Gynecology 5th year, 5th & 6th lectures (Dr. Sallama Kamil)


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The lecture has been given on May 16th & 18th, 2011 by Dr. Sallama Kamil.

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Gynecology 5th year, 5th & 6th lectures (Dr. Sallama Kamil)

  1. 1. بسم الله الرحمن الرحيم Ovarian tumours By Dr. Sallama kamel
  2. 2. The classification of ovarian cysts and tumours: <ul><li>A.Non-neoplastic functional cysts: </li></ul><ul><li>-Follicular cysts. </li></ul><ul><li>-Leuteal cysts. </li></ul><ul><li>-Theca- lutein and granulosa lutein cysts. </li></ul><ul><li>-Endometriotic cysts. </li></ul><ul><li>B.Primary ovarian neoplasms: </li></ul><ul><li>1. Epithelial tumours ( benign, borderline or malignant): </li></ul><ul><li>-Serous tumour. </li></ul><ul><li>-Mucinous tumour. </li></ul><ul><li>-Endometrioid tumour.- </li></ul><ul><li>-Clear cell ( mesonephroid ) tumour. </li></ul><ul><li>-Brenner tumour. </li></ul><ul><li>-Undifferentiated carcinoma. </li></ul>
  3. 3. 2.Sex cord stromal tumours: <ul><li>-Granulosa cell tumour. </li></ul><ul><li>-Theca cell tumour. </li></ul><ul><li>-Fibroma. </li></ul><ul><li>-Androblastoma: sertoli-leydig cell tumour. </li></ul><ul><li>-Gynandroblastoma. </li></ul><ul><li>3.Germ cell tumour: </li></ul><ul><li>a. Benign: </li></ul><ul><li>-cystic Teratoma and </li></ul><ul><li>-solid teratoma. </li></ul><ul><li>b.Malignant: </li></ul><ul><li>-Dysgerminoma. </li></ul><ul><li>-Malignant change in cystic teratoma. </li></ul><ul><li>-Malignant solid teratoma. </li></ul><ul><li>-Non-gestational choriocarcinoma. </li></ul><ul><li>-Yolk sac tumour (endodermal sinus tumour). </li></ul><ul><li>C. Metastatic tumours: </li></ul>
  4. 4. <ul><li>Physiological cyst </li></ul><ul><li>-They are simply large versions of the cysts that forms in the ovary during the normal ovarian cycle. </li></ul><ul><li>-Most are asymptomatic and found incidentally on pelvic examination or ultrasound. </li></ul><ul><li>-They are most common in young women. </li></ul><ul><li>-They may be a complication of ovarian induction. </li></ul><ul><li>-They also occur in women with trophoblastic disease. </li></ul>
  5. 5. <ul><li>1.Follicular cysts: </li></ul><ul><li> it result from the non-rupture of a dominant follicle or the failure of atresia in a non-dominant follicle. </li></ul><ul><li>2. Luteal cysts: </li></ul><ul><li> Less common than follicular cyst. </li></ul><ul><li> Are more likely to present with intra-peritoneal bleeding. </li></ul><ul><li> They may also rupture. </li></ul><ul><li> This is usually happens on day 20-26 of the cycle. </li></ul><ul><li>3.Theca-lutein and granulosa lutein cysts. </li></ul><ul><li>-These occurs in association with Hydatidiform moles or </li></ul><ul><li>choriocarcinoma. </li></ul><ul><li>They are usually bilateral and usually resolve spontaneously after </li></ul><ul><li>evacuation of the mole. </li></ul><ul><li>-Similar cysts may formed if excessive doses of gonadotrophins or of </li></ul><ul><li>clomiphines are given to induce ovulation causing hyperstimulation </li></ul><ul><li>syndrome. </li></ul>
  6. 6. <ul><li>-In most of the cases physiological cysts resolve spontaneously and does not need any surgical interference unless they cause an acute symptoms or their size exceed 10cm. </li></ul>
