Malignant ovarian tumors DR NN CHAVAN 19102023 .pptx

An intriguing session on malignant ovarian tumors that sheds light on the complexities of this disease.

1. Malignant ovarian tumoUrs COR CONNECT LIVE WEBINAR PG STAR SERIES 13, 19/10/2023 NAGPUR OBSTETRICS AND GYNAECOLOGY SOCIETY DR. NIRANJAN CHAVAN PROFESSOR & HEAD OF UNIT, LTMMC & SION HOSPITAL, SION, MUMBAI- 022.

2. DR. NIRANJAN CHAVAN MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP, DIPLOMA IN ENDOSCOPY (USA) Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital President, MOGS (2022-2023) Joint Treasurer, FOGSI (2021-2025) Organising Secretary, AICOG Mumbai 2025 Treasurer, AFG (2023-2024) Member Oncology Committee, SAFOG (2021-2023) Dean AGOG & Chief Content Director, HIGHGRAD & FEMAS Courses Editor-in-Chief, FEMAS, JGOG & TOA Journal 68 publications in International and National Journals with 173 Citations National Coordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-2022) Chair & Convener, FOGSI Cell Violence Against Doctors (2015-16) Member, Oncology Committee AOFOG (2013-2015) Coordinator of 11 batches of MUHS recognized Certificate Course of B.I.M.I.E at L.T.M.G.H (2010-16) Member, Managing Committee IAGE (2013-17), (2018-20), (2022-2023) Editorial Board, European Journal of Gynaec . Oncology (Italy) Course Coordinator of 3 batches of Advanced Minimal Access Gynaec Surgery (AMAS) at LTMGH (2018-19)

3. Normal ovaries • Normal size 5 x 3 x 3cm • Variation i n dimensions can result from endogenous hormone production in ovaries with age and menstrual cycle • Exogenous substances may affect size, including OCs, GRH agonists, or ovulation-inducing medication.

4. MALIGNANT OVARIAN TUMOURS • 6% of all cancers among women • 15-20% of all gynecological cancers • 4th most common cause of cancer death exceeded only by Breast, Colon and lung. • Highest incidence in industrialised countries, Sweden having highest (14.9/100000) and Japan having lowest incidence rate(2.7). • Incidence in India - 4.6/100000

5. RISK FACTORS The most important risk factor- Nulligravida • Incessant Ovulation Theory -suggest more the ovulatory traumas, more are chances of epithelial cell cancers. • Early Menarche, Late Menopause, delayed first pregnancy (more than 30 years) • Ovulation inducing Drugs • Talcum powder and Asbestos

6. • Hormone Replacement Therapy more than 10 years • History of Breast Cancer • Hereditary Breast Ovarian Cancer- Associated with BRCAL and BRCA2 mutation • Hereditary Non Polyposis colorectal Cancer- Associated with endometrial and ovarian cancer. Asshclated with three DNA mismatch repair. MLH2, MSH2, MSH6

7. The type of cell where the cancer begins determines the type of ovarian cancer. Ovarian cancer types include: Epithelial Ovarian Cancer .  This type is the most common. It includes several subtypes, including serous carcinoma and mucinous carcinoma. Stromal Tumors .  These rare tumors are usually diagnosed at an earlier stage than other ovarian cancers. Germ Cell Tumor s .  These rare ovarian cancers tend to occur at a younger age. Types of Ovarian Cancer

8. PRIMARY EPITHELIAL TUMOURS • All types can be benign, malignant and borderline. • Benign-Gross-Cystic Microcopic -fine papilla, no stromal invasion, no nuclear atypia • Borderline- Gross-Cystic with solid foci Microscopic-complex papilia , nuclear atypia, no stromal invasion • Malignant- Gross-Mostly solid with foci of hemorrhages and necrosis Microscopic-Papillary complexity, Stratification, nuclear atypia, Stromal invasion.

9. Epithelial tumoUr of ovary

10. GERM CELL TUMOUR- DYSGERMINOMA • Most common age-1st 2 decades • Rapidly growing, May present as palpable abdominal mass • Dysgerminoma- The commonest germ cell tumour • 10-30 years of age • Tumor markers - HCG, LDH, AFP • Treatment is surgery followed by radiation after 30 years. • Fertility loss is a concern. So in younger patients conservative treatment with Preservation of fertility is mainstay of treatment.

11. Dysgerminoma

12. YOLK SAC TUMOUR/ ENDODERMAL SINUS TUMOUR • Mean age - 16-18 years • 100% unilateral • Highly malignant with rapid growth • Gross - soft, greyish brown areas • Microscopic - Schiller Duval bodies

13. YOLK SAC TUMOUR Schiller Duval bodies

14. Schiller Duval bodies A Schiller Duval body is a cellular structure that is characterized by the presence of a central blood vessel surrounded by layers of tumor cells

15. EMBRYONAL CARCINOMA • Most malignant. • Present as abdominal mass. • Present at very young age-mean -14 years • Tumor markers - HCG, AFP.

16. METASTATIC TUMOURS • Krukenberg Tumours: Smooth surface • Bilateral • Primary from-Mainly stomach, large Bowel, Breast • Signet ring cells are the hallmark on microscopic picture

17. KRUKENBERG TUMOUR SIGNET RING APPERANCE

18. Krukenberg tumour Krukenburg tumor is a metastatic malignancy of the ovary characterized by mucin-rich signet-ring adenocarcinoma that primarily arises from a gastrointestinal site in most cases and less commonly from other sites. Often these tumors are bilateral (over 80%), given their metastatic nature. 

