Dr . Saadeh Jaber OBGYN consultant 2010 Ovarian Cancer Dr . Saadeh Jaber OBGYN consultant 2010

Epidemiology Second most common gynecological cancer . >35 , median 70 It accounts for deaths more than cancer of cervix and uterus together

Etiology The ovulation theory Genetics others These two associations support the ‘incessant ovulation’ theory of ovarian cancer.  Each month a woman’s ovary releases an egg (ovulation).  Release of the egg disrupts the outer lining of the ovary (epithelium) which the body repairs.  The ‘incessant ovulation’ theory postulates that the greater the number of times a women ovulates (produces eggs) in her lifetime, the greater the risk of developing ovarian cancer as during the repair of the epithelium the cells become abnormal and develop into cancer cells.  Alcohol and milk

Risk factors and Prevention Number of life time ovulations age > 35 Infertility Nulliparity Late menopasue Family history BRCA 1 +2 Prevention Use of OCP Breastfeeding Multiparity Tubal sterilization

Genetics Familial Ovarian cancer 5-10% of epithelial cancers (usually serous adencarcinoma) 1 relative ---- 2.5% 2 relatives 30-40 % Most have breast and colorectal cancer BRCA 1 & BRCA 2 HNPCC 5-10% are associated with genetically predisposed syndromes

Classification Primary vs Secondary Histological type

Primary Vs Secondary Secondary : 7% Common primary cancers are breast cancer and gastrointestinal cancer “Krukenberg tumour”

Histological origin

Epithelial Serous Mucinous Endometroid Sex cord stromal Granulosa Sertoli-Leydig cell Germ cell Dysgerminoma Endodermal sinus Immature teratoma Choriocarcinoma Epithelial

Epithelial Cell tumor 85 % of malignant tumors 60-70 yrs Worst prognosis CEA , CA-125 Arise from the surface epithelium

Serous Mucinous Clear cell Brenner Endometroid Epithelial Serous

Borderline epithelial tumors 10% of the epithelial cells Atypia, mitotic activity , but no invasion of the stroma Good prognosis Most are serous or mucinous

Germ Cell tumor Second most common type of ovarian cancer 5-10% 20-40 yrs Better prognosis LDH, AFP,B-HCG Usually solid

Sex Cord Tumors Least common ovarian neoplasm 5-8 % of ovarian cancers and 30 % of all tumors Low grade malignancy Hormonally active Arise from the sex cords of the embyonic gonads before they differentiate into male or female

Clinical findings Usually absent or nonspecific GI symptoms Urinary symptoms Postmenopausal bleeding Virilization Acute abdomen 2\3 in stage 3 GI: abdominal pain anddiscomfort are most common presenting coplaint . NV , distention, early satiety,bowel habit changes – speard in the peritoneal cavity Estrogen – unopposed hyperplasia

Diagnosis – Investigations U\S Tumor markers Bariun enema IVP Chest X-ray, abdominal X-ray CT/PET

U/S Solid and cystic, septation, irregularly shaped

Diagnosis – Markers Ovarian Tumor Serum marker Dysgerminoma LDH Endodermal sinus AFP Choriocarcinoma B-HCG Granulosa tumor Inhibin Sertoli-leydig cell Testosterone

Metastasis Mainly through the peritoneal fluid Lymphatic spread Least common hematogeneous

Management Surgery: TAH/BSO Pelvic and aortic lymph node dissection Omentectomy Appendectomy Washings Biopsies

Prognosis The five-year survival rate for all stages of ovarian cancer is 45.5%. Germ cell tumors of the ovary have a much better prognosis than other ovarian cancers, in part because they tend to grow rapidly to a very large size, hence they are detected sooner.

Incidence Mortality