Fallopian Tube and Ovarian Malignancy Schwartz's Principles of Surgery Chapter 41. Gynecology

Epithelial Fallopian Tube and Ovarian Malignancy  Presentation and Screening of Tubal and Epithelial Ovarian Neoplasms: 22,400 new cases and 15,280 deaths fractional death rate of 68% most deadly of gynecologic cancers Common symptoms for either benign or malignant ovarian tumors include : pelvic discomfort, cramping, pain, fullness, headache, backache, and others

 ovarian cancer symptom index: describes symptoms of bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary symptoms of urgency or frequency  CA 125 is used commonly but has only been approved by the U.S. Food and Drug Administration for use as a biomarker to follow response to therapy for ovarian and tubal cancer patients.

Risk Factors  Approximately 90% of ovarian cancer is sporadic; of the remaining 10% of cases, 75% of hereditary ovarian cancers has been attributed to mutations in the BRCA1 and BRCA2 genes, 7% to hereditary nonpolyposis colorectal cancer syndrome, and the remainder to familial cancer of undefined genetic origin.

 Controversy exists as to the protective effect of oral contraception pills.  The only confirmed prevention is risk-reducing salpingo- oophorectomy (RRSO).  A RRSO procedure must include, at a minimum, the complete resection of the ovaries and extrauterine fallopian tubes bilaterally.

Types of Epithelial Tubal and Ovarian Neoplasms  Benign Neoplasms: Cystic masses are the most common benign findings and include: follicular cysts, endometriomas, and cystadenomas or cystadenofibromas.

Tubal Intraepithelial Neoplasia  The ovary contains limited epithelium, the single-cell thick-surface epithelial layer and the epithelium lining inclusion cysts.  The fallopian tube contains the largest surface area of epithelium in the gynecologic organs. This epithelium is organized in a serous papillary pattern, one that is seen in well-differentiated ovarian and tubal neoplasms.

Low Malignant Potential Tumor  histology includes all subtypes identified for frank malignancy: papillary serous, mucinous, clear-cell, endometrioid, and transitional or Brenner tumor.  Surgical intervention is the recommendation of choice. Stages I and II LMP tumors have a 10-year survival of nearly 100%.

Invasive Tubal and Epithelial Ovarian Cancers  Initial staging and cytoreduction  Interval debulking  Second look procedures  Secondary cytoreduction  Palliation of disease complications

Primary Debulking Surgery  Standard primary debulking of epithelial ovarian cancer includes removal of the uterus, tubes, ovaries, and omentum.  Dissection of pelvic and periaortic lymph nodes is required if no gross intraperitoneal disease (>2 cm in longest diameter) is seen.

Nonepithelial Cancers of the Ovary and Fallopian Tube  Germ Cell Tumors occur most commonly in women under age 30 years old, grow and disseminate rapidly, and are symptomatic.  Most common are the benign forms of teratomas; within the malignant category, the most common malignant form is dysgerminoma.

Sex Cord-Stromal Cell Tumors  combinations of the mesenchymal (fibromas, sarcomas) and sex cord cell components (granulosa, theca, Sertoli, Leydig.