Transcript MALIGNANT OVARIAN TUMOUR

MALIGNANT OVARIAN
TUMOUR
By: Dr. Johara Al-Mutawa
Assistant Professor &
Consultant
INTRODUCTION:
* It is common gynaecological tumour
continue to kill more women than
all other gynaecological cancer
* In England the incidents of ovarian
cancer 1.4 higher than cervical and
endometrial cancer but lower than breast
cancer 7.1%
* Eventually 80 to 85% of women
with ovarian cancer die
* Most ovarian cancer as epithelial in
origin and incidence increase risk
with age.
Germ cell tumour rare and occur mainly
in children and young women.
* Survival rater 5 years in 60% of stage I
disease ovarian malignancy.
Histopathology and Classification of
ovarian mass.
* Ovarian mass
Physiological
Neoplastic
Benign
Malignant
* WHO provide international classification
that has been universally accepted
Histological classification of ovarian
Tumour
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Epithelial Tumour
Serous Tumour
Mucinous Tumour
Endometrial Tumour
Clear Tumour
Mixed Tumour
Undifferentiated and Unclassified
Tumour
Sex-Cord Stromal tumours
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Granulosa –stromal cell tumours
Sertoli – stromal cell tumours
Gynandroblastoma
Sex – cord tumour with annular tubules
Unclassified sex-cord tumoursSteroid cell
tumours
Ovarian germ-cell tumours
* Dysgerminoma
* Teratoma (immature, mature and
monodermal)
* Yolk sac tumour (endodermal sinus
tumour)
* Embryonal carcinoma
* Polyembryoma
* Choriocarcinoma
* Mixed germ-cell tumour
Epithelial Tumour – Arise from surface epithelium of
ovary account from 60-65 % of ovarian tumour and
approximately 90% are malignant.
Benign
border line
malignant
Sex cord stromal tumour
- Derived from sex cord & Stroma of ovary
- Account approximately 8% of all ovarian tumour
Germ Cell Tumour =
- Arise from germ cells
- Account from 30% of ovarian
tumour in the form of mature cyst
tertoma (Dermoid Cysts) and 1 – 3
% of ovarian malignancy and
represent 60% of ovarian cancer in
children and adolescents.
Epithelial ovarian tumour –
*common bilateral
*Serous – most common 40 –
50%.
*Mucinous 10% large size
associated with
pseudomyxoma ovari
* Endometrial ovarian cancer: account
for 20% of epithelial tumour. 10%
associated with endometrial cancer.
* Brenner tumour – very small proportion
- 99% Benign
* Clear Cell cancer – Account from 5 –10%
10%
- Worse prognosis
* Mixed epethilium ovarian tumour
Borderline ovarian tumour:
* Account approximately 15% of epithelial
ovarian cancer.
* They are low malignant potential.
* Affecting young women and may present
in pregnancy
* Microscopically they show malignant
features but no stromal invasion.
* They have good prognosis.
Sex cord stromal tumours:
* They are composed of granuloza, theca
and serotoli cells.
* Granuloza cell tumour produce
oestrogen and serotoli-stromal produce
androgen.
* Most of them are benign and most
clinically malignant are granuloza cell T.
* Meig syyndrome - fibroma + ascites and
right hydrothorax
Germ Cell Tumour:
* Account approximately 30% of ovarian
tumour.
* Commonest in the first two decade of
life.
*
Sysgerminoma is the commonest
75% present in stage I disease
10-15% Bilateral
5-10% occur in female with abnormal
gonads
Teratomas: drived from 2 -3
embroyonic layers
Mature (Dermoid Cysts) – Commonest
ovarian tumour
-
Benign
Unilateral (10-15% Bilateral)
Leading to torsion.
Contain teeth and hair in the cyst.
Malignant transformation 2%
Immature Teratoma:
* 2nd commonest germ cell malignancy.
* Account for 20% ovarian cancer in
female under 20 years of age.
* Unilateral
* classified according to differentiation
and quantity of immature tissue.