19. SPREAD • Transcelomic - 'exfoliated cells • Lymphatic • Direct • Haematogenous

20. SYMPTOMS AND SIGNS • Symptoms - Non specific like abdominal distension, dyspepsia, dull aching abdominal pain, sudden weight loss • Signs- Anemia , Supraclavicular and inguinal lymphadenopathy • Edema of leg, Ascites, Abdominal lump, • On P/V- Nodules palpated in posterior fornix separate from uterus • Pleural Effusion

21. OVARIAN TUMOUR SCREENING MULTI MODEL • Ca 125 and Ultrasound scanning •Ca 125 >30 u\mil is abnormal •Ca 125 is an antigen found in the foetal amniotic and coelomic epithelium in adults. • It is found in mesothelial cells of pleura, pericardium and tubal, endometrial, endocervical and the ovary.

22. • The surface epithelium of normal foetal and adult ovaries does not express the antigen except in inclusion cysts, papillae or metaplasia • An elevated level is found in 50% of stage 1 and 90% in women with advanced disease • Sensitivity is 97% Specificity is 96% • False positive in : Ca endometrium Ca colon, endometriosis, fibroid, PID, pregnancy and menstruation

23. RISK OF MALIGNANCY INDEX (RMI) RMI- U*M*CA125 • U-Ultrasound score. 1 point each for multilocularity , metastasis, bilaterality , solidareas • M-Menopausal State- 1-Premenopausal 3- Postmenopausal Low Risk-<25 Moderate - 25-250 High->250

24. TUMOUR MARKERS • CA-125 -> Most widely used but non specific. Extremely useful for follow up after the Treatment • HE4 -> Most specific and sensitive tumour marker • Ova-1 ---> Transthyretin, ApolipoproteinA1, Transferrin, Beta2 macroglobulin, CA-125. FDA Approved • Other Markers - HCG, LDH, Human epididymis protein 4, Mesothelin , B7H4,Decoy receptor3

25. RISK OF OVARIAN CANCER ALGORITHM (ROCA) • Based on slope of CA-125 measurements at regular intervals. • Proposed to increase performance of single threshold measurement of CA-25 Being evaluated with TVS as a two stage screening process

26. FIGO STAGING 2015

27. MANAGEMENT • Preop Evaluation • Surgical management • Chemotherapy • NACT • Follow-up

28. PRE OP EVALUATION • Blood investigations- CBC, LFT, RFT, FBS, PLBS, TSH • ECG • Urine routine microscopy • Imaging- TAS/TVS/CECT,MRI/PET scan • Tumour markers • Mammography • Gl endoscopies

29. FNAC • Poor sensitivity • Causes spillage of tumor cells •Only for those patients who can’t undergo surgical intervention and need neo-adjuvant chemotherapy(NACT)

30. MANAGEMENT SPECTRUM • Primary Surgery Early Stage Ovarian Cancer 2. Advanced stage ovarian Cancer • Neoadjuvant chemotherapy and interval cytoreductive surgery • Laparoscopic Surgery

31. SURGERY Sequential Systematic exploration of organs Beginning with- peritoneum of cul-de-sac and small bowel mesentry . Ascending colon, Liver, Omentum , Undersurface of right and left hemidiaphragm Stomach And finally Tranverse colon, spleen, descending colon and bladder peritoneum

32. TAH+BSO • Suspicious areas biopsied • Infracolic omentectomy /omental wedge biopsy • Retroperitoneal lymph node sampling

33. SURGICAL TREATMENT • BORDERLINE TUMOUR- Unilateral oophorectomy, No subsequent chemo required • Stage1 epithelial - TAHBSO + lymph node sampling • Stage2 epithelial-TAHBSO+ PALTINUM BASED CHEMOTHERAPY • Advance Cancers - Neoadjuvant Chemotherapy with Cytoreductive surgery

34. CHEMOTHERAPY • No of cycles: 6-8 Advanced stage cancers 3-6 Earlier stage cancers • Platinum based chemotherapy is required • Currently CARBOPLATIN + PACLITAXEL is found to have better survival rate

35. OTHER IMAGING MODALITIES CT , MRI, PET not recommended in the initial evaluation • CT scan: evaluating • LN involvement • Omental mets , peritoneal deposits, hepatic mets • Obstructive uropathy • or a probable alternate primary site when cancer is suspected based upon TVS • MRI: differentiating non adnexal pelvic masses (like leiomyomata ), expensive and inconvenient

36. INDICATIONS FOR SURGERY Any solid ovarian lesion • Any ovarian lesion with papillary vegetation on the cyst wall • Any adnexal mass >10cm in diameter • Palpable adnexal mass in a premenarchal or postmenopausal women • Torsion or rupture suspected

37. CYST ASPIRATION Diagnostic cytology has poor sensitivity to detect malignancy, ranging from 25% to 82% Not therapeutic, even when a benign mass is aspirated Approx. 25% of cysts will recur within 1 year Aspiration of a malignant mass may induce spillage and seeding of cancer cells into the peritoneal cavity.

38. OPERATIVE MODALITIES Laparoscopy vs laparotomy - decision based on suspicion of malignancy and technical expertise • No RCTs comparing recurrence rates following laparoscopy or laparotomy • The objective is to try cystectomy if possible • Laparoscopic surgery for benign ovarian tumours is associated with less pain, shorter hospital stay, and fewer adverse events than with laparotomy

39. SURGERY Young women : Ovarian cystectomy Oophorectomy ( Salpingo -oophorectomy) Parous women : Total Abdominal Hysterectomy with Bilateral oophorectomy Others: Individualisation

40. THANK YOU!