Malignant Ovarian Tumors

1
Malignant Ovarian Tumors

• Dr.Omar aldabbas
• Assisstant prof.
• MUTA university
• OBGYN specialist

2
Introduction

• The second most common malignancy 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.

3
Aetiology

• Ovulation theory more common in 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.

4
Histologic classification of ovarian tumors

• Germ cell tumors
• 1- Dysgerminoma.
• 2- Endodermal sinus tumor (Yolk sac tumor)
• 3- Embryonal cell tumor
• 4- Choriocarcinoma
• 5- Malignant teratoma.
• 6- Mixed tumors.
• Metastatic tumors (Krukenberg tumors)

• Epithelial tumors
• 1- Serous carcinoma
• 2- Mucinous car.
• 3- Endometrioid car.
• 4- clear cell car.
• 5- Brenner tumor.
• 6- undifferentiated car.
• Sex cord stromal tumor
• 1- Granulosa cell tumor
• 2- Androblastoma.
• 3- Gynandroblastoma.

5
Epithelial malignant tumors

• Well-differentiated epithelial tumors tend to 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.

6
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.

7
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.

8
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.

9
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.

10
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.

11
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.

12
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.

13
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.

14
Clinical Diagnosis

• Abdominal pain, discomfort and distension.
• Feeling of a lump.
• Indigestion, urinary frequency, weight lost 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.

15
Investigations

• Full blood count, renal and liver function tests,
  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.

16
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.

17
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.

18
Surgery

• The main is to remove the whole tumor (stage I
  and II) or to remove as much as possible from the
  tumor (debulking operation).
• The operation in early stages includes TAHBSO
  and infracolic omntectomy.
• In young nulliparous women with stage Ia ,
  unilateral salpingo-oophorectomy can be done.
  This is also applied to borderline malignancy.

19
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.

20
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.

21
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.

22
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.

23
Thank you