Embryonic Markers:
* Yolk sac tumour
AFP - (rare tumor)
* Ovarian choriocarcinoma secret BHCG
(rare tumour)
* Normal level does not exclude diagnosis.
* Teratoma & dysgemenoma does not
secret this tumor marker.
Secondary ovarian malignancy:
* Account up to 10%.
* Metastases form
Colon
Stomach
Breast
Female genital tract
Krukenberg Tumour: Bilateral
enlarged ovaries
* Ovarian metastatic tumour from
gastric or colon cancer.
* Microscopic assessment – signet
ring cells.
* CEA marker increase
Eitology:
* Environmental Factors:
-
Unknown
High fat diet
Perineal dusting with talcum powder
Risk of caffeine intake and radiation
unclean.
- Role of certain viral infection (Mumps,
rubella, influenza) inconclusive results.
Reproductive and Hormonal factors:
* Contraceptive pill
* Pregnancy
* Breast feeding
* Tubal ligation and Hysterectomy
- early menarche
- late menopause
- nulliparity
•This suggest continous ovulation is
important factor.
* Using of ovulatory stimulants and
subsequent development of epithelial
ovarian cancer is currently lacking.
* Heriditary factors not more than 10% of
all ovarian cancer.
* BRCAI responsible for 5% of ovarian
cancer in young women < 40 years.
Screening of ovarian cancer:
* No role of ovarian screening in
asymptomatic population.
* Women at risk of developing ovarian
cancer based on family history 10%
offered screening.
* Women risk vague pelvic abdominal
symptoms warrant complete history and
examination including vaginal and rectal
examination.
Risk of Malignancy index (RMI)
Serum Ca 12.5
USS Score (0-3) calculated by:
multilocular cysts
Solid area
Bilateral lession
Metastasis
Ascites
Menopausal status
1 for premenopausal
3 for post menopausal
This RMI to identify cases for referral
to Gynaecology Oncologist
Symptoms:
* Early stage – Pressure symptom
* Late stage – metastatic effect to bowel
mesentery and ascites.
- Vaginal bleeding less
common.
Clinical Signs:
* Supraclavicular, axillary, inguinal lymph
nodes.
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*
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Breast examination
Chest examination – pleural effusion
Abdominal examination – liver size
Pelvic & rectal examination – Irregular
solid mass suggestive of malignancy.
INVESTIGATIONS
-
For blood count
Urea and electrolyte
Liver function test
Tumor marker
Ca 125
AFP & B-HCG
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CEA
U/S for pelvis, kidney and liver
MIR
CT Scan
Endometrial biopsy
Endoscopy
Staging of primary ovarian cancer:
Stage
Description
(%)
I
Ia
Ib
Ic
II
IIa
IIb
IIc
Confined to one/both ovaries
Limited to a single ovary, no ascites;
capsule intact with no surface tumour
Limited to both ovaries, no ascites;
capsule intact with no surface tumour
One or both ovaries have ruptured
capsule or surface tumour, malignant
ascites or positive peritoneal washings
Extension to pelvic structures
Extension to uterus or fallopian tubes
Extension to other pelvic tissues
As for IIA or IIB but one or both ovaries
have ruptured capsule or surface tumour;
malignant ascites or positive
peritoneal washings
5 –year
survival
89.9
84.7
80
69.9
63.7
66.5
III
IIIa
58.5
IIIb
39.9
IIIc
28.7
IV
16.8
As for stage I/II but also with peritoneal
Implants outside pelvis or with positive
retroperitoneal lymph nodes
Histologically confirmed microscopic
seeding of abdominal peritoneal surfaces
and negative retroperitoneal lymph nodes
Histologically confirmed implants of
abdominal peritoneal surfaces <2cm
and negative retroperitoneal lymph nodes
Histologically confirmed implants of
abdominal peritoneal surfaces <2 cm or
positive retroperitoneal lymph nodes
Distant metastases (including liver
parenchyma/positive pleural fluid cytology)
Metastatic ovarian spread:
* Direct – tubes uterus - bladder
* Trascoelmic along peritoneal surface.
