ovarian neoplasms. anita chudecka - głaz ovarian neoplasms
TRANSCRIPT
Ovarian neoplasms. Anita Chudecka - Głaz
• Human ovarian neoplasms (especially epithelial ovarian cancer) presents a major challenge to oncological research , because they are frequently diagnosed late and show poor prognosis and low survival despite the apparent success of chemotherapy in achieving remission with no evidence of disease.
Ovarian neoplasms. Anita Chudecka - Głaz
Epithelial ovarian cancer is the fourth most common cause of death from cancer in women and the most lethal of gynaecologic neoplasms.
Epithelial ovarian cancer is the fourth most common cause of death from cancer in women
and the most lethal of gynaecologic neoplasms.
Ovarian neoplasms. Anita Chudecka - Głaz
• The most important positive prognostic feature continues to be diagnosis at an early stage.
• BUT EARLY STAGE OVARIAN CANCERS DON’T PRODUCE
SYMPTOMS !!!
Ovarian neoplasms. Anita Chudecka - Głaz
• The incidence of ovarian cancer is relatively high in Scandinavian (15/100000) countries , lower in western Europe and North America ( 10/100000 ) and low in Japan (3/100000).
Ovarian neoplasms. Anita Chudecka - Głaz
ETIOLOGY
• Two hypotheses have been proposed to explain the biological mechanisms that increase the risk of ovarian cancer :
genetics
gonadotropin hypothesis
Ovarian neoplasms. Anita Chudecka - Głaz
ETIOLOGY
The involvement of gonadotropins in human ovarian carcinoma is backed by a number of epidemiological and experimental studies showing:
increase occurrence of disease with exposure to high levels of LH , FSH during menopause , after ovariectomy or during fertility treatment
Ovarian neoplasms. Anita Chudecka - Głaz
ETIOLOGY
reduced risk of cancer associated with multiple pregnancies, oral contraceptives , breast - feeding
LH and hCG receptors are expressed in 40% of epithelial ovarian cancer
LHRH receptors are expressed in almost 80% of EOC
Ovarian neoplasms. Anita Chudecka - Głaz
ETIOLOGY
deficit of cases of ovarian cancer among women with diagnosis of alcoholism in
animals ovarian cancer may be induced by gonadal radiation or chemical toxins that cause premature oocyte death , but hypophysectomized animals do not develop ovarian tumours after oocyte depletion which suggests a specific role of gonadotropins
Ovarian neoplasms. Anita Chudecka - Głaz
ETIOLOGY
other risk factors:
diettalcpelvic irradiationviruses age
Ovarian neoplasms. Anita Chudecka - Głaz
ETIOLOGY
other risk factors:
PIDendometriosisblood grouplegal status education
Ovarian neoplasms. Anita Chudecka - Głaz
SYMPTOMS
EOC oftenest are asymptomatic until advanced stage , when the prognosis is poor and 5 year survival less then 40%.
EOCoftenest are asymptomatic until advanced stage ,
when the prognosis is poor and 5 year survival less then 40%.
Ovarian neoplasms. Anita Chudecka - Głaz
SYMPTOMS
Irrespective of histology , most ovarian neoplasms when they have large size in advanced stage cause symptoms by exerting pressure on contiguous structures (urinary frequency, pelvic discomfort and constipation).
Ovarian neoplasms. Anita Chudecka - Głaz
SYMPTOMS
The most common :
abdominal swellingfatigueabdominal pain
Ovarian neoplasms. Anita Chudecka - Głaz
SYMPTOMS
Upper abdominal metastases or ascites cause nausea, heart burn , bloating , weight loss and anorexia.
Acute abdominal pain secondary to haemorrhage , rupture or torsion can all result from tumour growth.
Ovarian neoplasms. Anita Chudecka - Głaz
SYMPTOMS
Biologically active hormones , including estrogen, progesterone, testosterone , corticosteroids and hCG can be produce by a variety of ovarian neoplasms and cause the predicted symptoms associated with each compound.
