Ovarian Tumor

OVARIAN TUMOR

By

Dr.Feng Quan Ling

CHARACTERS WHO CLASSIFICATION PATHOLOGY METASTASES HISTOLOGICAL GRADES STAGING CLINICAL MANIFESTATION DIAGNOSIS DIFFERENTIAL DIAGNOSIS COMPLICATION RISK FACTORS & PREVENTION MANAGEMENT

CHARACTERS • Common

disease---comprise about 32% of all genital tumors in female • Ovarian cancer is the 5th leading cause of cancer death in women and the leading cause of death from gynecologic malignancies. • High mortality rate in malignant tumors

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Ovarian cancer is disproportionately deadly for a number of reasons: • Symptoms are vague and non-specific • Ovarian cancers shed malignant cells that frequently

implant on the uterus, bladder, bowel and omentum (wangmo), and begin forming new tumor growths before cancer is even suspected. • Because no cost-effective screening test for ovarian cancer exists, more than 50 percent of women with ovarian cancer are diagnosed in the advanced stages of the disease.

WHO CLASSIFICATION • WHO classification of ovarian tumor is according to the origination of ovarian tumor

• Epithelial tumors surface epithelium of the ovary • Sex cord tumors sex cord cells of ovarian cortex • Germ cell tumors primordial germ cells • Metastatic tumors gastrointestinal or breast

PATHOLOGY • It is complicated. • Pay attention to _women age _ unilateral or bilateral _tumor size,shape,consistency,stiffness lateral,cut surface _character (benign or malignant) _5-year survival rate _prognosis

PATHOLOGY PATHOLOGY

•Epithelial tumor of ovary It can be divided into • benign, • borderline malignant • malignant tumors Borderline malignant _have some of the cellular characteristics of malignancy, _grow slowly _rate of metastasis is low and relapse is late _clinical courses and prognosis are between B & M

PATHOLOGY PATHOLOGY

Epithelial tumor _serious tumor • Serious cystadenoma • Borderline serious cystadenomas • Serious cystadenocarcinomas

PATHOLOGY PATHOLOGY

Serious cystadenoma • • • • • • • •

very common mostly unilateral smooth external surface content is generally a thin watery serosity usually one cavity divided into simple and papillary type Benign The rate of malignant change is 35%

PATHOLOGY PATHOLOGY

Serious cystadenocarcinomas • • • • • • •

very common mostly bilateral large in size smooth surface or papilli growing content is turbid or hemorrhagic multiple cavity 5-year survival rate is only 20-30%

Serious cystadenocarcinomas

PATHOLOGY PATHOLOGY

mucinous cystadenoma • • • • • •

Common Benign unilateral bluish white surface huge size mucin fluid in cyst is thick contain mucoprotein or glycoprotein. • rate of malignancy is 5-10%

PATHOLOGY PATHOLOGY

mucinous cystadenocarcinoma • unilateral • cut surface has both cystic and solid areas • 5-year survival rate is only 40-50%

PATHOLOGY PATHOLOGY

•Ovarian germ cell tumor • occur in children and young women in the reproductive age group • only mature teratoma is benign • others are all malignant • except dysgerminoma, other malignancy are all high-malignant and prognosis is poor

PATHOLOGY PATHOLOGY

Teratoma (1) • composed of 2-3 germ layers • most part are cystic and few part is solid • mature teratoma belongs to benign called mature cystic teratoma or dermoid cyst • frequently unilateral • filled with thick yellowish greasy fluid,hair,and sometimes tooth or bone • rate of malignant change is 2-4%

PATHOLOGY PATHOLOGY

Teratoma (2) • immature teratomas are unilateral solid body • irregular surface • cut surface is brittle and soft like cerebral tissue • rate of metastases and recurrence is high • 5-year survival rate is 20%.

PATHOLOGY PATHOLOGY

Dysgerminoma • • • •

malignant bilateral common in right round or ovoid, moderate size with smooth surface • cut surface is solid and grayish pink. • very sensitive to radiation therapy • the 5-year survival rate can reach 90%

Dysgerminoma

PATHOLOGY PATHOLOGY

Endodermal sinus tumor • tissue structure is very similar to endodermal sinus of the rat's • • • • • •

placenta their morphology resemble yolksac of human's embryo,so it's also called yolk sac tumor highly malignant Unilateral, round or ovoid cut surface is solid and brittle tumor cells can produce AFP,which can be identified,its concentration is parallel to growth and decline of tumor, has become an important mark in diagnosis,treatment and monitor. mean survival time was only 12-18 months in the past.

Endodermal sinus tumor

PATHOLOGY PATHOLOGY

•Sex cord-stromal tumors of ovary • Granulosa-stromal cell tumor. 1-granulosa cell tumor. 2- theca cell tumor 3-fibroma • Sertoli-leydig cell tumors

PATHOLOGY PATHOLOGY

granulosa cell tumor. • • • • • • •

low-malignant functional tumors frequently occur in women of 50 years old. tumor cell can secret estrogen generally prognosis is good 5-year survival rate may reach about 80% because these tumors recur after a long interval, prolonged follow up is necessary

PATHOLOGY PATHOLOGY

theca cell tumor • mostly benign • usually diagnosed in postmenopause women, rarely in women below 40 years old • have more obvious symptoms of femininity • prognosis is better than ovarian carcinoma

PATHOLOGY PATHOLOGY

fibroma • • • •

occur in middle aged women, solid,benign ,unilateral,moderate in size. smooth surface Occasionally these tumors will be associated with ascites and pleural effusions, a situation that is called MEIGS syndrome. These ascites and pleural effusions will go down spontaneously after removal of tumor.

fibroma

PATHOLOGY PATHOLOGY

Sertoli-leydig cell tumors • • • • • •

also called androblastoma, found in young women mostly benign with abnormal masculinization symptoms 10-30% tumors are malignant 5 year survival rate is 70-90%

PATHOLOGY PATHOLOGY

•Secondary of metastatic carcinoma of ovary. • primary lesion usually in GIT (gastrointestinal), breast, genitalia(uterus,oviduct). • Krukenberg tumor is a special metastatic adenocarcinoma from GIT. It is solid moderate in size. prognosis is poor most patients die a year after operation.

