Title: OVARIAN NEOPLASM
1OVARIAN NEOPLASM
2OVARIAN NEOPLASM
- NON-NEOPLASTIC functional cyst
- Primary
- Secondary
3Non-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
4Non-neoplastic
- Corpus luteal
- excessive bleeding into corpus luteum
- Cyst filled with blood
- Delayed period pain
- Usually the following period is heavy
5Non-neoplastic
- Granulosa-theca lutein cyst
- in molar pregnancy or part of hyperstimulation
syndrome - due to excessive gonadotrophin
- Polycystic ovary
- Endometriotic cyst
6Primary ovarian tumors
- Epithelial
- Benign
- Borderline
- Malignant
- Germ cell tumors
- Sex cord (gonadal stromal) tumors
7Epithelial tumors
- Serous most common
- Mucinous
- Endometrioid
- may be associated with primary endometrial
caner - Clear cell(mesonephroid)
- ?associated with endometriosis in 25
- ?worst prognosis
- Brenner
8Epithelial 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
9Epithelial 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
10Borderline 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.
11Germ 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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14Malignant 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
15Malignant 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
16Sex 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
17Sex 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
18Metastatic tumors
- Always bilateral. From mucin secreting tumors,
stomach and colon (krukenberg tumors) - May be secondary to breast
19Malignant 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
20INCIDENCE
NEWLY DIAGNOSED CASES IN ENGLAND AND WALES 1994-96
21Presentation by stage
22ETIOLOGY
RISK FACTOR PROTECTIVE FACTOR
nulliparitry Number of pregnancies
Family history OCCP
Fertility drugs Tubal ligation
23Presentation
- Silent disease 75 present at advanced stage
- Symptoms of abdominal involvement
- Symptoms of distant metastases
- General malaise, weight loss
- Hormonal production
24Complication of ovarian tumors
- Torsion
- common with dermoid/fibroma
- Severe abdominal pain/vomitting
- Rupture
- Haemorrhage
- Impaction
- infection
25Ovarian tumor and pregnancy
- Found incidentally
- Corpus luteal/dermoid
- 2 are malignant
- If discover early and persist , surgery around 16
weeks - If complicated operate immediately
26Physical 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
27Investigation
- Uss /CT scan
- Tumor markers( ca125,CEA, HCG,alpha FP
- Urea and electrolyte
- LFT
- Chest X ray
- Ascitic tap
- Calculate RISK MALIGNANCY INDEX
28RISK 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
29FIGO 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
30MANAGMENT
- Surgery
- primary
- interval debulking
- palliative
- second look surgery
- Chemotherapy
31Primary 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
32Interval 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
33Chemotherapy
- Indication stage 1c and above
-
- Platinium based
- Taxol
- 6 cycles at 3 weekly intervals
- Monitoring
- examination
- CA125
- FBC, UE
34SECOND LOOK SURGERY
- Assess response to chemotherapy
- Plan future management
- Only in research context.
35Palliative surgery
- Removal of intestinal obstruction
- Survival is very poor
- Quality of life considerations
36Five year survival
37Five year survival
Five year survival rates in England and
Wales 1986-1990
38Follow 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
39Ovarian 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
40screening
- Problems
- - no pre-cancerous stage
- - unknown natural course
- TVS AND CA125 ON YEARLY BASIS
- ONGOING STUDY TO EVALUATE THIS.