A full case introduction and presentation on Ovarian Carcinoma.

1. OVARIAN CARCINOMA
MODERATOR: DR. K.K DAS
PROFESSOR
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
GAUHATI MEDICAL COLLEGE AND HOSPITAL.

2. PRESENTED BY STUDENTS OF 8TH
SEMESTER
ROLL
NO.
NAME
50 RUPANKAR NANDI
51 DEEP UJJAL DAS
52 KANGKANA KAVERI PATHAK
53 KHADIZA AN TAHERA
54 SUNITA KUMARI
55 HIMANKA RAJ SARMA
56 JYOTIPRASAD BHATTACHARYYA
PRESENTED BY-

3. INTRODUCTION
• Ovarian tumours refer to a complex wide spectrum of neoplasms
involving a variety of histological tissues ranging from epithelial
tissues, connective tissues, specialized hormone-secreting cells to
germinal and embryonal cells.
• The most common are epithelial tumours forming 80% of all
tumours.
• 80 % of the tumours are benign and 20 % are malignant.
• Of all the malignant tumours, 90% are epithelial in origin, 80% are
primary in the ovary and 20% are secondary.

4. WHO CLASSIFICATION OF OVARIAN
TUMOURS
1) Common epithelial tumours
• Serous tumours
• Mucinous tumours
• Endometroid tumours
• Clear cell tumours
• Brenner tumours
• Mixed epithelial tumours
• Undifferentiated carcinoma
• Unclassified epithelial tumours
2) Sex cord tumours
• Granulosa stromal cell tumours
• Androblastomas – Sertoli Leydig cell tumour
• Gynandroblastomas
• Unclassified tumours
3) Lipid cell tumour

5. 4) Germ cell tumours
• Dysgerminoma
• Endodermal sinus tumour
• Embryonal Carcinoma
• Choriocarcinoma
• Polyembryoma
• Teratoma
• Mixed forms
5) Gonadoblastoma
• Pure
• Mixed
6) Soft tissue tumours not specific to ovary
7) Unclassified tumours
8) Secondary tumours (Metastatic)
9) Tumour like conditions

6. • Asymptomatic
• Heaviness and abdominal discomfort
• Mass in the lower abdomen
• Acute lower abdominal pain of dull aching nature
• Pressure symptoms
• Bilateral pitting edema
• Menstrual symptoms
CLINICAL SIGNS AND SYMPTOMS OF
OVARIAN MASSES

7. FEATURES BENIGN MALIGNANT
HISTORY -Child bearing period
-Slow growing
-No pain
-Adolescent,
Elderly(more than 50) - Rapidly
growing
-pain in advanced stage
EXAMINATION -Usually unilateral, cystic, well defined
and mobile.
-No Ascites
-May be bilateral, solid, fixed
-Ascites may be present
USG -Cystic, well defined Soild and fixed
DOPPLER USG No increased vascularity Increased vascularity
MARKER CA125 usually normal CA125 raised
OPERATIVE FINDINGS Well defined ovarian cystic tumour Fixed tumour, often bilateral
No metastatic nodules Metastasis may be present
DIFFERENTIATION BETWEEN
BENIGN AND MALIGNANT OVARIAN TUMOURS

8. COMPLICATIONS
1. Torsion
2. Rupture
3. Infection
4. Impaction
5. Adhesions and intestinal obstruction
6. Malignant change
7. Pseudomyxoma peritonei
8. Haemorrhage

9. HISTORY

10. PATIENT PARTICULARS
• Name: Borjano Gogoi
• Age: 65 years
• Sex: Female
• Address: Kondoli, District- Nagaon
• Education: Illiterate
• Occupation: Housewife
• Religion: Hindu
• Husband‘s Name: Vagoram Gogoi
• Date of admission : 08-03-2019
• Date of examination: 20-03-2019

11. CHIEF COMPLAINTS
• Lump in the lower abdomen for the last 1
year
• Pain in the lower abdomen for last 9 months

12. HISTORY OF PRESENT ILLNESS
• The patient complains of a lump in the abdomen since one year. It was gradual
in onset. Initially the patient noticed small swelling in the right lower
abdomen. It progressively increased in size and now the swelling occupies the
lower part of the abdomen below the umbilicus.
• The patient complains of pain in the lower abdomen for the last 9 months. It
was insidious in onset non progressive and has a constant dull aching
character. There was no radiation, referral or shifting of pain. It has no
aggravating or relieving factor.

