OVARIAN CANCER
Di Wen,M.D.,Ph.D
2003-10-27 Ovarian Cancer 2
Definition
Ovarian tumors may arise at any age,
but are commonest between 30 and 60,
1.Ovarian tumors are particularly liable to be
or to become malignant,
2.In their early stages they are
asymptomatic and painless,
3.They may grow to a large size and tend to
undergo mechanical complications such as
torsion and perforation,
OVARIAN TUMOURS
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Definition
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,
CARCINOMA OF THE OVARY
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Risk Factor
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,
CARCINOMA OF THE OVARY
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Incidence
Nearly 25% of all ovarian neoplasm
are malignant,Approximately 80％
of them are primary growths of the
ovary,the remainder being
secondary,usually carcinomata,
CARCINOMA OF THE OVARY
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Primary Carcinoma of the Ovary
80％ of all cases of primary
carcinoma of the ovary arise in serous
or mucinous cysts,
CARCINOMA OF THE OVARY
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Solid Carcinoma of the Ovary
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,
CARCINOMA OF THE OVARY
2003-10-27 Ovarian Cancer 8
Symptoms due to Size
Lack of any specific
symptoms,ovarian tumors
are often large by the time
the doctor is consulted,
CLINICAL FEATURES OF OVARIAN TUMOURS
2003-10-27 Ovarian Cancer 9
Menstrual function is
seldom upset,and any irregularity is
attributed to the patient’s ‘time of
life’,
2003-10-27 Ovarian Cancer 10
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,
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Pressure Symptoms
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,
CLINICAL FEATURES OF OVARIAN TUMOURS
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CLINICAL FEATURES OF OVARIAN TUMOURS
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CLINICAL FEATURES OF OVARIAN TUMOURS
2003-10-27 Ovarian Cancer 14
CLINICAL FEATURES OF OVARIAN TUMOURS
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CLINICAL FEATURES OF OVARIAN TUMOURS
2003-10-27 Ovarian Cancer 16
General rule
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,
DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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ASCITES
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,
DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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Uterine Fibroids
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,
DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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Complications of Ovarian Tumors
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),
TORSION of the PEDICLE
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TORSION of the PEDICLE
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Clinical Features
Subacute
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,
TORSION of the PEDICLE
2003-10-27 Ovarian Cancer 29
Clinical Features
Acute
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,
Pain tends to be intense and
continuous,
TORSION of the PEDICLE
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Clinical Features
Differential Diagnosis
‘Surgical Conditions’ (i.e,those conditions
commonly seen and dealt with by a general
surgeon.)
Acute appendicitis
Meckel’s diverticulitis
Obstruction of bowel
Diverticulitis
TORSION of the PEDICLE
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Ruptured Cyst
This may occur alone or in
conjunction with torsion,Rupture is
not particularly upsetting to the
patient unless the contents are
irritant,
TORSION of the PEDICLE
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TORSION of the PEDICLE
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TORSION of the PEDICLE
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RUPTURE OF OVARIAN CYST
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RUPTURE OF OVARIAN CYST RUPTURE OF OVARIAN CYST
RUPTURE OF OVARIAN CYST
2003-10-27 Ovarian Cancer 36
PSEUDOMYXOMA PERITONEI
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,
RUPTURE OF OVARIAN CYST
2003-10-27 Ovarian Cancer 37
HYDROTHORAX
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,
RUPTURE OF OVARIAN CYST
2003-10-27 Ovarian Cancer 38
Features suggestive of malignancy
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,
2.Rapid growth,
3.Ascites,
2003-10-27 Ovarian Cancer 39
Features suggestive of malignancy
4.Solid tumours,especially when bilateral,
5.Multilocular cysts with solid areas,(At
least 10% of cysts are malignant),
6.Pain,Pressure pain can occur with any
tumor; but referred pain suggests
malignant involvement of nerve roots,
7.Tumor markers,such as CA125,may be
measured in the blood,but a normal level
does not exclude malignancy,
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Histological Classification
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,
OVARIAN TUMOURS
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PRIMARY EPITHELIAL TUMOR
1.Mucinous cystadenoma or
cystadencarcinoma (of,Cervical epithelium),
2.Serous cystadenoma or
cystadenocarcinoma (of, tubal epithelium),
3.Endometrioma or Endometrioid carcinoma
(of,Endometrium),
4.Clear cell carcinoma,
5.Brenner tumour,
OVARIAN TUMOURS
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STROMATOUS TUMOURS GERM CELL TUMOURS
.Fibroma or sarcoma,
.Dysgerminoma,
.Teratoma,
.Gonadoblastoma,
.Yolk sac tumour,
.Carcinoid
.Thyroid tumour Choriocarcinoma
OVARIAN TUMOURS
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HORMONE-PRODUCING TUMORS
Estrogen-producing,
Granulosa cell tumour,
Thecoma,
Androgen-prodicing,
