Ovarian cancer : 👉Clinical features about the signs and symptoms 👉Spread - types of spread and important lymph node spread with picture 👉Screening about the tumor markers , clinically ,by advanced technology like ultrasound imaging and genetic testing and risk of malignancy index also there . Important is clinical diagnosis , lymph node examination and USG .

1.  CLINICAL FEATURES
 SPREAD
 SCREENING
BY:
PRIYANKA SALUNKHE
FINAL YEAR MBBS

2. CLINICAL FEATURES:
SYMPTOMS:
 Early stage ovarian carcinoma is an asymptomatic . The presenting complaints are usually of
short duration and insidious in onset. Symptoms are not specific.
 Feeling of abdominal distension and vague discomfort.
 Sudden loss of weight.
 Abdominal swelling which may be rapid.
 Dull abdominal pain
 Features of dyspepsia such as flatulence and eructations.
 Menstrual abnormality is conspicuously absent .
 Respiratory distress- may be mechanical due to ascites or
due to pleural effusion.

3. SIGNS:
 GENERAL EXAMINATION REVEALS:
 Cachexia and pallor.
 Jaundice may be evident in late cases.
 Left supraclavicular lymph gland [ virchow's ] may be enlarged.
 Edema of leg or vulva is characterisitc of malignant.
Left supraclavi
cular node enl
argement

4.  PER ABDOMEN:
 Liver may be enlarged, firm and nodular.
 A mass is felt in the hypogastrium. Too often it may be bilateral . Followed by features:
 Feel – solid or heterogenous.
 Mobility - Mobile or restricted.
 Tenderness - usually present.
 Surfaces – irregular.
 Margins - well-defined but the lower pole is usually not reached.
 Percussion – usually dull over the tumor: may be resonant due to overlying instestinal
adhesions.
SOLID OVARIAN
TUMOR [ RIGHT ]

5.  Per Vaginum :
 The uterus may be separated from the mass felt per abdomen.
 Nodules may be felt through the posterior fornix. If it is more than 1 cm, the diagnosis of
malignancy is almost certain.

6. SPREAD:
 The modes of spread are:
 TRANSCOELOMIC
 LYMPHATIC
 DIRECT
 HEMATOGENOUS

7. TRANSCOELOMIC SPREAD:
 Implantation of malignant cells occurs by:
 Direct exfoliation of cells.
 Penetration of tumor capsule.
 Rupture of the capsule.
 Exfoliated cells in the peritoneal fluid flow along the paracolic gutters.
 Multiple secondary deposit are formed on the peritoneal surfaces specially in the pouch of
douglas , in the omentum , diaphragm, retroperitoneal nodes and serous surfaces of the
abdominopelvic organs.

8. LYMPHATICS:
 The lymphatic spread is to the draining lymph nodes namely paraaortic and superior gastric
nodes.
 The pelvic nodes may be involved through peritoneal permeation into the sub peritoneal
lymphatics.
 The left supra-clavicluar nodes are enlarged due to obstruction of the efferent lymphatics
channel of the nodes by the tumor emboli, as it enters the thoracic duct just prior to its
drainage into the left subclavian vein.
 Lateral lymphatic spread through the broad ligament to the pelvic nodes may occur.
 Retrograde spread in advanced disease may occur to the inguinal nodes through the round
ligament .

9. DIRECT:
 After the capsule is broken, the spread occurs directly to the adjacent organs such as tubes,
broad ligament, intestine, omentum and uterus.
HEAMTOGENOUS:
 The blood stream metastasis is late and the involved organs are lungs, liver, bones, etc.

10. SCREENING PROCEDURES:
 CLINICAL.
 TUMOUR MARKERS.
 ULTRASOUND IMAGING.
 RISK OF MALIGNANCY INDEX [ RMI ] .
 GENETIC TESTING.

11. CLINICAL:
 Regular and periodic clinical examination of the 'high risk group' is done.
 High risk group : age group 40-60 years, familial cancer [ breast, endometrial, ovarian,
colorectal], history of removal of benign ovarian tumor, postmenopausal palpable ovary,
relative or absolute infertility, women workers in asbestos related industries.
 Bimanual pelvic examination is an asymptomatic women may detect an adnexal mass.
 However, clinical examination is not specific.

12. TUMOR MARKERS:
 CA 125 is a glycoprotein, which has been used for screening of epithelial cancers of the ovary.
 Value more than 35 U/ml is suggestive of epithelial ovarian cancer.
 It is used for monitoring the chemotherapy and follow up.
 But it not a tumor specific antigen .
 There are several other conditions, where level of CA-125 is raised:
 NORMAL WOMEN [ 1%], CARCINOMAS OF BREAST, LUNG, COLON AND ENDOMETRIUM,
ENDOMETRIOSIS, PELVIC INFLAMMATORY DISEASE, PERITONITIS.

13. ULTRASOUND IMAGING:
 Transvaginal color doppler imaging has been able to differentiate benign from malignant tumors by
assessment of its vascular supply and intratumoral blood flow.
 Increased neoangiogenesis in ovarian malignancy causes central neovasularitary.
 Study of vascular parameters, e.g. Pulsatility index [ PI] <1.0 increase the risk of malignancy.
 Recently three dimensional, contrast enhanced, power doppler sonography is found to be more
diagnostic.

14. RISK OF MALIGNANCY INDEX [ RMI] :
 RMI = U * M * CA 125.
 U = USG score [one point each for : multi – locular cyst , solid areas, metastasis, ascites, bilateral
lesions].
 M = 3 [ postmenopausal women]
 CA-125 level in U/mL . Value more than 35 U/ml.
 The risk of cancer is 75% when the RMI value is >250.

15. GENETIC TESTING:
 HEREDITARY BREAST OVARIAN CANCER SYNDROME:
 80 –95% cases of all familial ovarian cancers.
 BRCA1 [chromosome 17q] and BRCA2 [ chromosome 13q] gene mutation are observed in majority
of cases.
 HEREDITARY NONPOLYPOSIS COLORECTAL CANCER [ HNPCC]:
 It is an autosomal dominant transmission.
 Women with HNPCC have life time risk of about 50% for endometrial cancer and 12% for ovarian
cancer.
 EARLY DETECTION : may be possible by detecting mutated copies of a gene products , using
polymerase chain reaction .

16. THANK YOU