
  malignancy.
• -It is rare for such tumours to be more than
  stage1, i.e. beyond one or two ovaries , and
  surgical removal of the pelvic organs usually
  results in cure.

17
3.Endometrioid cystadenoma

• -These are very similar to ovarian endometriosis.
• -They may be associated with pelvic pain and
  dyspareunia due to adhesions.
• -It may coexist with uterine endometrial
  adenocarcinoma.
• 4.Clear cell tumours( mesonephroid)
• -They arise from serosal cells showing little
  differentiation, and are only rarely benign.
• -The typical histological appearance is of clear
  or hobnail cells( which have scanty cytoplasm and
  large nuclei) arranged in mixed patterns .

18
5.Brenner tumours

• -These account for only 1-2 of all ovarian
  tumours.
• -They are bilateral in 10-15.
• -The vast majority is benign but can occasionally
  be borderline or malignant
• -Three quarter occurs in women over the age of
  40.
• -The majority is less than 2cm in diameter.
• -Some secrete oestrogens and abnormal vaginal
  bleeding is a common presentation.
• Macroscopically a Brenner tumour resembles a
  fibroma, being a solid tumour with a white cut
  surface.
• Histologically -It consists of islands of round
  transitional-like epithelium in a dense fibrotic
  stroma giving a solid appearance.

19
Germ cell tumours

• It is among the commonest ovarian tumours seen
  in women of less than 30years old.
• ?In women under 20 years ,up to 80 of ovarian
  malignancies are due to germ cell tumours.
• Overall only 2-3 percent are malignant .
• These tumours arise from a totipotential germ
  cell
• Thus they contain element of all three germ
  layer( embryonic differentiation).
• Differentiation into embryonic tissues result in
  teratoma
• (dermoid cyst).
• Differentiation into extra-embryonic tissues
  results in ovarian Choriocarcinoma or endodermal
  sinus tumour.
• When neither embryonic nor extra-embryonic
  differentiation occurs, dysgerminoma results.

20
Dermoid cyst (mature cystic teratoma)

• -This is the commonest germ cell tumour and it is
  benign.
• -It results from differentiation into embryonic
  tissues.
• -It account for about 40 of all ovarian
  neoplasm.
• -It is most common in young women and the median
  age of presentation is 30 years old.
• -it contain a variety of tissues derived from the
  two or more of the primary germ layers..
• -The dermoid cyst is usually unilocular cyst.
• -Less than 15cm in diameter
• -It is often lined by epithelium like the
  epidermis and contain skin appendages, teeth ,
  sebaceous material , hair and nervous tissues,
  cartilage bone and thyroid tissues.
• -The cavity of the cyst contain yellow greasy
  material.

21
Dermoid cysts
22

• -The majority of dermoid cysts (60) are
  asymptomatic.
• -However it may undergo torsion.
• -Less commonly it may rupture spontaneously,
  either suddenly causing an acute abdomen and
  chemical peritonitis, or slowly causing chronic
  granulomatous peritonitis.
• -During pregnancy, rupture is more common due to
  external pressure from expanding gravid uterus or
  to trauma during delivery.
• -Some dermoid cysts contain single type of
  tissues like thyroid tissue and called stroma
  ovarii and might present with feature of
  hyperthyroidism.
• Mature solid teratoma
• -These are tumours contain mature tissues just
  like the dermoid cyst but are solid.
• -They must be differentiated from immature
  teratomas which are malignant.

23
Malignant germ cell tumours

• These are rare tumours accounting for only 3 of
  ovarian cancers.
• 1.Dysgerminoma
• -This is the most common malignant germ cell
  tumours accounting for about 50.
• -Nearly all occur in young women less than 30
  years old.
• -Spread mainly by lymphatics.
• -They are solid tumours with a smooth or nodular
  external surface.
• -The mean diameter is 15cm.
• -Approximately 10 are bilateral( the only
  malignant germ cell tumour that can be bilateral
  ).
• -Pure Dysgerminoma have a good prognosis as they
  are normally stage 1 tumours in 75 of cases.
• -It may occur in cases of gonadal dysgenesis,and
  it is radiosensitive.

