Transcript Epithelial tumors The most common histological type accounting for

Chapter 21
Female Genital Tumor
6. Ovarian Tumor
Women’s Hospital, School of Medicine, Zhejiang university
Xiaodong Cheng
Ovarian tumor
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Common gynecologic malignant tumors
Occur in females of all ages
but different histological types in different ageperiods
Epithelial ovarian carcinoma with poor prognosis
5-year survival rate about 30-40%
the mortality rate ranks first in gynecological
malignancies
General Introduction
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Histological classification
very complicated
Most histological types in body organs
The current classification
issued by WHO in 2014
Histologic types of ovarian tumor
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Ovarain epithelial tumor
Germ cell tumor
Sex-cord stromal cell tumor
Stromal cell tumor
Non-specific ovarian soft tissue tumor
Lymphoma & Medullary tumor
Tumor-like lesions
Secondary tumor
Symptoms and signs
Benign tumors
 No symptoms as tumor is small
 Abdominal distention or pelvic mass as
tumor is medium size
 Gynecological examinations
A spherical mass on one side of the uterus,
cystic, smooth surface, movable
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Symptoms and signs
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Ovarian cancer
early stage
asymptomatic, often found occasionally by gynecological
examinations
Late stages
Abdominal distention, abdominal mass, ascites
End-stage
Weight loss, severe anemia, cachexia
Transvagina-rectnum examination
 Pelvic masses: bilateral , solid or semi-solid, not movable
Complications
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pedicel retortion
Common gynecological emergency
 Frequency about 10%
 Usually occur in mass with a longer pedicle, medium size,
good movability, and center deflection
 Blood flow blocked and tumor necrosis after retortion
Symptoms: one side of lower abdomen pain concomitant
nausea and vomit,
Signs: Mass with high tension and tenderness
Treatment emergency surgery once diagnosed
Complications
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Rupture
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Frequency about 3%
Traumatic and spontaneous
Symptom
lower abdominal pain
related to the size of rupture
the quality and quantity of cyst fluid
Signs
abdominal tenderness
muscle intensity
ascites
Treatment
emergency surgery
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Complications
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Infection
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Due to rupture, retorsion or the near organs’ infection
Symptoms
fever, abdominal pain
Signs
mass, abdominal tenderness,
muscle intensity
Treatment
anti-infection, surgery
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Malignant change
surgery as soon as possible
Diagnosis
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Benign tumors
No specific symptoms
A mass found occasionally by physical examination
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Ovarian cancer
No specific symptoms
Gynecological examination
bilateral pelvic mass, solid , poor movability, with ascites,
uterus rectum nest nodules
Diagnosis
Adjuvant examinations
Imaging techniques
 Ultrasonography ：
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mainly used to diagnose primary lesion
accuracy rate above 90%
difficult to measure the diameter <1cm lesion
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Radiology (X-Ray, CT, MRI)
mainly used to diagnose the metastatic lesion
Ultrasound: ovarian cancer
Diagnosis
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Adjuvant examinations
Tumor markers
§CA125
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rise up in 80% epithelial cancers
more used for disease monitoring and prognosis evaluation
§AFP
rise in endodermal sinus tumor
§hCG
ovarian choriacarcinoma
§Sex hormone
sex-cord stromal cell tumor
Laparoscopy
Ascitic cytology
Metastatic pathway
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Features
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Widely disseminated in abdominal cavity
Subclinical metastasis
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pathways
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spread directly and
abdominal cavity plant
lymph metastasis
blood vessel metastasis
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Clinical surgical-pathology staging (2013，FIGO)
Stage
I
Growth limited to ovaries
Growth limited to one side ovaries; no ascites. No
tumor on external surface; capsules intact
Growth limited to both ovaries; no ascites. No
IB
tumor on external surface; capsules intact
Tumor either IA or IB but with tumor on surface
of one or both ovaries;or with capsule ruptured; or
IC(IC1/IC2/IC3)
with ascites containing malignant cells, or with
positive peritoneal washings
Growth involving one or both ovaries with pelvic extension.
Extension and/or metastasis to the uterus and/or
IIA
tubes.
IIB
Extension to other pelvic tissues.
Tumor involving one or both ovaries with peritoneal implants outside pelvis and/or positive
retroperitoneal or inguinal nodes. Superficial liver metastasis equals Stage III.
Tumor grossly limited to true pelvis with negative
nodes, but with histologically confirmed
IIIA(IIIA1/IIIA2)
microscopic seeding of abdominal peritoneal
surfaces.