13. • The patient also complains of increase in frequency and amount of
urination, but there was no pain, burning sensation and straining during
urination.
• The patient doesn’t complain of any abnormal bleeding per vagina. There
is no history of any abnormal hair growth, any change in voice and acne.
• There is no history of cough, breathing difficulty, jaundice or bone pain.
• There is a history of weight loss. Her sleep and bowel pattern were
unaffected. But appetite is decreased.

14. PAST OBSTETRIC HISTORY

15. HISTORY OF PAST ILLNESS
• Patient is a known hypertensive since 3 years and is non- diabetic.
• There is no history of similar medical illness in the past.
• There is no past history of tuberculosis.
• There is no significant medical or surgical history in the past.

16. She attained menarche at the age of 13 years.
She had regular cycles of 28 days during her reproductive life and she
attained her menopause at the age of 47 years.
MENSTRUAL HISTORY

17. PERSONAL HISTORY
• She takes an average Assamese non vegetarian diet with 3
major meals consisting of rice, dal, vegetables and meat, fish
occasionally.
• The patient does not smoke or consume alcohol, doesn't chew
tobacco but chews betel-nut occasionally.

18. • There are 5 members in her family.
• There is a history of similar illness of her younger sister and she died of the
same cause one year back.
• There is no history of diabetes mellitus, hypertension, tuberculosis, or any
other malignancies among the family members.
FAMILY HISTORY

19. SOCIO-ECONOMIC HISTORY
• The patient belongs to a lower socio-economic group.
• Per capita income is Rs. 1500/month.
• She lives in a kutcha house with four rooms with no
separate kitchen.
• They consume water from tubewell after filtering.
• They use firewood for cooking.

20. ALLERGIC HISTORY
• She is not known to be allergic to any inhalant, ingestant or
contactant till date.
DRUG HISTORY
• She has been taking medications for hypertension since
last 3 years.

21. IMMUNIZATION HISTORY
• The immunization status of the patient is
unknown.
• No BCG scar is seen

22. GENERAL EXAMINATION

23. GENERAL EXAMINATION
(as done on 19 February 2019)
• Appearance: Patient looks ill.
• Consciousness- conscious, co-
operative and well oriented to
time, place and person
• Decubitus: of choice
• Built: thin
• Nutrition: poor
• Height: 158cm
• Weight : 37 Kg
• BMI : 18.02kg per sq metre
• Hair : Grey hair
• Icterus: Absent
• Pallor: Present
• Cyanosis: Absent
• Teeth and gums: Teeth are stained,
gums are unhealthy
• Condition of oral cavity and tongue:
Oral cavity is unhealthy, Tongue is
pale but moist
• Neck vein: Not engorged
• Neck glands: Not palpable
• Clubbing: Absent
• Koilonychia: Absent
• Oedema: Bilateral pedal edema
present which is pitting in character.

24. VITALS
• Respiratory rate: 20/min.
Regular in rhythm, and thoraco abdominal type.
• Blood pressure: 140/90 mm Hg in right upper arm in supine position.
• Pulse: 84 beats/min
– Regular in rhythm
– Normal in volume and character.
– The condition of the arterial wall is normal
– No radio-radial and radio-femoral delay found
– All other peripheral pulses are bilaterally and symmetrically palpable.
• Temperature: 98⁰F

25. SYSTEMIC EXAMINATION

26. SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM:
• Inspection:
• - Shape and size of chest is normal.
• - Movement of chest is bilaterally symmetrical.
• - Respiratory Rate is 16/min and is regular in rhythm.
• Palpation:
• - Trachea is in the midline.
• - Chest expansion is normal.
• - Vocal fremitus is bilaterally symmetrical and normal.
• Percussion:
• - Lung field is uniformly resonant in all areas.
• Auscultation:
• - Normal vesicular breath sounds are heard and no
• additional sounds are heard.
• - Vocal resonance is normal on both sides.