24

• 2.Yolk sac tumour ( endodermal sinus tumour).
• -These are the second most common malignant germ
  cell tumour of the ovary.
• -Making 10-15 over all and reaching a higher
  proportion in children
• -The tumour is usually well encapsulated and
  solid.
• -It may present as acute abdomen due to rupture
  of the tumour following necrosis.
• -It secrete alfa-feto protein (AFP) which can be
  used as a tumour marker.

25

• 3.Immature Solid Teratoma
• -These account for approximately 20 of malignant
  germ cell tumours with a peak incidence in the
  second decade of life.
• -They contain embryonic( immature) tissues and
  they are highly malignant.
• 4.Non gestational Choriocarcinoma
• -These generally arise as a component of a solid
  teratoma.
• -They consist of syncytiotrophoblast and
  cytotrophoblast and secret gonadotrophin, which
  can be used as a diagnostic marker.

26
sex cord stromal tumours

• -These account for only 4 of benign ovarian
  tumours.
• -They occur at any age from prepubertal children
  to elderly, postmenopausal women.
• -They secrete hormones and present with the
  results of inappropriate hormone effects.
• 1.Granulosa cell tumours
• -These are all malignant tumours but they are
  generally confined to the ovary when they present
  and so have a good prognosis.
• -They grow very slowly and recurrences are often
  seen 10-20 years later.
• -They are solid in most cases.
• -Some produce oestrogens causing postmenopausal
  bleeding in older women or precocity in
  prepubertal girls and
• -most appear to secrete inhibin which can be used
  to monitor treatment..

27
2.Theca cell tumours

• -Almost all are benign, solid and unilateral
  tumours.
• -They present in the sixth decade of life.
• -Many produce oestrogens in sufficient quantity
  to have systemic effects such as precocious
  puberty, postmenopausal bleeding , endometrial
  hyperplasia and endometrial cancer.

28
3.Fibroma

• -These unusual tumours are most frequent around
  50 years of age.
• -Most are derived from stromal cells and are
  similar to thecomas.
• -They are hard mobile and lobulated with
  glistening white surface .
• -Less than 10 are bilateral.
• -Meigs syndrome ( ascites , pleural effusion in
  association with a fibroma of the ovary) is seen
  in only 1 of cases.

29
4.Sertoli- leydig cell tumours

• -These are usually of low grade malignancy.
• -Most occur around 30 years of age.
• -They are rare ( only 0.2 of ovarian tumours).
• -Many produce androgens and signs of virilization
  are seen in three-quarters of patients

30

• Benign ovarian tumours
• presentation
• -Asymptomatic.
• -Pain.
• -Abdominal swelling.
• -Pressure effects.
• -Menstrual disturbances.
• -Hormonal effects.
• -Abnormal cervical smear.

31
1.Asymptomatic

• Many benign ovarian tumours are found
  incidentally in the course of investigating
  another unrelated problem or during a routine
  examination.
• 2.Pain
• -Acute pain from an ovarian tumour may result
  from complication e.g. torsion, rupture,
  haemorrhage or infection.
• -Torsion give rise to a sharp, constant pain
  caused by ischaemia of the cyst and areas may
  become infarcted.
• -Haemorrhage into the cyst may cause pain as the
  capsule is stretched.
• -Rupture of the cyst causes intraperitoneal
  bleeding mimicking ectopic pregnancy (this
  happens mostly with a luteal cyst ).
• -Chronic lower abdominal pain sometimes results
  from the pressure of a benign ovarian tumour but
  is more common if endometriosis or infection is
  present.

32
Twisted ovarian cyst
33
3.Abdominal swelling

• -Patients seldom note abdominal swelling until
  the tumour is very large .
• -A benign mucinous cyst may occasionally fill the
  entire abdominal cavity.
• 4.Miscellaneous
• pressure effects. -Gastro-intestinal or urinary
  symptoms may result from pressure of large
  tumour.
• -In extreme cases, oedema of the legs, varicose
  veins and haemorrhoids may result.
• -menstrual disturbances
• Occasionally the patient will complain of
  menstrual disturbances but this may coincidence
  rather than due to the tumour.
• -hormonal effects
• rarely Sex cord tumours may present with
  oestrogens effects such as precocious puberty,
  menorrhagia and glandular hyperplasia, breast
  enlargement and postmenopausal bleeding.
• -Secretion of androgens may cause hirsutism and
  acne initially progressing to frank virilism with
  deepening of the voice or clitoral hypertrophy.