Ovarian neoplasms. Anita Chudecka - Głaz
DIAGNOSIS1. Physical examination-bimanual rectovaginal pelvic
examination
2. Ultrasound investigation
3. Tumour markers
4. Ascites puncture
5. Biopsy the tumour
6. Laparoscopy
7. CT
8. NMR
9. Chest X ray
Ovarian neoplasms. Anita Chudecka - Głaz
ULTRASONOGRAPHY
abdominaltransvaginal TVS
colour Doppler CDI
ULTRASONOGRAPHY
Ovarian neoplasms. Anita Chudecka - Głaz
TUMOR MARKERS
epithelial ovarian cancer
CA 125CA 125 CA 19-9 CEA
Ovarian neoplasms. Anita Chudecka - Głaz
TUMOR MARKERS
endodermal sinus tumors
embryonal carcinomas
mixed germ cell tumorsrarely immature teratoma and polyembryoma
AFPAFP
Ovarian neoplasms. Anita Chudecka - Głaz
TUMOR MARKERS
chorioncarcinoma
embryonal carcinoma
mixed germ cell tumors
polyembryoma
hCGhCG
Ovarian neoplasms. Anita Chudecka - Głaz
TUMOR MARKERS
adult granulosa cell tumors
thecomas
ESTRADIOLESTRADIOL
PREMENOPAUSAL OVARIAN MASS
EXCLUDE NON-GYNAECOLOGICAL PROBLEM
Surgical evaluation
Solid or complex on US
OR > 6 cm
ORElevated
AFP/hCG/LDHOR
Elevated CA 125
Simple on USAND
< 6 cmAND
Normal CA 125
Observation for 6-8 weeksand
Gonadotrpopin suppression
Peristent on US
POSTMENOPAUSAL OVARIAN MASS
EXCLUDE NON-GYNAECOLOGICAL PROBLEM
SurgicalEvaluation
SymptomaticOROR
Complex on USOROR
> 3 cmOROR
Elevated CA 125
AsymptomaticANDAND
Simple on USANDAND
< 3 cmANDAND
Normal CA 125
Observe withFollow up
US
Ovarian neoplasms. Anita Chudecka - Głaz
DIFFERENTIAL DIAGNOSIS
gynaecologic
tuboovarian abscessectopic pregnancyleiomyomafallopian tube neoplasialuteal or follicular cysts
Ovarian neoplasms. Anita Chudecka - Głaz
DIFFERENTIAL DIAGNOSIS
gynaecologic
ovarian hyperthecosispregnancy luteomatheca-lutein cystsendometriomasimple cysts
Ovarian neoplasms. Anita Chudecka - Głaz
DIFFERENTIAL DIAGNOSIS
nongynaecologic
diverticular diseaseappendiceal abscess Crohn’s diseaseprimary nongynaecological malignancypelvic kidney
Ovarian neoplasms. Anita Chudecka - Głaz
CLASSIFICATION
1. Epithelial ovarian tumours - 70% of all ovarian neoplasms
2. Sex cord stromal tumours 5-10%
3. Germ cell tumours 15-20%
4. Metastatic 5 %
5. Other
Ovarian neoplasms. Anita Chudecka - Głaz
serous
m ucinous
endom etrioid
clear cell
Brenner-transitional cell
m ixed m esoderm al
undifferentiated
unclassified
EOC(m alignant, borderline, benign)
Ovarian neoplasms. Anita Chudecka - Głaz
SEX CORD STROMAL TUMOURS
1. Granulosa stromal cell granulosa cell thecoma-fibroma
2. Sertoli stromal cell
3. Lipid cell tumours
4. Gynanandroblastoma
Ovarian neoplasms. Anita Chudecka - Głaz
GERM CELL TUMOURS
1. Dysgerminoma
2. Endodermal sinus tumour
3. Embryonal carcinoma
4. Polyembryoma
5. Chorioncarcinoma
6. Teratomas
7. Mixed forms
8. Gonadoblastoma
Ovarian neoplasms. Anita Chudecka - Głaz
STAGE II
Growth involving one or both ovaries with pelvic extension
Ovarian neoplasms. Anita Chudecka - Głaz
STAGE III
Tumour involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperotoneal or inguinal nodes; superficial liver metastasis ; tumour is limited to the true pelvis but with histologically proven malignant extension to small bowel or omentum
Ovarian neoplasms. Anita Chudecka - Głaz
STAGE IV
Tumour involving one or both ovaries with distant metastases; if pleural effusion is present , there must be positive cytology to allot a case to stage IV
Ovarian neoplasms. Anita Chudecka - Głaz
Five - year survival rates for epithelial ovarian cancer
Stage
IA 82,3%
IB 74,9%
IC 67,7%
IIA 60,6%
IIB&IIC 53,8%
III 22,7%
IV 8 %
Ovarian neoplasms. Anita Chudecka - Głaz
PREDICTORS OF SURVIVAL
stage grade age residual disease max. cytoreductive surgery histopathology others ( protein p53, CA 125, EGF-R)
Ovarian neoplasms. Anita Chudecka - Głaz
TREATMENT
• surgical• chemotherapy• radiotherapy• hormonal treatment
postoperative
procedures
Nowotwory jajnika. Anita Chudecka - Głaz
SURGICAL TREATMENT
cytoreductive operation: hysterectomy bilateral oophorectomy omentectomy appendectomy lypmphadenectomy ??