Sertoli-Leydig cell tumour (Arrhenoblastoma),
Hilar cell tumour,
Lipoid cell tumour,
OVARIAN TUMOURS
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krukenberg tumour
There is one well-known
secondary tumour of the ovary,the
krukenberg tumour,a secondary
of a stomach carcinoma,
OVARIAN TUMOURS
2003-10-27 Ovarian Cancer 45
Definition
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,
OVARIAN TUMOURS --MUCINOUS CYSTADENOMA
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OVARIAN TUMOURS --MUCINOUS CYSTADENOMA
2003-10-27 Ovarian Cancer 47
signs and symptoms
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,
OVARIAN TUMOURS --MUCINOUS CYSTADENOMA
2003-10-27 Ovarian Cancer 48
Definition
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,
OVARIAN TUMORS --MUCINOUS CYSTADENOCARCINOMA
2003-10-27 Ovarian Cancer 49
Definition
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,
OVARIAN TUMORS --SEROUS CYSTADENOMA
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OVARIAN TUMORS --SEROUS CYSTADENOMA
2003-10-27 Ovarian Cancer 51
Definition
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,
OVARIAN TUMORS --SEROUS CYSTADENOCARCINOMA
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Endometrioid Carcinoma of the Ovary
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,
CARCINOMA OF THE OVARY
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Endometrioid Carcinoma of the Ovary
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,
CARCINOMA OF THE OVARY
2003-10-27 Ovarian Cancer 54
Clear Cell Carcinoma
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,
CARCINOMA OF THE OVARY
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Secondary Carcinoma of the Ovary
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,
CARCINOMA OF THE OVARY
2003-10-27 Ovarian Cancer 56
Secondary Carcinoma of the Ovary
Ovarian metastases from extra-
genital tumors are not uncommon,The
commonest sites of primary growth
are breast,stomach and large
intestine,
CARCINOMA OF THE OVARY
2003-10-27 Ovarian Cancer 57
FIBROMA
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,
The fibroma is believed by many to be a
thecoma which has undergone fibrous
transformation,It is sometimes associated
with Meig’s syndrome,
CARCINOMA OF THE OVARY
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GERM CELL TUMOURS
There are four main types of gern cell
tumour,
.Dysgerminoma;
.Tumours of tissues found in the embryo or
adult ---- the teratomata;
.Tumours of dysgenetic gonads ---- commonly a
gonadoblastoma;
.Tumours of extra-embryonic tissues such as
choriocarcinoma or yolk sac tumour,
CARCINOMA OF THE OVARY
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Dysgerminoma
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,
CARCINOMA OF THE OVARY
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Yolk sac tumor
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,
CARCINOMA OF THE OVARY
2003-10-27 Ovarian Cancer 63
CARCINOMA OF THE OVARY
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Estrogen-producing Tumors
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,
CARCINOMA OF THE OVARY
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Estrogen-producing Tumors
In childhood there is accelerated
skeletal growth and appearance of sex hair,
5% occur in children precocious puberty,
60% occur in child-bearing years irregular
menstruation,
30% occur in post-menopausal women
post-menopausal bleeding,
CARCINOMA OF THE OVARY
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ANDOROGEN-PRODUCING TUMOURS
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,
CARCINOMA OF THE OVARY
2003-10-27 Ovarian Cancer 67
Direct
The first spread is directly into
neighbouring structures – peritoneum,
uterus,bladder,bowel and omentum,
Spread of Ovarian Cancer
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Lymphatics
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,
Spread of Ovarian Cancer
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Blood stream
Blood spread is usually late,to
the liver and lungs,
Spread of Ovarian Cancer
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General Principle
1.To classify the growth according to
its extent of spread (staging) as
accurately as possible,
2.To remove as much cancerous tissue
as possible (‘surgical debulking’;’cyto-
reductive treatment’),
SURGICAL PROCEDURES IN OVARIAN CANCER
2003-10-27 Ovarian Cancer 73
General Rule
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,
SURGICAL TREATMENT OF OVARIAN TUMMOURS
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SURGICAL TREATMENT OF OVARIAN TUMMOURS
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SURGICAL TREATMENT OF OVARIAN TUMMOURS
2003-10-27 Ovarian Cancer 76
SURGICAL TREATMENT OF OVARIAN TUMMOURS
2003-10-27 Ovarian Cancer 77
General Principle
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,
TREATMENT OF OVARIAN CANCER
2003-10-27 Ovarian Cancer 78
General Principle
Ovarian carcinoma is staged surgically,so
laparotomy is an essential part of
management for most patients,
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,
TREATMENT OF OVARIAN CANCER
2003-10-27 Ovarian Cancer 79
General Principle
Follow-up with intensive chemotherapy,using
various combinations of antineoplastic
drugs,Taxanes,probably combined with
platinum compounds,are an appropriate
first choice,
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,
TREATMENT OF OVARIAN CANCER
2003-10-27 Ovarian Cancer 80
Incision
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,
SURGICAL PROCEDURES IN OVARIAN CANCER
2003-10-27 Ovarian Cancer 81
Cytology
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,
SURGICAL PROCEDURES IN OVARIAN CANCER
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SURGICAL PROCEDURES IN OVARIAN CANCER