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15

  1. 1. OVARIAN CANCER Di Wen, M.D.,Ph.D
  2. 2. <ul><li>Definition </li></ul><ul><li>Ovarian tumors may arise at any age, but are commonest between 30 and 60. </li></ul><ul><li>1.Ovarian tumors are particularly liable to be or to become malignant. </li></ul><ul><li>2.In their early stages they are asymptomatic and painless. </li></ul><ul><li>3.They may grow to a large size and tend to undergo mechanical complications such as torsion and perforation. </li></ul>OVARIAN TUMOURS
  3. 3. <ul><li>Definition </li></ul><ul><li>In developed countries , women have a lifetime risk of developing ovarian cancer of about 1.4% , which is slightly greater than the risk of cervical or endometrial cancers, but well below the 7% average risk of breast cancer . </li></ul>CARCINOMA OF THE OVARY
  4. 4. <ul><li>Risk Factor </li></ul><ul><li>Genetic factor are sometimes involved 、 as in the Lynch Syndrome of familial breast colorectal and ovarian cancer . Ovulation induction with Clomiphene over more than year carries a l0-fold increased risk of ovarian cancer, Long-term ora1 contraceptive use reduces the incidence of ovarian cancers . </li></ul>CARCINOMA OF THE OVARY
  5. 5. <ul><li>Incidence </li></ul><ul><li>Nearly 25% of all ovarian neoplasm are malignant . Approximately 80 % of them are primary growths of the ovary 、 the remainder being secondary , usually carcinomata . </li></ul>CARCINOMA OF THE OVARY
  6. 6. <ul><li>Primary Carcinoma of the Ovary </li></ul><ul><li>80 % of all cases of primary carcinoma of the ovary arise in serous or mucinous cysts. </li></ul>CARCINOMA OF THE OVARY
  7. 7. <ul><li>Solid Carcinoma of the Ovary </li></ul><ul><li>This accounts for 10% of primary carcinoma. It is arise commonly bilateral but one tumor is usually larger than the other. The ovarian shape is retained for a time and there is a well-marked pedicle but soon the tumors become fixed. Secondary deposits occur in the omentum and ascites develops. </li></ul>CARCINOMA OF THE OVARY
  8. 8. <ul><li>Symptoms due to Size </li></ul><ul><li>Lack of any specific symptoms, ovarian tumors are often large by the time the doctor is consulted. </li></ul>CLINICAL FEATURES OF OVARIAN TUMOURS
  9. 9. <ul><li>Menstrual function is seldom upset, and any irregularity is attributed to the patient’s ‘time of life ’. </li></ul>
  10. 10. <ul><li>She may have noticed that her clothes are getting tight ant attributed this to weight gain or, if the abdominal swelling has coincided with amenorrhea she may believe herself to be pregnant. </li></ul>
  11. 11. <ul><li>Pressure Symptoms </li></ul><ul><li>These are commonly increased frequency of micturition , gastro-intestinal symptoms and a dull pain in the lower abdomen. Very large tumors may cause respiratory embarrassment and edema or varicosities in the legs, and a characteristic ‘ ovarian cachexia’ develops, due perhaps to interference with alimentary function. </li></ul>CLINICAL FEATURES OF OVARIAN TUMOURS
  12. 12. CLINICAL FEATURES OF OVARIAN TUMOURS
  13. 13. CLINICAL FEATURES OF OVARIAN TUMOURS
  14. 14. CLINICAL FEATURES OF OVARIAN TUMOURS
  15. 15. CLINICAL FEATURES OF OVARIAN TUMOURS
  16. 16. <ul><li>General rule </li></ul><ul><li>An experienced examiner will recognize an ovarian tumor mainly because ovarian tumor is, in the circumstances, the most likely diagnosis. All abdominal swellings should be subjected to ultrasound and X-ray examination. </li></ul>DIFFERENTIAL DIAGNOSIS
  17. 17. DIFFERENTIAL DIAGNOSIS
  18. 18. <ul><li>ASCITES </li></ul><ul><li>A fluid thrill may be elicited from an ovarian cyst, and ascites and tumor may coexist; but as a rule the distinction should be easily made. </li></ul>DIFFERENTIAL DIAGNOSIS
  19. 19. DIFFERENTIAL DIAGNOSIS
