60259273 Malignant Ovarian Tumour

8/4/2019 60259273 Malignant Ovarian Tumour

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MALIGNANT OVARIANMALIGNANT OVARIANTUMOURTUMOUR

By: Dr. Johara Al-MutawaBy: Dr. Johara Al-Mutawa

Assistant Professor &Assistant Professor &

ConsultantConsultant


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::

* It is common gynaecological tumour* It is common gynaecological tumour

continue to kill more women thancontinue to kill more women than

all other gynaecological cancerall other gynaecological cancer

* In England the incidents of ovarian* In England the incidents of ovarian

cancer 1.4 higher than cervical andcancer 1.4 higher than cervical andendometrial cancer but lower than breastendometrial cancer but lower than breast

cancer 7.1%cancer 7.1%

* Eventually 80 to 85% of women* Eventually 80 to 85% of women

with ovarian cancer diewith ovarian cancer die* Most ovarian cancer as epithelial in* Most ovarian cancer as epithelial in

origin and incidence increase riskorigin and incidence increase risk

with age.with age.


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Germ cell tumour rare and occur mainlyGerm cell tumour rare and occur mainly

in children and young women.in children and young women.

* Survival rater 5 years in 60% of stage I* Survival rater 5 years in 60% of stage I

disease ovarian malignancy.disease ovarian malignancy.

Histopathology and Classification ofHistopathology and Classification of

ovarian mass.ovarian mass.

* Ovarian mass Physiological* Ovarian mass Physiological

NeoplasticNeoplastic BenignBenign

MalignantMalignant

* WHO provide international classification* WHO provide international classification

that has been universally acceptedthat has been universally accepted


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Histological classification of ovarianHistological classification of ovarian

TumourTumour

Epithelial TumourEpithelial Tumour

* Serous Tumour* Serous Tumour* Mucinous Tumour* Mucinous Tumour

* Endometrial Tumour* Endometrial Tumour

* Clear Tumour* Clear Tumour

* Mixed Tumour* Mixed Tumour

* Undifferentiated and Unclassified* Undifferentiated and Unclassified

TumourTumour


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Sex-Cord Stromal tumoursSex-Cord Stromal tumours

* Granulosa stromal cell tumours* Granulosa stromal cell tumours* Sertoli stromal cell tumours* Sertoli stromal cell tumours

* Gynandroblastoma* Gynandroblastoma

* Sex cord tumour with annular tubules* Sex cord tumour with annular tubules

* Unclassified sex-cord tumoursSteroid cell* Unclassified sex-cord tumoursSteroid celltumourstumours


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Ovarian germ-cell tumoursOvarian germ-cell tumours

* Dysgerminoma* Dysgerminoma

* Teratoma (immature, mature and* Teratoma (immature, mature and

monodermal)monodermal)

* Yolk sac tumour (endodermal sinus* Yolk sac tumour (endodermal sinus

tumour)tumour)

* Embryonal carcinoma* Embryonal carcinoma

* Polyembryoma* Polyembryoma* Choriocarcinoma* Choriocarcinoma

* Mixed germ-cell tumour* Mixed germ-cell tumour


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Epithelial Tumour Arise from surface epithelium ofEpithelial Tumour Arise from surface epithelium of

ovary account from 60-65 % of ovarian tumour andovary account from 60-65 % of ovarian tumour and

approximately 90% are malignant.approximately 90% are malignant.

BenignBenign

border lineborder line

malignantmalignant

Sex cord stromal tumourSex cord stromal tumour

- Derived from sex cord & Stroma of ovary- Derived from sex cord & Stroma of ovary

- Account approximately 8% of all ovarian tumour- Account approximately 8% of all ovarian tumour


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Germ Cell Tumour =Germ Cell Tumour =

- Arise from germ cells- Arise from germ cells- Account from 30% of ovarian- Account from 30% of ovarian

tumour in the form of mature cysttumour in the form of mature cyst

tertoma (Dermoid Cysts) and 1 3tertoma (Dermoid Cysts) and 1 3

% of ovarian malignancy and% of ovarian malignancy and

represent 60% of ovarian cancer inrepresent 60% of ovarian cancer in

children and adolescents.children and adolescents.


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Epithelial ovarian tumour Epithelial ovarian tumour

*common bilateral*common bilateral

*Serous most common 40 *Serous most common 40

50%.50%.*Mucinous 10% large size*Mucinous 10% large size

associated withassociated withpseudomyxoma ovaripseudomyxoma ovari


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* Endometrial ovarian cancer: account* Endometrial ovarian cancer: account

for 20% of epithelial tumour. 10%for 20% of epithelial tumour. 10%

associated with endometrial cancer.associated with endometrial cancer.