  7. 7. Epithelial tumours: <ul><li>-These tumours arise from the ovarian surface epithelium. </li></ul><ul><li>-So they arise from the Coelomic epithelium overlying the embryonic gonadal ridge. </li></ul><ul><li>Since the epithelial covering of the ovary and the mullerian </li></ul><ul><li>duct ( from which the tubal, endometrial and cervical </li></ul><ul><li>epithelium are derived ) are both from coelomic epithelium , </li></ul><ul><li>comparable metaplastic transformation into different types of </li></ul><ul><li>epithelium is possible. </li></ul><ul><li>-So the cells may differentiate to endocervical cells giving rise to mucinous cystadenoma . </li></ul><ul><li>-Differentiation into endometrial cells give rise to Endometrioid tumour . </li></ul><ul><li>-Differentiation to tubal epithelium give rise to serous cystadenoma. </li></ul><ul><li>-Differentiation along uro-epithelium give rise to Brenner tumour. </li></ul><ul><li>They are most common in women over 40 years old. </li></ul>
  8. 8. 1.Serous cystadenoma: <ul><li>-These are the most common epithelial tumours with a range from benign to the highly malignant . </li></ul><ul><li>-The benign form are called benign serous cyst. </li></ul><ul><li>-It is unilocular cyst with papilliferous processes on the inner surface and occasionally on the outer surface. </li></ul><ul><li>-The lining epithelium is cuboidal or columnar and may be ciliated. </li></ul><ul><li>-The cyst contain thin serous fluid. </li></ul><ul><li>-They are usually smaller than the mucinous tumour. </li></ul><ul><li>-They are often bilateral </li></ul><ul><li>-They occur most commonly in late reproductive and early postmenopausal life. </li></ul>
  9. 9. Serous cyst adenoma
  10. 10. The malignant form called Serous papilliferous carcinoma: <ul><li>-This is the commonest primary ovarian carcinoma. </li></ul><ul><li>-It is bilateral in 50%. </li></ul><ul><li>-The growth often penetrates the capsule and project on the external surface with dissemination of the cells into the peritoneal cavity giving multiple seedling metastases and ascites. </li></ul><ul><li>-The cyst contains many papillary processes which have proliferated so much that they almost fill the cavity and there may be exophytic papillary growth on the surface. </li></ul><ul><li>-The lining cells are multilayer and may invade normal tissues. </li></ul>
  11. 11. Serous papilliferous carcinoma:
  12. 12. 2.Mucinous cystadenoma: <ul><li>-The 2 nd most common epithelial tumour. </li></ul><ul><li>-They are large, unilateral , multilocular cysts with smooth inner surface. </li></ul><ul><li>-The lining epithelium is columnar mucous-secreting cells. </li></ul><ul><li>-The cyst contain thick glutinous fluid. </li></ul><ul><li>Malignant mucinous cyst (Mucinous carcinoma): </li></ul><ul><li>Constitute 10% of ovarian cancers. </li></ul><ul><li>-On histological examination, 5% of mucinous cysts found to be malignant. </li></ul><ul><li>Epithelial tumours of borderline malignancy: </li></ul><ul><li>- mean that the tumour carry some of the features of malignancy( e.g. multilayering of cells and nuclear atypia). </li></ul><ul><li>-But there is no stromal invasion. </li></ul>
  13. 13. 3.Endometrioid cystadenoma: <ul><li>-These are very similar to ovarian endometriosis. </li></ul><ul><li>-They may be associated with pelvic pain and dyspareunia due to adhesions. </li></ul><ul><li>4.Clear cell tumours( mesonephroid): </li></ul><ul><li>-They arise from serosal cells showing little differentiation, and are only rarely benign. </li></ul><ul><li>-The typical histological appearance is of clear or hobnail cells </li></ul>
  14. 14. 5.Brenner tumours: <ul><li>Macroscopically: a Brenner tumour resembles a fibroma, being a solid tumour with a white cut surface. </li></ul><ul><li>Histologically: -It consists of islands of round transitional-like epithelium in a dense fibrotic stroma giving a solid appearance. </li></ul>