  20. 20. <ul><li>Uterine Fibroids </li></ul><ul><li>A large midline intramural fibroid may be impossible to distinguish from a solid ovarian tumor until the abdomen is opened and an entirely different surgical problem encountered. </li></ul>DIFFERENTIAL DIAGNOSIS
  21. 21. DIFFERENTIAL DIAGNOSIS
  22. 22. DIFFERENTIAL DIAGNOSIS
  23. 23. DIFFERENTIAL DIAGNOSIS
  24. 24. DIFFERENTIAL DIAGNOSIS
  25. 25. DIFFERENTIAL DIAGNOSIS
  26. 26. <ul><li>Complications of Ovarian Tumors </li></ul><ul><li>This is the commonest complication and may occur with any tumor except those with adhesions. The thin-walled veins of the pedicle are obstructed first while the arterial supply continues. As a result there is hemorrhage into the tumor and into the peritoneum, and if not treated gangrene will occur. Very rarely the pedicle atrophies and the tumor obtains a new blood supply through its adhesions to surrounding viscera (parasitic tumor). </li></ul>TORSION of the PEDICLE
  27. 27. TORSION of the PEDICLE
  28. 28. <ul><li>Clinical Features </li></ul><ul><li>Subacute </li></ul><ul><li>The patient complains of recurrent abdominal pain which passes off as the pedicle untwists. There is a rise in pulse and temperature during the bleeding; and over a period anemia develops. </li></ul>TORSION of the PEDICLE
  29. 29. <ul><li>Clinical Features </li></ul><ul><li>Acute </li></ul><ul><li>The signs and symptoms are those of an acute abdominal condition. The problem becomes one of differential diagnosis to exclude those conditions in which laparotomy is not needed and laparoscopy may be useful. </li></ul><ul><li>Pain tends to be intense and continuous. </li></ul>TORSION of the PEDICLE
  30. 30. <ul><li>Clinical Features </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>‘ Surgical Conditions’ (i.e. those conditions commonly seen and dealt with by a general surgeon.) </li></ul><ul><li>Acute appendicitis </li></ul><ul><li>Meckel’s diverticulitis </li></ul><ul><li>Obstruction of bowel </li></ul><ul><li>Diverticulitis </li></ul>TORSION of the PEDICLE
  31. 31. <ul><li>Ruptured Cyst </li></ul><ul><li>This may occur alone or in conjunction with torsion. Rupture is not particularly upsetting to the patient unless the contents are irritant. </li></ul>TORSION of the PEDICLE
  32. 32. TORSION of the PEDICLE
  33. 33. TORSION of the PEDICLE
  34. 34. RUPTURE OF OVARIAN CYST
  35. 35. RUPTURE OF OVARIAN CYST RUPTURE OF OVARIAN CYST RUPTURE OF OVARIAN CYST
  36. 36. <ul><li>PSEUDOMYXOMA PERITONEI </li></ul><ul><li>This rare condition occasionally but not inevitably follows mthe rupture of a mucinous cystadenoma. The epithelial cells implant on the peritoneum and continue to secrete a gelatinous pseudomucin which is not absorbed, or secretion is faster than absorption. The abdominal cavity is eventually filled with the jelly, while the secreting cells spread over the parietal and visceral peritoneum. </li></ul>RUPTURE OF OVARIAN CYST
  37. 37. <ul><li>HYDROTHORAX </li></ul><ul><li>Hydrothorax may accompany ascites due to any cause, or may occur as an accompaniment of a lung tumor. The so-called Meigs’ syndrome describes the specific condition of ascites and hydrothorax in conjunction with benign ovarian fibroma. </li></ul>RUPTURE OF OVARIAN CYST
  38. 38. <ul><li>Features suggestive of malignancy </li></ul><ul><li>1. Age. If the patient is over 50 the chance of malignancy is over 50% as opposed to less than 15% in premenopausal women. Tumors in childhood are usually malignant. </li></ul><ul><li>2. Rapid growth. </li></ul><ul><li>3. Ascites. </li></ul>
  39. 39. <ul><li>Features suggestive of malignancy </li></ul><ul><li>4. Solid tumours , especially when bilateral. </li></ul><ul><li>5. Multilocular cysts with solid areas. (At least 10% of cysts are malignant). </li></ul><ul><li>6. Pain . Pressure pain can occur with any tumor; but referred pain suggests malignant involvement of nerve roots. </li></ul><ul><li>7. Tumor markers , such as CA125, may be measured in the blood, but a normal level does not exclude malignancy. </li></ul>