* Brenner tumour very small proportion* Brenner tumour very small proportion

- 99% Benign- 99% Benign

* Clear Cell cancer Account from 5 10%* Clear Cell cancer Account from 5 10%

10%10%- Worse prognosis- Worse prognosis

* Mixed epethilium ovarian tumour* Mixed epethilium ovarian tumour


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Borderline ovarian tumour:Borderline ovarian tumour:

* Account approximately 15% of epithelial* Account approximately 15% of epithelialovarian cancer.ovarian cancer.

* They are low malignant potential.* They are low malignant potential.

* Affecting young women and may present* Affecting young women and may present

in pregnancyin pregnancy

* Microscopically they show malignant* Microscopically they show malignantfeatures but no stromal invasion.features but no stromal invasion.

* They have good prognosis.* They have good prognosis.


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Sex cord stromal tumours:Sex cord stromal tumours:

** They are composed of granuloza, thecaThey are composed of granuloza, thecaand serotoli cells.and serotoli cells.

* Granuloza cell tumour produce* Granuloza cell tumour produce

oestrogen and serotoli-stromal produceoestrogen and serotoli-stromal produceandrogen.androgen.

* Most of them are benign and most* Most of them are benign and most

clinically malignant are granuloza cell T.clinically malignant are granuloza cell T.

* Meig syyndrome - fibroma + ascites and* Meig syyndrome - fibroma + ascites and


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Germ Cell Tumour:Germ Cell Tumour:

* Account approximately 30% of ovarian* Account approximately 30% of ovariantumour.tumour.

* Commonest in the first two decade of* Commonest in the first two decade of

life.life.

* Sysgerminoma is the commonest* Sysgerminoma is the commonest

75% present in stage I disease75% present in stage I disease

10-15% Bilateral10-15% Bilateral

5-10% occur in female with abnormal5-10% occur in female with abnormal

gonadsgonads


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Teratomas: drived from 2 -3Teratomas: drived from 2 -3

embroyonic layersembroyonic layers

Mature (Dermoid Cysts) CommonestMature (Dermoid Cysts) Commonest

ovarian tumourovarian tumour

- Benign- Benign

- Unilateral (10-15% Bilateral)- Unilateral (10-15% Bilateral)

- Leading to torsion.- Leading to torsion.- Contain teeth and hair in the cyst.- Contain teeth and hair in the cyst.

- Malignant transformation 2%- Malignant transformation 2%


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Immature Teratoma:Immature Teratoma:

* 2* 2ndnd commonest germ cell malignancy.commonest germ cell malignancy.

* Account for 20% ovarian cancer in* Account for 20% ovarian cancer infemale under 20 years of age.female under 20 years of age.

* Unilateral* Unilateral

* classified according to differentiation* classified according to differentiation

and quantity of immature tissue.and quantity of immature tissue.


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Embryonic Markers:Embryonic Markers:

* Yolk sac tumour AFP - (rare tumor)* Yolk sac tumour AFP - (rare tumor)

* Ovarian choriocarcinoma secret BHCG* Ovarian choriocarcinoma secret BHCG(rare tumour)(rare tumour)

* Normal level does not exclude diagnosis.* Normal level does not exclude diagnosis.

* Teratoma & dysgemenoma does not* Teratoma & dysgemenoma does not

secret this tumor marker.secret this tumor marker.


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Secondary ovarian malignancy:Secondary ovarian malignancy:

* Account up to 10%.* Account up to 10%.

* Metastases form Colon* Metastases form Colon

StomachStomach

BreastBreast

Female genitalFemale genitaltracttract


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Krukenberg Tumour: BilateralKrukenberg Tumour: Bilateral

enlarged ovariesenlarged ovaries

* Ovarian metastatic tumour from* Ovarian metastatic tumour from

gastric or colon cancer.gastric or colon cancer.

* Microscopic assessment signet* Microscopic assessment signet

ring cells.ring cells.

* CEA marker increase* CEA marker increase


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Eitology:Eitology:

* Environmental Factors:* Environmental Factors:

- Unknown- Unknown

- High fat diet- High fat diet

- Perineal dusting with talcum powder- Perineal dusting with talcum powder- Risk of caffeine intake and radiation- Risk of caffeine intake and radiation

unclean.unclean.

