OVARIAN CANCER Di Wen, M.D.,Ph.D

Ovarian Cancer2 Definition Ovarian tumors may arise at any age, but are commonest between 30 and 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

Ovarian Cancer3 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

Ovarian Cancer4 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

Ovarian Cancer5 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

Ovarian Cancer6 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

Ovarian Cancer7 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

Ovarian Cancer8 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

Ovarian Cancer9 Menstrual function is seldom upset, and any irregularity is attributed to the patient ’ s ‘ time of life ’.

Ovarian Cancer10 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.

Ovarian Cancer11 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

Ovarian Cancer12 CLINICAL FEATURES OF OVARIAN TUMOURS

Ovarian Cancer13 CLINICAL FEATURES OF OVARIAN TUMOURS

Ovarian Cancer14 CLINICAL FEATURES OF OVARIAN TUMOURS

Ovarian Cancer15 CLINICAL FEATURES OF OVARIAN TUMOURS

Ovarian Cancer16 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

Ovarian Cancer17 DIFFERENTIAL DIAGNOSIS

Ovarian Cancer18 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

Ovarian Cancer19 DIFFERENTIAL DIAGNOSIS

Ovarian Cancer20 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

Ovarian Cancer21 DIFFERENTIAL DIAGNOSIS

Ovarian Cancer22 DIFFERENTIAL DIAGNOSIS

Ovarian Cancer23 DIFFERENTIAL DIAGNOSIS

Ovarian Cancer24 DIFFERENTIAL DIAGNOSIS

Ovarian Cancer25 DIFFERENTIAL DIAGNOSIS

Ovarian Cancer26 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

Ovarian Cancer27 TORSION of the PEDICLE

Ovarian Cancer28 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

Ovarian Cancer29 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

Ovarian Cancer30 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

Ovarian Cancer31 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

Ovarian Cancer32 TORSION of the PEDICLE

Ovarian Cancer33 TORSION of the PEDICLE

Ovarian Cancer34 RUPTURE OF OVARIAN CYST

Ovarian Cancer35 RUPTURE OF OVARIAN CYST

Ovarian Cancer36 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

Ovarian Cancer37 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

Ovarian Cancer38 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.

Ovarian Cancer39 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.

Ovarian Cancer40 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

Ovarian Cancer41 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

Ovarian Cancer42 STROMATOUS TUMOURS GERM CELL TUMOURS.Fibroma or sarcoma..Dysgerminoma..Teratoma..Gonadoblastoma..Yolk sac tumour..Carcinoid.Thyroid tumour Choriocarcinoma OVARIAN TUMOURS

Ovarian Cancer43 HORMONE-PRODUCING TUMORSEstrogen-producing: Granulosa cell tumour. Thecoma.Androgen-prodicing: Sertoli-Leydig cell tumour (Arrhenoblastoma). Hilar cell tumour. Lipoid cell tumour. OVARIAN TUMOURS

Ovarian Cancer44 krukenberg tumour There is one well-known secondary tumour of the ovary, the krukenberg tumour, a secondary of a stomach carcinoma. OVARIAN TUMOURS

Ovarian Cancer45 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

Ovarian Cancer46 OVARIAN TUMOURS -- MUCINOUS CYSTADENOMA

Ovarian Cancer47 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

Ovarian Cancer48 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

Ovarian Cancer49 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

Ovarian Cancer50 OVARIAN TUMORS --SEROUS CYSTADENOMA

Ovarian Cancer51 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

Ovarian Cancer52 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

Ovarian Cancer53 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

Ovarian Cancer54 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

Ovarian Cancer55 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

Ovarian Cancer56 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

Ovarian Cancer57 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

Ovarian Cancer58 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

Ovarian Cancer59 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

Ovarian Cancer60

Ovarian Cancer61

Ovarian Cancer62 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

Ovarian Cancer63 CARCINOMA OF THE OVARY

Ovarian Cancer64 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

Ovarian Cancer65 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

Ovarian Cancer66 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

Ovarian Cancer67 Direct The first spread is directly into neighbouring structures – peritoneum, uterus, bladder, bowel and omentum. Spread of Ovarian Cancer

Ovarian Cancer68 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

Ovarian Cancer69 Blood stream Blood spread is usually late, to the liver and lungs. Spread of Ovarian Cancer

Ovarian Cancer70

Ovarian Cancer71

Ovarian Cancer72 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

Ovarian Cancer73 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

Ovarian Cancer74 SURGICAL TREATMENT OF OVARIAN TUMMOURS

Ovarian Cancer75 SURGICAL TREATMENT OF OVARIAN TUMMOURS

Ovarian Cancer76 SURGICAL TREATMENT OF OVARIAN TUMMOURS

Ovarian Cancer77 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

Ovarian Cancer78 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

Ovarian Cancer79 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

Ovarian Cancer80 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

Ovarian Cancer81 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

Ovarian Cancer82 SURGICAL PROCEDURES IN OVARIAN CANCER