34
Diagnosis

• 1.Full history
• -Details of the presenting symptoms and a full
  gynaecological history should be obtained with
  particular reference to the date of the last
  menstrual period , the regularity of the cycle,
  any previous pregnancies , contraception,
  medication and family history ( particularly of
  ovarian, breast and bowel cancer ).
• 2.Examination ( abdominal and pelvic
  examination)
• -If the patient presented with acute abdomen look
  for evidence of hypovolaemia.
• -The neck , axilla and groins should be examined
  for lymphadenopathy.
• A malignant ovarian tumour may cause a pleural
  effusion.
• -This is much less commonly found with benign
  tumour.
• -Also some patient may have ankle oedema.
• -The abdomen should be inspected for distension
  by fluid or by the tumour itself.
• -A male distribution of hair may suggest a rare
  androgen-producing tumour.

35
Bimanual examination

• -This is an essential part of assessment.
• -To palpate the mass , its mobility, consistency.
• -Presence of nodules in the pouch of Douglas and
  the degree of tenderness.
• -A cystic mobile mass is mostly benign, while a
  hard, irregular fixed mass is likely to be
  malignant.

36
Investigations

• . Ultrasound
• -Trans-abdominal and trans-vaginal ultrasound can
  demonstrate the presence of an ovarian mass with
  reasonable sensitivity and specificity.
• -However it can not distinguish reliably between
  benign and malignant tumours but solid masses are
  more likely to be malignant than the purely
  cystic mass.
• -The use of colour- flow Doppler may increase the
  reliability of ultrasound.
• -MRI may have a role in differentiating benign
  and malignant ovarian tumours.

37
Radiological investigations

• -A chest X- ray is essential to detect metastatic
  disease in the lungs or a pleural effusion .
• -Occasionally an abdominal X-ray may show
  calcification, suggesting the possibility of a
  benign teratoma.
• -A barium enema is indicated only if the mass is
  irregular or fixed, or if there are bowel
  symptoms.
• Blood test and serum markers
• -Elevated WBC count may indicate infection.
• -Ca125
• Raised serum Ca125 is strongly suggestive of
  ovarian carcinoma, especially in postmenopausal
  women.

38

• -Women with extensive endometriosis also have
  elevated levels but the concentration is usually
  not as high as that seen with malignant disease.
• - B-HCG level is elevated in women with
  choriocarcinoma.
• -Oestradiol levels may be elevated in some women
  with physiological follicular cysts and sex cord
  stromal tumours.
• -Androgens are increased with Sertoli-lydig
  tumours.
• -Raised alpha-fetoprotein levels suggest a yolk
  sac tumour.

39
Management of benign ovarian tumours

• This will depend upon the
• -Severity of the symptoms.
• -Age of the patient .
• -The risk of malignancy.
• -Her desire for future pregnancy.
• The asymptomatic women
• The older women
• Women over 50 years of age are more likely to
  have a malignancy so surgery is usually
  indicated.
• -but for a simple cyst less than 6cm in diameter
  with a normal Ca 125 and normal vascular
  resistance pattern are likely to be benign and
  may safely be managed conservatively.

40
-So a 2nd ultrasound should be made after 12
weeks if there is no change in the cyst happened,
follow up with six-

• Monthly ultrasound and Ca125 estimation is safe.
• Most would resolve in 3 years but some do persist
  for up to 7 years.
• In pre-menopausal women
• -Young women of less than 35 years are both more
  likely to wish to have further children and are
  less likely to have malignant epithelial tumour.
• 1-A normal follicular cyst up to 3 cm in diameter
  requires no further investigation.
• 2-A clear unilocular cyst of 3-10 cm identified
  by ultrasound should be re- examined after 12
  weeks for evidence of diminution in size .

41
- If the cysts persists, such women may be
followed with a six-monthly ultrasound and Ca125
estimations.

• -The use of combined oral contraceptive pills is
  unlikely to accelerate the resolution of a
  functional cyst.
• -If the cyst does enlarge , laparoscopy or
  laparotomy may be indicated.
• 3.A cyst of more than 10 cm is unlikely to be
  physiological or to resolve spontaneously and
  operation indicated.
• The patient with symptoms
• If the patient present with severe acute pain or
  signs of intraperitoneal bleeding an emergency
  laparoscopy or laparotomy will be required.