  15. 15. Germ cell tumours: <ul><li>• • It is among the commonest ovarian tumours seen in women of less than 30years old. </li></ul><ul><li>● Amongst women under 20 years ,up to 80% of ovarian malignancies are due to germ cell tumours. </li></ul><ul><li>• Overall only 2-3 percent are malignant . </li></ul><ul><li>• These tumours arise from a totipotential germ cell </li></ul><ul><li>• Thus they contain element of all three germ layer( embryonic differentiation). </li></ul><ul><li>Differentiation into embryonic tissues result in teratoma </li></ul><ul><li>(dermoid cyst). </li></ul><ul><li>• Differentiation into extra-embryonic tissues results in ovarian choriocharcinoma or endodermal sinus tumour. </li></ul><ul><li>• When neither embryonic nor extra-embryonic differentiation occurs, dysgerminoma results . </li></ul>
  16. 16. Dermoid cyst (mature cystic teratoma) <ul><li>-This is the commonest germ cell tumour and it is benign. </li></ul><ul><li>-It results from differentiation into embryonic tissues. </li></ul><ul><li>-It account for about 40% of all ovarian neoplasm. </li></ul><ul><li>-It is most common in young women and the median age of presentation is 30 years old. </li></ul><ul><li>-it contain a variety of tissues derived from the two or more of the primary germ layers.. </li></ul><ul><li>-The dermoid cyst is usually unillocular cyst. </li></ul><ul><li>-Less than 15cm in diameter </li></ul><ul><li>-It is often lined by epithelium like the epidermis and contain skin appendages, teeth , sebaceous material , hair and nervous tissues, cartilage bone and thyroid tissues. </li></ul><ul><li>-The cavity of the cyst contain yellow greasy material. </li></ul>
  17. 17. <ul><li>-The majority of dermoid cysts (60%) are asymptomatic. </li></ul><ul><li>-However it may undergo torsion. </li></ul><ul><li>-Less commonly it may rupture spontaneously, either suddenly causing an acute abdomen and chemical peritonitis, or slowly causing chronic granulomatous peritonitis. </li></ul><ul><li>-During pregnancy, rupture is more common due to external pressure from expanding gravid uterus or to trauma during delivery. </li></ul><ul><li>Mature solid teratoma: </li></ul><ul><li>-These are tumours contain mature tissues just like the dermoid cyst but are solid. </li></ul>
  18. 18. Mature cystic teratoma
  19. 19. Malignant germ cell tumours: <ul><li>These are rare tumours accounting for only 3% of ovarian cancers. </li></ul><ul><li>1.Dysgerminoma: </li></ul><ul><li>2.Yolk sac tumour ( endodermal sinus tumour). Secret alpha feto protein </li></ul><ul><li>3.Immature Solid teratoma: </li></ul><ul><li>4.Non gestational choriocarcinoma: secret HCG. </li></ul>
  20. 20. sex cord stromal tumours: <ul><li>-These account for only 4% of benign ovarian tumours. </li></ul><ul><li>-They occur at any age from prepubertal children to elderly, postmenopausal women. </li></ul><ul><li>-They secrete hormones and present with the results of inappropriate hormone effects. </li></ul><ul><li>1.Granulosa cell tumours: secret estrogen. </li></ul><ul><li>2.Theca cell tumours: also secret estrogen. </li></ul><ul><li>3.Fibroma: - </li></ul><ul><li>Meig ’ s syndrome ( ascites , pleural effusion in association with a fibroma of the ovary) is seen in only 1% of cases. </li></ul><ul><li>4.Sertoli- leydig cell tumours: </li></ul>
  21. 21. <ul><li>Clinical presentation of ovarian tumours </li></ul><ul><li>-Asymptomatic. </li></ul><ul><li>-Pain. </li></ul><ul><li>-Abdominal swelling. </li></ul><ul><li>-Pressure effects. </li></ul><ul><li>-Menstrual disturbances. </li></ul><ul><li>-Hormonal effects. </li></ul><ul><li>-Abnormal cervical smear. </li></ul>
  22. 22. 1.Asymptomatic: <ul><li>Many benign ovarian tumours are found incidentally in the course of investigating another unrelated problem or during a routine examination. </li></ul><ul><li>2.Pain : </li></ul><ul><li>-Acute pain from an ovarian tumour may result from </li></ul><ul><li>complication e.g. torsion, rupture, haemorrhage or infection. </li></ul><ul><li>-Torsion give rise to a sharp, constant pain caused by </li></ul><ul><li>ischaemia of the cyst and areas may become infarcted. </li></ul><ul><li>- Haemorrhage into the cyst may cause pain as the capsule is </li></ul><ul><li>stretched. </li></ul><ul><li>- Rupture of the cyst causes intraperitoneal bleeding mimicking </li></ul><ul><li>ectopic pregnancy (this happens mostly with a luteal cyst ). </li></ul>