  40. 40. <ul><li>Histological Classification </li></ul><ul><li>Most tumors arise from the ovarian stroma and germinal epithelium. The embryonic coelom from which that epithelium develops also gives rise to the Mullerian duct from which develop the structures of the genital tract, and it is this common origin which explains the great variety of epithelial patterns which are met with. </li></ul>OVARIAN TUMOURS
  41. 41. <ul><li>PRIMARY EPITHELIAL TUMOR </li></ul><ul><li>1.Mucinous cystadenoma or cystadencarcinoma (of. Cervical epithelium). </li></ul><ul><li>2.Serous cystadenoma or cystadenocarcinoma (of . tubal epithelium). </li></ul><ul><li>3.Endometrioma or Endometrioid carcinoma (of. Endometrium). </li></ul><ul><li>4.Clear cell carcinoma. </li></ul><ul><li>5.Brenner tumour. </li></ul>OVARIAN TUMOURS
  42. 42. <ul><li>STROMATOUS TUMOURS GERM CELL TUMOURS </li></ul><ul><ul><li>.Fibroma or sarcoma. </li></ul></ul><ul><ul><li>.Dysgerminoma. </li></ul></ul><ul><ul><li>.Teratoma. </li></ul></ul><ul><ul><li>.Gonadoblastoma. </li></ul></ul><ul><ul><li>.Yolk sac tumour. </li></ul></ul><ul><ul><li>.Carcinoid </li></ul></ul><ul><ul><li>.Thyroid tumour Choriocarcinoma </li></ul></ul>OVARIAN TUMOURS
  43. 43. <ul><li>HORMONE-PRODUCING TUMORS </li></ul><ul><li>Estrogen-producing: </li></ul><ul><ul><li>Granulosa cell tumour. </li></ul></ul><ul><ul><li>Thecoma. </li></ul></ul><ul><li>Androgen-prodicing: </li></ul><ul><ul><li>Sertoli-Leydig cell tumour (Arrhenoblastoma). </li></ul></ul><ul><ul><li>Hilar cell tumour. </li></ul></ul><ul><ul><li>Lipoid cell tumour. </li></ul></ul>OVARIAN TUMOURS
  44. 44. krukenberg tumour <ul><li>There is one well-known secondary tumour of the ovary, the krukenberg tumour, a secondary of a stomach carcinoma. </li></ul>OVARIAN TUMOURS
  45. 45. <ul><li>Definition </li></ul><ul><li>A unilocular or multilocular cyst of ovary lined by tall columnar epithelium resembling that of the cervix or large intestine . It is usually large and may reach immense proportions, occupying the whole peritoneal cavity and compressing other organs. It may occur at any age . </li></ul>OVARIAN TUMOURS -- MUCINOUS CYSTADENOMA
  46. 46. OVARIAN TUMOURS -- MUCINOUS CYSTADENOMA
  47. 47. <ul><li>signs and symptoms </li></ul><ul><li>The signs and symptoms are those generally associated with any non-functioning ovarian tumor. Rupture may occur and seeding of the epithelium on the peritoneal surface may cause pseudomyxoma peritonei. </li></ul>OVARIAN TUMOURS -- MUCINOUS CYSTADENOMA
  48. 48. <ul><li>Definition </li></ul><ul><li>This is only a third as common as the serous variety. Malignancy in a mucinous cyst is characterised by the formation of areas of solid carcinoma in the wall. The cells are columnar, show mitoses and tend to form glandular structures. </li></ul>OVARIAN TUMORS --MUCINOUS CYSTADENOCARCINOMA
  49. 49. <ul><li>Definition </li></ul><ul><li>A unilocular or multilocular cyst lined by epithelium similar to the fallopian tube. They are the most common benign epithelial tumors and form 20% of all ovarian neoplasm. In 10% of cases they are bilateral. It is uncommon to find them large than a fetal head. </li></ul>OVARIAN TUMORS --SEROUS CYSTADENOMA
  50. 50. OVARIAN TUMORS --SEROUS CYSTADENOMA
  51. 51. <ul><li>Definition </li></ul><ul><li>This is by far the commonest primary carcinoma, accounting for 60% of all cases, and in over half the cases it is bilateral. The cysts are always of papillary type and the epithelium burrowing through the capsule produces papillary processes on the serous surface. Extension of the growth to the pelvis and adjacent organs fixes the tumor. Ascites is always present. </li></ul>OVARIAN TUMORS --SEROUS CYSTADENOCARCINOMA
