Transcript Ovarian Cancer[1].

Ovarian
Cancer
PROF. MOHAMMED ADDAR
GYNEONCOLOGIST
Introduction

Fifth most common cancer in women

Fifth most frequent cause of cancer death

1 in 70 newborn girls will develop cancer
during her lifetime

Disease of postmenopausal women and
all ages

Year 2000
 23000
new cases
 14000
deaths
Etiology

Cause is unknown

Predisposing factors
 Repeated
 Infertility
 PCO
ovulation
treatment
2.5 fold increase
 Unopposed
estrogen therapy
Etiology

Increase risk by
 High
diet in saturated animal fats
 Alcohol
and milk (never
confirmed)
 Exposure
to talk powder
Etiology

Protective factors
 Chronic
anovulation
 Multiparty
 Breast
feeding
 Pregnancy
pregnancy
 COC
-reduction 13-19% per
Pills decrease by 50% for 5 years
and more of use

Over 90% develop sporadically

10% of epithelial based on genetic
predisposition

Turner syndrome(45,XO) dysgerminoma
and gonadoplastoma

Two first degree relatives –risk 50%
hereditary

In two forms
 Breast
and ovarian syndrome (BOC)
 Germline
mutation in BRCA1 gene on
chromosome 17(28-44%)
 Less
common BRCA2 on
chromosome 13 (1/800)
 Lyncy
II syndrome (hereditary
nonpolyposis colorectal cancer
syndrome )HNPCC
Histopathology


Divided to three categories according to cell type
of origin

Epithelia neoplasms

Germ cell neoplasms

Sex cord and stromal neoplasms
May be the site of metastatic disease

Neoplasms metastatic to the ovary
1-Epithelia neoplasms

Tend to occur in the sixth decade of life

Derived from the ovarian surface mesothelial
cells , six types:

Serous

Mucinous

endometroid

clear cell

Transitional cell

undifferentiated

Account for over 60% of all ovarian neoplasms

More than 90% of malignant ovarian tumors
Ovarian serous
cystadenocarcinoma

Most common 35-50% of all epithelial
tumors

Bilateral in 40-60%

85% with extra ovarian spread at
diagnosis

Over 50% exceeds 15 cm, solid areas,
hemorrhage, cyst wall invasion

Most poorly dfferentiated
Mucinous neoplasms

10-20% of epithelial ovarian tumor

Second most common type of epithelial
ovarian carcinoma

Bilateral in less than 10%

Average size is 16-17 cm (large)
,multilocular ,viscous mucus
Pseudomyxoma peritonei

Unusual condition

Associated with mucinous neoplasms of ovary

Progressive accumulation of mucinous in
abdominal cavity

May be associated with appendix

Benign

Potentially morbid ,intestinal obstruction

Mortality rate approaches 50%
Endometroidal neoplasm

Adenometroidal pattern

Bilateral in 30-50%

30% of patients will have endometrial carcinoma
of uterus as primary
Clear cell carcinoma

Called mesonephroid carcinoma

5% of epithelial ovarian cancer

Small size

Aggressive ,hypercalcimeia ,hyperpyrexia

Cystic and solid
Transitional cell
carcinoma

Brenner

Newly described

Present with advanced stage

Poorer prognosis
Undifferentiated
carcinoma

Accounts for less than 10% of epithelial

Absence of any distinguishing microscopic
features that permit its placement in one of the
other histologic categories.
2-Germ cell neoplasms

Tend to occur in second and third decade of life

Better prognosis

Many produce biological markers

Types:

Dysgerminoma

Young females (Seminoma in male)

30-40% of germ cell tumors

Unilateral in 85-90%

Solid
 Endometrial
 Was
sinus tumor
called yolk sac tumor
 Second
most common germ cell tumor
 Occurs
in 20% of cases
 Bilateral
in less than 5%
 Commonly
 Produces
present with acute abdomen
AFP


