OVARIAN CANCER
Di Wen, M.D.,Ph.D
OVARIAN TUMOURS
Definition
Ovarian tumors may arise at any age,
but are commonest between 30 and 60.
1.Ovarian tumors are particularly liable to be
or to become malignant.
2.In
their
early
stages
they
are
asymptomatic and painless.
3.They may grow to a large size and tend to
undergo mechanical complications such as
torsion and perforation.
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CARCINOMA OF THE OVARY
Definition
In developed countries，women have a
lifetime risk of developing ovarian cancer
of about 1.4%，which is slightly greater
than the risk of cervical or endometrial
cancers, but well below the 7% average
risk of breast cancer．
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CARCINOMA OF THE OVARY
Risk Factor
Genetic factor are sometimes involved、
as in the Lynch Syndrome of familial
breast colorectal and ovarian
cancer．Ovulation induction with
Clomiphene over more than year carries a
l0-fold increased risk of ovarian cancer,
Long-term ora1 contraceptive use reduces
the incidence of ovarian cancers．
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CARCINOMA OF THE OVARY
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．
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CARCINOMA OF THE OVARY
Primary Carcinoma of the Ovary
80％ of all cases of primary
carcinoma of the ovary arise in serous
or mucinous cysts.
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CARCINOMA OF THE OVARY
Solid Carcinoma of the Ovary
This accounts for 10% of primary
carcinoma. It is arise commonly bilateral
but one tumor is usually larger than the
other. The ovarian shape is retained for a
time and there is a well-marked pedicle but
soon the tumors become fixed. Secondary
deposits occur in the omentum and ascites
develops.
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CLINICAL FEATURES OF OVARIAN TUMOURS
Symptoms due to Size
Lack
of
any
specific
symptoms, ovarian tumors
are often large by the time
the doctor is consulted.
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Menstrual
function
is
seldom upset, and any irregularity is
attributed to the patient’s ‘time of
life’.
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She may have noticed that her
clothes are getting tight ant
attributed this to weight gain or, if
the abdominal swelling has coincided
with amenorrhea she may believe
herself to be pregnant.
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CLINICAL FEATURES OF OVARIAN TUMOURS
Pressure Symptoms
These
are
commonly
increased
frequency of micturition, gastrointestinal symptoms and 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, due perhaps
to interference with alimentary function.
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CLINICAL FEATURES OF OVARIAN TUMOURS
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CLINICAL FEATURES OF OVARIAN TUMOURS
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CLINICAL FEATURES OF OVARIAN TUMOURS
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CLINICAL FEATURES OF OVARIAN TUMOURS
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DIFFERENTIAL DIAGNOSIS
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.
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DIFFERENTIAL DIAGNOSIS
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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.
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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.
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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TORSION of the PEDICLE
Complications of Ovarian Tumors
This is the commonest complication and
may occur with any tumor except those with
adhesions. The thin-walled veins of the pedicle
are obstructed first while the arterial supply
continues. As a result there is hemorrhage into
the tumor and into the peritoneum, and if not
treated gangrene will occur. Very rarely the
pedicle atrophies and the tumor obtains a new
blood supply through its adhesions to
surrounding viscera (parasitic tumor).
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TORSION of the PEDICLE
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TORSION of the PEDICLE
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.
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TORSION of the PEDICLE
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
continuous.
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to
be
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intense
and
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TORSION of the PEDICLE
Clinical Features
Differential Diagnosis
‘Surgical Conditions’ (i.e. those conditions
commonly seen and dealt with by a general
surgeon.)
Acute appendicitis
Meckel’s diverticulitis
Obstruction of bowel
Diverticulitis
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TORSION of the PEDICLE
Ruptured Cyst
This may occur alone or in
conjunction with torsion. Rupture is
not particularly upsetting to the
patient unless the contents are
irritant.
