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OVARIAN TUMOUR - an overview Sachin Maiti  MD,MRCOG,DFFP Research Registrar Wirral Hospital NHS Trust,UK
Epithelial Ovarian Tumour <ul><li>Most common gynaecological Malignancy in developed countries </li></ul><ul><li>15/100,00...
Epithelial Ovarian Tumour <ul><li>90% derived from coelomic epithelium </li></ul><ul><li>75-80% serous </li></ul><ul><li>1...
Epithelial Ovarian Tumour <ul><li>Age 56 </li></ul><ul><li>80-90 > 40 years, 30-40% >60 years </li></ul><ul><li>1 in 10 of...
Epithelial Ovarian Tumour <ul><li>Prevention:- </li></ul><ul><li>Pregnancy (RR 0.3-0.4) </li></ul><ul><li>OCP (RR 0.5) </l...
Epithelial Ovarian Tumour <ul><li>SCREENING:- </li></ul><ul><li>TVS (1 in 10) </li></ul><ul><li>Doppler US </li></ul><ul><...
Hereditary Ovarian CA <ul><li>5-10% </li></ul><ul><li>BRCA1 & BRCA2 </li></ul><ul><li>HNPCC </li></ul><ul><li>AD, mutation...
Impact of BRCA-1
Differential Diagnosis <ul><li>Benign cyst </li></ul><ul><li>Endometriosis </li></ul><ul><li>PID </li></ul><ul><li>Fibroid...
Risk of Malignancy Index (RMI) <ul><li>USS </li></ul><ul><li>Menopausal status </li></ul><ul><li>CA125 </li></ul><ul><li>R...
Investigations <ul><li>History/Examination </li></ul><ul><li>FBC, LFT, CA125 (CEA) </li></ul><ul><li>USS/CT </li></ul><ul>...
CA125 <ul><li>Secreted by Mullarian & Coelomic epithelium </li></ul><ul><li>>30 ku/l in PMW, risk of ov ca 36 fold  </li><...
Poor prognostic factors <ul><li>High grade </li></ul><ul><li>Aneuploidy </li></ul><ul><li>Serous vs Mucinous </li></ul><ul...
Borderline tumours <ul><li>Low malignant potential </li></ul><ul><li>Confined to one ovary for long time </li></ul><ul><li...
Aim of Surgery <ul><li>Establish diagnosis </li></ul><ul><li>Staging </li></ul><ul><li>Primary Cytoreduction </li></ul><ul...
Treatment <ul><li>Surgery- cytoreduction <1-2cms </li></ul><ul><li>TAH+BSO+Omental Biopsy+washings </li></ul><ul><li>Bowel...
Survival <ul><li>Stage 1 76-93% </li></ul><ul><li>Stage 2 60-74% </li></ul><ul><li>Stage 3A 40% </li></ul><ul><li>Stage 3B...
Non Epithelial Ovarian Tumour <ul><li>Uncommon, 10% of all ovarian ca </li></ul><ul><li>Germ Cell Tumours </li></ul><ul><l...
Germ Cell Tumours <ul><li>Arise from primordial germ cell </li></ul><ul><li>1/10 as common as testicular tumours </li></ul...
Germ cell tumours <ul><li>Dysgerminomas 30-40% </li></ul><ul><li>Teratomas (Immature/Mature) </li></ul><ul><li>Monodermal ...
Dysgerminoma <ul><li>Most common GCT </li></ul><ul><li>75% -10-30years, 5% <10years </li></ul><ul><li>20-30% of tumours in...
Dysgerminomas <ul><li>Treatment - Surgery+ Chemotherapy </li></ul><ul><li>Staging, USO </li></ul><ul><li>Fertility preserv...
Immature Teratomas <ul><li>10-20% of ov tumours in <20years </li></ul><ul><li>50% occur 10-20years </li></ul><ul><li>Malig...
