Ovarian Cancer Gynecology Imp concept.ppt

Ovarian cancer

1. Ovarian Cancer
PROF. MOHAMMED ADDAR
GYNEONCOLOGIST

2. Introduction
Fifth most common cancer in women
Fifth most frequent cause of cancer death
1 in 70 newborn girls will develop cancer
during her lifetime
Disease of postmenopausal women and all
ages
Year 2000
23000 new cases
14000 deaths

3. Etiology
Cause is unknown
Predisposing factors
Repeated ovulation
Infertility treatment
PCO 2.5 fold increase
Unopposed estrogen therapy

4. Etiology
Increase risk by
High diet in saturated animal fats
Alcohol and milk (never confirmed)
Exposure to talk powder

5. Etiology
Protective factors
Chronic anovulation
Multiparty
Breast feeding
Pregnancy -reduction 13-19% per
pregnancy
COC Pills decrease by 50% for 5 years and
more of use

6. Over 90% develop sporadically
10% of epithelial based on genetic
predisposition
Turner syndrome(45,XO) dysgerminoma and
gonadoplastoma
Two first degree relatives –risk 50%

7. hereditary
In two forms
Breast and ovarian syndrome (BOC)
Germline mutation in BRCA1 gene on
chromosome 17(28-44%)
Less common BRCA2 on chromosome 13
(1/800)
Lyncy II syndrome (hereditary nonpolyposis
colorectal cancer syndrome )HNPCC

8. Histopathology
Divided to three categories according to cell type of
origin
Epithelia neoplasms
Germ cell neoplasms
Sex cord and stromal neoplasms
May be the site of metastatic disease
Neoplasms metastatic to the ovary

9. 1-Epithelia neoplasms
Tend to occur in the sixth decade of life
Derived from the ovarian surface mesothelialcells , six
types:
Serous
Mucinous
endometroid
clear cell
Transitional cell
undifferentiated
Account for over 60% of all ovarian neoplasms
More than 90% of malignant ovarian tumors

10. Ovarian serous
cystadenocarcinoma
Most common 35-50% of all epithelial tumors
Bilateral in 40-60%
85% with extra ovarian spread at diagnosis
Over 50% exceeds 15 cm, solid areas,
hemorrhage, cyst wall invasion
Most poorly dfferentiated

11. Mucinous neoplasms
10-20% of epithelial ovarian tumor
Second most common type of epithelial
ovarian carcinoma
Bilateral in less than 10%
Average size is 16-17 cm (large) ,multilocular
,viscous mucus

12. Pseudomyxoma peritonei
Unusual condition
Associated with mucinous neoplasms of ovary
Progressive accumulation of mucinous in abdominal
cavity
May be associated with appendix
Benign
Potentially morbid ,intestinal obstruction
Mortality rate approaches 50%

13. Endometroidal neoplasm
Adenometroidal pattern
Bilateral in 30-50%
30% of patients will have endometrial carcinoma of
uterus as primary

14. Clear cell carcinoma
Called mesonephroid carcinoma
5% of epithelial ovarian cancer
Small size
Aggressive ,hypercalcimeia ,hyperpyrexia
Cystic and solid

15. Transitional cell carcinoma
Brenner
Newly described
Present with advanced stage
Poorer prognosis

16. Undifferentiated carcinoma
Accounts for less than 10% of epithelial
Absence of any distinguishing microscopic features
that permit its placement in one of the other histologic
categories.

17. 2-Germ cell neoplasms
Tend to occur in second and third decade of life
Better prognosis
Many produce biological markers
Types:
Dysgerminoma
Young females (Seminomain male)
30-40% of germ cell tumors
Unilateral in 85-90%
Solid

18. Endometrial sinus tumor
Was called yolk sac tumor
Second most common germ cell tumor
Occurs in 20% of cases
Bilateral in less than 5%
Commonly present with acute abdomen
Produces AFP

19. Immature teratomas
Malignant counterpart of mature cystic
teratoma
20% of germ cell neoplasms
Bilateral in less than 5%
Elevated serum AFP
Three germ layers
Immature neuroectodermalelement
Mature teratomas
Common at age 20 to 30
Most common neoplasm diagnosed during
pregnancy
Less than 2% goes malignant after age of 40

20. Embryonal carcinoma
Very rare in pure form
HCG and AFP are usually elevated
Choriocarcinoma
rare germ cell tumor unrelated to
pregnancy
Lower elevation HCG
May cause precocious puberty, uterine
bleeding or amenorrhea

21. Gonadoblastoma
Rare
More common on the right than left ovary
Occur in second decade of life
Associated with presence of Y chromosome
Mixed germ cell tumors
Accounts for 10% of germ cell tumor
Contains two or more germ cell elements
dysgerminoma and endometrial sinus tumor
ocurs together

22. 3-Sex Cord-Stromal tumors
Granulosa cell tumor
1-2% of all ovarian neoplasms
Most common malignant tumor of sex cord-sromal
Associated with hyperestrogenism
May cause precocious puberty(girls) ,adenomatous
hyperplasia and vaginal bleeding(postmenopausal
women)

23. Ovarian thecoma
Associated with hyperesrogenism
Benign tumor
Ovarian fibroma
Benign tumor
Associated with Meig’ssyndrome
Sertoli-stromalcell tumors
Rare
consist of testicular structures
Occur during third decade
Usually virilizing
Rarely bilateral

24. 4-Neoplasms metastatic to the
ovary
Accounts for 25% of all ovarian malignancy
Mimic primary ovarian cancer
Present as bilateral adnexalmasses
25% unilateral
Common primary cancers
Breast (40%_
Stomach (Krukenbergtumors)
Colon
endometrium

