OVARIAN TUMORSFahad zakwan

Introduction• Ovarian cancer is a cancerous growth arising from the ovary.

• Symptoms are frequently very subtle early on and this makes their diagnosis often delayed

• They are grouped as:

Primary: arise denovo in the ovary

Secondary (metastatic): results from spread from other sites of the body e.g the breast

PRIMARY OVARIAN TUMORS

• Epithelial ovarian tumors are derived from the cells on the surface

of the ovary. This is the most common form of ovarian cancer and occurs primarily in adults.

• Germ cell ovarian tumors are derived from the egg producing cells within the body of the ovary. This occurs primarily in children and teens.

• Stromal ovarian tumors are also rare in comparison to epithelial tumors and this class of tumors often produces steroid hormones.

Risk factors for developing ovarian tumors

• Parity (Nuliparous and low parity women are at an increased risk

• Family history of breast cancer

• Hereditary ovarian cancer.

Breast/ovarian cancer syndrome

Lynch II/ HNPCC (hereditary nonpolyposis colorectal cancer) syndrome

Classifying epithelial tumors

1. Malignant

2. Borderline

3. Benign

1. Serous adenocarcinoma

2. Mucinous tumors

Adenocarcinoma

Pseudomyxoma peritonei

3. Endometrioid Tumors

Adenocarcinoma

Malignant mixed müllerian tumor

4. Clear cell adenocarcinoma

5. Transitional cell tumors

Malignant Brenner tumor

Transitional cell carcinoma

6. Squamous cell carcinoma

7. Mixed carcinoma

8. Undifferentiated carcinoma

9. Small cell carcinoma

PathologyRisk Factors for Developing Epithelial Ovarian Cancer

1. Nulliparity

2. Early menarche

3. Late menopause

4. White race

5. Increasing age

6. Family history

Signs and Symptoms

• Ovarian cancer typically is portrayed as a "silent killer"

without appreciable signs or symptoms until advanced disease is obvious clinically.

• Actually, patients are often symptomatic for several months before the diagnosis, even with early-stage disease

The difficulty is in distinguishing these symptoms from those that occur normally in women or other diseases makes the diagnosis challenging

• Commonly they present with:1. increased abdominal size, 2. bloating, 3. urinary urgency, and pelvic pain are reported. 4. Additionally, fatigue, indigestion, inability to eat normally,

constipation, and back pain may be noted5. Abnormal vaginal bleeding occurs rarely. Unfortunately, many women and clinicians are quick to

attribute such symptoms to menopause, aging, dietary changes, stress, depression, or functional bowel problems. As a result, weeks or months often pass before medical advice is sought or diagnostic studies are performed.

Physical Examination• A pelvic or pelvic-abdominal mass is palpable in most patients with

ovarian cancer.• In general, malignant tumors tend to be solid, nodular, and fixed, but

there are no pathognomonic findings that distinguish these growths from benign tumors.

• Paradoxically, a huge mass filling the pelvis and abdomen more often represents a benign tumor or low-grade malignancy.

To aid surgical planning, a rectovaginal examination also should be performed.

In advanced ovarian cancers wasting is always present coupled with features of metastasis to other sites

• The presence of a fluid wave or less commonly, flank bulging suggests the presence of significant ascites.

In a woman with a pelvic mass and ascites, the diagnosis is ovarian cancer until proven

otherwise. However, ascites without an identifiable pelvic mass

suggests the possibility of cirrhosis or other primary malignancies such as gastric or pancreatic cancers.

In advanced disease, examination of the upper abdomen usually reveals a central mass signifying omental caking.

• Auscultation of the chest is also important because patients with malignant pleural effusions may not be overtly symptomatic. The remainder of the examination should include palpation of the peripheral nodes in addition to a general physical assessment.

Laboratory Testing• A routine complete blood count and metabolic panel/blood

chemistry often demonstrate a few characteristic features

• The serum CA125 test is integral to management of epithelial ovarian cancer.

• With mucinous tumors, the serum tumor markers cancer antigen 19-9 (CA-19-9) and carcinoembryonic antigen (CEA) may be better indicators of disease than CA125

Sonography/USS• In general, malignant tumors are multiloculated, solid or

echogenic, large (>5 cm), and have thick septa with areas of nodularity

• Other features may include papillary projections or neovascularization—demonstrated by Doppler flow

Although several presumptive models have been described in an attempt to distinguish benign masses from ovarian cancers preoperatively, none has been implemented universally

Radiography • Every patient with suspected ovarian cancer should

have a chest radiograph to detect pulmonary effusions or infrequently, pulmonary metastases.

