Malignancy of the endometrium, ov, ft

24/03/2017 #DLSHSI_GYNEONCO2017 @doc_magno
Malignant Neoplasm of the
Endometrium, Ovary, Fallopian Tube
and Peritoneum
Angelito Magno M.D., FPOGS, FSGOP, FPSCPC
De La Salle Health Sciences InsRtute
March 24, 2017

Endometrial Cancer
•  13th MC cancer in both sexes
•  7th leading site among women
•  3rd MC gynecologic malignancy
•  Most common malignancy of the female
genital tract in the US and other developed
countries

Endometrial Cancer
•  Perimenopausal and Postmenopausal age
(50-65 years old)
•  10-15%- younger than 50 years
•  5% - women less than 40 years old

Endometrial Pathology: Progression
Normal Hyperplasia Cancer
Unopposed
Estrogen

Early Menarche
HPNCC/ Lynch syndrome
Age

SYMPTOMS and SIGNS
•  Postmenopausal bleeding
•  Abnormal premenopausal and
perimenopausal bleeding
•  Discharge
•  Pelvic pain
•  Uterine enlargement

Transvaginal ultrasonography
•  Threshold: Endometrial
thickness
•  ReproducRve age
–  ProliferaRve phase: 8mm
–  Secretory phase: up to
1.4cm
•  Postmenopausal age:
<5mm
•  Not a useful tool for
asymptomaRc Tamoxifen
users

DIAGNOSIS
•  Histologic examinaRon of the endometrium
•  Oﬃce Endometrial Biopsy
–  Novak’s curet
–  Pipelle- useful if the endometrial thickness of >6mm
–  1st line in the diagnosis of endometrial cancer
–  Endometrial sample is obtained in the clinic with no
anesthesia
–  Advisable only for postmenopausal women with
thickened endometrium (not for pre-menopausal
women)

Oﬃce Endometrial Biopsy

Diagnosis
•  If inadequate outpaRent evaluaRon or sample
– FracRonal/Endometrial curefage
– Hysteroscopy

FracRonal curefage
•  Under regional anesthesia
•  Complete scraping of the endocervical and
endometrial linings

DIAGNOSIS
HYSTEROSCOPY
•  Videoscope is introduced
transcervically to visualize
endometrial cavity
•  Together with biopsy,
considered the gold
standard for the
invesRgaRon of women
with symptoms of
endometrial pathology

Papsmear
•  Screening tool for
cervical cancer
•  NOT a good screening
tool for endometrial
cancer
•  Only 50% or less of
cases detected by
papsmear

Endometrioid adenocarcinoma
•  Most common type of endometrial cancer
•  Glands are in back to back pafern with
minimal or no in between stroma

Back to back
pafern

Degree of differenRaRon
•  Grade 1- well-differenRated, <5% solid
components
•  Grade 2- moderately differenRated, 6-50%
solid component
•  Grade 3- poorly differenRated, >50% solid
component

Adenocarcinoma with squamous
component
•  Previously termed as adenoacanthoma or
adenosquamous carcinoma
•  Mixture of glandular (adeno) and squamous
epithelium
•  Prognosis depends on the diﬀerenRaRon of
the glandular component and not from
squamous part

Uterine Papillary Serous Carcinoma
•  Highly virulent
•  Uncommon histologic subtype of endometrial
carcinomas (5% to 10%)
•  Histologically resemble papillary serous
carcinomas of the ovary
•  Finger-like (papilla) projecRons

Clear Cell Carcinoma
•  less common (<5%)
•  Resembles clear cell adenocarcinomas of the
ovary, cervix, and vagina
•  Hobnail cells
•  Clear cytoplasm with nucleus on the side

UPSC and Clear cell
•  Prognosis is worse than the typical
endometrioid adenocarcinoma
•  Stage 1 endometrioid adenoarcinoma has 5
year survival of >90 % but only 50% in both
UPSC and Clear cell carcinoma

*ReporRng of posiRve peritoneal cytology

Stage I: conﬁned to the Corpus
IA- Endometrium or
<50% of the
myometrium

IB- > 50% of the
endometrium

Stage II: Cervical stroma but not beyond the
uterus
II: tumor invades
the cervical
stroma
*invasion of cervical
glands is NOW stage
IA

