Ovarian Cancer DI WEN M.D., Ph.D., Professor & Chairman Department Of Obstetrics & Gynecology Renji...

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Ovarian Cancer DI WEN M.D., Ph.D.,

Professor & Chairman

Department Of Obstetrics & Gynecology

Renji Hospital Affiliated to SJTU School of Medicine

22006-11-1 七年制 Ovarian Cancer

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

Risk FactorsFamily history

Ovarian cancerBreast cancerColon cancer

Genetic factorsOlder ageCaucasianMore menstrual circles during lifetime

(Ovulation induction)

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.

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 patient’s ‘time of life’.

symptomsIncreased abdominal size

symptomsPressure symptoms

Gastro-intestinal symptoms (Bloating)Urge to urinateplevic 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.

CLINICAL FEATURES OF OVARIAN TUMOURS

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.

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.

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.

Histological Classification Most tumors arise from the ovarian str

oma 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.

Primary Epithelial TumorMucinous cystadenoma or cystadencarcinoma

(of. Cervical epithelium).

Serous cystadenoma or cystadenocarcinoma

(of . tubal epithelium).

Endometrioma or Endometrioid carcinoma

(of. Endometrium).

Clear cell carcinoma.

Brenner tumour.

Ovarian Germ Cell Tumor

Fibroma or sarcoma.

.Dysgerminoma.

.Teratoma.

.Gonadoblastoma.

.Yolk sac tumour.

.Carcinoid

.Thyroid tumour Choriocarcinoma

Gonadal Sex Cord Stromal Tumor

Estrogen-producing:Estrogen-producing:Granulosa cell tumour.

Thecoma.

Androgen-prodicing:Androgen-prodicing:Sertoli-Leydig cell tumor (Arrhenoblastoma).

Hilar cell tumour.

Lipoid cell tumour.

Krukenberg Tumor

There is one well-known secondary tumour of the ovary, the

krukenberg tumour, a secondary of a stomach carcinoma.

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.

OVARIAN TUMOURS --MUCINOUS CYSTADENOMA

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.

OVARIAN TUMORS --SEROUS CYSTADENOMA

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.

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.

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.

Fibroma This is composed of fibro

us 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 Meig’s syndrome.

Dysgerminoma This is the only solid ova

rian 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.

TeratomaCystic teratoma or der

moidSolid teratoma

Yolk Sac Tumor

Children and young adults

highly malignant

alphafetoprotein

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.

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.

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.

Spread -Direct

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

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.

Spread -Blood Stream

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

Staging of ovarian cancer

STAGE I Growth limited to ovariesIa 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.

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.

Stage III Extrapelvic intraperitoneal spread and/or retroperitoneal or inguinal positive nodes, or superficial lover metastases.

IIIa Apparent limitation to true pelvisIIIb Histologically proven abdominal peritoneal superficial implants<2cm diameter.IIIc Abdominal implants>2cm diameter or positive retroperitoneal or inguinal nodes.

Stage IV

Distant metastases or pleural effusion with positive cyotlogy or parenchymal liver metastases.

DiagnosisPelvic examUltrasoundCT scanCA125 blood testSURGERY

TORSION of the PEDICLE

The commonest complication

Occur with any tumor

Except those with adhesions

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.

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.

Ruptured Cyst This may occur alone or in conjunction with

torsion. Rupture is not particularly upsetting to the patient unless the contents are irritant.

Suggestive of MalignancyAge. 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.

Suggestive of MalignancySolid tumours, especially when bilateral.Multilocular cysts with solid areas. (At least 1

0% 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.

Treatment

Surgery Chemotherapy Radiation Therapy ? Hormonal Therapy

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 debulking’;’cyto-reductive treatment’).

Surgical Procedures Benign ovarian over 10 cm in diameter m

ust 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.

SURGICAL TREATMENT OF OVARIAN TUMMOURS

Follow-up Follow-up with intensive che

motherapy, using various combinations of antineoplastic drugs. Taxanes, probably combined with platinum compounds, are an appropriate first choice.

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.

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.

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.

SURGICAL PROCEDURES IN OVARIAN CANCER

DI WEN M.D., Ph.D.

Professor & Chairman

Department of Obstetrics & Gynecology

Renji Hospital Affiliated to SJTU School of Medicine

Thanks for Your Attention

Hereditary Breast and Ovarian Cancer: BRCA1

• Autosomal Dominant TransmissionAutosomal Dominant Transmission

• Precise Risk for Male Breast Cancer UnclearPrecise Risk for Male Breast Cancer Unclear

• Increased Risk for Prostate Cancer?Increased Risk for Prostate Cancer?

Breast cancerBreast cancer 50% 50%85%85%

Second primary breast cancerSecond primary breast cancer 40% 40%60%60%

Ovarian cancerOvarian cancer 20% 20%60%60%

Adapted from ASCO

Hereditary Breast and Ovarian Cancer: BRCA2

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

breast cancerbreast cancer (50%(50%85%)85%)

ovarian cancerovarian cancer (10%(10%20%)20%)

male breast cancermale breast cancer (6%)(6%)

Ovarian Cancer DI WEN M.D., Ph.D., Professor & Chairman Department Of Obstetrics & Gynecology Renji...

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