Tumor of one or both ovaries with histologically
confirmed implants to abdominal peritoneal
IIIB
surfaces, none exceeding 2 cm in diameter Nodes
are negative.
Abdominal implants >2 cm in diameter and/or
IIIC
positive retroperitoneal or inguinal nodes.
Growth involving one or both ovaries with distant metastasis. If pleural effusion present, must be
positive cytology to assign a case to Stage IV. Parenchymal live metastasis equals Stage IV.
IA
II
III
IV
Therapy
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Surgery
Objectives
To confirm the diagnosis
To resect tumor
To determine surgical-pathology staging of malignancy
Chemotherapy and radiation
for malignancy
follow-up
ovarian cancer is easy to recurrent and should be longterm follow-up
Epithelial tumors
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The most common histological type
accounting for 50-70% of the primary tumor
85-90% of malignant tumor
Derived from ovarian germinal epithelium
belong to the primitive body cavity epithelium
have potential to differentiate into a variety of
Mullerian epithelia
More common in older women
Can be divided into benign, borderline, malignant
tumors
Epithelial tumors
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Borderline tumors
low malignant potential tumors
 pathological features of malignant tumor
cells but no stromal invasion
 clinically slower development, fewer
metastasis and more later recurrence
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Histological classification
Epithelial tumors
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Serous tumors
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Mucinous tumors
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Endometrioid tumor
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Clear cell tumor
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Brenner tumor
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Mixed epithelial tumors
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Undifferentiated carcinoma
Pathology
Serous tumors
cancer cell differentiate into oviduct epithelial
 Serous cystadenoma
Mostly unilateral, spherical, smooth, cystic, serous fluid
Microscope: simple columnar epithelium
 serous cystadenocarcinoma
Mostly bilateral, semi-substantive, multiple antrum cystoid,
cavity filled with papilla, crisp, bloody cyst fluid
Microscope: cubic or columnar epithelium, stratified,
arranged in ≥4 layers, cellular atypia, stromal invasion
Serous
tumors
Serous cancer
Pathology
Mucinous tumors
cancer cell differentiate into enteric or cervical endometrial
 Mucinous cystadenoma
Mostly unilateral, large size, cystic, and often have more
capsules with the jelly-like mucus
Microscope: simple columnar epithelium, can see goblet and
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argyrophil cells
If tumor rupture, tumor cells seed in peritoneal to form
peritoneal myxoma
Mucinous cystadenocarcinoma
Mostly unilateral, cystic, cystic see the papilla, bloody cyst
fluid
Microscope: columnar epithelium, stratified, arranged in ≥ 3
layers, cellular atypia, stromal invasion
Mucinous tumors
Mucinous cancer
Pathology
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Endometrioid tumor
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Benign, borderline tumor is few
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Endometrioid carcinoma
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Mostly unilateral, cystic or solid, with papilla,
bloody cyst fluid.
Microscope: similar to endometrial cancer
Often concomitant with endometrial cancer
Endometrioid cancer
Pathology
Clear cell tumors
 Benign tumors are few
 Clear cell carcinoma
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Mostly unilateral, cystic or solid
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Microscope: alveolar tumor cells with abundant cytoplasm ,
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atypia nuclear
Easy to lymph node and liver metastasis
Often concomitant with endometriosis and hypercalcemia
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Brenner tumor
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Differentiate and formate from transitional epithelum
Most are benign, unilateral, diameter <5cm, hardware
quality
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Clear cell tumors
Brenner tumor
Epithelial Tumors
Treatment
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benign tumors
Once diagnosed, surgical extension
 reproductive period women
ovarian tumor resection or oophorectomy
perimenopausal and postmenopausal women
● adnexectomy
● hysterectomy and bilateral salpingo-oophorectomy
Notices in surgery
① differentiate the benign and malignant tumors
during surgery (grossly, frozen section )
② take out the tumor integrally
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Epithelial Tumors
Treatment
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malignancy
Principle: surgery combined with chemotherapy and radiotherapy
 surgery
Early stage:
Staging surgery
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Cytology for ascites or peritoneal washings
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Complete pelvic and abdominal exploration
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Omentectomy
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Back peritoneum lymph nodes excision
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Hysterectomy + bilateral salpingoophorectomy
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Conservative surgery
only for eligible young women desiring childbearing
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Epithelial Tumors
Treatment
 malignancy
 surgery
Advanced stage:
Cytoreductive surgery (debulking surgery)
Resect primar and metastatic tuomrs as much
as possible , to minimize diameter of residual
tumor (<1cm)
Epithelial Tumors
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Chemotherapy
Major adjuvant therapy, post-surgery
Commonly used drugs
cisplatin, carboplatin, paclitaxel, CTX, others.