Immature teratomas
 Malignant counterpart of mature cystic
teratoma
 20% of germ cell neoplasms
 Bilateral in less than 5%
 Elevated serum AFP
 Three germ layers
 Immature neuroectodermal element
Mature teratomas
 Common at age 20 to 30
 Most common neoplasm diagnosed
during pregnancy
 Less than 2% goes malignant after age of
40
 Embryonal
carcinoma
 Very
rare in pure form
 HCG
and AFP are usually elevated
 Choriocarcinoma
 rare
germ cell tumor unrelated to
pregnancy
 Lower
 May
elevation HCG
cause precocious puberty,
uterine bleeding or amenorrhea
 Gonadoblastoma
 Rare
 More
common on the right than left ovary
 Occur
in second decade of life
 Associated
with presence of Y
chromosome
 Mixed
germ cell tumors
 Accounts
 Contains
for 10% of germ cell tumor
two or more germ cell elements
 dysgerminoma
and endometrial sinus
tumor ocurs together
3-Sex Cord-Stromal tumors

Granulosa cell tumor

1-2% of all ovarian neoplasms

Most common malignant tumor of sex cordsromal

Associated with hyperestrogenism

May cause precocious puberty(girls)
,adenomatous hyperplasia and vaginal
bleeding(postmenopausal women)



Ovarian thecoma

Associated with hyperesrogenism

Benign tumor
Ovarian fibroma

Benign tumor

Associated with Meig’s syndrome
Sertoli-stromal cell tumors

Rare

consist of testicular structures

Occur during third decade

Usually virilizing

Rarely bilateral
4-Neoplasms metastatic to the
ovary

Accounts for 25% of all ovarian malignancy

Mimic primary ovarian cancer

Present as bilateral adnexal masses

25% unilateral

Common primary cancers

Breast (40%_

Stomach (Krukenberg tumors)

Colon

endometrium
Diagnosis of ovarian Cancer

Insidious disease

Non specific GIT complains

Abdominal distention

Pelvic weight

Menstrual abnormalities in 15%

Rarely excessive estrogens or androgens
Screening

Routine pelvic examination

Ultrasound examination

Tumor markers
 CA-125
antigen from fetal amniotic
and coelomic epithelium
 TAG
72 ,M-CSF ,OVX1
Evaluation of the patient with
suspected ovarian neoplasm

Child and postmenopausal women at great risk of
malignancy

Reproductive women is likely to have functional
cyst or endometrioma

Differential diagnosis is influenced by

Age

Characteristic of the mass on pelvic
examination

Radiographic appearance
Physical Examination

Comprehensive examination

Lymph node , Sister Mary Joseph’s nodule

Abdomen examination

Pelvic examination
Characteristics
Benign
Malignant
Mobility
Mobile
Fixed
Consistency
Cystic
Solid or Firm
Bilateral/Unilater Unilateral
al
Bilateral
Cul-de-sac
Nodular
Smooth
Radiographic Evaluation

Trans abdominal ultrasound

Trans vaginal ultrasound

Color flow Doppler
Consistency
Simple cyst
<10cm in size
Solid or cystic
and solid
Septations
Septations <1mm Multiple
in thickness
septations >3mm
in size
Uni or bilateral
unilateral
Bilateral
others
Calcification,
teeth
ascites
Radiographic
Evaluation,,,,

Computed tomography (CT)
 Pelvic
organs and Retroperitoneal
structures

Magnetic resonance imaging (MRI)
 Nature
of ovarian neoplasm

X ray chest

Barium enema

mammogram
Laboratory Evaluation

CBC

Serum electrolytes

hCG (pregnancy)

AFP ,LDH lactate dehydrogenase (young
girls)