27. CARDIOVASCULAR SYSTEM
• Inspection:
 Shape and size of the Precordium is normal.
 No bulging or visible pulsations are seen.
• Palpation:
 Apex beat is felt in the 5th intercostal space just inside the mid-clavicular line.
• Auscultation:
 1st and 2nd heart sounds are heard normally.
 No additional heart sounds are heard.

28. CENTRAL NERVOUS SYSTEM
• Higher mental functions
 Patient is alert, conscious and well oriented to time, place and person.
• Cranial nerves are intact.
• Motor system is normal.
• Sensory function is normal.
• Reflexes and jerks are normal.
• Gait is normal

29. BREAST EXAMINATION
Inspection-
• Both the breast are normal in size and shape.
• No dimpling seen
• Skin over the breast is normal. No engorged veins are seen.
• Nipples are healthy and everted.
• Areola is healthy, no cracks, fissures, eczema seen.
Palpation
• No local rise in temperature.
• No tenderness.
• no mass or lump felt.

30. GYNAECOLOGICAL EXAMINATION
Abdominal Examination
● On inspection, the abdomen appears normal.
● Abdominal wall moves bilaterally and symmetrically with
respiration.
● Umbilicus is in the midline and inverted.
● A localized swelling is seen occupying the lower part of abdomen.
● No pigmentation or scars seen over the skin
● No engorged veins or visible persistalsis or pulsations observed.
● The hernial sites and the external genitalia look normal.

31. Palpation
Superficial Palpation
● No local rise of temperature.
● Tenderness is present over the lower abdomen.
● Abdominal guarding is felt.
● A mass is felt over the hypogastrium which also
extends up to to the right and left iliac fossa and the
umbilicus.

32. Deep Palpation
● A hard lump of size 10cmx18cm is felt over the
hypogastrium,more towards the right side, corresponding to 24
weeks of gestational size.
● It has ill defined margins, is hard in consistency, having an
irregular surface,. Is immobile and is not fixed to the underlying
skin.
● Inguinal lymph nodes are not palpable.
● Liver is palpable 4cm below the right subcostal margin. It is firm
in consistency, non tender and having rounded edges.
● Spleen and kidneys are not palpable.

33. Persussion
● A dull note is heard over the lump.
● Shifting dullness is present.
● Fluid thrill is absent.

34. Auscultation
● Normal bowel sounds are heard.

35. PELVIC EXAMINATION
Local examination
● The external genitalia looks normal.
● No discharge, scar mark or growth seen.
● Urethral orifice looks normal
● No prolapse of the genitalia is seen.

36. Per speculum examination
● The cervix and vagina appear healthy.
● No ulceration or induration seen.
● Does not bleed on touch.

37. Bimanual examination
● A right sided lump is felt, which is hard in consistency and
immobile.
● Anterior and right fornix are full.
● No luymp can be felt over the posterior and left fornix.
● Uterus is sperate from the mass.
● No cervical movement seen with the movement of the
mass.

38. Rectal Examination
● The Pouch of Douglas appears full.

39. PROVISIONAL DIAGNOSIS
 The patient, Saru Daimary, 70 years old, presenting with a
Lump in the lower abdomen for the last 1 year and Pain in the
lower abdomen for last 9 months is provisionally diagnosed to
be a case of right sided ovarian tumour which is probably
malignant.

40. DIFFERENTIAL DIAGNOSIS
• Full Bladder
• Pregnancy
• Myoma
• Ascites
• Lesions-
 Large hydronephrosis
 Benign ovarian tumours
 Other tumours like enlarged spleen
 Mesenteric cysts
 Mucocele of appendix or gall bladder
 Hydatid cysts
 Pancreatic cysts

41. INVESTIGATIONS

42. INVESTIGATIONS
Routine Blood Examination
 Blood Group: B positive
 Haemoglobin : 7.8 g/dl (12- 15 g/dl)
 Total leucocytic count : 6.17 x 10^3/ µL
DLC
 Neutrophils : 52.3% (35- 72)
 Lymphocytes: 35.5% (20- 40)
 Monocytes: 9% (2-10)
 Eosinophil: 3.2% ( 1- 6)