Stage III: Local or regional spread
IIIA: Involvement of
serosa of the corpus
and Adnexa
* PosiRve peritoneal
cytology is no longer stage
IIIA

IIIB: Vaginal and/
or Parametrial
involvement
Parametrial Rssue:
paravaginal Rssues,
broad ligament,
cardinal ligament,
paracervical Rssues,
other pelvic Rssues

IIIC: Regional Nodes

IIIC1: pelvic
nodes
IIIC2: paraaorRc
nodes w/ or
w/o pelvic nodes

Stage IVA:
IVA: bladder
mucosa or rectal
mucosal
involvement

Stage IVB
IVB: Distant
metastases
including intra-
abdominal
organs and
inguinal nodes
* intra-abdominal
organs= organs
above the pelvic brim

PosiRve Peritoneal cytology
•  Should be reported separately without
changing the stage
•  Example:
– Endometrial adenocarcinoma, endometrioid type,
stage IB, (+) peritoneal ﬂuid cytology

PrognosRc Factors
Clinical Factors Pathologic Factors
Age
Stage
Race
Tumor grade
Histologic type
Tumor size
Depth of myometrial
invasion,
Vascular spaces
involvement
Extrauterine involvement
(lymph nodes, peritoneum
or adnexa)
Factors that aﬀect prognosis of the paRents

STAGE

MYOMETRIAL INVASION

Pafern of Spread
•  A. Direct extension
– Transtubal or transcervical/transvaginal spread
•  B. LymphaRcs
•  C. Hematogenous

Pafern of Spread
(LymphaRcs)
(1) a small lymphaRc branch
along the round ligament
that runs to the inguinal
femoral nodes

Pafern of Spread
(LymphaRcs)

(2) branches from the tubal
(3) ovarian pedicles
(infundibulopelvic
ligaments), which are large
lymphaRcs that drain into
the para-aorRc nodes;

Pafern of Spread
(LymphaRcs)

(4) the broad ligament
lymphaRcs that drain directly
to the pelvic nodes

Pafern of Spread
(LymphaRcs)
(1) a small lymphaRc branch
along the round ligament
that runs to the inguinal
femoral nodes
(2) branches from the tubal
(3) ovarian pedicles
(infundibulopelvic
ligaments), which are large
lymphaRcs that drain into
the para-aorRc nodes;
(4) the broad ligament
lymphaRcs that drain directly
to the pelvic nodes

2,3,4- clinically most
important

EvaluaRon

•  Imaging techniques- CT Scan, MRI, PET/CT
Scan
•  Color Doppler Ultrasound
•  CA 125

IMAGING TECHNIQUES
- SGOP 2015 CPG

Color Doppler Ultrasound
•  adjunct ultrasound
•  Detects neovascularizaRon (abnormal vessel
formaRon)
•  High resistance index- feature of malignancy

Cancer AnRgen (Ca) 125
•  Generally used in epithelial ovarian cancer
•  Used in advanced stage endometrial cancer to
detect extrauterine involvement and as post-
operaRve monitoring
•  Not useful in early stage disease
•  Non-speciﬁc to endometrial cancer

SURGERY
•  primary treatment modality
•  Surgicopathologic staging (using the 2009
FIGO Staging system)
•  ExcepRons:
– PaRents with poor surgical risk due to unstable
medical condiRons
– Young cancer paRents desirous of future ferRlity
– Will use the 1971 FIGO Clinical Staging System of
Endometrial cancer

Surgery
Complete staging
•  Peritoneal ﬂuid washing
•  Total hysterectomy with salpingo-
oophorectomy
•  Bilateral pelvic lymphadenectomy
•  *Para-aorRc lymphadectomy
– Not done for low risk cancer

Surgery
•  Surgical staging
(1) tumor spread within the uterus
(2) degree of penetraRon into the myometrium
(3) extrauterine spread to retroperitoneal
nodes, adnexa, and/or the peritoneal cavity

Surgery
•  Open surgery/ Laparotomy
•  Minimally invasive approach
– ConvenRonal Laparoscopy
– RoboRc

Minimally invasive techniques
Advantages
•  Same pathologic outcome (adequacy of
Rssues, node number)
•  Shorter hospital stay
•  Smaller wound
•  Befer QOL post-operaRvely
•  Less blood loss, less complicaRons

