Ovarian cancer is a major cause of morbidity and mortality in gynecological patients. They often present late with pressure symptoms caused by their large size. The most common type is high grade serous carcinoma. Treatment involves surgical staging and debulking followed by chemotherapy with carboplatin, which is the standard treatment. Prognosis is poor due to lack of effective screening, and most cases are diagnosed at advanced stages, with overall 5-year survival rates ranging from 5-30% for stages III and IV.

1. OVARIAN CANCER
DR ZAHID ALI NOHRI
MPHIL PATHOLOGY(PG)

2. INTRODUCTION
Ovarian cancer is a major cause of
morbidity and mortality in gynecological
patients. They are usually asymptomatic
and present late due to pressure
symptoms caused by their large size.
They may be diagnosed incidentally on
ultrasound examination done for
another cause

4. Ovarian function including follicular maturation, ovulation and corpus
luteum formation is regulated by a complex system composed of
hypothalamus, pituitary and ovary itself

5. Epidemiology
Ovarian cancer accounts for 3–4% of cancer in women
5th common malignant tumor in female in Pakistan after breast,
esophagus, lymphomas,
oral cavity.
Second most common gynecologic malignancy in the women after cervical
cancer
it is a leading cause of death from gynecological malignancies (WHO
cancer statistics,2015)
More common in white people
Average lifetime risk is 1 in 70

6. Risk Factors
 Personal Factors
• Increasing age
• Personal history of Breast cancer
 Genetic Factors
• Family history of ovarian cancer
• BRCA1/BRCA2 mutation
• Hereditary nonpolyposis colorectal cancer(Lynch
syndrome)

7.  Reproductive Factors
• Nulliparity
• Early menarche
• Late menopause
• Infertility
• Polycystic ovarian syndrome
• Endometriosis
• ovulation inducing drugs
• Hormone replacement therapy
 Enviromental factors
• Obesity and high fat diet
• Talc exposure
• Cigarette smoking (for mucinous ovarian cancer)

8. Protective factors
Multiparity: First pregnancy before age 30
Oral contraceptives: 5 years of use cuts risk nearly
in half
Tubal ligation
Hysterectomy
Bilateral oopherectomy
Lactation
Epidemiologic and laboratory evidence suggest a
potential role for retinoids , vitamin D, NSAIDs as
preventive agents for ovarian cancer

9. Pathophysiology
Most theories of the pathophysiology of ovarian
cancer include the concept that it begins with the
differentiation of the cells overlying the ovary.
During ovulation, these cells can be incorporated
into the ovary, where they then proliferate. Ovarian
cancer typically spreads to the peritoneal surfaces
and omentum.

10. Classification
Ovarian tumors can be divided into three major categories based on the
cell type of origin .
1. Epithelial Cell Tumors
Tumors start from the cells that cover the outer surface of the ovary. It
is the most
common type of ovarian tumor.
2. Sex Cord Stromal Tumors
Tumors start from structural Tissue cells that hold the ovary together
and produce the
female hormones.
3. Germ Cell Tumors
Tumors start in the cells responsible for developing the eggs in the
ovary.

11. WHO Classification of Ovarian Tumors
1. Epithelial Tumors
i) Serous Tumor
Benign
a) cystadenoma
b) papillary cystadenoma
c) surface papilloma
Borderline
a) papillary Cyst Tumors
b) surface papillary tumors
c) adenofibroma , cyst adenofibroma
Malignant
a) adenocarcinoma
b) surface papillary adenocarcinoma
c) adenocarcinofibroma

12. ii)Mucinous tumors
Benign
a) cyst adenoma
b) adenofibroma
c) cystadenofibroma
Borderline
a) intestinal type
b) endocervical type
Malignant
a) adenocarcinoma
b) adenocarcinofibroma

13. iii) Endometrioid Tumors
Benign
a) cyst adenoma
b) adenofibroma
c) cystadenofibroma
Borderline
a) cystic tumor
b) adenofibroma
c) cystadenofibroma
Malignant
a) adenocarcinoma
b) adenocarcinofibroma
c) adenosarcoma
d) malignant Mullerian mixed tumor
(carcinosarcoma)
e) endometrioid stromal sarcoma (low
grade)
f) undifferentiated ovarian sarcoma

14. iv) Clear cell tumors
Benign
a) Cystadenoma
b) adenofibroma
c) cystadenofibroma
Borderline
a) cystic tumor
b) adenofibroma
c) cystadenofibroma
Malignant
a) adenocarcinoma
b) adenocarcinofibroma

15. v) Transitional cell tumors
Benign
Brenner tumor
Borderline
Borderline Brenner tumor
Malignant
a) Transitional cell carcinoma ( Non
Brenner type)
b) Malignant Brenner tumor

16. vi) Squamous cell tumors
Squamous cell carcinoma
 Epidermoid cyst
vii) Mixed Epithelial
Tumors
viii) Undifferentiated
carcinoma

17. 2. Sex cord Stromal Tumors
a) Granulosa Stromal Cell tumors
Granulosa cell tumor group
i) Adult Granulosa cell tumor
ii) Juvenile Granulosa cell tumor
Thecoma-Fibroma group
• Thecoma
• Fibroma
• Cellular Fibromama
• Fibrosarcoma
• Stromal tumor with minor sex cord
element
• Sclerosing stromal tumor
• Signet-ring stromal tumor
• Unclassified (fibrothecoma)

