OVARIAN NEOPLASM

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OVARIAN NEOPLASM
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OVARIAN NEOPLASM

• NON-NEOPLASTIC functional cyst
• Primary
• Secondary

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Non-neoplastic

• Follicular cyst
• usually less than 5 cm
• Benign and a symptomatic
• Thin wall, contain clear fluid
• Rescan in 4 weeks
• If enlarge or symptomatic, consider surgery

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Non-neoplastic

• Corpus luteal
• excessive bleeding into corpus luteum
• Cyst filled with blood
• Delayed period pain
• Usually the following period is heavy

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Non-neoplastic

• Granulosa-theca lutein cyst
• in molar pregnancy or part of hyperstimulation
  syndrome
• due to excessive gonadotrophin
• Polycystic ovary
• Endometriotic cyst

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Primary ovarian tumors

• Epithelial
• Benign
• Borderline
• Malignant
• Germ cell tumors
• Sex cord (gonadal stromal) tumors

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Epithelial tumors

• Serous most common
• Mucinous
• Endometrioid
• may be associated with primary endometrial
  caner
• Clear cell(mesonephroid)
• ?associated with endometriosis in 25
• ?worst prognosis
• Brenner

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Epithelial tumors

• Mucinous
• large tumors. Multilocular filled with mucin
• If rupturedpseudomyxoma peritonei
• Serous
• contain clear fluid
• Often bilateral. Around age of menopause
• Malignant type is the commonest ovarian cancer

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Epithelial tumors

• Endometrioid
• few cases arise in endometriosis
• 30 coexist with primary endometrial cancer
• Brenner
• usually benign.occur in reproductive life
• May be associated with endometrial hyperplasia
• May coexist with mucinous cystadenoma
• Clear cell

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Borderline tumors

• Epithelial tumors with no invasion of basement
  membrane
• 15 of epithelial tumors, mostly serous and stage
  1 (70-85).
• 10 year survival is 95
• Late recurrence
• Extensive histological sectioning is essential to
  exclude invasion.

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Germ cell tumors

• Dermoid cyst (benign cystic teratoma)
• 25 of all ovarian neoplasm
• Contain tissue derived from two or more germ cell
  layers
• Unilocular cyst. May contain teeth, bone ,
  cartilage, nerves, hair, thyroid,.. Tissues
• Almost always benign. Malignant changes may occur
  in any component
• Occur at any age.peak is 20-30 years.
• Bilateral in 20

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Malignant Germ cell tumors

• Rare. 3 of ovarian cancers
• Solid teratoma peak incidence in second decade
• Non-gestational choriocarcinoma
• secrete HCG
• May be component of solid teratoma

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Malignant Germ cell tumors

• Yolk-sac (endodermal sinus)
• highly malignant. Affect young age
• Partly solid. Secrete alpha feto-protein
• Dysgerminoma
• most common. Highly malignant
• Usually spread by lymphatics
• Very radiosensitive
• Occur in young women. May arise in gonadal
  dysgenesis

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Sex cord tumors

• Granulosa-theca cell tumors
• moderate to large size
• Solid, as enlarge may have cystic spaces
• Yellow tinge on cut surface
• Thecoma is benign.but granulosa is malignant
• Occur at any age .50 postmenopausal
• Secret estrogen
• Usually stage 1. Late recurrence

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Sex cord tumors

• Androgen- secreting tumors
• Androblastoma,Sertoli-leydig,
• Gynandroblastoma
• Cause virilization
• Fibroma
• solid tumor
• May be associated with meigs syndrome
• Tend to have long pedicle

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Metastatic tumors

• Always bilateral. From mucin secreting tumors,
  stomach and colon (krukenberg tumors)
• May be secondary to breast

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Malignant epithelial ovarian tumors

• Wide variety of tumors
• 25 of female genital tract tumors
• In U.K, the most common pelvic cancer
• Worst prognosis of all female genital tract
  cancers
• Life time risk is 1
• Spread by local spread, lymphatic and rarely by
  blood

