Transcript Clinical manifestation

BENING AND MALIGNANT
OVARIAN TUMOR
PRESENTED BY:
NAZARZADEH .REZA. MD
REFERENCE: SCHWARTZ & SABISTON
MANAGEMENT OF PELVIC MASS
ULTRA SOUND :
 When a pelvic mass is discovered on
examination uitrasuond can be helpful in
determining characteristic that are worrisome for
malignancy:
 Asimple cyct in premenopusal patient will not be
cancerous
 Mass with complex features such as septation
papillation and solid componant is more
worrisome
In a premenopausal with a simple cyct
ultra sound should be repeated in 6to 8
weeks to see if it is corpus luteum.
In post menopausal with complex
massevaluation include CT to ruleout
omental .D or other site of primery tumor.
Barum enemais done to rule out
involvement or primery colonic tumor
CA -125
UNFORTUNATLY it is not specific for
ovarean cancer
It may be elevated in lung ;appendical and
signetring cell carcinomas
In premenopausal elevated in :
 Leiomyomas;endometriosis;menstruation
;pregnancy ;and pelvic inflamatory .D
THEREFORE
Should not be checked in the
premenopausal patient with a
pelvic mass
How ever in the post menopausal . P with a
pelvic mass and elevated CA-125 ovarain
cancers is diagnosed in 80% of these
patients
In patient with potential for carcinomatosis
laparoscopy shouldn’t be done because of
port site metastasis that occurs quickly
and can make debulking difficult.
If all indications are that the lesion is
benign ovarian cystectomy or drainage is
indicated
If there is a higher level of suspicion or the
patient is menopausal oophorectomy is
performed and frozen section histologic
diagnosis is provided
MALIGNANT
TUMOR
OVARIAN CARCINOMA
Ovarian carcinomas are divided
histologically into:
 Epithelial,
 Germ cell,
 Stromal.
Epidemiology
The majority of the 27,000 or more cases
of ovarian cancer diagnosed annually in
the United States are of the epithelial type.
 The median age at diagnosis for epithelial
ovarian cancer is 61 years,
Approximately 15,000 women die of this
disease in the United States annually.
 Approximately 5% of patients with
epithelial tumors come from families where
one or more first-degree relatives also
have the disease.
prophylactic
oophorectomy may be considered at
 In such families,
the completion of childbearing, especially
if specific BRCA I or
mutations are identified.
BRCA2
• Primary peritoneal carcinomatosis has
been reported in women who have
undergone prophylactic surgery,
• however. Life-long screening with CA 125
levels, pelvic examination, and vaginal
ultrasonography of women from affected
families is important.
Early lesions largely asymptomatic
Advanced tumors may produce only
nonspecific symptoms such as early
satiety, abdominal distention, and vague
gastrointestinal symptoms.

cost-effective screening programs using serum
markers such as CA 125 and vaginal ultrasound
examination are being developed.

Currently, the more than 70% of women with
epithelial cancer have stage III tumors at the
time of diagnosis.

Widespread peritoneal dissemination, omental
involvement, and ascites are the rule, rather than
the exception, in these women.
TREATMENT
 In general, therapy for epithelial ovarian
cancer consists of surgical resection and
appropriate staging followed by
adjuvant radiation or chemotherapy.
 Women with low-grade early stage (IA or IB)
cancers who have undergone appropriate
surgical staging may be treated with surgery
without adjuvant therapy.
If the lesion is bilateral (stage IB),
abdominal hysterectomy and bilateral
salpingo-oophorectomy are sufficient.
It is in the limited group of patients with
unilateral histologic grade I or 2 lesions
that fertility can be preserved by performing
adnexectomy and staging biopsies without
removing the uterus or contralateral ovary
and fallopian tube.
In all other patients (stage lA, grade 3,
and stage IC and above),
appropriate initial surgery includes bilateral
salpingo-oophorectomy, abdominal
hysterectomy if the uterus has not been
removed on a prior occasion, appropriate
staging, and tumor resection.
STAGING
 Staging indicates surgical resection or biopsy of all
potential areas of tumor spread.
.
 Among patients whose cancer is confined to one or both
ovaries at the time of gross inspection, occult
metastases can be identified by careful surgical staging
in one-third.