Preferred to platinum-based combination chemotherapy
“Gold standard”: carboplatin and paclitaxel combination
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Radiotherapy
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For metastasis and recurrence
Others immunotherapy
Prognosis
5-year survival rate of Ia stage >90％
5-year survival rate of advanced stage <30％
Ovarian germ cell tumor
Features
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From primitive germ cells in embryonic gonad
Ability to produce diversity organizations
Frequency: account for 20~40% in all ovarian tumors
More common in young women and girls
Sensitive to chemotherapy ，most can be reserved for
reproductive function
Abnormal tumor markers: AFP, HCG
Histologic classification
Germ cell tumors
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dysgerminoma
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endodermal sinus tumor
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embryonal tumor
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polyembryoma
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choriocarcinoma
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teratomas
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mixed tumor
Pathology
Teratomas
Comprised of multi-germ layer , rarely one layer
 Mostly are mature , few are immature
 Mature teratomas（dermoid cyst）
 benign tumor，the most common germ cell tumor
 frequently single side, cystoid with smooth surface,
contains tissues of fat, hair, teeth and bone
 microscopy： scolex contains three layers
 malignant transformation: squamocarcinoma in
scolex epilithium
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Mature Cystic Teratoma
Immature ovarian teratoma
Pathology
Dysgerminoma
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Moderate malignant tumor
Mostly occurs at puberty and child-bearing perild
Single side, solid
Microscopy ：rotundity or mostly cornual cells
Extraordinary sensitive to radiotherapy
dysgerminoma
Pathology
Endodermal sinus tumor
 Common in children and young women
 Highly malignant, poor prognosis
 Single side with large mass, fragile, obvious
bleeding and necrosis;
 Microscopy：loose reticulate and endothelial
sinus structure
 Produce AFP
Endodermal sinus tumor
Treatment
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Benign tumor
The same as epilithial tumors
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Malignant tumor
Surgery
Lateral salpingoophorectomy regardless any stage as long
as opposite side ovary and uterus are not involved
Chemotherapy
Sensitive to chemotherapy : BEP BVP VAC
Radiotherapy
sensitive for Dysgerminoma，seldom used for young ages
Sex cord-stromal tumors
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From sex cord and stromal tissues of embryonic
gonad
Frequency: account for 5％ in all ovarian tumors
Comprised or uni- or multi-cell components
Mostly are benign or low malignant tumor
Produce steroid hormones, with endocrine funtion,
produce female or male features, also called
“functioning ovarian tumor ”
Histologic classification
Sex cord-stromal tumors
 Granulosa cell -stromal cell tumors
 Sertoli-stromal cell tumors
 Granudroblastoma
Pathology
Granulosa cell tumors
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Adult form and child form
Adult form
common
low malignant，produce E2，female features
solid or partly cystic
microscopy: Granulosa cell, Call-Exner body
Child form
seldom, highly malignant
Granulosa cell
tumor
Granulosa cell
tumor
Granulosa cell
tumor
Granulosa
cell
tumor
Call–Exner
bodies
(sex cordstromal
tumors )
stromal cell
tumors
Pathology
Ovarian thecoma (theca cell tumor)
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Benign，seldom malignant
Single side, solid.
Microscopy
short spindle cells, spiral arrangement
Female features
Ovarian thecoma
Pathology
Fibroma
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Benign
Single side, solid, hardness
Microscopy
short spindle cells, knitting arrangement.
Meigs syndrome
fibroma combination with ascites or
hydrothorax, naturally disappear after tumor
excision
Fibroma
Treatment
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Benign tumor
surgery as same as epithelial tumor
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Malignant tumor
Surgery
Conservative surgery for young women with stage I,
desiring childbearing
Radical surgery for others
Chemotherapy
Combinated Chemotherapy
Regimens: as same as germ cell or epilithelial tumors
Ovarian metastatic tumors
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Origin
any organs’ tumors
commonly from breast, gastrointestinal and genital tract
Krukenberg tumors (signet ring cell tumor)
 From gastrointestinal
 Bilateral, solid, median size, without adhension
ovary –shape or kidney-shape
 microscopy：signet ring cells
 Surgery combined with chemotherapy and radiotherapy
 Poor prognosis
Krukenberg tumors
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