Ovarian cancer

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Ovarian cancer

  1. 1. Ovarian Carcinoma Khalid Sait Professor of Obstetrics and Gynecology and Gynecological oncology Faculty of Medicine King Abdulaziz University
  2. 2. QUESTIONS •  DIFFERNTIAL DIAGNOSIS OF ADNEXIAL MASS •  CLASSIFICATION OF OVARIAN MASS •  TUMOUR MARKER IN EACH CANCER •  PATHOGNOMIC FEATURE OF EACH TUMOUR •  INVESTIGATION AND MANAGEMENT OF OVARIAN MASS •  OVARIAN CANCER ACCORDING TO AGE GROUP •  RISK FACTOR AND PREVENTION AND SCREENING •  STAGING •  TYPE OF CHEMOTHERAPY USE IN DIFF. OVARIAN CANCER
  3. 3. Pelvic mass before puberty •  Newborn Functional ovarian cyst •  Children Ovarian germ cell tumour Wilm’s tumor neuroblastoma lymphoma other ( GI, musculoskeletal)
  4. 4. Pelvic mass in the young women •  Congenital anomalies such as imporferated hymen and blind uterine horn to be considered in adolescents •  Common causes of adnexial mass functional cyst PID(toa …) choclet cyst •  Germ cell tumors
  5. 5. Pelvic mass in the peri/post menopausal women •  Neoplasm ( benign and malignant )
  6. 6. Ovarian Mass •  Pathologic behavior : Non neoplastic Neoplastic –  (benign,malign, borderline). •  Morphology(cystic,solid). •  Histogenesis.
  7. 7. Ovarian Mass Neoplastic Epithelial T Germ cell T. Sex cord T. Stromal T. Others( Metastatic….) Non neoplastic Physiological: Lutein cysts. Follicular cysts. Endometrial cysts: endometriosis Inflammatory
  8. 8. Evaluation of Ovarian Mass •  Preoperative assessment: History Physical Examination Tumour markers Ultrasound •  Intra-operative assessment
  9. 9. Lab evaluation •  Young patients with large complex or solid masses: CA 125-LDH-AFP-HCG •  Peri/post menpousal women: CA 125 – CEA •  Other marker : testosterone, estriol and inhibin A
  10. 10. CA 125 •  Correlates with stage of disease Increase 90 % - Stage II,III,IV Increase 50 % - Stage I
  11. 11. CA-125 Malignant conditions •  Cervical CA •  Fallopian tube CA •  Endometrial CA •  Pancreatic CA •  Colon CA •  Breast CA •  Lymphoma •  Mesothelioma Benign conditions •  Endometriosis/ Menses •  Uterine fibroids •  PID •  Pregnancy •  Diverticulitis •  Pancreatitis •  Liver disease •  Renal failure •  Appendicitis
  12. 12. Sonographic parameters Risk of malignancy Lower Higher Tumour size <10cm >=10 cm Septae Absent or thin (1-2 mm) Thick Number of loculi unilocular Multilocular Over all echo density* Hypo-echogenic homogenous Increased and / or mixed and / or solid component Papillary excrescences absent present * Excludes dermoid cyst/endometrioma
  13. 13. ROMA and RMI Risk of Ovarian Malignancy Algorithm CA 125 + HE4+Menopausal status Risk of Malignancy Index CA 125 + US+ Menopausal status
  14. 14. Evaluation of Ovarian Mass •  Preoperative assessment: History Physical Examination Tumour markers Ultrasound •  Intra-operative assessment
  15. 15. AIDA Storz
  16. 16. complications of benign ov Tumours •  torsion •  hemorrhage •  rupture •  infection •  incarceration •  malignant change •  complications during pregnancy
  17. 17. Clinical picture cancer ovary Benign ovarian Tumours + The following suggest malignancy •  age:mostly postmenopausal •  pain: chronic and persistent •  rapid course •  bilaterality •  Solidity ( variegated consistency ) •  fixity •  metastases :nodules in DP, lymph nodes •  ascitis •  edema LL •  cachexia
  18. 18. Epidemiology •  23,000 cases annually •  15,900 deaths annually •  4th common cause of cancer mortality •  Most (70%) diagnosed at advanced stage where cure is uncommon.
  19. 19. TEN LEADING CANCER SITES IN WOMEN
  20. 20. Patterns of spread •  Direct extension •  Exfoliation of clonogenic cells •  Lymphatic spread
