Malignant Ovarian Malignant Ovarian TumorsTumors

Dr.Omar aldabbasDr.Omar aldabbas

Assisstant prof.Assisstant prof.

MUTA universityMUTA university

OBGYN specialistOBGYN specialist

IntroductionIntroduction

• The second most common malignancy of The second most common malignancy of the genital system.the genital system.

• The most common cause of death from The most common cause of death from malignancy due to late diagnosismalignancy due to late diagnosis

• Most of the tumors are of epithelial origin. Most of the tumors are of epithelial origin. Occurs after the age of 35 years with Occurs after the age of 35 years with increasing incidence with advancing age.increasing incidence with advancing age.

• Only 3% occurs before 35 years of age and Only 3% occurs before 35 years of age and they are mostly non-epithelial in origin as they are mostly non-epithelial in origin as germ cell tumors.germ cell tumors.

AetiologyAetiology

• Ovulation theory: more common in Ovulation theory: more common in nulliparity, early menarche and late nulliparity, early menarche and late menopause. Oral contraceptive pills menopause. Oral contraceptive pills reduces the risk.reduces the risk.

• Infertility treatment: there is a link Infertility treatment: there is a link between prolonged ovulation between prolonged ovulation induction and ovarian malignancy.induction and ovarian malignancy.

• Genetic factors: strong family Genetic factors: strong family history of breast, colorectal and history of breast, colorectal and ovarian cancer.ovarian cancer.

Histologic classification Histologic classification of ovarian tumorsof ovarian tumors

• Epithelial tumors:Epithelial tumors:

1- Serous carcinoma1- Serous carcinoma

2- Mucinous car.2- Mucinous car.

3- Endometrioid car.3- Endometrioid car.

4- clear cell car.4- clear cell car.

5- Brenner tumor.5- Brenner tumor.

6- undifferentiated car.6- undifferentiated car.

• Sex cord stromal tumor:Sex cord stromal tumor:

1- Granulosa cell tumor1- Granulosa cell tumor

2- Androblastoma.2- Androblastoma.

3- Gynandroblastoma.3- Gynandroblastoma.

• Germ cell tumors:Germ cell tumors:1- Dysgerminoma.1- Dysgerminoma.2- Endodermal sinus 2- Endodermal sinus

tumor (Yolk sac tumor (Yolk sac tumor)tumor)

3- Embryonal cell tumor3- Embryonal cell tumor4- Choriocarcinoma4- Choriocarcinoma5- Malignant teratoma.5- Malignant teratoma.6- Mixed tumors.6- Mixed tumors.• Metastatic tumorsMetastatic tumors

(Krukenberg tumors)(Krukenberg tumors)

Epithelial malignant Epithelial malignant tumorstumors• Well-differentiated epithelial tumors Well-differentiated epithelial tumors

tend to be associated will early stage tend to be associated will early stage disease.disease.

• There is no difference in survival There is no difference in survival between different epithelial types.between different epithelial types.

• Mucinous and endometrial lesions Mucinous and endometrial lesions have better prognosis than serous have better prognosis than serous cystadeno carcinoma.cystadeno carcinoma.

Serous Serous cystadenocarcinomacystadenocarcinoma

• Has both solid and cystic elements.Has both solid and cystic elements.

• Has a papillary pattern with stromal Has a papillary pattern with stromal invasion.invasion.

• Psammoma bodies are often present.Psammoma bodies are often present.

• Glandular tissue may be present.Glandular tissue may be present.

• The tumor could be at any stage of The tumor could be at any stage of differentiation.differentiation.

Mucinous Mucinous cystadenocarcinomacystadenocarcinoma

• Account for 10% of malignant Account for 10% of malignant ovarian tumors.ovarian tumors.

• Usually multilocular, thin-walled Usually multilocular, thin-walled cysts containing mucinous fluid.cysts containing mucinous fluid.

• They are the largest tumors of the They are the largest tumors of the ovary.ovary.

• A cyst diameter of 25 cm is common.A cyst diameter of 25 cm is common.

Endometrioid carcinomaEndometrioid carcinoma

• Resemble to endometrial carcinomas.Resemble to endometrial carcinomas.

• Mostly they are cystic, unilocular, and Mostly they are cystic, unilocular, and contain turbid brown fluid.contain turbid brown fluid.

• They could occurs in association with They could occurs in association with endometriosis and endometrial endometriosis and endometrial tumors of the body of the uterus.tumors of the body of the uterus.

Clear cell carcinoma Clear cell carcinoma (mesonephroid)(mesonephroid)

• The lest common (5%).The lest common (5%).

• On histopathology, they have a clear On histopathology, they have a clear cell pattern.cell pattern.

• It has a strong association to ovarian It has a strong association to ovarian endometriosis and endometrioid endometriosis and endometrioid cancer. cancer.

Borderline epithelial Borderline epithelial tumorstumors• 10% of ovarian tumors are borderline 10% of ovarian tumors are borderline

malignant.malignant.• They show varying degree of nuclear They show varying degree of nuclear

atypia and increased mitotic activity.atypia and increased mitotic activity.• There is no stromal invasion.There is no stromal invasion.• They remain confined to the ovary.They remain confined to the ovary.• Rarely, peritoneal metastasis occurs.Rarely, peritoneal metastasis occurs.

Staging for primary Staging for primary ovarian carcinomaovarian carcinoma

Stage I:Stage I: Growth limited to ovaries Growth limited to ovaries

Ia:Ia: One ovary,no ascites,capsule intact. One ovary,no ascites,capsule intact.

Ib:Ib: Two ovaries, no ascites, capsule Two ovaries, no ascites, capsule intact.intact.

Ic:Ic: one or both ovaries with ascites one or both ovaries with ascites containing malignant cells and/or containing malignant cells and/or invasion through the capsule. invasion through the capsule.