Ovarian neoplasms. Anita Chudecka - Głaz
CHEMOTHERAPY
• CT• PC• PAC
• Vepesid or
Ifosfamid with CDDP as II LINE CHT.
• Hycamptin or Gemzar as III LINE CHT.
I LINE CHEMOTHERAPY
Ovarian neoplasms. Anita Chudecka - Głaz
SURGICAL TREATMENT - EOC
benignIn young women conservative surgery usually including
cystectomy or oophorectomy. In postmenopausal women TAH/BSO should be considered to avoid the risk of cancer in the future.
borderlineIn young women conservative surgery oophorectomy or USO
can be performed. In women who have completed their child bearing a TAH/BSO/Omentectomy is appropriate always with very precise surgical staging.
Ovarian neoplasms. Anita Chudecka - Głaz
SURGICAL TREATMENT - EOC
malignantIn all cases we have to carry out cytoreductive
surgery. It includes TAH/BSO complete omentectomy with resection of any metastatic lesions. In some cases bowel resection and retroperitoneal lymphadenectomy are necessary in order to obtain optimum cytoreduction. Optimum cytoreduction is achieved when the largest residual tumour mass measures less then 1,5 cm.
Ovarian neoplasms. Anita Chudecka - Głaz
POSTOPERATIVE TREATMENT - EOC
chemotherapy Platinum-based combination with paclitaxel chemotherapy is
now the standard postoperative treatment for patient with ovarian cancer
radiation therapyIt is useful method especially in patient who have positive
second-look laparoscopy or laparotomy after chemotherapy treatment but the residual mass are less than 2 cm.
hormonal treatment
Ovarian neoplasms. Anita Chudecka - Głaz
FOLLOW - UP
second-look laparoscopy every year during first 5 year to detect early microscopic relapse
CA 125 every 3 to 4 month complete medical history physical examination rectovaginal pelvic examination
Ovarian neoplasms. Anita Chudecka - Głaz
SCREENING
Screening is recommended in women with HOCS and HBOCS and include:
rectovaginal pelvic examination CA 125 determination TVS prophylactic TAH/BSO
Ovarian neoplasms. Anita Chudecka - Głaz
MALIGNANT GERM CELL TUMOURS
Dysgerminoma most common germ cell malignancy , in 10-15% is bilateral , survival rate for early stage is 95% and even in advanced stage grater then 80% when appropriate adjuvant therapy is given. LDH is useful tumour marker. hCG levels is elevated in small number of patients. In young women and stage I unilateral oophorectomy is recommended with inspection and biopsy of opposite ovary and staging with retroperitoneal lymphadenectomy. In other women TAH/BSO. Adjuvant therapy should be given in all patients radiotherapy and/or chemotherpy.
Ovarian neoplasms. Anita Chudecka - Głaz
MALIGNANT GERM CELL TUMOUR
Embryonal carcinoma is quite rare , rarely bilateral and trends to spread intraperitoneally , survival is slightly better then with EST using the same platinum based chemotherapy regiments . Both AFP and hCG can serve as tumour markers. Surgical treatment depend on age and stage . Adjuvant therapy ( chemotherapy) is recommended in all cases.
Ovarian neoplasms. Anita Chudecka - Głaz
MALIGNANT GERM CELL TUMOURS
Immature teratoma represents approximately 20% of all malignant germ cell tumours and 25 % in girls under 10. After grade surgicopathologic stage is the most prognostic factors. Fortunately most patient are diagnosed with early stage. Occasionally immature carcinoma produce AFP as tumour marker but hCG is never produced. Surgical treatment depend on age and stage. Chemotherapy is kind of adjuvant therapy but only in immature teratoma of all malignant germ cell tumours chemotherapy in stage IA grade I does not benefit.