 If staging is improperly performed and adjuvant therapy
omitted in patients whose tumors are apparently
confined to the ovary, 35% will suffer preventable
relapse.
Epithelial ovarian cancers disseminate
along peritoneal surfaces and by lymphatic
channels. The first site of spread is the
pelvic peritoneum.
Later the abdominal peritoneal surfaces
and diaphragms are involved.
The omentum is a common site for
metastases, as are both the para-aortic
and pelvic lymph nodes.
Because the abdominal cavity in its entirety
is not accessible through a transverse
pelvic incision, it is paramount that surgery
for ovarian malignancies beperformed
through a full-length midline abdominal
incision.
After the peritoneal cavity is entered, the
visceral and parietal surfaces are
inspected for metastatic disease, and any
suspicious areas are biopsied.
If ascites is present, it should be aspirated and
heparinized. Cytologic evaluation for metastatic
cells or clusters is then performed.
If no ascites is found, peritoneal washings with
balanced salt solution or lactated Ringer's
solution are obtained from the abdominal
cavity and submitted for cytologic evaluation after
centrifugation and fixation.
I
Appropriately staged patients with
histologic grade I or grade 2 tumors
confined to one or both ovaries (stage IA
or IB) require no postoperative therapy.
Five-year survival in this group of patients
exceeds 90%.
Those patients who have stage I, grade 3
lesions, stage IC tumors (malignant
peritoneal washings, rupture of tumor,
surface excrescences, or ascites), or
stage II cancers that are completely
resected may be treated equally well with
systemic chemotherapy, radiotherapy
of the whole abdomen, or a single
instillation of intraperitonealRADIO
ACTIVE CHROMIC PHPSPHATE.
Women with stages III and IV disease
require systemic chemotherapy with
cisplatin or carboplatin, generally in
combination with a taxane such as
paclitaxel.
Survival at 5 years in such patients may
exceed 20%, although this rate drops as
low as 10% at 10 years.
 It is widely accepted that patients in whom little or no
residual disease remains after initial operation, on
average, live longer than those in whom a great deal of
tumor remains unresected.
 The terms debulking and cytoreduction indicate
aggressive surgical removal of ovarian cancer.
 When disease remaining after surgical resection
consists of nodules or plaques less than I to 2 cm in
diameter, the surgical effort is termed optimal, and when
a larger volume of residual disease remains, the surgical
removal is termed suboptimal.
 Resection of nodules involving the small or large
bowel is warranted if the exercise results in
complete removal of all observed disease.
 Such procedures are probably not indicated if
tumor remains at other sites.
 After surgical extirpation of the tumor, patients
with suboptimal ovarian cancers must be treated
with chemotherapy.
 Approximately 80% ofthese tumors will respond
to platinum-based combination therapy;
Resection of advanced tumor
• When advanced ovarian carcinoma is
discovered at the time of exploratory
laparotomy, the first reaction is often one
of resignation.
• There has been a tendency to perform a
diagnostic biopsy and close the abdomen
without further surgical intervention.
 In experienced hands, however, successful
reduction of tumor volume to nodules 2 cm or
less is possible in at least 50% of women with
advanced ovarian cancer.
 If the primary surgeon is incapable of obtaining
such results, the patient should be referred to
one with sufficient expertise in this area.
 Survival following chemotherapy is inversely
related to the volume of residual disease at the
time of primary surgery.
Several techniques ensure adequate
resection.
• First, most ovarian cancer is found on
peritoneal surfaces and not invading
viscera.
• A retroperitoneal approach thus facilitates
mobilization of the involved mesothelium.
The lateral aspects of the paracolic gutters
may be incised and dissection carried
medially to undermine tumors in these
location
 The ovarian artery and vein should be identified at this
point and securely ligated before division.
It is often useful to dissect the ureter from the underlying
pelvic peritoneum and retract it laterally with a vessel
loop. This allows access to the lateral pelvic peritoneum.
 Tumor nodules on anterior and posterior cul-de-sac
peritoneum may be resected by developing planes in the
retroperitoneal spaces and isolating the disease from the
underlying bladder, sigmoid colon, and ureters.
 Opening the pararectal and paravesical spaces
facilitates this dissection and also allows access to the
uterine vessels, which then may be clamped, ligated,
and divided. When the hysterectomy and adnexectomy
are complete, the omentum may be resected.