* Lymphatic spread – pelvic and para
aortic lymph nodes.
* Haematogenous spread - liver
- lung
Technique for Surgical Staging:
* Midline incision – adequate access for
surgical staging and full inspections.
1. Sending ascites or peritoneal washing
2. Performing total hystrectomy and
bilateral salpingo –ophorectomy.
3. Omentectomy
4. Peritoneal biopsy all suspicious area.
5. Diaphragmatic biopsy or scraping.
6. Sampling of pelvic and a paraaortic
lymph nodes.
Surgical Management of Ovarian
Cancer:
* Primary surgery in early epithelial
ovarian cancer.
In young patient – fertility is important:
* Laparotomy is gold, standard for
diagnosis and staging
* Frozen section is useful.
* Delaying procedure until histopathology
is available regardin further surgical
management to be made in consultation
with patient and cancer team.
Primary surgery in advanced epithelium
ovarian cancer.
* Primary cytoreductive surgery followed
by chemotherapy is current gold
standard.
* Cytoreductive surgery – remove all
primary cancer and if possible
metastatic disease to tumor load to
achieve optimal status.
Chemotherapy:
*
Additional therapy in early stage disease
with high risk factor.
* Standard adjuvant depending involve IV
chemotherapy single agent active in
epithelial ovarian cancer.
Include: Alkalizing agent (cyclophosophomide)
- platinuim compound (cisplatin)
- taxanes (paclitaxel)
- paclitaxel and platinum became new standard
of care in advanced ovarian cancer.
- pallative surgery – bowel obstruction involve –
bowel resection and intestinal bypass.
Germ cell tumour:
* Adequate surgical staging.
* Cytoreduction and adjuvant
chemotherapy is the standard therapy.
* Usually occur in young patient so
conservative of contralateral ovary and
uterus is appropriate.
* In dysgeminoma and Immature tertoma
stage I ovarian cancer further therapy.
From all after patient 2-3 cycles of
combination therapy.
* Tumor marker useful in monitoring
disease and planning management.
Sex cord stromal tumour:
Surgery is the gold standard but
early stage can be managed by
unilateral oophorectomy and
endometrial biopsy when fertility is
important.
Treatment of ovarian Cancer
The principle of Treatment
1. Surgical staging – Laparotomy to classify the
growth to its extent of spread.
2. Surgical removal of as much malignant
tissue as possible( surgical debulking; cytoreductive treatment), may involve partial
resection of bladder and bowel.
3. Follow up with intensive chemotherapy using
various combination of drugs Toxanes with
platinium are first choice of treatment.
4. Second look laparatomy or laparoscopy to
determine effectiveness of chemotherapy
only performed for clinical trails.
- Cooperation with general surgeon and
experience in field of chemotherapy and
radiotherapy.
- Treatment by radiotherapy only for pallation.
- CA 125 is usually raised in advanced ovarian
cancer and used to assess response to
chemotherapy.
Chemotherapy:
- Act by inhibiting cell deviation
* Alkalyting agent preventing replication of DNA
- cyclophosphoamide
- Chloraambucil
*Antimitotic antibiotic – Prevent DNA
protein synthesis – actinomycin D
Antimetabolites: Preventing the synthesis
of nucleoprotein
Methotrexate:
Other Non Alkylating agent
* Cisplatin
-Carboplatin
* Taxanes – Paclitaxel
Toxicity:
-
Bone marrow depression
gastrointestinal
neurotoxic
nephrotoxic
alopecia
candiatoxic
liver failure
regular check up for marrow and liver
function
Prognosis for epithelial ovarian cancer
Stage
I
II
III
IV
5 years survival
60 – 70%
40 - 50%
5 - 10%
nil
Borderline epithelial Tumour - has
excellent prognosis
-
5 years 90 – 95%
- 15 years survival 70-85%- For serous
tumour
- 5-10% for mucinous
- Chemotherapy is effective in the in frequent
germ cell tumour
Thank you and
Good Luck!