43. • Platelets: 331 x 10^3 /ul ( 150- 400 x 10^3 / µl)
• RBS : 81 mg/ dl ( 80- 120 mg/dl)
• Serum Creatinine: 0.6 mg/dl (0.66- 1.25 mg/ dl)
• Serum TSH: 1.23 mIU/L ( 0.465- 4.68 mIU/L)
• VDRL: non reactive
• HIV-I & II: non reactive
• HBs Ag: non reactive
• Prothrombin Time: 14 sec
• aPTT: 38 sec

44.  Total bilirubin : 0.48 mg/dl ( 0.2- 1.3 mg/dl)
 Conjugated bilirubin : 0.0 mg/dl ( 0- 0.3 mg/dl)
 Unconjugated bilirubin : 0.48 mg/dl ( 0- 1.1 mg/dl)
 Aspartate transaminase(AST): 44U/L
 Alanine transaminase(ALT): 45U/L
 Alkaline phosphatase(ALKP): 250U/L
LIVER FUNCTION TESTS

45.  TUMOUR MARKER:
• CA 125: 1950 U/ml
• CEA: 349 ng/ml
• CA19-9: 73.7 U/ml
 CHEST- XRAY: Normal
 ELECTROCARDIOGRAPHY: Normal

46. ULTRASONOGRAPY
• UTERUS-
 Uterus is atrophic in size
• OVARIES-
 Both the ovaries are not traceable.
 A large multiloculated cyst of size 120*140*60mm in size is noted in the right
side. There are solid areas present in the cyst.
 No fluid is seen in the POD.
 URINARY BLADDER-
 Bladder is minimally distended.
 IMPRESSION– USG reveals
large right adnexal cystic mass
likely to be of ovarian origin.

47. FINAL DIAGNOSIS
• The patient, Borjano Gogoi, aged 65 years, is
diagnosed to be a case of right sided malignant
ovarian tumour.

48. MANAGEMENT

49. STAGING OF OVARIAN CARCINOMA

50. MANAGEMENT
• Laparatomy and maximal reduction is the primary and gold standard
treatment in all ovarian malignant tumours. Surgical Staging is followed by
definitive surgery or debulking followed by chemotherapy or radiotherapy.
• Surgical staging involves systemic exploration of the undersurface of the
diaphragm, liver, stomach, bowel and omentum. The paraaortic lymph nodes
should be palpated.

51. • Debulking:- Optimal debulking surgery is now considered treatment for
all stages of ovarian cancer.
• Borderline malignancy: Total abdominal hysterectomy and bilateral
salpingoophorectomy should be done in older women.
• Stage I and II: The operable cases should undergo total hysterectomy
and bilateral salpingo-oophorectomy with omentectomy.
• Stage III and IV: Advanced and inoperable cases will benefit from
debulking surgery and removal of the tumour.Post operative
chemotherapy improves the survival and quality of life.

52. In ovarian cancer, chemotherapy is used as-
-Neoadjuvant therapy
-Concomitant therapy
-Adjuvant therapy
Neoadjuvant (before surgery or radiotherapy) The drug shrinks the tumour, reduces
micrometastasis. Disadvantage of neoadjuvant therapy is it delays specific therapy. Drugs used
are cisplatin, carboplatin, bleomycin, ifosfamide—with 50–70% response.
Concomitant therapy (during treatment) acts as radiosensitizer, and enhances radiotherapy
effect, but increases toxicity .
Adjuvant therapy (drugs mentioned above) is employed following surgery or radiotherapy but
response to local residual/recurrence is low, because of poor vascularity of the tumour. The
distal metastasis however responds better to adjuvant chemotherapy, because of its intact
vascularity.

53. SUMMARY
• Our patient, Borjano Gogoi, 65 years old, Hindu by religion, hailing from
Kondoli, presented with a Lump in the lower abdomen for the last 1 year
and Pain in the lower abdomen for last 9 months.
• On examination, an irregular lump of 10X14 cm , hard in consistency
is felt over the lower abdomen. On percussion, a dull note is heard
over the lump.
• On bimanual examination, a lump is felt which is hard in consistency
and is immobile.

54. • USG reveals large right adnexal cystic mass likely to be a ovarian origin.
• Also the tumour markers (CA125, CEA, CA19-9) all are elevated.
• So based on the above mentioned history, clinical examination and
investigations, we have come to the conclusion that the patient is
suffering from “Right sided malignant ovarian tumour”.

55. THANK YOU