Staging for primary Staging for primary ovarian carcinomaovarian carcinoma

Stage II:Stage II: Stage one with pelvic Stage one with pelvic extension.extension.

Stage III:Stage III: Peritoneal implants outside Peritoneal implants outside the pelvis or positive lymph node or the pelvis or positive lymph node or superficial liver metastasis.superficial liver metastasis.

Stage IV:Stage IV: Distant metastasis, pleural Distant metastasis, pleural effusion with positive malignant cells, effusion with positive malignant cells, Deep liver involvement.Deep liver involvement.

Clinical historyClinical history

• In two-thirds of patients presents at In two-thirds of patients presents at late stages.late stages.

• This is due to late symptoms and This is due to late symptoms and difficult early diagnosis.difficult early diagnosis.

• Some of the tumors are rapidly Some of the tumors are rapidly growing.growing.

Clinical DiagnosisClinical Diagnosis

• Abdominal pain, discomfort and distension.Abdominal pain, discomfort and distension.• Feeling of a lump.Feeling of a lump.• Indigestion, urinary frequency, weight lost and Indigestion, urinary frequency, weight lost and

rarely abnormal menses or post menopausal rarely abnormal menses or post menopausal bleeding.bleeding.

• On examination, hard mass arising from the On examination, hard mass arising from the pelvis. Ascites may be present. The tumor is pelvis. Ascites may be present. The tumor is fixed and tender. Irregular pelvic masses may fixed and tender. Irregular pelvic masses may be felt on vaginal or rectal exam which suggest be felt on vaginal or rectal exam which suggest metastesis. Palpable inguinal or neck nodes.metastesis. Palpable inguinal or neck nodes.

InvestigationsInvestigations

• Full blood count, renal and liver function Full blood count, renal and liver function tests, electrolytes,blood sugar and chest x-tests, electrolytes,blood sugar and chest x-ray.ray.

• Barium enema or colonoscopy to exclude Barium enema or colonoscopy to exclude bowel involvement.bowel involvement.

• IVU for renal and ureteric involvement.IVU for renal and ureteric involvement.

• Ultrasonography for mass and ascites.Ultrasonography for mass and ascites.

• Ca125 estimation.Ca125 estimation.

• Laparotomy.Laparotomy.

Screening for ovarian Screening for ovarian cancercancer• Because of late diagnosis, much effort Because of late diagnosis, much effort

has been made to screen for ovarian has been made to screen for ovarian cancer.cancer.

• Till now no specific tumor marker has Till now no specific tumor marker has been found for epithelial tumors.been found for epithelial tumors.

• Ultrasonography and Ca125 are in use.Ultrasonography and Ca125 are in use.• Inhibin for granulosa cell tumor.Inhibin for granulosa cell tumor.• Beta-hCG for choriocarcinoma.Beta-hCG for choriocarcinoma.• Alpha -fetoprotien in germ cell tumors.Alpha -fetoprotien in germ cell tumors.

SurgerySurgery

• Is the mainstay for both diagnosis and Is the mainstay for both diagnosis and treatment.treatment.

• Vertical incision is required.Vertical incision is required.

• A sample of ascitic fluid or peritoneal A sample of ascitic fluid or peritoneal wash send for cytology.wash send for cytology.

• The abdomen should be inspected for The abdomen should be inspected for metastasis and lymph node metastasis and lymph node involvement.involvement.

SurgerySurgery

• The main is to remove the whole tumor (stage The main is to remove the whole tumor (stage I and II) or to remove as much as possible I and II) or to remove as much as possible from the tumor (debulking operation).from the tumor (debulking operation).

• The operation in early stages includes The operation in early stages includes TAH+BSO and infracolic omntectomy.TAH+BSO and infracolic omntectomy.

• In young nulliparous women with stage Ia , In young nulliparous women with stage Ia , unilateral salpingo-oophorectomy can be unilateral salpingo-oophorectomy can be done. This is also applied to borderline done. This is also applied to borderline malignancy.malignancy.

SurgerySurgery

• After debulking operation, After debulking operation, chemotherapy should be used.chemotherapy should be used.

• Interval debulking surgery: a second Interval debulking surgery: a second surgery after chemotherapy for surgery after chemotherapy for residual tumor.residual tumor.

• Surgery is the only treatment for Surgery is the only treatment for stage I. All others need further stage I. All others need further treatment.treatment.

ChemotherapyChemotherapy

• This treatment is for stages II to IV.This treatment is for stages II to IV.

• The drugs in common use are: The drugs in common use are: Carboplatin or cisplatin and taxol.Carboplatin or cisplatin and taxol.

• Chemotherapy is used to prolong Chemotherapy is used to prolong clinical remission and for palliation in clinical remission and for palliation in advanced and recurrent disease.advanced and recurrent disease.

• It is given for 5-6 cycles at 3-4 weekly It is given for 5-6 cycles at 3-4 weekly intervals.intervals.

PrognosisPrognosis

• Borderline tumors have a good long-Borderline tumors have a good long-term prognosis.term prognosis.

• Stage I have a 5 year survival rate of Stage I have a 5 year survival rate of 90%.90%.

• For stage III and IV is only 10%.For stage III and IV is only 10%.

• The overall survival rate is around The overall survival rate is around 23%. 23%.

Non-epithelial malignant Non-epithelial malignant tumorstumors

• This constitute around 10% of all This constitute around 10% of all malignant ovarian tumors.malignant ovarian tumors.

• The staging is similar to epithelial The staging is similar to epithelial tumors.tumors.

• The treatment is similar.The treatment is similar.

• Radiotherapy is hardly used in the Radiotherapy is hardly used in the treatment of ovarian cancer.treatment of ovarian cancer.