Other treatment modaliRes
•  Unstable medical condiRons
•  Young paRents desirous of pregnancy
•  RadiaRon alone
•  Medical therapy

RadiaRon
•  RadiaRon alone: Inferior than surgery
– Stage 1 surgery alone: 87% 5 yr survival versus
67% for radiaRon alone
– Not recommended for paRents desirous of
pregnancy (radiaRon will kill the ovaries)
•  As adjuvant therapy: given post-operaRve
treatment if with poor prognosRc factors
– Increases survival of paRents with advanced
endometrial cancer

Stage 1
SGOP 2015 CPG

Stage II
SGOP 2015 CPG

Stage III
SGOP 2015 CPG

Stage IV
SGOP 2015 CPG

UPSC and Clear Cell Histology
SGOP 2015 CPG
Similar surgical treatment with
ovarian cancer because UPSC and
clear cell cancer behave like ovarian
cancer

Medical/ ConservaRve treatment
ConservaRve treatment is only oﬀered to paRents who
have:
•  Well diﬀerenRated tumor (endometrioid type)
•  No myometrial invasion (as evaluated by MRI)
•  No cervical involvement
•  No extrauterine involvement:
–  No adnexal involvement
–  No parametrial involvement
–  No vaginal involvement
–  No suspicious retroperitoneal nodes or no evidence of
lymph node metastasis
–  NegaRve PFC
•  No LVSI (lymphovasular space invasion)
•  No contraindicaRons for medical management
SGOP 2015 CPG

The following are also essenRal:
•  ProgesRn receptor posiRvity
•  PaRent understands and accepts that this is
not standard treatment
– (Informed consent) – Inform paRents that the
procedure of preservaRon of ferRlity is sRll
experimental and there is low pregnancy rate
•  PaRent with strong desire to preserve her
childbearing potenRal

•  Agents used: DuraRon of treatment is variable
• Megestrol acetate 40-60 mg/day
• Medroxyprogesterone acetate (MPA) 100-800
mg/day
• Levonorgestrel-containing intrauterine system
(LNG-IUS)
• Tamoxifen + ProgesRns
• Anastrozole + ProgesRns

Monitoring:
•  repeat dilataRon and curefage auer 3 months of
therapy
•  No response auer 3 months of therapy =
treatment failure
•  maintenance treatment with oral contracepRve
pills (OCPs), cyclic progesRns, depot
medroxyprogesterone acetate (DMPA), or LNG-
IUS unRl pregnancy is desired
•  If pregnancy is desired, afempts should be made
auer 3 months from reversion of the cancer.


OVARIAN CANCER

Ovarian Cancer
•  2nd most common gynecologic cancer and
most common cause of cancer death in the
U.S
•  Incidence increases with age (beyond 50
years)- epithelial tumor

2010 Philippine Cancer Facts and EsRmates
0 2000 4000 6000 8000 10000 12000 14000
Stomach
Thyroid
Leukemia
Corpus
Liver
Ovary
Colon/rectum
Lung
Cervix
Breast
Es#mated leading new cancer cases, females
5th

2010 Philippine Cancer Facts and EsRmates
EsRmated Leading New Cancer Deaths, females
0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000
Brain/NS
Corpus
Stomach
Ovary
Leukemia
Colon/rectum
Liver
Cervix
Lung
Breast
7th

Pathogenesis
A. AccumulaRon of geneRc aberraRon
-Ras family of oncogenes
- p53
B. Inherited gene mutaRon
- BRCA mutaRon & Lynch Syndrome
C. De Novo proliferaRon
- incessant ovulaRon
- PID and Endometriosis associated tumors

Pa0ern of Spread:
•  Transcoelomic disseminaRon or
direct extension
•  LymphaRc
•  Hematogenous

PresentaRons
•  Non-speciﬁc (early saRety, epigastric pain,
bloatedness, weight loss)
•  Abdominal enlargement
•  Pelvic mass
•  Vaginal bleeding

DIAGNOSIS
•  Ultrasound remains to be the most helpful imaging
examinaRon for ovarian cancer diagnosis with the highest
sensiRvity

•  CA 125 and HE4 (more speciﬁc tumor marker for ovarian
cancer)
*However, ROUTINE screening for average-risk women using
TVUTS, CA 125 and pelvic exam is not recommended