  52. 52. <ul><li>Endometrioid Carcinoma of the Ovary </li></ul><ul><li>It is now recognized that carcinoma of the ovary may be of endometrial type, sometimes arising in endometrioma. Attacks of pain, unusual with ovarian cancer, are common. Sometimes there is uterine bleeding in post-menopausal cases. </li></ul>CARCINOMA OF THE OVARY
  53. 53. <ul><li>Endometrioid Carcinoma of the Ovary </li></ul><ul><li>Usually the lesion is cystic and chocolate brown in color. If such a cyst ruptures spontaneously, malignancy should be suspected. The histology varies as in uterine carcinoma. It may be a well-differentiated adenocarcinoma, an adeno-acanthoma, mucinous adenocarcinoma or clear-celled carcinoma. </li></ul>CARCINOMA OF THE OVARY
  54. 54. <ul><li>Clear Cell Carcinoma </li></ul><ul><li>It is doubtful if this exists as a distinct entity. Clear cells may be seen in almost any variety of ovarian carcinoma, but occasionally a carcinoma, usually solid, consists almost entirely of polygonal cells with clear cytoplasm. It behaves in the same way as any other solid carcinoma and has the same prognosis. </li></ul>CARCINOMA OF THE OVARY
  55. 55. <ul><li>Secondary Carcinoma of the Ovary </li></ul><ul><li>The ovary may be the site of secondary deposits from growths arising in other parts of the genital tract. These are usually overshadowed by the clinical manifestations of the primary growth. </li></ul>CARCINOMA OF THE OVARY
  56. 56. <ul><li>Secondary Carcinoma of the Ovary </li></ul><ul><li>Ovarian metastases from extra-genital tumors are not uncommon. The commonest sites of primary growth are breast, stomach and large intestine . </li></ul>CARCINOMA OF THE OVARY
  57. 57. <ul><li>FIBROMA </li></ul><ul><li>This is composed of fibrous tissue and resembles fibromata found elsewhere. It is most common in the elderly and accounts for 4-5% of all ovarian neoplasm. </li></ul><ul><li>The fibroma is believed by many to be a thecoma which has undergone fibrous transformation. It is sometimes associated with Meig’s syndrome . </li></ul>CARCINOMA OF THE OVARY
  58. 58. <ul><li>GERM CELL TUMOURS </li></ul><ul><li>There are four main types of gern cell tumour: </li></ul><ul><ul><li>.Dysgerminoma; </li></ul></ul><ul><ul><li>.Tumours of tissues found in the embryo or adult ---- the teratomata; </li></ul></ul><ul><ul><li>.Tumours of dysgenetic gonads ---- commonly a gonadoblastoma; </li></ul></ul><ul><ul><li>.Tumours of extra-embryonic tissues such as choriocarcinoma or yolk sac tumour. </li></ul></ul>CARCINOMA OF THE OVARY
  59. 59. <ul><li>Dysgerminoma </li></ul><ul><li>This is the only solid ovarian tumor of characteristic appearance. Usually ovoid with a smooth capsule, it is of rubbery consistency and greyish colour. It is commonest in younger age groups, under 30 years as a rule, and is often bilateral. Sometimes it is found in cases of intersex. </li></ul>CARCINOMA OF THE OVARY
  60. 62. <ul><li>Yolk sac tumor </li></ul><ul><li>This is a rare tumor found in children and young adults . It has a variable histological structure and is highly malignant . The main interest lies in the fact that it produces alphafetoprotein and the blood levels can be used as a diagnostic test and as a means of monitoring response to treatment. </li></ul>CARCINOMA OF THE OVARY
  61. 63. CARCINOMA OF THE OVARY
  62. 64. <ul><li>Estrogen-producing Tumors </li></ul><ul><li>These belong to the granulosa-theca cell group and are found at all ages. They account for 3% of all solid tumors of the ovary. </li></ul>CARCINOMA OF THE OVARY
  63. 65. <ul><li>Estrogen-producing Tumors </li></ul><ul><li>In childhood there is accelerated skeletal growth and appearance of sex hair. </li></ul><ul><li>5% occur in children precocious puberty . </li></ul><ul><li>60% occur in child-bearing years irregular menstruation. </li></ul><ul><li>30% occur in post-menopausal women post-menopausal bleeding. </li></ul>CARCINOMA OF THE OVARY