- Role of certain viral infection (Mumps,- Role of certain viral infection (Mumps,

rubella, influenza) inconclusive results.rubella, influenza) inconclusive results.


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Reproductive and Hormonal factors:Reproductive and Hormonal factors:

* Contraceptive pill* Contraceptive pill* Pregnancy* Pregnancy

* Breast feeding* Breast feeding

* Tubal ligation and Hysterectomy* Tubal ligation and Hysterectomy

- early menarche- early menarche

- late menopause- late menopause

- nulliparity- nulliparity


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This suggest continous ovulation isThis suggest continous ovulation is

important factor.important factor.

* Using of ovulatory stimulants and* Using of ovulatory stimulants and

subsequent development of epithelialsubsequent development of epithelial

ovarian cancer is currently lacking.ovarian cancer is currently lacking.

* Heriditary factors not more than 10% of* Heriditary factors not more than 10% of

all ovarian cancer.all ovarian cancer.

* BRCAI responsible for 5% of ovarian* BRCAI responsible for 5% of ovarian

cancer in young women < 40 years.cancer in young women < 40 years.


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Screening of ovarian cancer:Screening of ovarian cancer:

* No role of ovarian screening in* No role of ovarian screening inasymptomatic population.asymptomatic population.

* Women at risk of developing ovarian* Women at risk of developing ovarian

cancer based on family history 10%cancer based on family history 10%offered screening.offered screening.

* Women risk vague pelvic abdominal* Women risk vague pelvic abdominal

symptoms warrant complete history andsymptoms warrant complete history andexamination including vaginal and rectalexamination including vaginal and rectal

examination.examination.


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Risk of Malignancy index (RMI)Risk of Malignancy index (RMI)

Serum Ca 12.5Serum Ca 12.5

USS Score (0-3) calculated by:USS Score (0-3) calculated by:

multilocular cystsmultilocular cysts

Solid areaSolid area

Bilateral lessionBilateral lession

MetastasisMetastasis

AscitesAscites

Menopausal status 1 for premenopausalMenopausal status 1 for premenopausal

3 for post menopausal3 for post menopausal


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This RMI to identify cases for referral toThis RMI to identify cases for referral to

Gynaecology OncologistGynaecology Oncologist

Symptoms:Symptoms:

* Early stage Pressure symptom* Early stage Pressure symptom

* Late stage metastatic effect to bowel* Late stage metastatic effect to bowel

mesentery and ascites.mesentery and ascites.- Vaginal bleeding less- Vaginal bleeding less

common.common.


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Clinical Signs:Clinical Signs:

* Supraclavicular, axillary, inguinal lymph* Supraclavicular, axillary, inguinal lymph

nodes.nodes.

* Breast examination* Breast examination* Chest examination pleural effusion* Chest examination pleural effusion

* Abdominal examination liver size* Abdominal examination liver size

* Pelvic & rectal examination Irregular* Pelvic & rectal examination Irregular

solid mass suggestive of malignancy.solid mass suggestive of malignancy.


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INVESTIGATIONSINVESTIGATIONS- For blood count- For blood count

- Urea and electrolyte- Urea and electrolyte- Liver function test- Liver function test

- Tumor marker- Tumor marker

- Ca 125- Ca 125

AFP & B-HCGAFP & B-HCG

- CEA- CEA- U/S for pelvis, kidney and liver- U/S for pelvis, kidney and liver

- MIR- MIR- CT Scan- CT Scan

- Endometrial biopsy- Endometrial biopsy

- Endoscopy- Endoscopy


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Staging of primary ovarian cancer:Staging of primary ovarian cancer:

Stage Description 5 yearStage Description 5 yearsurvivalsurvival

(%)(%)

I Confined to one/both ovariesI Confined to one/both ovaries

Ia Limited to a single ovary, no ascites; 89.9Ia Limited to a single ovary, no ascites; 89.9

capsule intact with no surface tumourcapsule intact with no surface tumourIb Limited to both ovaries, no ascites; 84.7Ib Limited to both ovaries, no ascites; 84.7

capsule intact with no surface tumourcapsule intact with no surface tumour

Ic One or both ovaries have ruptured 80Ic One or both ovaries have ruptured 80

capsule or surface tumour, malignantcapsule or surface tumour, malignant

ascites or positive peritoneal washingsascites or positive peritoneal washings

II Extension to pelvic structuresII Extension to pelvic structuresIIa Extension to uterus or fallopian tubes 69.9IIa Extension to uterus or fallopian tubes 69.9