CA-125
Surgical Treatment of
Epithelial Cancer

Surgery is the corner stone of therapy

Surgical staging to
 Reduce
amount of disease
 Evaluate

the extent of spread
Debulking or cytoreduvtive surgery is
removal
 Primary
tumor
 Associated
metastasis disease
Intra operative
differentiation
Benign
Simple
Unilateral
No adhesions
Smooth surface
Intact capsule
Malignant
Adhesions
Rupture
Ascites
Solid areas
Areas of hemorrhage
or necrosis
Multi loculated mass
Bilateral
Most common location of
metastases

Peritoneum 85%

Omentum 70%

Liver 35%

Pleura 33%

Lung 25%

Bone 15%
Procedures in staging

Sample of ascites or peritoneal washings from
Para colic gutters , pelvic and sub

diaphragmatic for cytology

Complete abdominal exploration

Intact removal of tumor

Infracolic omentectomy

Biopsies of abdominal peritoneal implants

Pelvic and Para aortic lymph node biopsies

Cytoreduvtive surgery to remove all visible
disease
International Federation of Gynecology
& Obstetrics (FIGO) Staging


Stage I. growth limited to the pelvis
 Ia- One ovary
 Ib- both ovaries
 Ic- Ia or Ib and ovarian surface tumor ,rupture
capsule, malignant ascites, peritoneal cytology
positive.
Stage II. Extension to the pelvis
 IIa- extension to the uterus or fallopian tube
 IIb- extension to the other pelvic tissues
 IIc- IIa or IIb and ovarian surface tumor ,rupture
capsule, malignant ascites, peritoneal cytology
positive.
International Federation of Gynecology
& Obstetrics (FIGO) Staging


Stage III. Extension to abdominal cavity
 IIIa - abdominal peritoneal surfaces with microscopic
metastases
 IIIb- tumor metastases <2cm in size
 IIIc- tumor metastases >2cm or metastatic disease in
pelvic para aortic or inguinal lymph nodes
Stage IV. Distant metastases
 Malignant pleural effusion
 Pulmonary parenchymal metastases
 Liver or splenic paranchyml metastases
 Metastases to thr supraclavicular lymph nodes or skin
Surgical treatment of Germ
Cell Neoplasms

Most are at early stage on young women

Removal of involved adnexia

Same complete surgical staging
Chemotherapy of epithelial cancer

Stage Ia and grade I, don’t need treatment

Agents ,cisplatin, carboplatin,
cyclophosphamide, paclitaxel

Compination paclitaxel 175mg/m2 and
cisplatin 75mg/m2 or carboplatin for 6
cycles at 3 week intervals

Toxic effects

Vomiting ,diarrhea ,alopecia, nephro and
ototoxicity and myelosuppression.
Chemotherapy of Germ Cell
Neoplasms

Curable

Dysgerminoma most radiation sensitive

Preserve future reproductive potential
with chemotherapy

Regimens ,vinblastine-bleomycincisplatin , vincristin-actinomycin, Dcyclophsphomide, bleomycin-etoposidecispltin
Complications of chemotherapy

Nausea vomiting alopecia
Agent
Toxicity
Cisplatin
Carboplatin
Cyclophosphamide
Paclitaxil
Altretamin
Etoposide
Bleomycin
Doxorubicin
Vincristine
ifosfamide
Nephrotoxicity,neurotoxicity, ototoxicity
Thrombocytopenia, neutropenia
Hemorrhagic cystitis, pulmonary fibrosis
Myelosuppression
Peripheral neuropathy
Myelosuppressiom
Pulmonary fibrosis
Cardiac toxicity
Neurotoxicity
Hemorrhgic cystitis,central neurotoxicity
Radiation therapy and
alternative

Very limited role in epithelial cancer

Dysgerminoma

Immunotherapy

Gen therapy
prognosis

Related to

Response to chemotherapy

Differentiation of tumor

Germ cell better than epithelial

Stage of the disease -5 year survival rate
(epithelial)

Stge I -75-93%

stageII- 65-74%

Stage III- 23-41%

Stage IV- 11%