1. Malignant Ovarian NeoplasmsBy
Salah T. Fayed, MD
Prof OB & GYN
Gynecologic Oncology Unit
Ain Shams University
Cairo, Egypt

2. WHY? Uterus gives rise to carcinoma or sarcoma
Cervix gives rise to carcinoma or sarcoma
Vulva and vagina almost exclusively give rise to carcinoma only
While Ovary can give rise to more than 20 types of ovarian cancers

3. BECAUSE
Ovary is a Unique Organ with Complex Embryological Origin and Structure
It has celomic surface epithelium
Germ cells
Specialized stroma
Non-specialized stroma

4. Malignant Ovarian Tumors
Primary:
Common Epithelial
Germ cell
Sex cord-stromal
Others
Secondary:
Breast
GIT
Uterus
Lymphoma-Leukemia

5. According to the cell of Origin
Epithelial Ovarian Cancer:
papillary serous.
Endometrioid,
mucinous,
clear cell,
undifferentiated)

6. Germ cell tumors: Dysgerminoma, Endodermal Sinus, Immature teratoma,
Non-gestational Choriocarcinoma
Mixed germ cell tumors

7. Sex cord stromal tumors
Granulosa cell tumor ( feminzing)
Sertoli-Leydig cell tumor (masulinizing)

8. Non-specialized stroma
Lymphoma
Sarcoma

9. Different types of ovarian tumors have:
Different biological behavior
Different incidence
Different age of occurrence
Different risk factors
Different strategies of management

10. Epithelial Ovarian Cancer (EOC) Epidemiology
Comprise 85% of ovarian cancer
Its rank differs in developed and under-developed countries
It is the first in Scandinavian countries and the second in united states after endometrial
It is less common among black races and in Latin America

11. Epithelial Ovarian Cancer: Epidemiology
A disease of post-menopausal women, although young patients in their twenties and thirties are not immune
Peak incidence at 60 years
No parity and low parity increase the risk
High parity and hormonal contraception decrease the risk
Constitute 23% of gyn. Cancers and responsible for 47% of gyn. Cancer Deaths

12. Epithelial Ovarian Cancer: Pathogenesis
As most of the cancers no definite etiology
Genetic factors are important
Women with a first degree relative with EOC have higher relative risk
History of breast cancer increases the relative risk
Excessive induction of ovulation may increase the risk
Repeated trauma of ovulation may play a role in theory

13. EOC: Histological Types
The most common varieties are:
Papillary serous cystadenocarcinoma
Endometrioid adenocarcinoma
Mucinous cystadenocarcinoma
Clear cell carcinoma
Undifferentiated carcinoma

14. EOC: Spread
Trans-peritoneal, the commonest as it is the only intra-peritoneal organ
Direct infiltration of near-by organs
Lymphatic to retro-peritoneal pelvic and para-aortic LN, rarely to inguinal and supraclavicular LN
Blood to distant organs and to liver parenchyma

15. Ovarian Cancer: Staging
Stage I: Confined to the Ovary (a, b &c)
Stage II: Confined to the pelvis (a, b &c)
Stage III: Abdomen and liver surface (a, b &c)
Stage IV: Liver Parenchyma, positive pleural effusion or distant metastases
These are the essential unforgettable elements of ovarian cancer stages

16. Early Ovarian Cancer I & II
Stage I
Ia: one ovary
Ib: both ovaries
Ic: Either + positive peritoneal cytology
Stage II
IIa: Genital
IIb: extra-genital
IIc: Either + positive peritoneal cytology

17. Late Ovarian cancer: III & IV
Stage III (Abdominal)
IIIa: Microscopic
IIIb: < 2 cm nodules
IIIc: > 2 cm nodules or (pelvic or para-aortic) LN metastases
Stage IV
Distant metastases
Positive pleural effusion
Parenchymatous liver metastases

18. EOC: Diagnosis
Early: Adnexal Mass, usually accidentally discovered as during the infertility workup
Late: The common presentation is vague abdominal discomfort, progressive abdominal enlargement, anorexia, weight loss, edema of the lower limbs, obstructive intestinal symptoms
Unfortunately 75% of EOC patients present late as stage III & IV with poor prognosis

19. Clinical Findings: General & Abdominal
Pallor is a common finding
Jaundice is a late sign of liver metastases
Lymphadenopathy including inguinal LN
Lower limb edema (hypoproteinemia and venous compression)
Ascites that may be tense
Pelviabdominal mass
Epigastric mass (Omental cake)

20. Clinical Findings: Pelvic
Adnexal mass (mobile or fixed)
Pelviabdominal mass
Frozen pelvis with amalgamation of the whole pelvic viscera
Hard nodular mass in Douglas pouch
A mass may infiltrate the rectal wall (PR)

21. Investigations Pelviabdominal Ultrasonography Pelviabdominal CT
Chest X-Ray
Upper and Lower GI Endoscopy
(to exclude primary GI malignancy)
Serum tumor marker (CA125)
Taping and cytological examination of Ascites
Routine pre-operative investigations

22. EOC: Management
Exploratory Laparotomy For Surgical Staging and Debulking:
Peritoneal Wash
TAH & BSO
Omentectomy
Palpation of the whole abdominal cavity
Excision of all resectable tumor masses
Pelvic and para-aortic LN sampling

25. Surgical Debulking Ovarian Cancer

26. Excision of involved organs

28. EOC: Management
Definitive Diagnosis is established only after surgical staging and histopathological examination
Almost all cases require post-operative Chemotherapy after Surgical Debulking

29. EOC Management cont. Combination Chemotherapy is the rule
Common regimens are:
Platinum-Cyclophosphamide (CP), accepted
Platinum-Paclitaxel (Taxol), standard

30. EOC: Prognosis & Survival
Tumor stage is the most important prognostic factor
5-year survival ranges from 90% for stage Ia to 10% for stage IV
Optimal debulking is an independent prognostic factor (residual masses < 1 cm)
Sensitivity to chemotherapy
Age: Younger patients have better prognosis

31. EOC: Radiotherapy It has very limited role in Ovarian Cancer
Its complications limits its use specially in presence of effective chemotherapy
Intra-peritoneal Radioactive Phosphorus is the only type of radiotherapy used nowadays
Its role is to eradicate microscopic residuals

32. EOC: Follow Up Follow up is mandatory
Serum tumor marker CA125 is the mainstay of follow in non-mucinous tumors
Clinical Examination every visit
Pelviabdominal U/S and CT are useful
Second look operations are NOT routienly done
The benefit of secondary debulking is doubtful
Second line chemotherapy in case of recurrence

33. EOC: cause of death Intestinal obstruction is the most common
Drug toxicity from chemotherapy
Coincidental thromboembolic disease
Metastases in vital organs as liver and brain

34. Borderline Ovarian Tumors (LMP)
A variety of epithelial tumors that grow slowly and have a tendency to recur after surgical removal
Mucinous is the most common followed by endometrioid and serous types
Multilayering, Atypia with NO stromal invasion are essential for diagnosis of Borderline Tumors

35. Borderline ovarian tumors (cont.)
Usually present as stage I but advanced stages III are sometimes seen
Treatment is essentially surgical with no role for Chemotherapy

36. Thank You
Dr. Salah Fayed