42
The pregnant patient

• -An ovarian cyst in pregnant women may undergo
  torsion or may bleed.
• -The pregnant women with an ovarian cyst is a
  special case because of the risk of surgery to
  the fetus.
• -Thus if the patient present with acute pain due
  to torsion or haemorrhage into an ovarian cyst or
  if appendicitis is a possibility, the correct
  course is to undertake a laparotomy regardless
  the stage of the pregnancy.
• -The operation should be covered with by
  tocolytic drugs and performed in a center with
  intensive neonatal care.
• -If asymptomatic cyst is discovered during the
  1st trimester, it is prudent to wait until after
  14 weeks gestation before removing it.

43
-This avoids the risk of removing a corpus luteal
cyst upon which the pregnancy might still be
dependent.

• -In the 2nd and 3rd trimesters , the management
  of an asymptomatic ovarian cyst may be either
  conservative or surgical.
• -Cysts lt 10cm , which have simple appearance on
  U/S , are unlikely to be malignant or to result
  in cyst accident and may therefore be followed by
  U/S.
• -Many may resolve spontaneously .
• If the cyst unresolved 6 weeks postpartum ,
  surgery indicated.

44
-Malignancy is uncommon in pregnancy occurring in
less than 3 of the cysts.

• -However a cyst with a features suggestive of
  malignancy on U/S , or one that is growing,
  should be removed surgically.
• -The tumour marker C 125 is not useful in
  pregnancy since it may be elevated in normal
  pregnancies.
• Prepubertal girl
• -Ovarian cysts are uncommon and often benign.
• -Teratoma and follicular cysts are the most
  common.
• -Presentation may be abdominal pain, distension
  or precocious puberty.
• -Management depends on
• -relief of symptoms.
• -exclusion of malignancy and
• -conservation of maximum ovarian tissue without
  depressing fertility.

45
Types of surgery for apparently benign ovarian
tumours

• For young women less than 35 years
• 1.Cystectomy ( removal of the cyst only).
• 2.Oophorectomy( removal of the ovary).
• For woman more than 45 years with ovarian cyst
  more than 6cm in diameter it is advisable to do
  total abdominal hysterectomy and bilateral
  salpingo-oopgorectomy.

46
Malignant disease of the ovary

• -Most ovarian tumours are of epithelial origin.
• -They are rare before the age of 35 years, but
  the incidence increases with age to a peak in the
  50-70 years.
• -Most epithelial tumours are not discovered until
  they have spread widely.
• -Surgery and chemotherapy forms the main stay of
  treatment.
• The results are poor.
• -The 5 year survival is around 38.
• -Only 3 of ovarian cancers are seen in women
  younger than 35 years and most are non-epithelial
  cancers such as germ cell tumours.

47

• 1.-Epithelial tumours account for 60-65 of all
  ovarian tumours and approximately 90 of those
  that are malignant (it is the most common).
• -It is a disease of late reproductive and
  postmenopausal women (average presentation at 64
  years).
• 2.Germ cell tumours, derived from the germ cells
  and account for 30 of ovarian tumours.
• Although they represent only 1-3 of all ovarian
  malignancies, they are commonest tumours
  encountered in children and adolescent (more than
  60 of ovarian cancers in this age group.
• 3.sex cord stromal tumours are derived from sex
  cord and stroma of the ovary and account for
  approximately 8 of all ovarian tumours (least
  common).

48
Incidence

• -The lifetime risk of developing ovarian cancer
  on the general population is 1.4 (one in 70).
• -Ovarian cancers are more prevalent in developed
  nations.
• -There are variations in incidence with
  ethnicity, Caucasian women have the highest
  incidence (14 per 100 000) whereas Asian women
  have a lower incidence (10 per 100 000).
• -There is a significant genetic aspect to ovarian
  cancer with earlier presentation at 54 years.

49
Aetiology and risk factors

• Epithelial ovarian cancer(EOC) is due to
  malignant transformation of the ovarian
  epithelium.
• There are two main theories regarding this
  malignant transformation
• 1.Incessant ovulation theory
• Continuous ovulation causing repeated trauma to
  the ovarian epithelium leading to genetic
  mutation and development of cancer.
• -This theory is supported by an increased
  incidence of EOC in nulliparous women, women with
  early menarche or late menopause .
• -reduced incidence in multiparous women and women
  used oral contraceptive pills

50

• 2.Excess gonadotrophin secretion
• This promotes higher levels of oestrogen which in
  turn leads to epithelial proliferation and
  malignant transformation of the ovarian
  epithelium.