  23. 23. 3.Abdominal swelling: <ul><li>-Patients seldom note abdominal swelling until the tumour is very large . </li></ul><ul><li>-A benign mucinous cyst may occasionally fill the entire abdominal cavity. </li></ul><ul><li>4. pressure effects. </li></ul><ul><li>-Gastro-intestinal or urinary symptoms may result from pressure of large tumour. </li></ul><ul><li>-In extreme cases, oedema of the legs, varicose veins and haemorrhoids may result. </li></ul><ul><li>5.menstrual disturbances: </li></ul><ul><li>Occasionally the patient will complain of menstrual disturbances but this may coincidence rather than due to the tumour. </li></ul>
  24. 24. 6.hormonal effects : <ul><li>-rarely Sex cord tumours may present with oestrogens effects such as precocious puberty, menorrhagia and glandular hyperplasia, breast enlargement and postmenopausal bleeding. </li></ul><ul><li>-Secretion of androgens may cause hirsuitism and acne initially progressing to frank virilism with deepening of the voice or clitoral hypertrophy. </li></ul>
  25. 25. Diagnosis: <ul><li>1.Full history: </li></ul><ul><li>-Details of the presenting symptoms and a full gynaecological history </li></ul><ul><li>should be obtained with particular reference to the date of the last </li></ul><ul><li>menstrual period , the regularity of the cycle, any previous </li></ul><ul><li>pregnancies , contraception, medication and family history </li></ul><ul><li>( particularly of ovarian, breast and bowel cancer ). </li></ul><ul><li>2.Examination ( abdominal and pelvic examination): </li></ul><ul><li>-If the patient presented with acute abdomen look for evidence of </li></ul><ul><li>hypovolaemia. </li></ul><ul><li>-The neck , axilla and groins should be examined for lymphadenopathy. </li></ul><ul><li>-A malignant ovarian tumour may cause a pleural effusion. </li></ul><ul><li>-This is much less commonly found with benign tumour. </li></ul><ul><li>-Also some patient may have ankle oedema. </li></ul><ul><li>-The abdomen should be inspected for distension by fluid (ascites) or </li></ul><ul><li>by the tumour itself. </li></ul><ul><li>-A male distribution of hair may suggest a rare androgen-producing </li></ul><ul><li>tumours. </li></ul>
  26. 26. Bimanual examination: <ul><li>-This is an essential part of assessment. </li></ul><ul><li>-To palpate the mass , its mobility, consistency. </li></ul><ul><li>-Presence of nodules in the pouch of Douglas and the degree of tenderness. </li></ul><ul><li>-A cystic mobile mass is mostly benign, </li></ul><ul><li>while a hard, irregular fixed mass is likely to be malignant. </li></ul>
  27. 27. Investigations: <ul><li>1.Ultrasound </li></ul><ul><li>-Trans-abdominal and trans-vaginal ultrasound can demonstrate the presence of an ovarian mass with reasonable sensitivity and specificity. </li></ul><ul><li>- However it can not distinguish reliably between benign and malignant tumours but solid masses are more likely to be malignant than the purely cystic mass. </li></ul><ul><li>-The use of colour- flow Doppler may increase the reliability of ultrasound. </li></ul><ul><li>-CT scan and MRI can be used but are more expensive. </li></ul>
  28. 28. 2.Radiological investigations: <ul><li>-A chest X- ray is essential to detect metastatic disease in the lungs or a pleural effusion . </li></ul><ul><li>-Occasionally an abdominal X-ray may show calcification, suggesting the possibility of a benign teratoma. </li></ul><ul><li>-A barium enema is indicated only if the mass is irregular or fixed, or if there are bowel symptoms. </li></ul><ul><li>3.Blood test and serum markers: </li></ul><ul><li>- Elevated WBC count may indicate infection. </li></ul><ul><li>- Ca 125 </li></ul><ul><li>Raised serum Ca 125 is strongly suggestive of ovarian carcinoma, especially in postmenopausal women. </li></ul>