Disease on the right diaphragm may be
resected by transecting the falciform
ligament and retracting the liver inferiorly.
If it serves to remove all remaining tumor,
splenectomy may be performed.
Resection of small and large bowel may
be performed if the operation removes all
Use of the ultrasound aspirator and
argon beam coagulator have resulted in
an increased ability to completely remove
tumors, including those that are implanted
on the serosal surfaces and mesentery of
the bowel.
With diligence it is often possible to remove
all appreciable disease with these
instruments.
Second _look
operation
Second _look laparatomy
Ovarian cancer often defies diagnosis
because it does not produce symptoms and
is detectable neither radiographically nor
serologically, even in relatively advanced
stages.
The assessment of ovarian cancer during
and after therapy is similarly difficult.
 Although CT or MRI may identify masses as
small as 2 to 3 em in diameter, neither technique
can reliably detect smaller masses
CA 125 is more sensitive than
radiographic or magnetic scanning,
but is also associated with a number of false
positive results and may not be elevated in
patients with mucinous tumors.,
The practice of performing exploratory
surgery following chemotherapy originated
during a time when alkylating agents were
used almost exclusively.
Because acute nonmyelocytic leukemia is
associated with prolonged administration of
such agents,
a "secondlook“ operation was
performed at an interval of 12 to 24
months following primery surgery
Presently, the duration of postoperative combination
chemotherapy is often only 5 to 6 months, and the risk
of leukemia is very low.
In approximately 20 to 30% of patients who receive such
treatment, no cancer will be identified at the time
of a second operation.
These patients have an excellent long-term prognosis
In women who have persistent microscopic disease,
the prognosis is also favorable,
those with persistent gross tumors, the prognosis is
relatively poor.
Second-look surgery is currently used
primarily as a research tool.
New treatment regimens can be evaluated
quickly by performing a second-look
operation,.
 Second-look surgery is also valuable
in determining when therapy can be
discontinued and when further treatment is
indicated
Palliative surgery
 In most cases of advanced ovarian cancer,
death is associated with bowel dysfunction or
frank obstruction.
 Although invasion of the small bowel and colon
is unusual, growth of the tumor adjacent to the
bowel leads to mesenteric compromise and
dysfunction usually heralded by distention,
nausea, and vomiting.
When bowel obstruction occurs early in
the clinical course of ovarian cance
particularly if it occurs before the
administration of chemotherapy, surgical
intervention is warranted and should
be aggressive.
Resection or bypass of the involved bowel
is indicated; colonic resection also may be
indicated.
 When bowel obstruction occurs after
chemotherapy, the prognosis is unfavorable.
Women who develop such difficulties have a
limited survival following surgical correction.
 Laparotomy may be complicated by intestinal
injury or fistula.
Often the best approach in these patients
is the use of a percutaneous or
endoscopically positioned gastrostomy
tube and intra venus fluids or
conservative nutritional support
Laparascopy in ovarian cancer
At present,
our ability to resect large ovarian cancers
successfully using laparoscopic equipment
is limited
Tumor with low malignant
potential
These are epithelial tumors of malignant
potential intermediate between benign
lesions and frank malignancies,
Histologically, most are of the serous type,
Although these tumors may be associated
with epithelial budding, atypia, mitoses,
and stratification,
 The median age of diagnosis is approximately 10years
younger than that of patients with epithelial cancers,
 The vast majority occur in stage I and have a favorable
prognosis,
Surgery should include abdominal hysterectomy and
bilateral salpingo-oophorectomy unless fertility
is to be preserved in patients with unilateral
lesions,
 These patients may undergo unilateral salpingooophorectomy
Ovarian cystectomy or nonextirpative resections
commonly result in recurrences,
Patients with stages III and IV lesions
have 5-year survival rates that approach
85% after complete surgical resection.
There is little evidence that chemotherapy
or radiotherapy administered after surgery
improves survival.
on the other hand, deaths from
chemotherapy-induced leukemia are
not uncommon.