SuggesRve of Ovarian malignancy
•  complex mass with both solid and cysRc
components
•  papillary excrescences and projecRons
•  internal echoes and septaRons
•  Ascites
•  peritoneal metastasis

Risk Factors
•  No deﬁnite cause
Factors that increase risk:
•  Nulliparity
•  Menstrual irregulariRes
•  Hx of breast or endometrial cancer
Factors that could be protecRve:
•  Pregnancy
•  Oral contracepRves

Poor Survival Rate due to:
•  Late diagnosis
•  No reliable screening methods
•  No deﬁnite risk factors
•  No known eRology
•  No precursor lesions
•  Non-speciﬁc symptoms and signs

Contrast of Surgical Findings
Benign Malignant
Surface papillae Rare Very common
Intracytic papillae Uncommon Very common
Solid areas Rare Very common
Bilaterality Rare Common
Adhesions Uncommon Common
Ascites (>100 ml) Rare Common
Necrosis Rare Common
Peritoneal
implants
Rare Common
Capsule intact Common Infrequent
Totally cystic Common Rare

FIGO 1988 FIGO 2014

FIGO Guidelines Commifee:

Revise the staging system to improve uRlity
and reproducibility

Ovarian, Fallopian tube and primary
peritoneal cancer: same staging system
because of common histology: Serous type

FIGO STAGE 1
NEW STAGING OLD STAGING
I Tumor confined to ovaries or fallopian
tube(s)
Tumor limited to the ovaries (one
or both)
IA Tumor limited to one ovary (capsule
intact) or fallopian tube
No tumor on ovarian or fallopian tube
surface
No malignant cells in the ascites or
peritoneal washings
Tumor limited to one ovary;
capsule intact
No tumor on ovarian surface
No malignant cells in ascites or
peritoneal washings
IB Tumor limited to both ovaries
(capsules intact) or fallopian tubes
No tumor on ovarian or fallopian tube
surface
No malignant cells in the ascites or
peritoneal washings
Tumor limited to both ovaries;
capsule intact
No tumor on ovarian surface
peritoneal washings

FIGO STAGE 1
I
Tumor confined to ovaries or fallopian
tube(s)
Tumor limited to the ovaries (one
or both)
IC
IC1
IC2
IC3
Tumor limited to one or both ovaries or
fallopian tubes with any of the
following:
Surgical spill intraoperatively
Capsule ruptured before surgery or
tumor on ovarian or fallopian tube
surface
Malignant cells in the ascites or
peritoneal washings
Tumor limited to one or both
ovaries with any of the following:
Capsule ruptured, tumor on
ovarian surface, malignant cells in
ascites or peritoneal washings

FIGO STAGE 2
II Tumor involves one or both ovaries or
fallopian tubes with pelvic extension
(below pelvic brim) or primary
peritoneal cancer
Tumor involves one or both
ovaries with pelvic extension
IIA Extension and/or implants on the
uterus and/or fallopian tubes and/or
ovaries
Extension and/or implants on
uterus and/or tube(s); no
malignant cells in ascites or
peritoneal washings
IIB Extension to other pelvic
intraperitoneal tissues
Extension to other pelvic tissues
peritoneal washings
IIC
Pelvic extension (IIa or IIb) with
malignant cells In ascites or
peritoneal washings

FIGO STAGE 3
III Tumor involves one or both
ovaries, fallopian tubes, or
primary peritoneal cancer, with
cytologically or histologically
conﬁrmed spread to the
peritoneum outside the pelvis
and/or metastasis to the
retroperitoneal lymph nodes
Tumor involves one or
both ovaries with
microscopically
conﬁrmed peritoneal
metastasis outside the
pelvis and/or regional
lymph node metastasis

FIGO STAGE 3
IIIA IIIA1
PosiRve retroperitoneal lymph
nodes only (cytologically or
histologically proven)
(i) Metastasis < 10 mm in greatest
dimension
(ii) Metastasis >10 mm in greatest
dimension
IIIA2
Microscopic extrapelvic (above the
pelvic brim) peritoneal involvement
with or without posiRve
retroperitoneal lymph nodes
Microscopic peritoneal
metastasis beyond pelvis

FIGO STAGE 3
IIIB Macroscopic peritoneal
metastasis beyond the pelvis up
to 2 cm in greatest dimension,
with or without metastasis to
the retroperitoneal lymph nodes
Macroscopic peritoneal
metastasis beyond the
pelvis, 2 cm or less in
greatest dimension