51
Aetiology and risk factors (summery)

• Increased risk
• 1.Nulliparity.
• 2.Early menarche and Late menopause , both of
  these are associated
• with long estimated numbers of years of
  ovulation.
• 3.increasing age at first birth.
• 4.The prolonged use of drugs for induction of
  ovulation.
• A recent cohort study of over 50000 women
  attending fertility clinics in
• Denmark found no evidence of a causal association
  between the use of
• ovulatory stimulants and the subsequent
  development of epithelial ovarian
• tumour and the association was due to the effect
  of nulliparity alone.
• 5.High fat diet and diet low in fibre and
  vitamine A
• 6- Perineal dusting with talcum powder. .
• 7. Obesity, endometriosis and the use of IUCD

52

• Reduced risk of ovarian cancer
• 1.Multiparity and early age at first pregnancy.
• 2.Breast feeding reduce the risk.
• 3.Oral contraceptive use reduces the risk by
• 20 after 5years of use.
• 4.Tubal ligation and hysterectomy with ovarian
  preservation.

53
Genetic factors in ovarian cancer

• -The life time risk for ovarian cancer is 1.4
• (one in 70).
• -It is estimated that around 10 of ovarian
  cancer have a genetic link.
• -A woman with one affected close relative has
  risk of 3-4, With two affected close relatives
  the risk increase to 40-50.
• -Hereditary cancers usually occur around 10
  years before sporadic cancers and are associated
  with other cancers.

54

• -The most common hereditary cancer is the breast
  ovarian cancer syndrome (BRCA) account for 90
  of hereditary tumors which are two types
• BRCA1 (80) and BRCA2 (15 ).
• these are due to mutation of the tumor
• suppression gene.
• -lynch syndrome which is colorectal cancer,
  endometrial cancer and 10 risk of ovarian
  cancer.

55
Management of women with family history of
ovarian cancer

• -Till now there is no screening test which can
  be applied for low risk population.
• - Screening with TVUS and CA125 is not advisable
  and not reliable for low risk population.
• -However ,women with strong family history (risk
  more than 10 ) should be referred to clinical
  genetics for assessment of the family tree.
• -If this suggest a hereditary cancer , testing
  for BRCA1 and BRCA2 may be offered.
• -Screening with yearly TVUS and CA 125 is offered
  to women aged 35 and over.
• -Prophylactic bilateral salpingo-oophorectomy has
  a role in patient who are found to be carrying a
  gene mutation and have completed her family.
• Also the woman can be advised to use COCP to
  reduce their risk of ovarian tumour.

56
Staging of ovarian cancer (FIGO staging )

• The staging of ovarian cancer is a clinical
  staging
• Stage 1 growth limited to the ovaries.
• Ia growth limited to one ovary.
• No ascites, no tumour on external surfaces
  capsule intact.
• Ib tumour limited to both ovaries.
• No ascites, no tumour on external surfaces
  capsule intact.
• Ic either stage 1a or 1b with ascites
  contain malignant cells or tumour on the surface
  of one or both ovaries.
• Stage II growth involving one or both ovaries
  with pelvic extension.
• Stage III growth involving one or both ovaries
  with peritoneal implants outside the pelvis or
  positive retroperitoneal or inguinal lymph nodes
  or superficial liver metastasis
• Stage IV growth involving one or both ovaries
  with distant
• metastasis, parenchymal liver metastasis equal
  stage 1V.

57
Stage III OVARIAN CANCER

• Stage III a
• Tumours grossly limited to pelvis with negative
  nodes but histologically confirmed peritoneal
  implants.
• Stage III b
• Abdominal implants ? 2cm. In diameter.
• Stage III c
• Abdominal implants ?2cm. In diameter, or positive
  retroperitoneal or inguinal lymph nodes

58
Technique for surgical staging

• -A midline incision is essential to allow
• adequate access for thorough surgical staging
• and should be performed whenever ovarian
• malignancy suspected.
• -A systematic exploration of all peritoneal
• surfaces and viscera is performed.