Germ cell tumor
 These tumors occur in women in the first three
decades of life
 Typically grow rapidly, producing symptoms of
distention and abdominal fullness, Torsion may
occur, producing an acute abdomen,
 Most are unilateral, and all have a tendency to
spread to the paraaortic lymph nodes, as well as
throughout the peritoneal cavity.
Dysgerminoma, the female equivalent
of testicular seminoma, is composed of
pure, undifferentiated germ cells.
It is bilateral in 10 to 15% of patients and is
occasionally associated with elevated
levels of hCG or lactate dehydrogenase
(LDH).
It is the most common ovarian malignancy
diagnosed during pregnancy
Patients bearing dysgerminomas should
undergo appropriate staging at the time of
the primary resection
But need not undergo hysterectomy
(if fertility is to be preserved) or
removal of the opposite ovary if it is
normal in appearance,
Adjuvant therapy is unnecessary unless
there is evidence of extraovarian
spread,
Either radiotherapy encompassing the
whole abdomen or systemic chemotherapy
can be given to patients with metastases,
The cure rate exceeds 90% even in
patients with metastases
The other germ cell tumors, in order
of frequency, are:
 Immature
teratoma
 Endodermal sinus, or "yolk sac," tumor
 Mixed tumors
 Embryonal carcinomas
 Choriocarcinomas
Elevated AFP levels are found in all
patients with endodermal sinus tumors
and mixed tumors that contain this
component
Embryonal carcinomas are associated
with abnormal levels of both AFP and
Hcg.
choriocarcinomas secrete hCG.
These tumors are invariably unilateral but may
spread by peritoneal, hematogenous, or
lymphatic routes.
Surgical therapy involves unilateral
oophorectomy and appropriate staging
Except for those with completely
resected stage I, grade I immature
teratomas and those with stage I
dysgerminoma, all patients with germ
cell tumors require systemic
chemotherapy
Three courses of a platinum and etoposidecontaining combination suffice in those patients
whose tumors are completely resected,
 Cure rates in these patients approach 90%.
In women with incompletely resected
nondysgerminomatous germ cell tumors, cure
may still be expected in more than
50%, but prolonged chemotherapy may be
necessary, These tumors are not
sensetive to radiotherapy.
BENING OVARIAN TUMORS
INCLODED:
 Non neoplastic cysts
 Non functioning tumors
 Functioning tumors
NON NEOPLASTIC CYST
By definative a cystic enlargementof ovary
should be at least 2.5 Cm in diameter to
be termed cyst :
Follicular cyst
Corpus luteum cyst
Endometriomas
Wolffian duct Remnant
Mullerian Dact Remnant
FULLICULAR CYST
These are enlarge graafian folicle
They grossly true symptom
They can rupture and peritoneal irritation
It can be spontaneosly regress
Corpus luteum cyst
It may become as large as 10 to11 Cm
They can rupture lead to sever hemorrhage
and vascular collapse
SYMPTOM :
Mimic to pregnancy and delayed
menses and spoting
Endometriomas
These account CHOCOLATE CYSTthat
detail preview
Wolffian duct remnant
They are ovarean cyst but mimic tumor of
ovary
They are small but may enlarge and infarct
These are incidental finding at laparotomy
and cause no difficult or symtom
NONFUNCTIONING TUMOR
INCLODE:
 Cystadenomas
 Matur
teratomas
 Berner Tumor
 Meigs syndrom
cystadenomase
-Appear as cyst with trans lucent wall and
clear fluid and lined by ciliated epithelium
-They are usaly on pedicle and may torsion
leading pain and infarct
They are adequatly treated by salpingo –
oophorectomy
two type of adenoma is there :
Serous cystadenoma
Mucinous cystadenoma
M –cystadenoma are less likely to be
malignant than S-cystadenoma
approximately 20% of S-cystadenoma and
5% m-cysadenoma are bilateral-cystic
lesion with solid componant not alwase
bining or malignant so :
It is usally necessary to excise
ovary completely
G 0- CARCINOMA
Some cystadenomase are classified as
borderline by hystologic exam that called
G 0 carcinomase
These are excellent prognosis
If they are unilateral may treted by
unilateral adnexectomy in
reprodactive women
Frozen-section examination of the tumor
at the time of surgical intervention is
necessary to determine the proper course
of therapy for patients in the reproductive
age group.
 The opposite ovary should be inspected.
