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1. OVARIAN TUMORS By dr. chaltu

2. Introduction.. Has three forms Benign =Functional & Pathologic Border line Malignant

3. BENIGN OVARIAN TUMORS Except the endometrial cyst all non neoplastic tumors are functional cysts also called as “cystic ovaries ”. Functional Cysts Follicular Cysts Corpus Luteum ( Granulosa Lutein ) Cysts Theca Lutein Cysts  Endometriomas  Hyperthecosis Polycystic Ovarian Syndrome  Luteoma of Pregnancy

4. BENIGN OVARIAN TUMORS----- Epithelial Tumors Serous Tumors  Mucinous Tumors  Endometrioid Lesions Clear Cell ( Mesonephroid ) Tumors Transitional Cell (Brenner) Tumors Sex Cord- Stromal Tumors  Thecoma  Fibroma  Hilus Cell Tumor Germ Cell Tumors Mature Teratomas ( dermoid cysts)

5. FUNCTIONAL CYSTS FOLLICULAR CYSTS Follicular cysts are common and vary in diameter from 3 to 8 cm.  Histologically , they are seen to be lined by an inner layer of granulosa cells and an outer layer of theca interna cells that may or may not be luteinized.  These cysts result from a failure in ovulation, most likely secondary to disturbances in the release of the pituitary gonadotropins . The fluid of the incompletely developed follicle is not reabsorbed, producing an enlarged follicular cyst. T ypically asymptomatic, although bleeding and torsion can occur. Most follicular cysts disappear spontaneously within 60 days without treatment.

6. B) CORPUS LUTEUM (GRANULOSA LUTEIN) CYSTS These are thin-walled unilocular cysts ranging from 3–11 cm in size. Following normal ovulation, the granulosa cells lining the follicle become luteinized. In the stage of vascularization , blood accumulates in the central cavity, producing the corpus hemorrhagicum . Resorption of the blood then results in a corpus Luteum , which is defined as a cyst when it grows larger than 3 cm. usually regress after 1 or 2 months in menstruating patients, and OCPs have been recommended but may be of questionable benefit.

7. C) ENDOMETRIOMAS In women with endometriosis, ovarian endometrial cysts can develop and grow up to 6–8 cm. These Endometriomas are also referred to as "chocolate cysts" because they contain thick, brown blood debris inside .

8. EPITHELIAL TUMORS Epithelial tumors account for approximately 60–80% of all true ovarian neoplasms and include  the common serous, mucinous , endometrioid , clear cell, and transitional cell (Brenner) tumors, and the stromal tumors with an epithelial element. The epithelium of these tumors arises from a common anlage , i.e., the mesothelium lining the coelomic cavity and ovarian surfaces.

9. Germ Cell Tumors MATURE TERATOMAS commonly referred to as dermoid cysts,compose some 40–50% of all benign ovarian neoplasms . They contain well-differentiated tissue derived from any of the 3 germ cell layers, including hair and teeth as ectodermal derivatives. They account for the majority of benign ovarian neoplasms in reproductive-age women and Usually are asymptomatic unless complications such as torsion or rupture occur . If symptomatic-mass, heaviness, dull aching lower abdominal pain

10. DIFFERENTIAL DIAGNOSIS  Full bladder Fibroid Encysted peritonitis Pregnancy  Ascites Mesenteric cyst Para-ovarian cyst

11. COMPLICATION Torsion of the pedicle  Intracystic hemorrhage Infection Rupture  Pseudomyxoma peritonei malignancy

12. OVARIAN CANCER

13. Ovarian cancer accounts for 3–4% of cancer in women. ovarian cancer is a disease of the postmenopausal woman, with the highest incidence among patients ages 65–74 years. The lifetime risk of developing ovarian cancer is approximately 1.4%, and the lifetime risk of dying from ovarian cancer is almost 1%.

14. RISK FACTORS Nulliparity Early menarche Late menopause White race Increasing age Residence in North America and Northern Europe Family history Personal history of breast cancer Ethnic background (European Jewish, Icelandic, Hungarian) Postmenopausal hormone therapy Pelvic inflammatory disease

15. Preventive Factors Smoking High parity Breast feeding Hysterectomy Tubal ligation Prolonged ( > 5 Yrs) use of COCs

16. Hereditary ovarian cancer Common=>15 % of Ovarian malignancy Diagnosed at early age=> 10 Yrs than sporadic BRACA I & II gene mutation is common one (75%) of inherited ovarian cancers The BRCA1 gene mutation ovarian ca risk is (39-46%) The BRCA2 gene mutation ovarian ca risk is (10-27%) High grade serous, but has better prognosis

17. Lynch syndrome( hereditary nonpolyposis colorectal cancer) (HNPCC) Patients with this syndrome have: risk of colon cancer (85%) Endometrial cancer(40 to 60%) ovarian cancer (10 to 12%).