  29. 29. <ul><li>- B-HCG level is elevated in women with choriocarcinoma. </li></ul><ul><li>-Oestradiol levels may be elevated in some women with physiological follicular cysts and sex cord stromal tumours. </li></ul><ul><li>-Androgens are increased with Sertoli-lydig tumours. </li></ul><ul><li>- Raised alpha-fetoprotein levels suggest a yolk sac tumour. </li></ul>
  30. 30. Management of benign ovarian tumours: <ul><li>This will depend upon the </li></ul><ul><li>-Severity of the symptoms. </li></ul><ul><li>-Age of the patient . </li></ul><ul><li>-The risk of malignancy. </li></ul><ul><li>-Her desire for future pregnancy. </li></ul><ul><li>The asymptomatic women: </li></ul><ul><li>The older women : </li></ul><ul><li>-Women over 50 years of age are more likely to have a malignancy so surgery is usually indicated. </li></ul>
  31. 31. <ul><li>In pre-menopausal women: </li></ul><ul><li>-Young women of less than 35 years are both more likely to wish to have further children and are less likely to have malignant epithelial tumour. </li></ul><ul><li>-A clear unilocular cyst of 3-10 cm identified </li></ul><ul><li>by ultrasound should be re- examined after </li></ul><ul><li>12 weeks for evidence of diminution in size . </li></ul>
  32. 32. - If the cysts persists, such women may be followed with a six-monthly ultrasound and Ca125 estimations. <ul><li>-If the cyst does enlarge , laparoscopy or laparotomy may be indicated. </li></ul><ul><li>.A cyst of more than 10 cm is unlikely to be physiological or to resolve spontaneously and operation indicated. </li></ul><ul><li>-The use of combined oral contraceptive pills is unlikely to accelerate the resolution of a functional cyst. </li></ul><ul><li>The patient with symptoms: </li></ul><ul><li>If the patient present with severe acute pain or signs of </li></ul><ul><li>intraperitoneal bleeding an emergency laparoscopy or </li></ul><ul><li>laparotomy will be required. </li></ul>
  33. 33. The pregnant patient: <ul><li>-An ovarian cyst in pregnant women may undergo torsion or may bleed. </li></ul><ul><li>-The pregnant women with an ovarian cyst is a special case because of the risk of surgery to the fetus. </li></ul><ul><li>- Thus if the patient present with acute pain due to torsion or haemorrhage into an ovarian cyst or if appendicitis is a possibility, the correct course is to undertake a laparotomy regardless the stage of the pregnancy. </li></ul><ul><li>-The operation should be covered with by tocolytic drugs and performed in a center with intensive neonatal care. </li></ul><ul><li>-If asymptomatic cyst is discovered during the 1 st trimester , it is prudent to wait until after 14 weeks ’ gestation before removing it. </li></ul>
  34. 34. -This avoids the risk of removing a corpus luteal cyst upon which the pregnancy might still be dependent. <ul><li>-In the 2 nd and 3 rd trimesters , the management of an asymptomatic ovarian cyst may be either conservative or surgical. </li></ul><ul><li>-Cysts < 10cm , which have simple appearance on U/S , are unlikely to be malignant or to result in cyst accident and may therefore be followed by U/S. </li></ul><ul><li>-Many may resolve spontaneously . </li></ul><ul><li>-If the cyst unresolved 6 weeks postpartum , surgery indicated. </li></ul>