Krukenberg tumor

PATHOLOGY PATHOLOGY

•Tumor-like conditions of ovary • • • • •

solitary follicle cyst corpus luteum cyst multiple luteinized follicular cyst polycystic ovary endometriosis of ovary

Metastases of the malignant ovarian tumor

Direct

spreading and peritoneal implantation Lymphatic spreading Blood Matastases

METASTASES OF THE MALIGNANT OVARIAN TUMOR • some

malignant ovarian tumors look localized but in fact a sub-clinical metastases have occured always to peritoneal, post peritoneal lymphonodi, omentum,diaphragm etc. • the metastatic ways mainly are directly spreading and peritoneal implantation. • metastases through blood vessels are rare.

HISTOLOGICAL GRADES OF MALIGNANT TUMOR 1)Highly differentiated 2)moderately differentiated 3)lowly differentiated

STAGING • stage 1=growth limited to ovaries • stage 2=growth involving one or both ovaries

with pelvic extension. • stage 3=tumors involving one or both ovaries with peritoneal implants outside pelvis and/or positive retroperitoneal or inguinal nodes • stage 4=growth involving one or both ovaries with distant metastases

I期

II 期

IIa 期 Ib 期

Ia 期

IIb 期

或

腹水阳性

Ic 期

IIc 期

III 期

IV 期 前锁骨淋巴结

种植性肝转移 恶性胸膜细胞 腹腔腹膜转移 肝实质性转移

CLINICAL MANIFESTATION(1) benign tumors • grow slowly. • In early stage have no symptoms, usually discovered in gynecological examination on occasion. • During gynecological examination we can touched mass : in unilateral or bilateral, cystic or solid, smooth surface, moved freely, no adhesion. • Large tumors can push adjacent organs.

CLINICAL MANIFESTATION(2) malignant tumors • very insidious and silent in terms of signs and symptoms • appearance of symptoms often indicated advanced stage of tumor • grow rapidly • symptoms generally depend on size, histological types and complications

DIAGNOSIS Depend on • age history • local signs • ultrasonic examination • radiological examination • cytological examination • laparoscopy • tumor markers (AFP,CA-125,hCG)

Antigen

markers AFP Hormone markers βHCG Enzyme LDH

R

R

DIFERENTIAL DIAGNOSIS • benign ovarian tumor • malignant ovarian tumors

benign ovarian tumor • tumor like disease of ovary follicle cyst and corporalutum are the commonest diameter less than 5cm generally unilateral thin walls disappear spontaneously in 2 months

• • • •

leiomyoma gestational uterus plentifull bladder ascites

malignant ovarian tumors • • • • •

secondary tumors of ovary endometriosis pelvic cellulitis TB peritonitis tumors except genital system

COMPLICATION • 1) torsion of pedicle these tumors have moderate size, long pedicle, great mobility and partiality, e.g dermoid cyst. • 2) rupture of cyst divided into spontaneous and traumatic types. • 3) infection • 4) malignantation

RISK FACTOR & PREVENTION Risk factors and • hereditary family factors • environmental factors • endocrine factors • virus factors • Repeated ovulation

Prevention • avoid above risk factors • General survey of age >30 • find and treat as early as possible • Oophorectomy • oral contraceptive

MANAGEMENT 1. Treatment of benign ovary tumors • a) Principles : surgical therapy • b) Range of remove : • c) Notes during operation 2. Treatment of malignant ovary tumor • a) Surgical therapy • b) Chemical therapy • c) Radiation therapy

Torsion of pedicle

b) Range of remove • related to : the age of patients , demand of fertility , condition of opposite ovary • i) Unilateral oophorectomy (or only excise tumour) (shell out of their ovarian beds) • ii) Bilateral oophorectomy • iii) Hysterectomy

c) Notes during operation • Distinguish the benign tumor from the malignant tumor • Histological examination (frozen section biopsy) • Remove completely

2-a) Surgical therapy • careful

exploration of organs in abdominal cavity including diaphragm • range of operation: hysterectomy and Bilateral salpingo-oophorectomy • cytoreductive surgery • removal of lymph nodes in reteroperitoneal space

2-b) Chemical therapy • Postoperative • • • • •

chemical therapy is helpful in preventing of replace of ovarian tumor Platinum- type drug and taxane Common drugs : alkylating agents, Anti-metabolic groups, Anti-biotic groups. Combined chemical therapy is better than therapy with single drug Choose effective chemical therapy according to the tumor histological type Neoadjuvant chemotherapy: prior to any attempt to perform cytoreductive suegery

2-c) Radiation therapy Sensitivity of different histological type tumors is different • Dysgerminoma is the most sensitive • Granulosa cell tumor has moderate sensitivity • Epithelial tumor has also a certain sensitivity

cytoreductive surgery • Even for advanced stage cases, the masses that can be found grossly should be removed to decrease the quantity of tumor cells as few as possible. • Leaving residual disease at the initial surgery that has a maximum diameter less than 1 cm at any site in the abdominal cavity.