Prof. Mohammad Emam Prof. of OB & GYN. Mansoura Faculty of Medicine EGYPT

Pathologic behavior : Non neoplastic Neoplastic (benign,malign, borderline). Morphology(cystic,solid). Histogenesis.

Ovarian tumours Neoplastic Epithelial T Sex cord T Germ cell T. others( Metastatic ….) Non neoplastic Lutein cysts. Endometrial cysts: ( follicular hematoma & endometriosis). Inflammatory Watered inclusion cyst cystic C.L. Pcos

EMAM

Neoplastic Ovarian Tumours Surface epithelial – % Germ cell tumors – 15-20% stromal – 10-15% Metastatic tumors – 5%

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. Ranks 3 r d among gynecologic cancers Ranks 5 th among women cancers.

TEN LEADING CANCER SITES IN WOMEN

Incidence of Gynecologic Cancers in Egyptian Women Breast Cancer Cervical Cancer Ovarian Cancer Uterine Cancer Percent Source: GLOBOCAN 2000.

Risk Factors Personal H : Any age ( common >40ys). Nulliparous. Late age 1 st preg History of breast or colon cancer. Gonadal Dysgenesis Talcum powder Increased risk in women who use talc powder on genital area

Risk Factors M.H: E arly menarche. Late menopause prolonged use of fertility drugs without achieving pregnancy Hormone replacement therapy > 10 years Uninterrupted ovulation. F.H Mother, sister or daughter with ovarian cancer.

Protective factors Multiparity: First pregnancy before age 30 Oral contraceptives. Hysterectomy Lactation Bilateral oopherectomy

Staging: Vertical incision. Aspirate, or saline washing. Careful assessment., Liver, rt hemidaphragm, All other organs as omentum, intestine, …. Para aortic LN sampling. Proper staging, for prognosis, selection of adjuvant therapy …..

Ovarian Cancer Staging Stage 1 1A: One ovary 1B: Both ovaries 1C: with malignant ascites, rupture surface tumor

Ovarian Cancer Staging Stage 2 2A: Reproductive organs 2B: Other pelvic organs 2C: with malignant ascites or washings

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

Ovarian Cancer Staging Stage 4 is disease outside the peritoneal cavity Liver parenchymal metastasis. Pleural effusion Supraclavicular nodes

Epithelial Tumours Benign Malignant Cystic (commenst) Solid = papillae Serous cysetoadenoma Papillary Serous cysetoadenoma Pseudomucinous cysetoadenoma 2ry (20%)1ry (80%) Solid (5%) Cystic (75%) Atypical Kruckenberg T Typical Carcinoma Border l

Ovarian Cysts Physiological: Pathological : Non neoplastic Neoplastic Mature G.F. Usually multiple & > 2.5cm

Epidemiology of Ovarian Cysts? Epidemiology of Ovarian Cysts? Many types Different underlying cause. Many women will have cysts during their childbearing years. Most are asymptomatic. Some types can cause serious health problems.

Serous Tumors Bilateral (30-66%). 75% benign/ bord. 25% malignant. One or few cysts, papillary/solid. Tall columnar ciliated epithelium. Papillary, solid, hemorrhage, necrosis or adhesions – malignancy.

Serous cystadenoma:

Serous Cystadenoma

Bilateral cystadenoma

Mucinous Tumors: Less common 25%, very large. Rarely malignant - 15%. Multiloculated, many small cysts. Rarely bilateral – 5-20%. Tall columnar, apical mucin. Pseudomyxoma peritonei.

Mucinous Cystadenoma:

BENIGN OVARIAN TUMORS Pseudomucinous Cystadenoma

BENIGN OVARIAN TUMORS Mutilocular Cystadenoma Simple cyst

MALIGNANT OVARIAN TUMORS Cystoadenocarcino ma

 The commenst cystic benign ovarian tumor is pseudomucinous cystadenoma.  The commenst ovarian carcinoma is papillary serous cystoadenocarcinoma.

Diagnosis Screening ( Early diagnosis) Advanced stages

Screening Generally Is to seek about certain problem in certain high risk gp.

Concept   Prevention is better than cure.   CCancer cx. Screening programs are in adulthood   BOv. cancer programs are still in relative infancy, why?

Phases of Tumourgenesis DysplasiaInvasive asymptomatic Invasive symptomatic Cancer cx. End. C. As cancer ovary Normal cells

Ovarian Cancer Screening BBenefit to screening is unproven AAnnual bimanual gynecologic examination TTransvaginal ultrasound CCA 125 serum levels SScreening may result in more unnecessary surgeries than new ovarian cancers

Diagnosis Of Advanced Stages

General Clinical Features: Less symptoms so late detection. Larger benign tumor High mortality in malignant tumors.

Diagnostic tools History General abdominal discomfort and/or pain (gas, indigestion, pressure, swelling, bloating, cramps.) Nausea, diarrhea, constipation, or frequent urination. Loss of appetite. Feeling of fullness even after a light meal. Weight gain or loss with no known reason.

Exam Abdomen Distention Mass Ascites DUB Rectal

Clinical criteria of malignancy Bilateral Fixed Variegated consistency Nodules in Douglas p Hgic ascites Common character of malignancy

Investigations:- Transvaginal Ultrasound – Tumor markers – CA-125, LPA (plasma lysophosphatidic acid) CT – assess spread to LN, pelvic and abdominal structures. MRI – best for distinguishing malignant from benign tumors

CA-125 Poor specificity (elevated in many gynecologic and non-gynecologic malignancies as well as benign conditions)

CA-125 Malignant conditions Cervical CA Fallopian tube CA Endometrial CA Pancreatic CA Colon CA Breast CA Lymphoma Mesothelioma Benign conditions Endometriosis/Men ses Uterine fibroids PID Pregnancy Diverticulitis Pancreatitis Liver disease Renal failure Appendicitis

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