25. Diagnosis of ovarian Cancer
Insidious disease
Non specific GIT complains
Abdominal distention
Pelvic weight
Menstrual abnormalities in 15%
Rarely excessive estrogens or androgens

26. Screening
Routine pelvic examination
Ultrasound examination
Tumor markers
CA-125 antigen from fetal amniotic and
coelomic epithelium
TAG 72 ,M-CSF ,OVX1

27. Evaluation of the patient with
suspected ovarian neoplasm
Child and postmenopausal women at great risk of
malignancy
Reproductive women is likely to have functional cyst or
endometrioma
Differential diagnosis is influenced by
Age
Characteristic of the mass on pelvic examination
Radiographic appearance

28. Physical Examination
Comprehensive examination
Lymph node , Sister Mary Joseph’s nodule
Abdomen examination
Pelvic examination
CharacteristicsBenign Malignant
Mobility Mobile Fixed
Consistency Cystic Solid or Firm
Bilateral/Unilatera
l
Unilateral Bilateral
Cul-de-sac Smooth Nodular

29. Radiographic Evaluation
Trans abdominal ultrasound
Trans vaginal ultrasound
Color flow Doppler
Consistency Simple cyst <10cm
in size
Solid or cystic and
solid
Septations Septations <1mm
in thickness
Multiple
septations >3mm
in size
Unior bilateralunilateral Bilateral
others Calcification, teethascites

30. Radiographic Evaluation,,,,
Computed tomography (CT)
Pelvic organs and Retroperitoneal
structures
Magnetic resonance imaging (MRI)
Nature of ovarian neoplasm
X ray chest
Barium enema
mammogram

31. Laboratory Evaluation
CBC
Serum electrolytes
hCG (pregnancy)
AFP ,LDH lactate dehydrogenase (young girls)
CA-125

32. Surgical Treatment of
Epithelial Cancer
Surgery is the corner stone of therapy
Surgical staging to
Reduce amount of disease
Evaluate the extent of spread
Debulking or cytoreduvtive surgery is
removal
Primary tumor
Associated metastasis disease

33. Intra operative
differentiation
Benign Malignant
Simple
Unilateral
No adhesions
Smooth surface
Intact capsule
Adhesions
Rupture
Ascites
Solid areas
Areas of hemorrhage
or necrosis
Multi loculatedmass
Bilateral

34. Most common location of
metastases
Peritoneum 85%
Omentum 70%
Liver 35%
Pleura 33%
Lung 25%
Bone 15%

35. Procedures in staging
Sample of ascites or peritoneal washings from Para
colic gutters , pelvic and sub
diaphragmatic for cytology
Complete abdominal exploration
Intact removal of tumor
Infracolic omentectomy
Biopsies of abdominal peritoneal implants
Pelvic and Para aortic lymph node biopsies
Cytoreduvtive surgery to remove all visible disease

36. International Federation of Gynecology &
Obstetrics (FIGO) Staging
Stage I. growth limited to the pelvis
Ia-One ovary
Ib-both ovaries
Ic-Iaor Iband ovarian surface tumor ,rupture
capsule, malignant ascites, peritoneal cytology
positive.
Stage II. Extension to the pelvis
IIa-extension to the uterus or fallopian tube
IIb-extension to the other pelvic tissues
IIc-IIaor IIband ovarian surface tumor ,rupture
capsule, malignant ascites, peritoneal cytology
positive.

37. International Federation of Gynecology &
Obstetrics (FIGO) Staging
Stage III. Extension to abdominal cavity
IIIa-abdominal peritoneal surfaces with microscopic
metastases
IIIb-tumor metastases <2cm in size
IIIc-tumor metastases >2cm or metastatic disease in
pelvic para aortic or inguinal lymph nodes
Stage IV. Distant metastases
Malignant pleural effusion
Pulmonary parenchymal metastases
Liver or splenic paranchymlmetastases
Metastases to thrsupraclavicular lymph nodes or skin

38. Surgical treatment of Germ Cell
Neoplasms
Most are at early stage on young women
Removal of involved adnexia
Same complete surgical staging

39. Chemotherapy of epithelial cancer
Stage Iaand grade I, don’t need treatment
Agents ,cisplatin, carboplatin,
cyclophosphamide, paclitaxel
Compinationpaclitaxel175mg/m2 and cisplatin
75mg/m2 or carboplatinfor 6 cycles at 3 week
intervals
Toxic effects
Vomiting ,diarrhea ,alopecia, nephroand
ototoxicityand myelosuppression.

40. Chemotherapy of Germ Cell
Neoplasms
Curable
Dysgerminoma most radiation sensitive
Preserve future reproductive potential with
chemotherapy
Regimens ,vinblastine-bleomycin-cisplatin ,
vincristin-actinomycin, D-cyclophsphomide,
bleomycin-etoposide-cispltin

41. Complications of chemotherapy
Nausea vomiting alopecia
Agent Toxicity
Cisplatin
Carboplatin
Cyclophosphamide
Paclitaxil
Altretamin
Etoposide
Bleomycin
Doxorubicin
Vincristine
ifosfamide
Nephrotoxicity,neurotoxicity, ototoxicity
Thrombocytopenia, neutropenia
Hemorrhagic cystitis, pulmonary fibrosis
Myelosuppression
Peripheral neuropathy
Myelosuppressiom
Pulmonary fibrosis
Cardiac toxicity
Neurotoxicity
Hemorrhgiccystitis,centralneurotoxicity

42. Radiation therapy and
alternative
Very limited role in epithelial cancer
Dysgerminoma
Immunotherapy
Gen therapy

43. prognosis
Related to
Response to chemotherapy
Differentiation of tumor
Germ cell better than epithelial
Stage of the disease -5 year survival rate
(epithelial)
StgeI -75-93%
stageII-65-74%
Stage III-23-41%
Stage IV-11%