59
-The staging laparotomy involve the following
steps

• Sending ascites or peritoneal washing for
  cytological assessment.
• Performing TAH and BSO.
• Omentectomy.
• Peritoneal biopsies of all suspecious areas or
  multiple random sampling if all surfaces are
  apparently normal.
• Diaphragmatic biopsies or scraping for
  cytological assessment.
• Sampling of pelvic and para-aortic lymph nodes.

60
Spread of ovarian malignancies

• - direct spread usually to the pelvic peritoneum
  and other pelvic organs ( uterus and broad
  ligament ).
• -Lymphatic spread commonly involves the pelvic
  and the para-aortic nodes.
• Spread may also involves the nodes of the neck or
  inguinal region.
• -Haematogenous spread
• -usually occurs late and involves mainly the
  liver, and lung.
• -Bone and brain metastasis sometimes seen.

61
Presentation and diagnosis

• -Abdominal pain or discomfort is the commonest
  presenting complaint.
• -Distension or feeling a lump is the next most
  frequent.
• -The patient may complain of
• -Indigestion.
• -Urinary frequency.
• -Weight loss.
• -Or rarely abnormal menses or postmenopausal
  bleeding.
• -A hard abdominal mass arising from the pelvis is
  highly suggestive especially with ascites.
• -A fixed, hard, irregular pelvic mass is usually
  felt best by combined vaginal and rectal
  examination.
• -The neck and groin should also be examined for
  enlarged nodes.

62
Investigations

• 1.full blood count.
• 2.Urea, electrolyte and liver function test.
• 3.Chest x-ray.
• 4.Sometimes, barium enema and colonoscopy is
  needed to differentiate between an ovarian and a
  colonic tumour or to assess bowel involvement.
• 5.IVP (intravenous urography).
• 6.Ultrasonography may help to confirm the
  presence of a pelvic .mass and detect ascites.
• 7.Tumour markers e.g. Ca 125.
• 8.In most women the diagnosis is uncertain
  before laparotomy is undertaken.

63
Surgery

• -Surgery is the mainstay of both the diagnosis
  and the treatment of ovarian cancer.
• -A vertical incision is required for an adequate
  exploration of the upper abdomen.
• -A sample of ascitic fluid or peritoneal washings
  with normal saline should be taken for cytology.
• -The pelvis and upper abdomen are explored
  carefully to identify metastatic disease.
• -The therapeutic objective of surgery for ovarian
  cancer is the removal of all tumour tissues.
• -This is usually possible in the majority of
  stage1 and stage 11, but impossible in advanced
  cases.
• -Because of the diffuse spread of the tumour
  throughout the peritoneal cavity , microscopic
  deposits will persist in almost all cases even
  when all macroscopic tumour have been excised.
• -Thus additional therapy usually required in most
  cases beyond stage1.

64
to resect all visible tumour requires a total
hysterectomy, bilateral salpingo-oophorectomy and
infra-colic omentectomy.

• -However , in a young , nulliparous woman with
  unilateral tumour and no ascites ( stage Ia ),
  unilateral salpingo-oophorectomy may be done
  after careful exploration to exclude metastatic
  disease , and curettage of the uterine cavity to
  exclude a synchronous endometrial tumour.
• -If the is subsequently found to be poorly
  differentiated or if the washings are positive, a
  second operation to clear the pelvis will be
  necessary.

65
Borderline disease usually present as a stage 1a
tumour confined to one ovary , in young women
this can be treated with unilateral oophorectomy.

• -For older women who complete her family a total
  hysterectomy and bilateral salpingo-oophorectomy
  is usually done.
• -When tumour tissues remain after initial
  surgery, a second laparotomy may be performed on
  those women who responded after two to four
  courses of chemotherapy.( this is called interval
  de-bulking surgery)
• -The chemotherapy is then resumed as soon as
  possible after the second operation.
• Chemotherapy
• -Women with stage Ia or Ib and well or moderately
  differentiated tumours will not require further
  treatment.
• -All other patient with invasive ovarian
  carcinoma require chemotherapy (stage II-IV
  possibly stage Ic ).
• -There is no evidence that adjuvant therapy
  affects the outcome in women with borderline
  tumour.
• -Drugs used are Carboplatin, cisplatin and taxol.
  

66
Prognosis

• Borderline tumour
• Long term prognosis excellent in most cases.
• Invasive tumours- 5 year survival rates.
• -90 for Stage Ia and 1b ( well or moderately
  differentiated ).
• -10 for stage III.
• -38 overall.

67
Thank you