IIb Extension to other pelvic tissues 63.7IIb Extension to other pelvic tissues 63.7

IIc As for IIA or IIB but one or both ovaries 66.5IIc As for IIA or IIB but one or both ovaries 66.5

have ruptured capsule or surface tumour;have ruptured capsule or surface tumour;

malignant ascites or positivemalignant ascites or positive

peritoneal washingsperitoneal washings


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III As for stage I/II but also with peritonealIII As for stage I/II but also with peritoneal

Implants outside pelvis or with positiveImplants outside pelvis or with positive

retroperitoneal lymph nodesretroperitoneal lymph nodes

IIIa Histologically confirmed microscopicIIIa Histologically confirmed microscopic58.558.5

seeding of abdominal peritoneal surfacesseeding of abdominal peritoneal surfaces

and negative retroperitoneal lymph nodesand negative retroperitoneal lymph nodes

IIIb Histologically confirmed implants ofIIIb Histologically confirmed implants of

39.939.9 abdominal peritoneal surfaces


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Metastatic ovarian spread:Metastatic ovarian spread:

* Direct tubes uterus - bladder* Direct tubes uterus - bladder* Trascoelmic along peritoneal surface.* Trascoelmic along peritoneal surface.

* Lymphatic spread pelvic and para* Lymphatic spread pelvic and para

aortic lymph nodes.aortic lymph nodes.

* Haematogenous spread - liver* Haematogenous spread - liver- lung- lung


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Technique for Surgical Staging:Technique for Surgical Staging:

* Midline incision adequate access for* Midline incision adequate access for

surgical staging and full inspections.surgical staging and full inspections.

1. Sending ascites or peritoneal washing1. Sending ascites or peritoneal washing2. Performing total hystrectomy and2. Performing total hystrectomy and

bilateral salpingo ophorectomy.bilateral salpingo ophorectomy.

3. Omentectomy3. Omentectomy

4. Peritoneal biopsy all suspicious area.4. Peritoneal biopsy all suspicious area.5. Diaphragmatic biopsy or scraping.5. Diaphragmatic biopsy or scraping.

6. Sampling of pelvic and a paraaortic6. Sampling of pelvic and a paraaortic

lymph nodes.lymph nodes.

S i l M t f O i


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Surgical Management of OvarianSurgical Management of Ovarian

Cancer:Cancer:

* Primary surgery in early epithelial* Primary surgery in early epithelial

ovarian cancer.ovarian cancer.

In young patient fertility is important:In young patient fertility is important:* Laparotomy is gold, standard for* Laparotomy is gold, standard for

diagnosis and stagingdiagnosis and staging

* Frozen section is useful.* Frozen section is useful.

* Delaying procedure until histopathology* Delaying procedure until histopathology

is available regardin further surgicalis available regardin further surgical

management to be made in consultationmanagement to be made in consultation

with patient and cancer team.with patient and cancer team.


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Primary surgery in advanced epitheliumPrimary surgery in advanced epithelium

ovarian cancer.ovarian cancer.

* Primary cytoreductive surgery followed* Primary cytoreductive surgery followed

by chemotherapy is current goldby chemotherapy is current goldstandard.standard.

* Cytoreductive surgery remove all* Cytoreductive surgery remove all

primary cancer and if possibleprimary cancer and if possiblemetastatic disease to tumor load tometastatic disease to tumor load to

achieve optimal status.achieve optimal status.

Ch thCh th


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Chemotherapy:Chemotherapy:

** Additional therapy in early stage diseaseAdditional therapy in early stage diseasewith high risk factor.with high risk factor.

* Standard adjuvant depending involve IV* Standard adjuvant depending involve IV

chemotherapy single agent active inchemotherapy single agent active in

epithelial ovarian cancer.epithelial ovarian cancer.

Include: Alkalizing agent (cyclophosophomide)Include: Alkalizing agent (cyclophosophomide)

- platinuim compound (cisplatin)- platinuim compound (cisplatin)

- taxanes (paclitaxel)- taxanes (paclitaxel)- paclitaxel and platinum became new standard- paclitaxel and platinum became new standard

of care in advanced ovarian cancer.of care in advanced ovarian cancer.

- pallative surgery bowel obstruction involve - pallative surgery bowel obstruction involve

bowel resection and intestinal bypass.bowel resection and intestinal bypass.

GG ll t


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Germ cell tumour:Germ cell tumour:

* Adequate surgical staging.* Adequate surgical staging.* Cytoreduction and adjuvant* Cytoreduction and adjuvant

chemotherapy is the standard therapy.chemotherapy is the standard therapy.

