Dr M.C.Bansal Ovarian MalignancyMBBS.,MS.FICOG.MICOG.
Epidemology 2nd most common of all genital cancers , accounts for 10-15 %incidence.In last 2 decades its incidence as well as survival rate has increased.The risk of woman developing ovarian cancer in her life time is 1:70to 1: 100.Women with low parity, infertility and delayed child bearingpredisposes higher chances.5-10% ovarian tumors are genaticaly affected ---BRACE_1&@mutations on chromosome 17 & 13 respectively . if one familymember is affected, the life long risk is 2.7% but it goer up to 13%with2 or more sibblings. They develop at earlier age < 40 years.. Inheritance pattern is autosomal dominant. The risk increases withadvancing age up to 70 years.Induction of ovulation, industrial pollution, talc use at perineum, Highdietary fat , western world have increased incidencesstreak ovaries, mums infection at puberty leading to prematureovarian failure.
Epidemology---- Protective factors Multiparity , ocs ,Breast feeding,anovulation ,Prophylactic oopherectomy.Late diagnosis and early metastasis are responsible forpoor prognosis.80% malignancies are of epithelial origion,.almost 80%report in late stage iii or iv .80% are primary carcinoma.20% are secondary form.Before menarche 10% are malignant.During reproductive period15% are malignant., but risesto > 50% after menopause.
Pathology• Epitehelial ovarian carcinoma---80-90% Papillary cystadenocarcinoma Mucinous cystadenocarcnoma• Nonepethelial carcinoma---10-20% these include malignancy of (A) Germcells (2)Sex cord stromal(3)Metastatic (4) Rare malignancy like Sarcoma, lipoid cell carcinoma.
Coincidence of uterine and ovarian cancer• In some cases primary lies in uterus and direct spread to ovaries• Primary in ovary and secondaries in uterus.• Estrogen / and progesteron producing tumor of ovary and primary cancer endometrium.• Cancer present in uterus and cancer in ovary are histologicaly different.• Theerfore extended hysterectomy along with bilateral oopherectomy should always be done in either case’
Spread• Lymphatic--- Para -aortic Lymph Nodes and superior gastric , mediastinal---pleural effusion , supra-clavicular.• Blood spread---uncommon---lungs• Direct spread through peritoneum----Rupture capsule—exfoliation of malignant cells, peritoneal irritation---ascites, omental cake., intestine, parietal, visceral peritoneum-- -- liver spleen, dome of diaphragm, uterus, tubes.
Management• Laparotomy and maximal removal of cancer tissue----intra operative staging, cytology of ascitic fluid, pan hysterectomy, partial or complete omantectomy, enucleation of cancer growth on parietal and visceral peritoneum with out perforating the viscera.• If non operable---intra peritoneal instillation of radioisotopes (p34)or chemotherapeutic agent.• Chemotherapy---followed by second look laparotomy to remove uterus ,ovaries ,omantum and any residual cancer tissue.• Radiotherapy for nodal metastasis.• Stem cell Therapy.• Immunotherapy.• Palliative therapy –to relieve pain(opiates/NSAIDs, nutritional supplimentaton(callories, proteins to keep Hb > 10 gm% and wt loss < 10 %), psychological support , symptomatic
Role of Laparoscopy in the Clinical Management of Ovarian CancerAt present, the role of laparoscopy in the management of ovarian cancer is evolving. There are several clinical settings in which the potential for this surgical modality has been investigated(a) primary surgery for early-stage ovarian cancer(b) restaging of unstaged ovarian cancer(c) primary cytoreductive surgery for advanced-stage ovariancancer(d) assessment of resectability(e) intra-peritoneal catheter placement(f) second-look surgery(g) secondary cytoreductive surgery.
STRATEGIES TO REDUCE THE INCIDENCE OF GENITAL TRACT MALIGNANCIES• First injection at elected time.• Second injection 2 months later.• Third injection 6 months after the first injection.• The cost of each injection is $200, and immunity is expected to last 5 years. The only benefit as seen today is a longer interval of screening in HPV- negative women. page 429 page 430 There have been advances in strategies evolved to reduce the incidence of genital cancers. The following are notable amongst these: 1. The role and value of periodic Pap smear tests is well-established in reducing the incidence of invasive carcinoma of the cervix.• 2. Evaluation of abnormal Pap tests with colposcopy-directed biopsies has enabled the diagnosis of intraepithelial cancers and diagnosis of early invasive cancer of the cervix.