Psudo myxoma peritonei
Occasionally, a condition known as
pseudomyxoma peritonei isencountered;
this is a locally infiltrating tumor composed
of multiple cysts containing thick mucin.
These tumors arise either from ovarian
mucinous cystadenomas or from
mucoceles of the appendix,
Histologically, they are benign,but by local
spread and infiltration they compromise
surrounding vital structures.
Localized tumors should be excised
completely, if possible. Both ovaries and
the appendix are removed, even though
they grossly appear to be normal.
Mature Teratoma
 These germ cell tumors are thought to
arise from the totipotential germ cells of the
ovary.
 The tumors often contain calcified masses,
and, occasionally, either teeth or pieces of
bone can be seen on abdominal
radiographs.
If a teratoma (dermoid) is
encountered in a young woman, it is
preferable to shell it out from the
ovarian stroma preserving functioning
tissue in the affected ovary.,
Mature teratomas occur at any age but
are more frequent in patients between 20
and 40 years old. They are benign
dermoid cysts.
 The occasional solid teratoma is usually
malignant (immature teratoma).
 If this material is spilled during surgery, a chemical
peritonitis may result; therefore, it is important to remove
these tumors intact.
 The opposite ovary should be inspected, but no further
operative procedure is performed if the opposite ovary
appears normal.
 In approximately 12% of patients, these tumors
are bilateral.
 In patients of childbearing age, some functional ovarian
tissue should be preserved.
 Immature teratomas are treated as other malignant
germ cell tumors, with conservative resection and
appropriate adjuvant chemotherapy.
Brener tumor
 These are rare epithelial tumors that usually
do not secrete hormones.
 Histologically, the epithelial elements are similar
to Walthard rests and are believed to arise from
them.
 These tumors occur primarily in later life and
have a small malignant potential.
Simple oophorectomy is usually sufficient therapy,
and the prognosis is excellent.
Meigs syndrome
 This pertains to ascites with hydrothorax,
seen in association with benign ovarian
tumors with fibrous elements, usually
fibromas.
 It is more common to see fluid
accumulation with ovarian fibromas that
are more than 6 cm in size.
 The cause of the condition is unknown, but the
ascitic fluid may originate from the tumor, as a
result of lymphatic obstruction of the ovary.
Frequently, this clinical picture is encountered
with other ovarian tumors, especially ovarian
malignancies, which can produce
a cytologically benign pleural effusion; in such
cases, it is termed apseudo-Meigs' syndrome.
Meigs' syndrome can be cured by excising
the fibroma.
Granulosa cell tumor
 Pure theca cell tumors (thecomas) are benign,
but those with granulosa cell elements may be
malignant It is often impossible to predict their
behavior from the histologic features,and
prolonged follow-up is necessary in order to
judge the nature.
 Usually, granulosa cell tumors elaborate
estrogen, but some of these tumors have no
hormone production,
In young girls, they are characteristically
manifested by isosexual precocity,
In elderly women, they are sometimes
associated with postmenopausal
bleeding or endometrial carcinoma. tumor
The tumor can occur at all ages from
childhood to the postmenopausal period,
most common in later life, with maximal
occurrence between the ages of 40and 60
years,
TREATMENT
 If the tumor is discovered in the reproductive
years and confined to one ovary without signs of
surface spread or dissemination:
simple oophorectomy may be sufficient therapy,
 IFIt is discovered in later life :
removal of both ovaries with the uterus is
indicated,
SERTOLI-LEYDIG CELL TUMOR
(ARRHENOBLASTOMAS)
These rare, but potentially malignant,
Tumors are associated with androgen
output and masculinization.
Rarely, they elaborate estrogen.
They usually occur in the reproductive age
group and appear to contain tubular
structures as well as Leydig-type cells.
TREATMENT
In young patients with a single involved ovary:
unilateral oophorectomy is adequate
therapy, provided there is no extension of the
tumor.
or
For older patients
for those with bilateral
involvement:
total hysterectomy and bilateral salpingooophorectomy are performed.
STROMA OVARII
 This term refers to the presence of grossly
detectable thyroid tissue in the ovary, usually
as the predominant element in dermoid
cysts.
 This tissue occasionally may produce the
clinical picture of hyperthyroidism and is
rarely malignant