Ovarian Tumours

MANAGEMENT OF OVARIAN TUMOURS BISSALLAH EKELE, DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY, USMANU DANFODIYO UNIVERSITY TEACHING HOSPITAL, SOKOTO, NIGERIA.

THE OVARY • MAIN INTERNAL FEMALE REPRODUCTIVE ORGAN • TRIPLE ORIGIN (CE,MESODERM,GC) • EACH IS ALMOND SHAPED (3X2X1) • NOT COVERED BY PERITONEUM • SURFACE(GE), CORTEX, MEDULLA • PRODUCE EGGS AND HORMONES

OVARIAN TUMOURS MAY BE • FUNCTIONAL (PHYSIOLOGICAL)* • INFLAMMATORY • ENDOMETRIOSIS • NEOPLASTIC* *PRIORITY

FUNCTIONAL OVARIAN CYSTS: • FOLLICULAR CYST • CORPUS LUTEUM CYST • THECA-LUTEIN CYST • POLYCYSTIC OVARIAN SYNDROME • LUTEOMA OF PREGNANCY (Repro. age group, asymptomatic, expectant mgt -60/d)

NEOPLASTIC OVARIAN TUMORS - BENIGN • PRIMARY -MALIGNANT

• SECONDARY (Breast,Stomach,Colon,Endometrium) ‘Krukenberg Tumors’

BENIGN OVARIAN TUMOURS: (ovary’s triple heritage) •

EPITHELIAL -SEROUS -MUCINOUS -ENDOMETRIOD -CLEAR CELL TUMOUR (MESONEPHROID) -TRANSITIONAL CELL TUMOUR (BRENNER)

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SEX-CORD STROMAL -THECOMA -FIBROMA (MEIG’S SYNDROME)

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GERM CELL -TERATOMAS (DERMOID CYST) MANAGEMENT: SURGERY (Age, Parity, Tumour characteristics) -Cystectomy, unilateral oophorectomy or TAH + BSO

MALIGNANT OVARIAN TUMORS • Greatest challenge to the Gynecologist • No pre-malignant phase • Inaccessible location • Late presentation (75%) • 3rd common cause of cancer death in African women

OVARIAN CARCINOMA HIGH RISK FACTORS -Reduced family size -Late age at 1st pregnancy -Family history (BOC Synd, Lynch II Syndrome) -Use of fertility drugs -Previous irradiation to ovaries -Higher socioeconomic status -White women -Blood group A

OVARIAN CARCINOMA REDUCED RISK: -Long term oral contraceptive users -Multiparous women -Women who breast-feed -Low socioeconomic status -Black women -Blood group O

OVARIAN CANCER DIAGNOSIS • CLINICAL History - Vague, non-specific, abd swelling, pain Exam - Abdomino-pelvic mass (B vs M) • RADIOLOGICAL – ultrasound, cxray, ct, mri • BIOCHEMICAL – tumor markers CA125,AFP,HCG,CEA • SURGICAL – diagnosis, staging, treatment

STAGING OVARIAN CANCER (FIGO) • STAGE I, growth limited to the ovaries a, b, c • STAGE II, + extension to the pelvis a, b, c • STAGE III, + extension abdominal cavity a, b, c (micro,<2cm, >2cm or nodes) • STAGE IV, + distant metastasis, liver para Pattern of spread = Direct, transcoelomic*, lymphatic, haematogenous.

TREATMENT • OPTIMAL THERAPY = MULTIDISCIPLNARY TEAM DESIGNATED GYNE CANCER CENTRE • SURGERY PRIMARY STEP (Remove all visible tumor) ‘OPTIMAL DEBULKING’ ‘CR’ - BSO - TAH - Omentectomy - Lymphadenectomy(Pelvic ¶-aortic) - Appendix / Bowel where indicated

TREATMENT • CHEMOTHERAPY (ADJUVANT-given after 1 rx) - None - Alkylating agents(cyclophosphamide) - Platinums (Cisplatin, Carboplatin) ‘Non-classic alkylators’ - Taxanes (paclitaxel, docetaxel) ‘Promote microtubule polymer formation’ - Combination Chemotherapy (Gold Standard, P-C, D-C) . How many courses?

• RADIOTHERAPY - Intraperitoneal radio-isotopes (32P, Au 198) - External Beam Therapy Limited use/ Out of favour . IMMUNOTHERAPY (Experimental: Interleukin-2, interferons) . ? SECOND LOOK SURGERY

OVARIAN CANCER PROGNOSIS DEPENDS ON STAGE OF DISEASE - Stage I, 85% 5-Year Survival - Stage II, 70% - Stage III, 30% - Stage IV ,10% (Histology type, grade, response chem)

PREVENTION • PRIMARY, SECONDARY AND TERTIARY LEVELS • NO UNIVERSAL SCREENING TOOL YET • POSITIVE FAMILY HISTORY (BRCA1 gene -17, BRCA2 -13) ?ULTRASOUND SCAN YEARLY ?CA 125 SERUM MEASURE

THANK YOU!