Endodermal Sinus tumours (Yolk sac tumours) <ul><li>1/3 present before menarche </li></ul><ul><li>median age 18years </li>...
Sex cord-stromal tumours <ul><li>5-8% of all ovarian malignancy </li></ul><ul><li>Granulosa-stromal cell tumour </li></ul>...
Granulosa cell tumour <ul><li>Low grade malignancy </li></ul><ul><li>2% Bilateral </li></ul><ul><li>Reproductive age, 5% p...
GCT <ul><li>Recurrence 5-30years </li></ul><ul><li>Haematogenous spread </li></ul><ul><li>Secrete Inhibin </li></ul><ul><l...
Sertoli-Leydig Tumour <ul><li>3-4 decade </li></ul><ul><li>75% <40 years </li></ul><ul><li>Low grade malignancy </li></ul>...
Metastatic Tumours <ul><li>5-6% of ovarian tumours </li></ul><ul><li>Breast, GIT </li></ul><ul><li>Tubal 13% </li></ul><ul...
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ovarian tumor

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  1. 1. OVARIAN TUMOUR - an overview Sachin Maiti MD,MRCOG,DFFP Research Registrar Wirral Hospital NHS Trust,UK
  2. 2. Epithelial Ovarian Tumour <ul><li>Most common gynaecological Malignancy in developed countries </li></ul><ul><li>15/100,000 </li></ul><ul><li>4000 deaths/year </li></ul><ul><li>2/3 present in advanced stage </li></ul><ul><li>Life time risk of ov ca = 1.5%, dying 1% </li></ul><ul><li>90% of ovarian tumours are epithelial origin </li></ul>
  3. 3. Epithelial Ovarian Tumour <ul><li>90% derived from coelomic epithelium </li></ul><ul><li>75-80% serous </li></ul><ul><li>10% mucinous </li></ul><ul><li>10% endometriod </li></ul><ul><li>1% Brenner, undifferentiated, clear cell </li></ul>
  4. 4. Epithelial Ovarian Tumour <ul><li>Age 56 </li></ul><ul><li>80-90 > 40 years, 30-40% >60 years </li></ul><ul><li>1 in 10 of ovarian tumour malignant <40 y </li></ul><ul><li>1 in 3 of ovarian tumour malignant >40 y </li></ul><ul><li>1% of ovarian tumours <20 y, 2/3 Germ CT </li></ul><ul><li>30% of ovarian tumours malignant in postmenopausal women </li></ul>
  5. 5. Epithelial Ovarian Tumour <ul><li>Prevention:- </li></ul><ul><li>Pregnancy (RR 0.3-0.4) </li></ul><ul><li>OCP (RR 0.5) </li></ul><ul><li>2 Children and OCP (RR 0.3) </li></ul><ul><li>Oophorectomy </li></ul>
  6. 6. Epithelial Ovarian Tumour <ul><li>SCREENING:- </li></ul><ul><li>TVS (1 in 10) </li></ul><ul><li>Doppler US </li></ul><ul><li>CA125 </li></ul><ul><li>TVS+CA125 (1 in 4 laparotomy) </li></ul>
  7. 7. Hereditary Ovarian CA <ul><li>5-10% </li></ul><ul><li>BRCA1 & BRCA2 </li></ul><ul><li>HNPCC </li></ul><ul><li>AD, mutations </li></ul><ul><li>Risk of ovarian ca 10years earlier </li></ul><ul><li>35-40% risk </li></ul>
  8. 8. Impact of BRCA-1
  9. 9. Differential Diagnosis <ul><li>Benign cyst </li></ul><ul><li>Endometriosis </li></ul><ul><li>PID </li></ul><ul><li>Fibroids </li></ul><ul><li>Pelvic Kidney </li></ul><ul><li>Retroperitoneal tumours </li></ul>