• 3. The practice of preferring total over subtotal hysterectomy for benign diseases (fibroids, adenomyosis, dysfunctional uterine bleeding- DUB) protects against risk of future cervical stump carcinoma estimated to occur in 2% of cases.• 4. Early diagnosis of sexually transmitted diseases (STDs) and their eradication. Herpes and HPV infections render an individual prone to cancer of vulva and the cervix. Barrier contraceptives protect against STD as well as cervical cancer.• 5. HPV vaccine is now available which may eradicate lower genital tract malignancies in young women. The available vaccine is type specific and therefore protective in only 60-70%.• 6. The treatment of cervical dysplasia by CO2 laser/conization for CIN lesions.
• 7. Addition of progestogens to oestrogens in hormone replacement therapy (HRT) reduces the risks of uterine endometrial cancer.• 8. Thorough investigation of a woman with postmenopausal bleeding often brings to light early unsuspected endometrial/ovarian/tubal cancers.• 9. The practice of routine removal of both ovaries when performing hysterectomy for benign conditions after the age of 50 years is a prophylaxis against risk of future ovarian cancer. Prophylactic oophorectomy in a genetically predisposed woman is recommended, though premature menopause remains a risk. This also reduces breast cancer by 50%.
• 10. Early diagnosis of ovarian cancer is the primary objective for long-term survival, though this is not obtained as of today. Seventy-five per cent tumours are advanced when diagnosed.• 11. Oral combined pills reduce the incidence of uterine and ovarian cancer by 40-50%. Barrier contraceptives prevent cervical cancer.• 12. Gene study can select women at high risk for cancer.
• 13. Evaluation of adnexal masses with scans, Doppler velocimetric studies, and CA-125 tumour marker to diagnose ovarian cancer.• 14. Hysteroscopy/laparoscopy/selective biopsies of suspicious lesions.• 15. Routine mammography for all women over the age of 40 years, earlier whenever clinical examination reveals a doubtful lump, or in women with strong family history of breast cancer.• For many women the obstetrician-gynaecologist is likely to be the only physician to provide them healthcare. Hence the importance of developing skills for evaluation and counselling for genital cancers and adopting clinical practices which reduce the future risks of genital cancers lies with the gynaecologists.
KEY POINTS• Vulval intraepithelial neoplasia (VIN) is a well-recognized entity which can be effectively treated by conservative surgery.• Vulval cancer, mostly squamous cell carcinoma, is encountered in 2-4% of all genital tract malignancies. An elderly woman of low parity and associated with previous STD is the high-risk case.• The treatment of vulval cancer is based on the age of the woman, type and extent of the lesion and involvement of the regional lymph nodes. Local wide excision, skinning vulvectomy with split skin graft, laser therapy and simple or radical vulvectomy have improved the survival rate without increasing the surgical morbidity.
• Endometrial cancer is the disease of the perimenopausal and postmenopausal women with low parity.• Endometrial cancer is fast becoming the more common cancer in women. Early menarche, late menopause, small family size, obesity, carbohydrate intolerance, PCOD-related infertility and unsupervised HRT in menopausal women contribute to its occurrence.• Oestrogen therapy, tamoxifen cause hyperplasia and endometrial cancer over a period of time. Oral combined pills have a protective effect and reduce the incidence by 40-50%.
• CT and MRI help in preoperative staging and determine the extent of spread of malignancy. Hysteroscopic evaluation and biopsy improve the diagnostic accuracy.• Abdominal hysterectomy with bilateral salpingo- oophorectomy, peritoneal washing and omental biopsy form the primary surgical therapy in early stages.• Radiotherapy and chemotherapy are recommended in the advanced stage of the disease and are also adjuvants to surgery.
• Progestogens are beneficial in advanced stages of endometrial cancer and pulmonary metastasis.• Carcinoma of the cervix is the most common genital tract cancer in women and ranks second to the breast cancer. It occurs in younger women.• Late marriage, contraception, small family size, improved personal hygiene, avoidance of extramarital relationships and regular gynaecological check-ups inclusive of a Pap test and colposcopy have contributed to the lowering of its incidence.• Endometrial cancer developing in a woman following unopposed oestrogen uptake is well-differentiated and less invasive with better prognosis. It also responds well to progestogens.
• Endocervical cancer has different aetiology and requires chemotherapy with radiotherapy, followed by radical surgery.• Fallopian tube cancer is rare, and is often mistaken for ovarian cancer. It is treated the same way as ovarian cancer.• Ovarian cancer is the second most common genital cancer. It remains asymptomatic for a long time. Many cases are already far advanced at the time of diagnosis. Germ cell tumours and mesenchymomas are known to occur in younger women. Epithelial tumours occur in older women. Surgical removal is adequate treatment for cases of borderline malignancy. Surgery followed by chemotherapy is indicated in advanced cases.• The gold standard is abdominal hysterectomy and bilateral salpingo-oophorectomy with omentectomy in the early and operative cases of ovarian cancer. Debulking, radiotherapy and chemotherapy prolong life and duration of remission.