FIGO STAGE 3
IIIC Macroscopic peritoneal
metastasis beyond the pelvis
more than 2 cm in greatest
dimension, with or without
metastasis to the retro-
peritoneal lymph nodes
(includes extension of tumor to
capsule of liver and spleen
without parenchymal
involvement of either organ)
Peritoneal metastasis
beyond pelvis, more
than 2 cm in greatest
dimension and/or
regional lymph node
metastasis

FIGO STAGE 4
IV
Distant metastasis excluding
peritoneal metastases

IVA: Pleural eﬀusion with posiRve
cytology

IVB: Parenchymal metastases and
metastases to extra-abdominal
organs (including inguinal lymph
nodes and lymph nodes outside
the abdominal cavity)
Growth involving one or
both ovaries with distant
metastases. If pleural
eﬀusion is present, there
must be posiRve cytology
to allot a case to Stage IV.
Parenchymal liver
metastasis equals Stage IV

Borderline tumor/ Low Malignant
PotenRal
•  10 to 15% of epithelial ovarian cancers
•  Most common: early stage
•  Rarely metastasize in lymph nodes
•  Nuclear atypia, straRﬁcaRon of the epithelium,
formaRon of microscopic papillary projecRons,
cellular pleomorphism, and mitoRc acRvity
•  ABSENCE of stromal invasion
•  Recurrence is possible (usually late)

Pathology: Serous CA
•  >50% of ovarian cancer are serous histology
•  Predominantly cysRc with thin ﬂuid within
with papillary excresences/ mural nodule
•  Resembles the fallopian tube epithelium
•  Pathognomonic: PSAMMOMA BODIES
•  CA-125: most useful tumor marker

Pathology: Serous CA

Pathology: Endometrioid
•  About 15 to 20 percent of epithelial ovarian
cancers
•  Histology: similar to the endometrial glands
•  Mixture of cysRc and solid mass.
•  Associated with Endometriosis and PID
•  CA-125 also useful

This can be cystic with smooth
surface and variable amounts of
intracystic soft or solid masses or
papillae. This can sometimes
have necrosis and hemorrhage.
There is irregular, infiltrative proliferation of
glandular type epithelium resembling
proliferative type endometrium with
cytologically malignant nuclear features.

Pathology: Mucinous
•  5 to 10 percent of true epithelial ovarian cancers
•  MulRloculated, mulRcysRc mass with thick
material within
•  Resembles mucin-secreRng adenocarcinomas of
intesRnal or endocervical origin
•  Associated with appendiceal tumor and
pseudomyxoma peritonei
•  CA-19-9 (tumor marker for mucin-producing cells
like appendix, pancreas, intesRne)

Pathology: Mucinous

Clear cell carcinoma of the Ovary
•  5 to 10 percent of epithelial ovarian cancers
•  CysRc mass with solid component
•  most frequently associated with pelvic
endometriosis and PID
•  Presence of clear cell and HOBNAIL cells

Clear cell carcinoma of the Ovary

Management: Ovarian cancer
Surgery
– Exploratory Laparotomy (midline verRcal)
– Peritoneal washing (diaphragm, right and leu
hemi-abdomen, pelvis)
– Careful inspecRon and palpaRon of all
peritoneal surfaces
– Biopsy and resecRon of any suspicious
lesions, masses, and adhesions
– Total abdominal hysterectomy + bilateral
salpingo-oophorectomy (THBSO)

•  Surgery
– (USO) with frozen secRon (FS) is permifed for
young paRents with stage I
– Infracolic omentectomy or infragastric
omentectomy
– Random peritoneal biopsies (undersurface of
the right hemidiaphragm, bladder reﬂecRon,
cul-de-sac, right and leu paracolic recesses
and pelvic sidewalls)
– Pelvic and paraaorRc lymph node sampling
– Appendectomy for mucinous tumors

– Paracentesis in iniRal management of ovarian mass is
not recommended
– Pfannensteil incision also not advised
– **Tumor debulking for advanced stage
– Chemotherapy as adjuvant therapy
•  CarboplaRn-Paclitaxel