  10. 10. Risk of Malignancy Index (RMI) <ul><li>USS </li></ul><ul><li>Menopausal status </li></ul><ul><li>CA125 </li></ul><ul><li>RMI = UxMxCA125 </li></ul><ul><li>High index of suspicion = RMI> 200 </li></ul>
  11. 11. Investigations <ul><li>History/Examination </li></ul><ul><li>FBC, LFT, CA125 (CEA) </li></ul><ul><li>USS/CT </li></ul><ul><li>Chest X-ray </li></ul><ul><li>Barium/Gastroscopy (if bowel symptoms) </li></ul><ul><li>Endometrial sample (PMB) </li></ul>
  12. 12. CA125 <ul><li>Secreted by Mullarian & Coelomic epithelium </li></ul><ul><li>>30 ku/l in PMW, risk of ov ca 36 fold </li></ul><ul><li>>96ku/l in PMW, PPV 96% </li></ul><ul><li>Stage 1- 50% </li></ul><ul><li>Stage 2- 60% </li></ul>
  13. 13. Poor prognostic factors <ul><li>High grade </li></ul><ul><li>Aneuploidy </li></ul><ul><li>Serous vs Mucinous </li></ul><ul><li>Lymphatic invasion, Ascitis, positive cyto </li></ul><ul><li>Clear cell histology </li></ul><ul><li>Poor performance status </li></ul><ul><li>Poor biochemical/haematological status </li></ul>
  14. 14. Borderline tumours <ul><li>Low malignant potential </li></ul><ul><li>Confined to one ovary for long time </li></ul><ul><li>Good prognosis, 86-90% </li></ul><ul><li>Age 30-50years </li></ul><ul><li>Metastatic implants can occur </li></ul><ul><li>Late recurrence </li></ul>
  15. 15. Aim of Surgery <ul><li>Establish diagnosis </li></ul><ul><li>Staging </li></ul><ul><li>Primary Cytoreduction </li></ul><ul><li>Interval/ Secondary cytoreduction </li></ul><ul><li>Palliative & salvage surgery </li></ul><ul><li>Laparoscopy/Aspiration NOT recommended </li></ul>
  16. 16. Treatment <ul><li>Surgery- cytoreduction <1-2cms </li></ul><ul><li>TAH+BSO+Omental Biopsy+washings </li></ul><ul><li>Bowel resection if impending obstruction </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Stage >1C (>2A) </li></ul><ul><li>Carboplatin +Taxol </li></ul>
  17. 17. Survival <ul><li>Stage 1 76-93% </li></ul><ul><li>Stage 2 60-74% </li></ul><ul><li>Stage 3A 40% </li></ul><ul><li>Stage 3B 25% </li></ul><ul><li>Stage 3C 23% </li></ul><ul><li>Stage 4 11% </li></ul><ul><li>Increased grade - decreased survival </li></ul>
  18. 18. Non Epithelial Ovarian Tumour <ul><li>Uncommon, 10% of all ovarian ca </li></ul><ul><li>Germ Cell Tumours </li></ul><ul><li>Sex Cord Tumours </li></ul><ul><li>Metastatic Tumours </li></ul><ul><li>Rare- Sarcomas, Lipoid cell tumours </li></ul><ul><li>Tumour markers- AFP, HCG, PALP, LDH </li></ul>
  19. 19. Germ Cell Tumours <ul><li>Arise from primordial germ cell </li></ul><ul><li>1/10 as common as testicular tumours </li></ul><ul><li>Most arise from undifferentiated germ cell in ovary </li></ul><ul><li>20-30% of all ovarian neoplasia </li></ul><ul><li>3% malignant, rapidly growing </li></ul><ul><li><20years, 70% Germ CT, 1/3 malignant </li></ul>
  20. 20. Germ cell tumours <ul><li>Dysgerminomas 30-40% </li></ul><ul><li>Teratomas (Immature/Mature) </li></ul><ul><li>Monodermal </li></ul><ul><li>Endodermal Sinus tumour (YST) </li></ul><ul><li>Embryonal carcinomas </li></ul><ul><li>Choriocarcinoma </li></ul><ul><li>Mixed form </li></ul>