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TORSION of the PEDICLE
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TORSION of the PEDICLE
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RUPTURE OF OVARIAN CYST
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RUPTURE OF OVARIAN CYST
RUPTURE OF OVARIAN CYST RUPTURE OF OVARIAN CYST
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RUPTURE OF OVARIAN CYST
PSEUDOMYXOMA PERITONEI
This rare condition occasionally but
not inevitably follows mthe rupture of a
mucinous cystadenoma. The epithelial
cells implant on the peritoneum and
continue
to
secrete
a
gelatinous
pseudomucin which is not absorbed, or
secretion is faster than absorption. The
abdominal cavity is eventually filled with
the jelly, while the secreting cells
spread over the parietal and visceral
peritoneum.
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RUPTURE OF OVARIAN CYST
HYDROTHORAX
Hydrothorax
may
accompany
ascites due to any cause, or may occur
as an accompaniment of a lung tumor.
The so-called Meigs’ syndrome
describes the specific condition of
ascites and hydrothorax in conjunction
with benign ovarian fibroma.
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Features suggestive of malignancy
1.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.
2.Rapid growth.
3.Ascites.
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Features suggestive of malignancy
4.Solid tumours, especially when bilateral.
5.Multilocular cysts with solid areas. (At
least 10% of cysts are malignant).
6.Pain. Pressure pain can occur with any
tumor; but referred pain suggests
malignant involvement of nerve roots.
7.Tumor markers, such as CA125, may be
measured in the blood, but a normal level
does not exclude malignancy.
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OVARIAN TUMOURS
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.
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OVARIAN TUMOURS
PRIMARY EPITHELIAL TUMOR
1.Mucinous
cystadenoma
or
cystadencarcinoma (of. Cervical epithelium).
2.Serous
cystadenoma
or
cystadenocarcinoma (of . tubal epithelium).
3.Endometrioma or Endometrioid carcinoma
(of. Endometrium).
4.Clear cell carcinoma.
5.Brenner tumour.
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OVARIAN TUMOURS
STROMATOUS TUMOURS GERM CELL TUMOURS
.Fibroma or sarcoma.
.Dysgerminoma.
.Teratoma.
.Gonadoblastoma.
.Yolk sac tumour.
.Carcinoid
.Thyroid tumour Choriocarcinoma
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OVARIAN TUMOURS
HORMONE-PRODUCING TUMORS
Estrogen-producing:
Granulosa cell tumour.
Thecoma.
Androgen-prodicing:
Sertoli-Leydig cell tumour (Arrhenoblastoma).
Hilar cell tumour.
Lipoid cell tumour.
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OVARIAN TUMOURS
krukenberg tumour
There
is
one
well-known
secondary tumour of the ovary, the
krukenberg tumour, a secondary
of a stomach carcinoma.
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OVARIAN TUMOURS --MUCINOUS CYSTADENOMA
Definition
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.
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OVARIAN TUMOURS --MUCINOUS CYSTADENOMA
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OVARIAN TUMOURS --MUCINOUS CYSTADENOMA
signs and symptoms
The signs and symptoms are those
generally associated with any nonfunctioning ovarian tumor. Rupture
may occur and seeding of the
epithelium on the peritoneal surface
may cause pseudomyxoma peritonei.
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OVARIAN TUMORS --MUCINOUS CYSTADENOCARCINOMA
Definition
This is only a third as common as
the serous variety. Malignancy in a
mucinous cyst is characterised by the
formation of areas of solid carcinoma
in the wall. The cells are columnar,
show mitoses and tend to form
glandular structures.
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OVARIAN TUMORS --SEROUS CYSTADENOMA
Definition
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.
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OVARIAN TUMORS --SEROUS CYSTADENOMA
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OVARIAN TUMORS --SEROUS CYSTADENOCARCINOMA
Definition
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.
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CARCINOMA OF THE OVARY
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.
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CARCINOMA OF THE OVARY
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 welldifferentiated adenocarcinoma, an adenoacanthoma, mucinous adenocarcinoma or
clear-celled carcinoma.