18. PREVENTION 1. Ovarian Cancer Screening: no evidence suggests that routine screening with serum markers, sono-graphy , or pelvic examinations lowers mortality rates. 2.Chemoprevention: COC use => 50% decreased risk of developing ovarian cancer. 3. Prophylactic Surgery: prophylactic bilateral salpingo-oophorectomy (BSO) for BRCA gene mutation Prophylactic TAH + BSO ff colonoscopy for Lynch syndrome

19. LOW-MALIGNANT-POTENTIAL TUMORS Accounts 10 to 15% of epithelial ovarian cancers. also termed borderline tumors Histologically , LMP tumors are distinguished from benign cysts by having at least two of the following features: Nuclear atypia , epithelial stratification, microscopic papillary projections, cellular pleomorphism , or mitotic activity

20. Mostly diagnosed early = stage 1 Confined to the ovary Has good prognosis Curable by surgery

21. HISTOPATHOLOGY OF OVARIAN CANCER 1.Epithelial-tumors : Serous tumors Malignant ( Adenocarcinoma,Adenocarcinofibroma ) Borderline(Papillary cystic tumor, Adenofibroma ) Benign ( Cystadenoma , Surface papilloma ) Mucinous tumors Malignant ( Adenocarcinoma ) Borderline(Intestinal type, endocervicallike ) Benign( Cystadenoma , Adenofibroma , … ) Endometrioid tumors , Clear-cell tumors Transitional cell tumors differentiated and unclassified tumors

22. 2.Germ-cell tumors Primitive germ-cell tumors( Dysgerminoma , Yolk sac tumor, Embryonal carcinoma, Polyembryoma , Choriocarcinoma ..)  Teratomas (Immature, Mature ) 3.Sex cord stromal :  Granulosa-stromal cell tumor ( Granulosa cell tumor, Thecoma-fibroma )  Sertoli-Leydig cell tumor ( androblastomas )  Sertoli cell tumor  Leydig cell tumor

23. 4.Secondary (metastatic) Breast, colon, stomach, endometrium , lymphoma

24. Epithelial Ovarian tumors Epithelial neoplasms are derived from the ovarian surface mesothelial cells and include several cell types: serous,  mucinous ,  endometrioid , clear cell, transitional cell, and undifferentiated . Account for more than 60% of all ovarian neoplasms and for more than 90% of malignant ovarian tumors.

25. Pathogenesis At least two distinct pathways : 1. The first tumor group devedops either from benign extraovarian lesions that implant on the ovary and subsequently undergo malignant transformation / from a portion of the ovarian surface epithelium that becomes entrapped within the ovarian cortex. Accounts 10% of malignant ovarian tumors. Are low-grade tumors

26. 2. The second, more common group High grade serous carcinomas arising from the fallopian tube fimbria . Serous tubal intraepithelial carcinoma (STIC) is a precursor condition.

27. Serous Tumor Accounts >50% of all epithelial ovarian ca Characterized by trans ceolomic spread Most high grade ( commonest ep.cancer) Includes ovarian, tubal & peritoneal cancers Most arise from STICs Usually diagnosed in advanced stages Cause of most recurrences Average age=63 Yrs Characterized by Psammoma bodies Tumor marker= CA-125

28. Endometrioid Tumors Accounts 15-20% of all epithelial ovarian ca are the second most common histologic type In 15 to 20% of cases, uterine endometrial adenocarcinoma coexists. many such patients are noted to have pelvic endometriosis. Most are low grade , stage I & large Has good prognosis

29. Mucinous tumor Largest of all=>often benign Most are low grade & cyst adenomas High grade lesion is rare=>very aggressive & resistant to CT, Most ( > 70 %) metastatic Tumor markers= CEA,CA19-9 Pseudomyxoma peritoneii

30. Rare epithelial tumors Brenner ( transitional cell) tumors Clear cell tumors Squamous cell cancer=>cystic teratomas, & also from the cervix Mixed epithelial cell cancers=> > 10 % share, classification to the major share Undifferentiated=> lack any of the histology of Mullerian cell types

31. Clinical presentation Symptoms Most are vague & non specific Pressure symptoms & abdominal swelling Sms of omental & bowel metastases, ascites Irregular & heavy menses Symptoms of metastases Weight loss

32. Clinical presentation.. Sign Pelvic mass=> fixed & solid Ascites Upper abdominal mass Ultrasound Areas of complexity Bilateral tumor Size > 8 cm Ascites

33. FIGO Staging of Carcinoma of the Ovary, Fallopian Tube, and Primary Peritoneal Carcinoma stage characteristic I Tumor confined to ovaries (or to fallopian tubes) IA Tumor limited to 1 ovary (or 1 tube); capsule intact, no tumor on surface, negative washings IB Tumor involves both ovaries (or both tubes) IC1 Tumor limited to 1 or both ovaries (or tubes), with surgical spill IC2 Tumor limited to 1 or both ovaries (or tubes), with capsule rupture before surgery or tumor on ovarian surface IC3 Tumor limited to 1 or both ovaries (or tubes), with malignant cells in ascites or peritoneal washings II Tumor involves 1 or both ovaries (or 1 or both tubes) with pelvic extension (below the pelvic brim) or primary peritoneal cancer IIA Extension and/or implants on uterus and/or fallopian tubes (and/or ovaries)