  21. 21. Dysgerminoma <ul><li>Most common GCT </li></ul><ul><li>75% -10-30years, 5% <10years </li></ul><ul><li>20-30% of tumours in pregnancy </li></ul><ul><li>5% abnormal gonads </li></ul><ul><li>85% stage 1 </li></ul><ul><li>10-15% bilateral </li></ul><ul><li>95% secrete PALP, LDH, 3% HCG </li></ul>
  22. 22. Dysgerminomas <ul><li>Treatment - Surgery+ Chemotherapy </li></ul><ul><li>Staging, USO </li></ul><ul><li>Fertility preservation </li></ul><ul><li>Stage 1A -surgery alone </li></ul><ul><li>Stage 1B or higher - surgery+chemo </li></ul><ul><li>BEP chemo </li></ul><ul><li>Prognosis- 90-100%, </li></ul>
  23. 23. Immature Teratomas <ul><li>10-20% of ov tumours in <20years </li></ul><ul><li>50% occur 10-20years </li></ul><ul><li>Malignant transformation- .5-2% in PMW </li></ul><ul><li>Tumour markers negative </li></ul><ul><li>Diagnosis- USS/ Histology </li></ul><ul><li>Surgery- Staging +USO, Chemo - BEP >1A </li></ul><ul><li>Survival - 70-80% </li></ul>
  24. 24. Endodermal Sinus tumours (Yolk sac tumours) <ul><li>1/3 present before menarche </li></ul><ul><li>median age 18years </li></ul><ul><li>10% mass </li></ul><ul><li>75% pelvic pain </li></ul><ul><li>Secrete AFP </li></ul><ul><li>Surgery + chemotherapy in all patients </li></ul><ul><li>Response rate 60% </li></ul>
  25. 25. Sex cord-stromal tumours <ul><li>5-8% of all ovarian malignancy </li></ul><ul><li>Granulosa-stromal cell tumour </li></ul><ul><li>Androblastroma </li></ul><ul><li>Gynandroblastoma ( attached slide) </li></ul><ul><li>unclassified </li></ul>
  26. 26. Granulosa cell tumour <ul><li>Low grade malignancy </li></ul><ul><li>2% Bilateral </li></ul><ul><li>Reproductive age, 5% prepubertal </li></ul><ul><li>25-50% endometrial hyperplasia </li></ul><ul><li>5% endometrial carcinoma </li></ul><ul><li>10% ascitis </li></ul><ul><li>Mostly stage 1 </li></ul>
  27. 27. GCT <ul><li>Recurrence 5-30years </li></ul><ul><li>Haematogenous spread </li></ul><ul><li>Secrete Inhibin </li></ul><ul><li>Treatment-Surgery- USO/TAHBSO </li></ul><ul><li>Chemotherapy no benefit </li></ul><ul><li>recurrence BEP </li></ul><ul><li>90% 10 year survival, 75% 20 year survival </li></ul>
  28. 28. Sertoli-Leydig Tumour <ul><li>3-4 decade </li></ul><ul><li>75% <40 years </li></ul><ul><li>Low grade malignancy </li></ul><ul><li>Produce androgens </li></ul><ul><li>70-85% - clinical virilization </li></ul><ul><li>Surgery - USO/TAH+BSO, No chemo </li></ul><ul><li>Survival 70-90% </li></ul>
  29. 29. Metastatic Tumours <ul><li>5-6% of ovarian tumours </li></ul><ul><li>Breast, GIT </li></ul><ul><li>Tubal 13% </li></ul><ul><li>Endometrial 5% </li></ul><ul><li>Breast 24% </li></ul><ul><li>Krukenburg 30-40% of metastatic ov ca (primary- stomach, colon, breast, biliary T) </li></ul>
  30. 30. Thank you
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