18. b) Sertoli-stromal cell tumos
Sertoli- Leydig cell tumor group (androblastomas)
• Well differentiated
• intermediate different
• Poorly differentiated (sarcomatoid)
• Retiform
Sertoli cell tumour
Stromal-Leydig cell tumour
c) Sex cord-stromal tumors of mixed or unclassified cell types
• Sex cord tumor with annular tubules
• Gynandroblastoma
• Sex cord-stromal tumor, unclassified
d) Steroid cell tumors
• Stromal luteoma
• Hilus cell tumor
• Leydig cell tumor
• Steroid cell tumor

19. 3.Germ Cell Tumors
Primitive germ cell tumous
Dysgerminoma
Yolk sac tumor
Embryonal carcinoma
Polyembryoma
Non-gestational choriocarcinoma
Mixed germ cell tumor
Biphasic or triphasic teratoma
Immature teratoma
Mature teratoma(solid and dermoid cyst)

20. Monodermal teratoma
Thyroid tumor group
• Struma ovaril(Benign/Malignant)
Carcinoid group
• Insular
• Trabecular
• Mucinous
• Strumal carcinoid
• Mixed
Neuroectodermal tumor group
• Ependymoma
• Primitive neuroectodermal tumor
• Medulloepithelioma
• Glioblastoma multiforme
Carcinoma group
• Squamous cell carcinoma
• Adenocarcinoma
Glandobastoma

21. Miscellaneous tumours
Small cell carcinoma, hypercalcaemic type
Small cell carcinoma, pulmonary type
Large cell neuroendocrine carcinoma
Hepatoid carcinoma
Primary ovarian mesothelioma
Wilms tumour
Gestational choriocarcinoma
Hydatidform mole
Adenoid cystic carcinoma
Basal cell tumour
Ovarian wolffian tumour
Paraganglioma
Soft tissue tumours not specific to the ovary
Malignant lymphoma

23. Clinical Presentation
History
Early Symptoms
• wide variety of vague and nonspecific symptoms
• Symptoms can be misdiagnosed as irritable bowel syndrome
• Abdominal bloating, discomfort and pain
• Pelvic pain or discomfort
• Back pain
• Irregular menstruation
• Post menopausal Vaginal bleeding
• Pain during sexual intercourse
Later Symptoms
• Cause by growing mass compressing other organs
• Urinary retention
• Bowel Obstruction
• Severe pelvic pain due to ovarian torsion

24. Physical Examaination
Pelvic examination may reveal increased abdominal girth
and/ or ascites
An adnexal mass is significant finding that often indicates
ovarian cancer, especially if it fixed, nodular, irregular, solid
And bilateral.
Lymph Node examination: palpation of the supraclavicular,
axillary and inguinal are may reveal the lymphadenopathy.
Sister Mary Joseph's nodule refers to a metastatic implant in
the umbilicus.

25. Investigations

26. Ultrasonograpgy
TVS is important diagnostic tool in the evaluation of patients
with a pelvic mass, may reveal complex cyst, defined as
containing both solid and cystic components.
CT/MRI abdomen/pelvis
especially helpful preoperatively if advanced disease.
Useful in assessment of retroperitoneal LN involvement
Biopsy
To confirm the suspected malignancy of a ovarian mass
removed during surgery
To evaluate histopathological pattern of tumor
Grading

27. Grading
Grading can help how the cancer will behave, including how fast it will
grow and spread which may impact on treatment
There are some ovarian tumors that rarely spread refered as borderline
or atypically proliferative tumors.
Most common type of ovarian cancer are simply divided into low grade
or high grade and grading number is not given
Most common type of ovarian cancer is high grade serous carcinoma.
Grade1 : well differentiated cancers have cells that closely resemble
normal cells and less likely to spread
 Grade 2: moderately differentiated
 Grade 3: poorly differentiated
 Grade 4: undifferentiated

28. Staging
Cancer staging is a proces determining the
extent to which a cancer has developed by
growing and spreading.

30. Treatment
1. Surgery
a) a total abdominal hysterectomy (TAH),
b) bilateral salpingo-oophorectomy (BSO),
c) omentectomy
d) Primary Cytoreductive surgery
removal of large, necrotic tumors with poor blood supply
that might lead to impaired chemotherapy delivery
permit residual tumor to proliferate more rapidly and
thereby enhance sensitivity to postoperative
chemotherapy
2. Chemotherapy
Carboplatin is now the standard platinum agent for
treating ovarian carcinoma
3. Radiotherapy

31. Stage IA and IB (grade2 and 3)
• Treated with TAH/BSO and staging
followed by chemotherapy
Stage II, III, and IV
• Surgery – cytoreductive surgery
• chemotherapy
Management plan

32. Screening
Unfortunately, there are no good screening methods for
ovarian cancer at present; most use a combination of
physical exam, CA125 levels, and TVS.
No role of routine screening in general population .
 Some follow women with high risk factors (e.g., family
history, BRCA mutation) using CA-125 and TVS

33. 
 Ovarian cancer usually has relatively poor prognosis due to lack of any clear
early detection or screening test and most of the cases diagnosed when
they reached advanced stage.
 Ovarian cancer metastasize early in its development ofen before it has
been diagnosed
 Typically it metastasize by growing in peritoneal cavity.
 It most likely to spread to the liver, pleural cavity, spleen, intestine, brain,
skin or lymphnode outside the abdomen
 Overall five-year survival rate of ovarian cancer is 46%.
 stage I and stage II ovarian cancer are 80% to 90% and 70%, respectively ;
 for stages III and IV ranges from 5% to 30%.
Prognosis