Transcript 6f55b37b-5c09-4926-a794

Malignant Ovarian Tumors
Dr.Omar aldabbas
Assisstant prof.
MUTA university
OBGYN specialist
Introduction
• The second most common malignancy
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of the genital system.
The most common cause of death from
malignancy due to late diagnosis
Most of the tumors are of epithelial
origin. Occurs after the age of 35 years
with increasing incidence with
advancing age.
Only 3% occurs before 35 years of age
and they are mostly non-epithelial in
origin as germ cell tumors.
Aetiology
• Ovulation theory: more common in
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nulliparity, early menarche and late
menopause. Oral contraceptive pills
reduces the risk.
Infertility treatment: there is a link
between prolonged ovulation induction
and ovarian malignancy.
Genetic factors: strong family history
of breast, colorectal and ovarian
cancer.
Histologic classification of
ovarian tumors
• Epithelial tumors:
• Germ cell tumors:
1- Dysgerminoma.
1- Serous carcinoma
2- Endodermal sinus tumor
2- Mucinous car.
(Yolk sac tumor)
3- Endometrioid car.
3- Embryonal cell tumor
4- clear cell car.
4- Choriocarcinoma
5- Brenner tumor.
5- Malignant teratoma.
6- undifferentiated car. 6- Mixed tumors.
• Sex cord stromal tumor:• Metastatic tumors
(Krukenberg tumors)
1- Granulosa cell tumor
2- Androblastoma.
3- Gynandroblastoma.
Epithelial malignant tumors
• Well-differentiated epithelial tumors tend to
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be associated will early stage disease.
There is no difference in survival between
different epithelial types.
Mucinous and endometrial lesions have
better prognosis than serous cystadeno
carcinoma.
Serous cystadenocarcinoma
• Has both solid and cystic elements.
• Has a papillary pattern with stromal
invasion.
• Psammoma bodies are often present.
• Glandular tissue may be present.
• The tumor could be at any stage of
differentiation.
Mucinous
cystadenocarcinoma
• Account for 10% of malignant ovarian
tumors.
• Usually multilocular, thin-walled cysts
containing mucinous fluid.
• They are the largest tumors of the ovary.
• A cyst diameter of 25 cm is common.
Endometrioid carcinoma
• Resemble to endometrial carcinomas.
• Mostly they are cystic, unilocular, and
contain turbid brown fluid.
• They could occurs in association with
endometriosis and endometrial tumors
of the body of the uterus.
Clear cell carcinoma
(mesonephroid)
• The lest common (5%).
• On histopathology, they have a clear cell
pattern.
• It has a strong association to ovarian
endometriosis and endometrioid cancer.
Borderline epithelial tumors
• 10% of ovarian tumors are borderline
malignant.
• They show varying degree of nuclear
atypia and increased mitotic activity.
• There is no stromal invasion.
• They remain confined to the ovary.
• Rarely, peritoneal metastasis occurs.
Staging for primary ovarian
carcinoma
Stage I: Growth limited to ovaries
Ia: One ovary,no ascites,capsule intact.
Ib: Two ovaries, no ascites, capsule
intact.
Ic: one or both ovaries with ascites
containing malignant cells and/or
invasion through the capsule.
Staging for primary ovarian
carcinoma
Stage II: Stage one with pelvic extension.
Stage III: Peritoneal implants outside the
pelvis or positive lymph node or superficial
liver metastasis.
Stage IV: Distant metastasis, pleural
effusion with positive malignant cells,
Deep liver involvement.
Clinical history
• In two-thirds of patients presents at late
stages.
• This is due to late symptoms and difficult
early diagnosis.
• Some of the tumors are rapidly growing.
Clinical Diagnosis
• Abdominal pain, discomfort and distension.
• Feeling of a lump.
• Indigestion, urinary frequency, weight lost
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and rarely abnormal menses or post
menopausal bleeding.
On examination, hard mass arising from the
pelvis. Ascites may be present. The tumor is
fixed and tender. Irregular pelvic masses may
be felt on vaginal or rectal exam which
suggest metastesis. Palpable inguinal or neck
nodes.
Investigations
• Full blood count, renal and liver function tests,
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electrolytes,blood sugar and chest x-ray.
Barium enema or colonoscopy to exclude bowel
involvement.
IVU for renal and ureteric involvement.
Ultrasonography for mass and ascites.
Ca125 estimation.
Laparotomy.
Screening for ovarian
cancer
• Because of late diagnosis, much effort has
been made to screen for ovarian cancer.
• Till now no specific tumor marker has
been found for epithelial tumors.
• Ultrasonography and Ca125 are in use.
• Inhibin for granulosa cell tumor.
• Beta-hCG for choriocarcinoma.
• Alpha -fetoprotien in germ cell tumors.
Surgery
• Is the mainstay for both diagnosis and
treatment.
• Vertical incision is required.
• A sample of ascitic fluid or peritoneal wash
send for cytology.
• The abdomen should be inspected for
metastasis and lymph node involvement.
Surgery
• The main is to remove the whole tumor
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(stage I and II) or to remove as much as
possible from the tumor (debulking
operation).
The operation in early stages includes
TAH+BSO and infracolic omntectomy.
In young nulliparous women with stage Ia ,
unilateral salpingo-oophorectomy can be
done. This is also applied to borderline
malignancy.
Surgery
• After debulking operation, chemotherapy
should be used.
• Interval debulking surgery: a second
surgery after chemotherapy for residual
tumor.
• Surgery is the only treatment for stage I.
All others need further treatment.
Chemotherapy
• This treatment is for stages II to IV.
• The drugs in common use are: Carboplatin
or cisplatin and taxol.
• Chemotherapy is used to prolong clinical
remission and for palliation in advanced
and recurrent disease.
• It is given for 5-6 cycles at 3-4 weekly
intervals.
Prognosis
• Borderline tumors have a good long-term
prognosis.
• Stage I have a 5 year survival rate of
90%.
• For stage III and IV is only 10%.
• The overall survival rate is around 23%.
Non-epithelial malignant
tumors
• This constitute around 10% of all
malignant ovarian tumors.
• The staging is similar to epithelial tumors.
• The treatment is similar.
• Radiotherapy is hardly used in the
treatment of ovarian cancer.