Ovarian neoplasms. Anita Chudecka - Głaz
MALIGNANT GERM CELL TUMOURS
Endodermal sinus tumour also known as “yolk sac tumour” is an extremely aggressive malignancy. Almost never is bilateral. Intraperitoneal and hematogenous spread is common. Commonly patients present with acute abdomen secondary to spontaneous rupture and haemorrhagiae. Platinum based chemotherapy significantly improves the survival. AFP is useful tumour marker.
Ovarian neoplasms. Anita Chudecka - Głaz
MALIGNANT GERM CELL TUMOURS
Chorioncarcinoma nongestational is extremely rare , 50% is diagnosed in prepuberatal females , produced hCG as tumour marker . Although gestsational chorioncarcinoma is treated successfully in most patients with platinum based chemotherapy , remission is less common in patients with nongestational type.
Polyembryoma Mixed
Ovarian neoplasms. Anita Chudecka - Głaz
BENIGN GERM CELL TUMOURS Gonadoblastoma is almost always found in patients with
gonadal dysgenesis associated with chromosome Y. In 50% coexist with malignant germ cell tumours
Teratomas 25-40% of all ovarian neoplasms. The most common is cystic teratoma - “dermoid cysts”. Most cases diagnosed in premenopausal women . Most patients are asymptomatic and often dermoids are diagnosed by usg. This tumours can be bilateral in 15%. The risk of malignancy is 1-2% and most commonly occurs in postmenopausal women.
Struma ovarii it is dermoid where thyroid tissue comprises greater than 50% of teratomas. This is unusual and accounts for only 2,7% of ovarian teratomas.
Ovarian neoplasms. Anita Chudecka - Głaz
SEX CORD STROMAL TUMOURS
Adult granulosa cell tumours (GCTs) excess estrogen production is often found causing
precocious puberty and menometrorrhagia in menstruating or postmenopausal. Endometrial hyperplasia or carcinoma is at 60% in patients with this tumour.50% occur in postmenopausal women and only 5% in prepubertal girls. It is interestin that this king of tumour may relapse after many years ( even above 20 ) after primary diagnosis. Estardiol and in nowadays inhibin are useful tumour marker.
Ovarian neoplasms. Anita Chudecka - Głaz
SEX CORD STROMAL TUMOURS
Juvenile granulosa cell tumours in 50% occur in prebubertal girls , rare relapse after many years from diagnosis , typically is early recurrence. Rarely lethal as GCTs.
Fibroma unilateral , diagnosed in 5 decade of life. Hormone production is unusual , eventually estrogen. It is benign tumour, when 1 to 3 mitoses are present is called cellular fibroma, if greater then 3 it is considered as fibrosarcoma.
Thecoma very similar to fibroma but more commonly produce etsrogen which causes postmenopausal bleeding , menorrhagia, endometrial hyperplasia or cancer.
Ovarian neoplasms. Anita Chudecka - Głaz
SEX CORD STROMAL TUMOURS
Sertoli stromal cell tumours 1 % of all ovarian neoplasms , many of these tumours androgen producing , many are hormonally inert and some occasionally may produce estrogen. Diagnosed of pure Sertoli tumours is unlikely in the presence of virilization. Rarely is malignant.
Sertoli-Leydig cell tumours are the most common in these group , 40% have evidence of estrogen or androgen production, unilateral and occur in 3 decade of life. Rather frequently is malignant.
Sex cord tumour with annular tubules (SCTAT) in 30% associated with Peutz-Jegers syndrome.
Ovarian neoplasms. Anita Chudecka - Głaz
SEX CORD STROMAL TUMOURS
Lipid cell tumour are typically virilizing with increased serum levels of testosteron and androstendione. Occasionally produce estrogen, estron and cortisol and in 10% cases Cushing Syndrom in found. In 20 % develop metastases.
Gynanroblastoma is rare ovarian tumours which contain granulosa stromal cell and Sertoli stromal cell tumours.
Leydig cell tumours mean age is 50 and almost always behaves in benign fashion. Testosterone is commonly produced resulting in mild virilization.