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CARCINOMA OF THE OVARY
Clear Cell Carcinoma
It is doubtful if this exists as a
distinct entity. Clear cells may be seen in
almost any variety of ovarian carcinoma,
but occasionally a carcinoma, usually solid,
consists almost entirely of polygonal cells
with clear cytoplasm. It behaves in the
same way as any other solid carcinoma and
has the same prognosis.
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CARCINOMA OF THE OVARY
Secondary Carcinoma of the Ovary
The ovary may be the site of secondary
deposits from growths arising in other
parts of the genital tract. These are
usually overshadowed by the clinical
manifestations of the primary growth.
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CARCINOMA OF THE OVARY
Secondary Carcinoma of the Ovary
Ovarian metastases from extragenital tumors are not uncommon. The
commonest sites of primary growth
are breast, stomach and large
intestine.
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CARCINOMA OF THE OVARY
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 Meig’s syndrome.
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CARCINOMA OF THE OVARY
GERM CELL TUMOURS
There are four main types of gern cell
tumour:
.Dysgerminoma;
.Tumours of tissues found in the embryo or
adult ---- the teratomata;
.Tumours of dysgenetic gonads ---- commonly a
gonadoblastoma;
.Tumours of extra-embryonic tissues such as
choriocarcinoma or yolk sac tumour.
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CARCINOMA OF THE OVARY
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.
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CARCINOMA OF THE OVARY
Yolk sac tumor
This is a rare tumor found in
children and young adults. It has a
variable histological structure and is
highly malignant. The main interest lies
in the fact that it produces
alphafetoprotein and the blood levels
can be used as a diagnostic test and as
a means of monitoring response to
treatment.
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CARCINOMA OF THE OVARY
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CARCINOMA OF THE OVARY
Estrogen-producing Tumors
These belong to the granulosatheca cell group and are found at all
ages. They account for 3% of all solid
tumors of the ovary.
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CARCINOMA 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.
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CARCINOMA OF THE OVARY
ANDOROGEN-PRODUCING TUMOURS
Three distinct types of masculinising
ovarian tumor are recognised: a) SertoliLeydig cell tumor (Arrhenoblastoma), b)
Hilar cell tumor, c) Lipoid cell tumor. All
three cause amenorrhoea.
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Spread of Ovarian Cancer
Direct
The first spread is directly into
neighbouring structures – peritoneum,
uterus, bladder, bowel and omentum.
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Spread of Ovarian Cancer
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.
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Spread of Ovarian Cancer
Blood stream
Blood spread is usually late, to
the liver and lungs.
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SURGICAL PROCEDURES IN OVARIAN CANCER
General Principle
1.To classify the growth according to
its extent of spread (staging) as
accurately as possible.
2.To remove as much cancerous tissue
as possible (‘surgical debulking’;’cytoreductive treatment’).
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SURGICAL TREATMENT OF OVARIAN TUMMOURS
General Rule
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.
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SURGICAL TREATMENT OF OVARIAN TUMMOURS
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SURGICAL TREATMENT OF OVARIAN TUMMOURS
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SURGICAL TREATMENT OF OVARIAN TUMMOURS
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TREATMENT OF OVARIAN CANCER
General Principle
Much attention is being directed towards
the treatment of epithelial ovarian cancer
which is now the most frequent cause of
death from gynecological malignancy. The
principles of treatment are:
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TREATMENT OF OVARIAN CANCER
General Principle
Ovarian carcinoma is staged surgically, so
laparotomy is an essential part of
management for most patients.
Surgical removal of as much malignant tissue
as possible, even if this should call for
resection of structures outside the normal
field of the gynecologist.
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TREATMENT OF OVARIAN CANCER
General Principle
Follow-up with intensive chemotherapy, using
various combinations of antineoplastic
drugs. Taxanes, probably combined with
platinum compounds, are an appropriate
first choice.
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.
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SURGICAL PROCEDURES IN OVARIAN CANCER
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.
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SURGICAL PROCEDURES IN OVARIAN CANCER
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.
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SURGICAL PROCEDURES IN OVARIAN CANCER
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