  35. 35. -Malignancy is uncommon in pregnancy occurring in less than 3% of the cysts. <ul><li>-However a cyst with a features suggestive of malignancy on </li></ul><ul><li>U/S , or one that is growing, should be removed surgically. </li></ul><ul><li>-The tumour marker C 125 is not useful in pregnancy since it may be </li></ul><ul><li>elevated in normal pregnancies. </li></ul><ul><li>Prepupertal girl: </li></ul><ul><li>-Ovarian cysts are uncommon and often benign. </li></ul><ul><li>-Teratoma and follicular cysts are the most common. </li></ul><ul><li>-Presentation may be abdominal pain, distension or precocious puberty. </li></ul><ul><li>-Management depends on: </li></ul><ul><li>-relief of symptoms. </li></ul><ul><li>-exclusion of malignancy and </li></ul><ul><li>-conservation of maximum ovarian tissue without depressing fertility. </li></ul>
  36. 36. Types of surgery for apparently benign ovarian tumours: <ul><li>For young women less than 35 years: </li></ul><ul><li>1.Cystectomy ( removal of the cyst only). </li></ul><ul><li>2.Oophorectomy( removal of the ovary with the cyst). </li></ul><ul><li>For woman more than 45 years with ovarian cyst more than 6cm in diameter it is advisable to do total abdominal hysterectomy and bilateral salpingo-oopgorectomy. </li></ul>
  37. 37. Malignant disease of the ovary: <ul><li>-Most ovarian tumours are of epithelial origin. </li></ul><ul><li>-They are rare before the age of 35 years, but the incidence increases with age to a peak in the 50-70 years. </li></ul><ul><li>-Most epithelial tumours are not discovered until they have spread widely. </li></ul><ul><li>-Surgery and chemotherapy forms the main stay of treatment. </li></ul><ul><li>The results are poor. </li></ul><ul><li>-The 5 year survival is less than 25%. </li></ul><ul><li>-Only 3 % of ovarian cancers are seen in women younger than 35 years and most are non-epithelial cancers such as germ cell tumours. </li></ul>
  38. 38. Risk factors predisposing for ovarian cancer: <ul><li>Continuous ovulation increase the risk as in: </li></ul><ul><li>1.Nulliparity. </li></ul><ul><li>2.Early menarche and Late menopause , both of these are associated </li></ul><ul><li>with long estimated numbers of years of ovulation. </li></ul><ul><li>3.increasing age at first birth. </li></ul><ul><li>4.The prolonged use of drugs for induction of ovulation. </li></ul><ul><li>5.Exposure to environmental substances e.g. Talc and asbestoses. </li></ul><ul><li>6.Family history of ovarian cancer: </li></ul><ul><li>There is a family history in 5-10 % of women with epithelial cancers. </li></ul><ul><li>A woman with one affected close relative has risk of 2.5% </li></ul><ul><li>With two affected close relatives the risk increase to 30-40%. </li></ul><ul><li>-Breast feeding reduce the risk. </li></ul><ul><li>-Also Oral contraceptive use reduces the risk by 50% after 5years of use. </li></ul>
  39. 39. Staging of ovarian cancer (FIGO staging ): <ul><li>The staging of ovarian cancer is a clinical staging </li></ul><ul><li>Stage 1 growth limited to the ovaries. </li></ul><ul><li>Ia growth limited to one ovary. </li></ul><ul><li>No ascites, no tumour on external surfaces ; capsule intact. </li></ul><ul><li>Ib tumour limited to both ovaries . </li></ul><ul><li>No ascites, no tumour on external surfaces; capsule intact. </li></ul><ul><li>Ic either stage 1a or 1b with ascites contain malignant cells or tumour on the surface of one or both ovaries. </li></ul><ul><li>Stage II : growth involving one or both ovaries with pelvic extension. </li></ul><ul><li>Stage III: growth involving one or both ovaries with peritoneal implants outside the pelvis or positive retroperitoneal or inguinal lymph nodes or superficial liver metastasis </li></ul><ul><li>Stage IV : growth involving one or both ovaries with distant </li></ul><ul><li>metastasis,parenchymal liver metastasis equal stage 1V. </li></ul>
  40. 40. Spread of ovarian malignancies: <ul><li>- direct spread: usually to the pelvic peritoneum and other pelvic organs ( uterus and broad ligament ). </li></ul><ul><li>-Lymphatic spread commonly involves the pelvic and the para-aortic nodes. </li></ul><ul><li>Spread may also involves the nodes of the neck or inguinal region. </li></ul><ul><li>-Haematogenous spread </li></ul><ul><li>-usually occurs late and involves mainly the liver, and lung. </li></ul><ul><li>-Bone and brain metastasis sometimes seen. </li></ul>