* Usually occur in young patient so* Usually occur in young patient so

conservative of contralateral ovary andconservative of contralateral ovary anduterus is appropriate.uterus is appropriate.

* In dysgeminoma and Immature tertoma* In dysgeminoma and Immature tertoma

stage I ovarian cancer further therapy.stage I ovarian cancer further therapy.

From all after patient 2-3 cycles ofFrom all after patient 2-3 cycles ofcombination therapy.combination therapy.

** Tumor marker useful in monitoringTumor marker useful in monitoring

disease and planning management.disease and planning management.


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Sex cord stromal tumour:Sex cord stromal tumour:

Surgery is the gold standard butSurgery is the gold standard but

early stage can be managed byearly stage can be managed byunilateral oophorectomy andunilateral oophorectomy and

endometrial biopsy when fertility isendometrial biopsy when fertility isimportant.important.


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Treatment of ovarian CancerTreatment of ovarian Cancer

The principle of TreatmentThe principle of Treatment

1. Surgical staging Laparotomy to classify the1. Surgical staging Laparotomy to classify the

growth to its extent of spread.growth to its extent of spread.

2. Surgical removal of as much malignant2. Surgical removal of as much malignant

tissue as possible( surgical debulking; cyto-tissue as possible( surgical debulking; cyto-reductive treatment), may involve partialreductive treatment), may involve partial

resection of bladder and bowel.resection of bladder and bowel.

3. Follow up with intensive chemotherapy using3. Follow up with intensive chemotherapy using

various combination of drugs Toxanes withvarious combination of drugs Toxanes withplatinium are first choice of treatment.platinium are first choice of treatment.

4. Second look laparatomy or laparoscopy to4. Second look laparatomy or laparoscopy to

determine effectiveness of chemotherapydetermine effectiveness of chemotherapy

only performed for clinical trails.only performed for clinical trails.


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- Cooperation with general surgeon and- Cooperation with general surgeon and

experience in field of chemotherapy andexperience in field of chemotherapy and

radiotherapy.radiotherapy.

- Treatment by radiotherapy only for pallation.- Treatment by radiotherapy only for pallation.- CA 125 is usually raised in advanced ovarian- CA 125 is usually raised in advanced ovarian

cancer and used to assess response tocancer and used to assess response to

chemotherapy.chemotherapy.

Chemotherapy:Chemotherapy:

- Act by inhibiting cell deviation- Act by inhibiting cell deviation

* Alkalyting agent preventing replication of DNA* Alkalyting agent preventing replication of DNA

- cyclophosphoamide- cyclophosphoamide

- Chloraambucil- Chloraambucil

*A ti it ti tibi ti P t DNA*Antimitotic antibiotic Prevent DNA


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*Antimitotic antibiotic Prevent DNA*Antimitotic antibiotic Prevent DNA

protein synthesis actinomycin Dprotein synthesis actinomycin D

Antimetabolites: Preventing the synthesisAntimetabolites: Preventing the synthesis

of nucleoproteinof nucleoprotein

Methotrexate:Methotrexate:

Other Non Alkylating agentOther Non Alkylating agent

* Cisplatin* Cisplatin

-Carboplatin-Carboplatin

* Taxanes Paclitaxel* Taxanes Paclitaxel


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Toxicity:Toxicity:

- Bone marrow depression- Bone marrow depression- gastrointestinal- gastrointestinal

- neurotoxic- neurotoxic

- nephrotoxic- nephrotoxic

- alopecia- alopecia

- candiatoxic- candiatoxic

- liver failure- liver failure

- regular check up for marrow and liver- regular check up for marrow and liverfunctionfunction


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Prognosis for epithelial ovarian cancerPrognosis for epithelial ovarian cancer

Stage 5 years survivalStage 5 years survival

I 60 70%I 60 70%

II 40 - 50%II 40 - 50%

III 5 - 10%III 5 - 10%

IV nilIV nil


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Borderline epithelial Tumour - hasBorderline epithelial Tumour - hasexcellent prognosisexcellent prognosis

-- 5 years 90 95%5 years 90 95%

- 15 years survival 70-85%- For serous- 15 years survival 70-85%- For seroustumourtumour

- 5-10% for mucinous- 5-10% for mucinous

- Chemotherapy is effective in the in frequent- Chemotherapy is effective in the in frequent

germ cell tumourgerm cell tumour


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Thank you andThank you and

Good Luck!Good Luck!

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60259273 Malignant Ovarian Tumour