  64. 66. <ul><li>ANDOROGEN-PRODUCING TUMOURS </li></ul><ul><li>Three distinct types of masculinising ovarian tumor are recognised: a) Sertoli-Leydig cell tumor (Arrhenoblastoma), b) Hilar cell tumor, c) Lipoid cell tumor. All three cause amenorrhoea . </li></ul>CARCINOMA OF THE OVARY
  65. 67. <ul><li>Direct </li></ul><ul><li>The first spread is directly into neighbouring structures – peritoneum, uterus, bladder, bowel and omentum. </li></ul>Spread of Ovarian Cancer
  66. 68. <ul><li>Lymphatics </li></ul><ul><li>Ovarian drainage is to the para-aortic glands, but sometimes to the pelvic and even inguinal groups. Cells seeded on to the peritoneum are drained via the lymphatic channels on the underside of the diaphragm into the subpleural glands and thence to the pleura. </li></ul>Spread of Ovarian Cancer
  67. 69. <ul><li>Blood stream </li></ul><ul><li>Blood spread is usually late, to the liver and lungs. </li></ul>Spread of Ovarian Cancer
  68. 72. <ul><li>General Principle </li></ul><ul><li>1.To classify the growth according to its extent of spread (staging) as accurately as possible. </li></ul><ul><li>2.To remove as much cancerous tissue as possible (‘ surgical debulking’;’cyto-reductive treatment ’). </li></ul>SURGICAL PROCEDURES IN OVARIAN CANCER
  69. 73. <ul><li>General Rule </li></ul><ul><li>Benign ovarian over 10 cm in diameter must be removed, but clinical and ultrasonically diagnosed cysts under 10 cm (the size of a lemon) in women under 35 years may be reviewed in a few months if there is no suspicion of malignancy. A follicular or luteral cyst may resolve spontaneously. </li></ul>SURGICAL TREATMENT OF OVARIAN TUMMOURS
  70. 74. SURGICAL TREATMENT OF OVARIAN TUMMOURS
  71. 75. SURGICAL TREATMENT OF OVARIAN TUMMOURS
  72. 76. SURGICAL TREATMENT OF OVARIAN TUMMOURS
  73. 77. <ul><li>General Principle </li></ul><ul><li>Much attention is being directed towards the treatment of epithelial ovarian cancer which is now the most frequent cause of death from gynecological malignancy. The principles of treatment are: </li></ul>TREATMENT OF OVARIAN CANCER
  74. 78. <ul><li>General Principle </li></ul><ul><li>Ovarian carcinoma is staged surgically, so laparotomy is an essential part of management for most patients. </li></ul><ul><li>Surgical removal of as much malignant tissue as possible, even if this should call for resection of structures outside the normal field of the gynecologist. </li></ul>TREATMENT OF OVARIAN CANCER
  75. 79. <ul><li>General Principle </li></ul><ul><li>Follow-up with intensive chemotherapy, using various combinations of antineoplastic drugs. Taxanes, probably combined with platinum compounds, are an appropriate first choice. </li></ul><ul><li>A ‘second look’ laparotomy or laparoscopy operation (SLO), to determine the actual effectiveness of the chemotherapy and to decide whether it should be stopped does not affect prognosis, so should only be performed with informed consent in clinical trials. </li></ul>TREATMENT OF OVARIAN CANCER
  76. 80. <ul><li>Incision </li></ul><ul><li>A vertical incision which can be extended is essential to allow a full inspection. Reduction of a cyst by tapping and extraction through a suprapubic incision is not acceptable practice. </li></ul>SURGICAL PROCEDURES IN OVARIAN CANCER
  77. 81. <ul><li>Cytology </li></ul><ul><li>Before handling the tumour, take specimens of ascitic fluid or peritoneal saline washings for cytological examination, and a cytology smear from the underside of the diaphragm. </li></ul>SURGICAL PROCEDURES IN OVARIAN CANCER
  78. 82. SURGICAL PROCEDURES IN OVARIAN CANCER

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