IndicaRons for “E” operaRon:
•  Any adnexal mass auer menopause or before
puberty
•  solid adnexal mass at any age
•  cysRc mass > 8 cm
•  cysRc mass bet 5-8 cm,
–  persistent > 8 wks
•  (+) complicaRons

Germ Cell tumors
•  most common ovarian malignancies
diagnosed during childhood and adolescence
•  Symptoms are similar to the epithelial
counterpart
•  Mass does not grow as big as the epithelial
tumors

Dysgerminoma
•  Most common malignant ovarian germ cell tumor
•  Most common ovarian malignancy detected during
pregnancy
•  the only germ cell malignancy with a signiﬁcant rate of
bilateral ovarian involvement (15-20%)
•  In general: Solid, cream-colored tumor
•  large, rounded, polyhedral clear cells that are rich in
cytoplasmic glycogen with lymphocyte inﬁltraRon
•  Lactate Dehydrogenase (LDH)- an impt. tumor marker
•  5%- (+) HCG

Yolk Sac tumor
•  Previously called Endodermal sinus tumor
•  Solid, yellowish tumor
•  Schiller-Duval bodies are pathognomonic
when present
•  Alpha-Fetoprotein (AFP) as tumor marker

IMMATURE TERATOMA
•  3rd most common malignant germ cell tumor
•  Gross: solid w/ cysRc spaces
•  Micro: immature Rssue derived from 3 germ
layers
•  usually from endodermal, e.g.
neuroepithelium
•  Tumor marker: AFP

This typically has a smooth surface
and is cystic. Cut section
demonstrates greasy yellow
sebaceous material and hair. Often
there is a thickening of the cyst wall
(Rokitansky's protuberance) from
which hair and sometimes teeth and
bone arise.
This cystic structure is lined
predominantly by skin and cutaneous
adnexal structures, usually with abundant
sebaceous and sweat glands. Hair is
almost always present. Other
components include cartilage, bone,
bronchial or gastrointestinal epithelium
and mature
glial tissue. If only skin and adnexal
structures are present it can be termed
dermoid cyst.
Sebace
ous
land
skin

Immature GlandsImmature Neural
Tissue
Immature Cartilage
The diagnosis of this tumor requires the presence of immature elements
derived from any of the three germ layers: skin elements, mature neural
tissue, connective tissue, cartilage, bone, gastrointestinal or bronchial
epithelium.
IMMATURE TERATOMA

Choriocarcinoma
•  High B-HCG
•  SyncyRotrophoblast and cytotrophoblast with
no dilated villi
•  Less common germ cell tumors:
– Polyembryona
– Embryonal carcinoma
– Immature teratoma


Germ Cell Tumors
Germ Cell Tumor Tumor Marker Histology
1. Dysgerminoma –
MC
LDH Lymphocytic
stromal infiltration
2. Endodermal
sinus tumor –
2MC
AFP Schiller – Duvall
Bodies
3. Teratoma,
immature – 3MC
Carcinoid
Struma ovarii
AFP
Neuroectodermal
4. Embryonal
Carcinoma
HCG, AFP Syncytio
5. Polyembryoma HCG
6. Choriocarcinoma HCG Syncytio / cyto

Management of Germ cell tumor
ConservaRve surgical management (USO) may be an opRon for malignant germ
cell tumor if the paRent is young or desirous of pregnancy due to high response
to chemotherapy

Sex-Cord tumor: Granulosa-cell tumor
•  Most common
•  Feminizing
•  Symptoms are age-determined
•  Pre-puberty - isosexual precocious puberty
•  ReproducRve - Abnormal menstrual cycles
•  Postmenopause - postmenopausal bleeding

Sex-Cord tumor: Granulosa-cell tumor
•  Gross: maybe solid or cysRc
•  Micro: Call-Exner Bodies - rosefe like
arrangement of granulosa cells
•  ComplicaRons: endometrial hyperplasia or
adenocarcinoma
•  RadiosensiRve
•  Bilaterality: 5%

Granulosa-cell tumor
•  Adult Granulosa cell tumor
– diagnosed auer age 30, with the average age
being 52 years
– menometrorrhagia and postmenopausal bleeding
are common
– inhibin A, inhibin B, and serum estradiol

Granulosa-cell tumor
•  Juvenile Granulosa cell tumor
– children and young adults, and half are diagnosed
before puberty. The mean age at diagnosis is 13
years
– isosexual peripheral precocious puberty
– More aggressive