  21. 21. Risk Factors •  Any age ( common >40ys) . •  Nulliparous. •  Late age 1st preg •  History of breast or colon cancer. •  Gonadal Dysgenesis •  Talcum powder –  Increased risk in women who use talc powder on genital area
  22. 22. Risk Factors •  M.H: – Early menarche. –  Late menopause –  prolonged use of fertility drugs without achieving pregnancy –  Uninterrupted ovulation. •  F.H – Mother, sister or daughter with ovarian cancer. – BRCA
  23. 23. Protective factors •  Multiparity: First pregnancy before age 30 •  Oral contraceptives. •  Hysterectomy •  Lactation •  Bilateral oopherectomy
  24. 24. •  Screening ( Early diagnosis) •  GENETIC TESTING
  25. 25. Treatment •  Depends on – Staging – Tumor type –  Age –  Desire for future fertility •  Include surgery, chemotherapy
  26. 26. Approach When approaching an adnexal mass, there are 2 important questions: •  Does this mass need to be removed or can it be observed? •  What are the chances of cancer?
  27. 27. Principle of surgical management •  Prepare the patient for the appropriate surgery ( GI preparation …..) •  Avoid intraoperative rupture of the cyst •  Obtain frozen section if suspecious •  Try to do the necessary procedure in one setting •  Try to preserve fertility and ovarian function in young patient
  28. 28. Guideline EORTIC, NCCN, NIH, SGO •  The more localized the disease appear , the more extensive the assessment should be( STAGING) Level II-3 A •  Optimal debulking for advance stage provide a median survival benefit Level II-b
  29. 29. Ovarian Ca - advanced disease Optimal Residual Disease better prognosis no residual tumor <0.5 cm 0.5 - 1.5 cm CORRELATES
  30. 30. Ovarian Cancer Staging •  Stage 1 – 1A: One ovary – 1B: Both ovaries – 1C: with malignant ascites, rupture surface tumor
  31. 31. Ovarian Cancer Staging •  Stage 2 – 2A: Reproductive organs – 2B: Other pelvic organs – 2C: with malignant ascites or washings
  32. 32. Ovarian Cancer Staging •  Stage 3 – 3A: microscopic upper abdominal disease – 3B: upper abdominal metastasis less than 2 centimeters – 3C: upper abdominal metastasis greater than 2 centimeters
  33. 33. Ovarian Cancer Staging •  Stage 4 is disease outside the peritoneal cavity – Liver parenchymal metastasis. – Pleural effusion – Supraclavicular nodes
  34. 34. Rationale of debulking •  Goldie-Coldman hypothesis
  35. 35. Adjuvant chemotherapy •  Carboplatin (Calvert AUC = 6-7) •  Taxol (175 mg/m2) •  x6 courses q3 weeks
  36. 36. Serous Tumors •  Bilateral (30-66%).
  37. 37. §  The commenst cystic benign ovarian tumor is cystadenoma. §  The commenst ovarian carcinoma is papillary serous cystoadenocarcino ma.
  38. 38. Mucinous Tumors: •  very large. •  Pseudomyxoma peritonei.
  39. 39. Germ cell tumour
  40. 40. Germ cell tumors classification: –  benign: Teratoma ( mature), –  malignant: Dysgerminoma, endodermal sinus t. immature teratoma, embryomal, choricarcinoma ? gonadoblastoma
  41. 41. ( Tumor marker) •  LDH: dysgerminoma •  AFP : endodermal sinus tumor •  HCG : choriocarcinoma, embryonal carcinoma
  42. 42. Cystic Teratoma
  43. 43. Dysgerminoma •  The most-common malignant germ cell tumor •  5% dysgenetic gonad •  Significant rate of bilaterality •  Radiation therapy; very sensitive
  44. 44. Immature Teratoma •  The second most common GCT •  Contains elements that resemble tissues derived from the embryo.
  45. 45. Endodermal sinus tumor •  Secrete AFP •  Hobnail bodies
  46. 46. Chemotherapy. BEP •  Cisplatin : 100mg/m i.v d1 •  Bleomycin : 10-15mg d1-3(24h inf) •  Etoposide : 100mg/m i.v d1-3
  47. 47. SEX CORD-STROMAL TUMORS( SCTS)
  48. 48. Granulosa Cell Tumor:
  49. 49. Sertoli lydig cell tumour •  Testestrone secreted
  50. 50. Metastatic Tumors of Ovary
  51. 51. Krukenberg Tumor:
  52. 52. Thanks •  www.jcsp.sa.com •  www.cabwt.kau.edu.sa

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