• Rarely, a barium enema is helpful clinically in excluding diverticular disease or colon cancer or in identifying involvement of the rectosigmoid by ovarian cancer.

Computed-Tomography Scanning (CT scan)

• The main advantage of computed tomography (CT) scanning is in treatment planning of women with advanced ovarian cancer. Preoperatively, it may detect disease in the liver, retroperitoneum, omentum, or elsewhere in the abdomen and thereby guide surgical

• However, CT scanning is not particularly reliable in detecting intraperitoneal disease smaller than 1 to 2 cm in diameter.

Moreover, the accuracy of CT scanning is poor for differentiating a benign ovarian mass from a malignant tumor when disease is limited to the pelvis. In these cases, transvaginal sonography is superior.

Paracentesis• A woman with a pelvic mass and ascites can be assumed to have

ovarian cancer until proven otherwise surgically.

Thus few patients require a diagnostic paracentesis to guide treatment. Moreover, this procedure typically is avoided diagnostically because cytologic results usually are nonspecific, and abdominal wall metastases may form at the needle entry site

However, paracentesis may be indicated for patients with ascites and the absence of a pelvic mass.

Staging ovarian cancersIA

• Growth limited to one ovary

IB

• Growth limited to both ovaries

IC

• Tumor limited to one or both ovaries, but with disease on the surface of one or both ovaries; or with capsule(s) ruptured; or with malignant ascites or positive peritoneal washings

IIA

• Extension and/or metastases to the uterus and/or tubes

IIB

• Extension to other pelvic tissues

IIC

• Tumor limited to the genital tract or other pelvic tissues, but with disease on the surface of one or both ovaries; or with capsule(s) ruptured; or with malignant ascites or positive peritoneal washings

IIIA• The cancer is present in one or both of the ovaries, and cancer

cells are also present in small ranges in parts of the abdomen with this stage without nodular involvement.

IIIB• On this particular stage, the cancer is present in one or both of

the ovaries, and cancer cells are also present in amounts less than 2 cm or 3/4″ in parts of the abdomen.

IIIC• Abdominal implants at least 2 cm in diameter and/or positive

pelvic, para-aortic, or inguinal nodes

IV

•Distant metastases, including malignant pleural effusion or parenchymal liver metastases

Management of Early-Stage Ovarian Cancer

• When a malignancy appears clinically confined to the ovary, surgical removal and comprehensive staging should be performed

• Fertility-Sparing Management :may be an option in selected patients when disease appears confined to one ovary in younger patients

• Adjuvant Chemotherapy: In general, patients with stage IA or IB, tumors should be treated with three to six cycles of platinum based-combinations

• multimodality therapy is particularly important to achieve the most successful outcome

Primary Cytoreductive Surgery

Primary Chemotherapy

PROGNOSTIC FACTORS1. Pathological factors.

• Morphology (granulose tumors have the best prognosis)

• Histological(Clear cell carcinoma have the best prognosis)

• Degree of differentiation of the tumor. ( unclassified and undifferentiated tumors have the worst prognosis)

2. Biological factors

• Patients with diploid tumors have a significant longer median survival than those with aneuploid tumors.

3. Clinical factors.

• Volume of ascites

• Patients age

• Extent of residual tumor after primary surgery

• Stage of the disease

• Performance status

SEX CORD-STROMAL TUMOR

• This group of tumors includes all those that contain the granulosa cell, theca cells, sertoli cells or leydigcells either singly or in combination.

• Accounts for 5-8% 0f all ovarian malignancies.

• They commonly secrete hormones and therefore endocrinological features may be more common than other physical signs

GERM CELL TUMORS• They are derived from he primordial germ cell of the ovary

• Both alpha-fetal proteins and hCG are secreted by some germ cell tumors, therefore the presence of circulating hormones can be clinically useful in the diagnosis of a pelvic mass as well as in monitoring the course of the patient after surgery.

• Placental alkaline phosphatase and lactate dehydrogenase are commonly produced by dysgeminomas and may be useful in monitoring the disease.

• In the first 2 decades of life almost 70% of ovarian tumors are of germ cell origin and one-third of these are malignant. Germ cell malignancies expand rapidly and often characterized by subacute pelvic pain related to capsular ditension, hemorrhage or necrosis.