Management of Granulosa cell tumor
Chemotherapy as adjuvant therapy (Bleomycin, Etoposide CisplaRn)

MetastaRc cancer of the ovary
•  Krukenberg tumor
•  Primary cancer originated from colon,
stomach, small intesRne, appendix
•  Solid mass
•  Commonly bilateral
•  Signet-ring cells

This tumor typically has rounded,
firm, white masses that may be
bosselated, yellow or white on cut
section. Fleshy, gelatinous or spongy
areas are common.
Presence of mucin-laden, signet-ring cells strewn
individually and in small clusters within a hypercellular
ovarian stroma (occasionally with storiform pattern).
The cytoplasm occasionally is granular and
eosinophilic rather than pale and vacuolated
(sometimes has bull's-eye appearance, containing
large vacuole with central eosinophilic body).
Krukenberg tumor

Primary Fallopian Tube Cancer
•  Incidence(US): 0.41 per 100,000 women
(‘0.14-1.8%’)
•  Age: 60-79 y/o highest incidence rates
•  Incidence(Phil): 0.1% - 0.5%of all
gynecologic cancers
•  Age: 40 - 65 years, mean = 52 years

Criteria to diagnose primary tubal
cancer:

1. Gross : main tumor in the fallopian tube
2. Micro : mucosa should be mainly involved
: TransiRon between benign &
malignant demonstrated

The oviducts, or fallopian tubes, vary from 8 - 14 cm in
length and are covered by peritoneum. It is divided into the
following potions: interstitium (a), isthmus (b), ampulla (c),
and infundibulum (d).
d
c
b
aa
b
c
d
Nomal Fallopian Tube

This is composed of fine branching papillae (Arrow)
covered by one or more layers of epithelium with
enlarged pleomorphic hyperchromatic nuclei (inset).
There is increased and abnormal mitoses. In poorly
differentiated areas, the tumor may grow in solid
sheets of cells with small or large foci of necrosis.
Invasive Adenocarcinoma Of Fallopian Tube

Pathology
•  The majority (88%) of PFTCs were adenocarcinomas;
–  Serous 44%
–  Endometrioid 19%.
–  Mixed 3.9 – 16.7%
–  UndiﬀerenRated 7.8 – 11.3%
–  Mucinous 3 – 7.6%
•  Tumor Grade
–  Grade I 15 – 20%
–  Grade II 20 – 30%
–  Grade III 50 – 65%
•  Laterality
–  Unilateral 89%
–  Bilateral 11%
•  Stage at diagnosis was fairly evenly distributed
–  localized (36%)
–  regional (30%)
–  distant (32%) Stewart et al,
2007


Clinical Features
Clinical Features Percentage
Vaginal bleeding or spotting 50%–60%
Abdominal pain, colicky or dull 30%–49%
Abdominal or pelvic mass 60% (range, 12%–84%)
Ascites 15%
Rare presentations (acute abdomen, palpable
inguinal node, umbilical-bone cerebral
metastases, cerebellar degeneration,
asymptomatic)
[38–41]
Postmenopausal bleeding or spotting with
negative Pap smear
Pectasides et al, 2009

LATZKO’S TRIAD
A syndrome which consists of:
1)  profuse watery or honey-colored vaginal
discharge,
2)  a pelvic mass, and
3)  colicky pelvic pain that essenRally goes
away upon sudden disappearance of the
mass

Although this triad is rarely found in pracRce,
it’s a classic diagnosRc syndrome for
fallopian tube disease.
Sotto & Manalo, 1994

Diagnosis
•  Imaging studies
– Ultrasound
– CT Scan
– MRI
•  CA-125 level
•  Cytology
•  Pathology

STAGING: Same as ovarian cancer

TREATMENT:
1. Surgery
ConservaRve: St IA & desirous of pregnancy
Complete: > St IB

2. Chemotherapy - adjuvant
Agents: same as in ovarian ca

3. Radiotherapy - role controversial

PROGNOSIS: Poor
5-year Survivval Rate
Stage I 60%
II 40%
III 10%
IV 0%

Primary Peritoneal Carcinoma
•  Up to 15 percent of typical epithelial ovarian cancers are
actually primary peritoneal carcinomas
•  Serous is the most common histology

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Malignancy of the endometrium, ov, ft

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