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INCIDENCE
NEWLY DIAGNOSED CASES IN ENGLAND AND WALES 1994-96
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Presentation by stage
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ETIOLOGY
RISK FACTOR PROTECTIVE FACTOR
nulliparitry Number of pregnancies
Family history OCCP
Fertility drugs Tubal ligation
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Presentation

• Silent disease 75 present at advanced stage
• Symptoms of abdominal involvement
• Symptoms of distant metastases
• General malaise, weight loss
• Hormonal production

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Complication of ovarian tumors

• Torsion
• common with dermoid/fibroma
• Severe abdominal pain/vomitting
• Rupture
• Haemorrhage
• Impaction
• infection

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Ovarian tumor and pregnancy

• Found incidentally
• Corpus luteal/dermoid
• 2 are malignant
• If discover early and persist , surgery around 16
  weeks
• If complicated operate immediately

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Physical signs

• Benign
• usually mobile.unless large or complicated
• Dermoid cyst anterior to bladder
• Malignant
• Bilateral
• Ascites
• Hard deposit in pelvis
• Leg edema
• Signs of bowel obstruction of ureteric obstruction

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Investigation

• Uss /CT scan
• Tumor markers( ca125,CEA, HCG,alpha FP
• Urea and electrolyte
• LFT
• Chest X ray
• Ascitic tap
• Calculate RISK MALIGNANCY INDEX

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RISK MALIGNANCY INDEX

• CA 125 estimation
• Menopausal status
• pre menopausal score 1
• post menopausal score 3
• Ultrasound score
• Multi locular, solid areas, bilateral, ascitis,
  intra abdominal mets.
• if 0 or 1 score 1
• if 2-5 score 3
• RMI CA125 X M X U

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FIGO Staging
Stage 1 Growth limited to one or both ovaries
Stage 2 Growth limited to one or both ovaries with pelvic extension
Stage 3 Tumor involving one/both ovaries with peritoneal implants outside pelvis/positive retroperitoneal or inguinal nodes
Stage 4 Growth involving one or both ovaries with distant metastasis


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MANAGMENT

• Surgery
• primary
• interval debulking
• palliative
• second look surgery
• Chemotherapy

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Primary surgery

• Primary cytoreduction
• TAH,BSO,OMETECTOMY,WASHINGS
• BOWEL SURGERY
• Optimal debulking less than 2 cm residual
  tumors
• Staging once histology is available
• If confined to ovary and young age conservative
  surgery

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Interval debulking

• Alternative to primary surgery
• medically unfit
• large ascitis
• severe malnutrition
• 3 cycles of chemotherapy surgery 3 more cycles
  of chemotherapy
• Aim to improve patient condition
• less extensive surgery to
  achieve optimal debulking
• May improve survival

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Chemotherapy

• Indication stage 1c and above
• Platinium based
• Taxol
• 6 cycles at 3 weekly intervals
• Monitoring
• examination
• CA125
• FBC, UE

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SECOND LOOK SURGERY

• Assess response to chemotherapy
• Plan future management
• Only in research context.

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Palliative surgery

• Removal of intestinal obstruction
• Survival is very poor
• Quality of life considerations

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Five year survival
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Five year survival
Five year survival rates in England and
Wales 1986-1990
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Follow up

• How aggressive?.
• Three monthly for one year then six monthly then
  yearly
• History,examination and CA125
• Imaging if recurrence is suspected clinically or
  by CA125

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Ovarian cancer screening

• Life time risk is 1
• 5 of tumors are genetic
• History of breast cancer increases risk by factor
  of 2
• History of ca ovary increases the risk by factor
  of 3
• One first degree relative affected risk 2.7
• 2 first degree relatives affected risk is
  13
• If BRCA1 mutation carrier risk is 50

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screening

• Problems
• - no pre-cancerous stage
• - unknown natural course
• TVS AND CA125 ON YEARLY BASIS
• ONGOING STUDY TO EVALUATE THIS.