  41. 41. Presentation and diagnosis: <ul><li>- Vague abdominal pain or discomfort is the commonest presenting complaint. </li></ul><ul><li>-Distension or feeling a lump is the next most frequent. </li></ul><ul><li>-The patient may complain of: </li></ul><ul><li>*Indigestion. </li></ul><ul><li>*Urinary frequency. </li></ul><ul><li>*Weight loss. </li></ul><ul><li>-Or rarely abnormal menses or postmenopausal bleeding. </li></ul><ul><li>A hard abdominal mass arising from the pelvis is highly suggestive especially with ascites. </li></ul><ul><li>-A fixed, hard, irregular pelvic mass is usually felt best by combined vaginal and rectal examination. </li></ul><ul><li>The neck and groin should also be examined for enlarged nodes. </li></ul>
  42. 42. Investigations : <ul><li>1.full blood count. </li></ul><ul><li>2.Urea, electrolyte and liver function test. </li></ul><ul><li>3.Chest x-ray. </li></ul><ul><li>4.Sometimes, barium enema and colonoscopy is needed to differentiate between an ovarian and a colonic tumour or to assess bowel involvement. </li></ul><ul><li>5.IVP (intravenous urography). </li></ul><ul><li>6.Ultrasonography may help to confirm the presence of a pelvic .mass and detect ascites. </li></ul><ul><li>7.Tumour markers e.g. Ca 125. </li></ul><ul><li>8.In most women the diagnosis is uncertain before laparotomy is undertaken. </li></ul>
  43. 43. Surgery : <ul><li>-Surgery is the mainstay of both the diagnosis and the treatment of ovarian cancer. </li></ul><ul><li>-A vertical incision is required for an adequate exploration of the upper abdomen. </li></ul><ul><li>-A sample of ascitic fluid or peritoneal washings with normal saline should be taken for cytology. </li></ul><ul><li>-The pelvis and upper abdomen are explored carefully to identify metastatic disease. </li></ul><ul><li>-The therapeutic objective of surgery for ovarian cancer is the removal of all tumour tissues. </li></ul><ul><li>-This is usually possible in the majority of stage I and stage II, but impossible in advanced cases. </li></ul>
  44. 44. To resect all visible tumour requires a total hysterectomy, bilateral salpingo-oophorectomy and infra-colic omentectomy. <ul><li>-However , in a young , nulliparous woman with unilateral tumour and no ascites ( stage Ia ), unilateral salpingo-oophorectomy may be done after careful exploration to exclude metastatic disease , and curettage of the uterine cavity to exclude a synchronous endometrial tumour. </li></ul><ul><li>-If the is subsequently found to be poorly differentiated or if the washings are positive, a second operation to clear the pelvis will be necessary. </li></ul>
  45. 45. <ul><li>- For older women who complete her family a total hysterectomy and bilateral salpingo-oophorectomy is usually done. </li></ul><ul><li>Chemotherapy: </li></ul><ul><li>-Women with stage Ia or Ib and well or moderately differentiated tumours will not require further treatment. </li></ul><ul><li>-All other patient with invasive ovarian carcinoma require chemotherapy (stage II-IV – possibly stage Ic ). </li></ul><ul><li>-There is no evidence that adjuvant therapy affects the outcome in women with borderline tumour. </li></ul><ul><li>-Drugs used are Carboplatin, cisplatin and taxol. </li></ul>
  46. 46. Prognosis: <ul><li>Borderline tumour: </li></ul><ul><li>Long term prognosis excellent in most cases. </li></ul><ul><li>Invasive tumours- 5 year survival rates. </li></ul><ul><li>-90% for Stage Ia and 1b ( well or moderately differentiated ). </li></ul><ul><li>-10 % for stage III. </li></ul><ul><li>-23% overall. </li></ul>
  47. 47. <ul><li>THANK YOU </li></ul>