34. IIB Extension to other pelvic intraperitoneal tissues III Tumor Involves 1 or both ovaries (or 1 or both tubes) with cytologlcally or hlstologlcally confirmed spread to the peritoneum outside the pelvis and/or metastasis to retroperitoneal lymph nodes III A1 Positive retroperitoneal lymph nodes only i Metastasis <=10 mm ii Metastasis > 1 O mm III A2 Microscopic, extrapelvic (above the brim) peritoneal involvement± positive retroperitoneal nodes IIIB Macroscopic, extrapelvic , peritoneal metastasis ~2 cm ± positive retroperitoneal nodes. Includes extension to capsule of liver/spleen IIIC Macroscopic, extrapelvic , peritoneal metastasis >2 cm± positive retroperitoneal lymph nodes. Includes extension to capsule of liver/spleen

35. IV Distant metastasis excluding peritoneal metastasis IVA Pleural effusion with positive cytology IVB Hepatic and/or splenic parenchymal metastasis, metastasis to extraabdominal organs (including inguinal lymph nodes and lymph nodes outside of the abdominal cavity)

36. Germ cell tumors From primitive ( Primordial) germ cells Young age groups 2-3 % of all ovarian cancers Good treatment out come=>curable Most arise in the gonads, some are extra gonadal Tumor markers=> hCG,LDH,a -FP Both benign & malignant forms Most of the time diagnosed early

37. Germ cell tumors Mature teratoma Dysgerminoma Immature teratoma Endodermal sinus ( Yolk sac) tumor Other rare tumors None gestational choriocarcinoma Embryonal cancer Poly embryoma Mixed

38. DYSGERMINOMA Is the female counterpart of the seminoma in the male. It occurs primarily in young females and accounts for approximately 30–40%of germ cell tumors.  is unilateral in 85–90% of cases.  Histologically , dysgerminoma mimics the pattern seen in the primitive gonad. Lymphocytes may invade the stroma . has favorable prognostic indicator.

39. TERATOMAS Immature teratomas are the malignant counterpart of the mature cystic teratoma , or dermoid , and are the most common germ cell malignancy. Malignant teratomas are found mostly <20 years old. bilateral in less than 5% of cases The serum AFP is usually elevated Microscopic reveals a Disordered collection of tissues derived from the three germ layers, with at least some of the components having an immature, embryonic appearance. The immature elements are commonly neuroectodermal and consist of small, round, malignant cells that may be associated with glia formation.

40. Sex-cord stromal cell tumors Supporting intra ovarian matrix=> stroma & germinal layers Sex cord cells=> Granulosa & Sertoli cells Mesenchymal cells=> Theca,leidig ,fibroblast Account 5 % of ovarian malignancies Most benign & low grade cancers Most diagnosed before age of 40 Yrs Slow growing Most of the time diagnosed early

41. Granulosa cell tumor Commonest=>70 % of SCSTs Most are stage I=> confined to the ovary Adult type AUB Tumor markers=Inhibin & AMH Juvenile=> young age Pseudo precosous puberty Behaves less aggressive than the adult form

42. Other rare forms Thecoma-Fibroma Sertoli cell tumors Sertoli- Leidig cell tumors Unclassified Gynandroblastoma

43. INVESTIGATION CBC, blood group, RH Serum electrolyte Tumor markers-CA 125, cytology Serum AFP, HCG LDH, LFT, RFT Barium enema Imaging –pelvic U/S, Doppler U/S, chest x-ray, IVU, Mammography, Colonoscopy, CT, MRI  Paracynthesis , thoracynthesis

44. DIFFERENTIAL DIAGNOSES Gynecologic origin Uterine –fibroids, adenomyosis Ovarian –benign, malignant Tubal Non gynecologic origin Gastrointestinal Urologic Retroperitoneal

45. GTD Chronic ectopic pregnancy  Hydatic cyst, mesenteric cyst  Nephroblastoma Polycystic kidney  Splenomegaly lymphoma

46. Treatment Surgery Staging Cytoreductive surgery ( Primary & Interval) Chemotherapy Neoadjuvant Adjuvant Second line Fertility preservation for GCT

47. 5-year survival rate of Epithelial Ovarian tumors Stages 5-Year Survival(%) I 92 II/III 72 IV 27 Unkwon stage 22

48. Most Important Favorable Prognostic Factors for Ovarian Cancer No ascites Younger age Early-stage disease Well-differentiated tumor Otherwise good health status Histologic type other than mucinous or clear cell Small disease volume prior to surgical debulking Small residual tumor following primary cytoreductive surgery

49. Thank U