Malignant Ovarian Tumour- By Nukesh

8/2/2019 Malignant Ovarian Tumour- By Nukesh

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MALIGNANT OVARIANTUMOUR

By: Mukesh Rao Vagadre

Group no 2, 5th year 2nd

sem


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:

* It is common gynaecological tumourcontinue to kill more women thanall other gynaecological cancer

* In England the incidents of ovarian

cancer 1.4 higher than cervical andendometrial cancer but lower than breastcancer 7.1%

* Eventually 80 to 85% of women

with ovarian cancer die* Most ovarian cancer as epithelial in

origin and incidence increase riskwith age.


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Histological classification of ovarianTumour

Epithelial Tumour

* Serous Tumour* Mucinous Tumour* Endometrial Tumour* Clear Tumour* Mixed Tumour* Undifferentiated and Unclassified

Tumour


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Sex-Cord Stromal tumours

* Granulosa

stromal cell tumours* Sertoli stromal cell tumours* Gynandroblastoma* Sex cord tumour with annular tubules

* Unclassified sex-cord tumoursSteroid celltumours


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Ovarian germ-cell tumours

* Dysgerminoma* Teratoma (immature, mature and

monodermal)* Yolk sac tumour (endodermal sinus

tumour)* Embryonal carcinoma

* Polyembryoma* Choriocarcinoma* Mixed germ-cell tumour


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Epithelial Tumour Arise from surface epithelium ofovary account from 60-65 % of ovarian tumour andapproximately 90% are malignant.

Benign

border line

malignant

Sex cord stromal tumour

- Derived from sex cord & Stroma of ovary- Account approximately 8% of all ovarian tumour


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Germ Cell Tumour =

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

tumour in the form of mature cysttertoma (Dermoid Cysts) and 1 3% of ovarian malignancy andrepresent 60% of ovarian cancer inchildren and adolescents.


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Epithelial ovarian tumour *common bilateral*Serous most common 40

50%.*Mucinous 10% large size

associated withpseudomyxoma ovari


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* Endometrial ovarian cancer: account

for 20% of epithelial tumour. 10%associated with endometrial cancer.

* Brenner tumour very small proportion

- 99% Benign

* Clear Cell cancer Account from 5 10%10%

- Worse prognosis

* Mixed epethilium ovarian tumour


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Borderline ovarian tumour:

* Account approximately 15% of epithelialovarian cancer.

* They are low malignant potential.

* Affecting young women and may presentin pregnancy

* Microscopically they show malignantfeatures but no stromal invasion.

* They have good prognosis.


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Sex cord stromal tumours:

* They are composed of granuloza, thecaand serotoli cells.

* Granuloza cell tumour produceoestrogen and serotoli-stromal produceandrogen.

* Most of them are benign and mostclinically malignant are granuloza cell T.

* Meig syyndrome - fibroma + ascites and

right hydrothorax


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Germ Cell Tumour:

* Account approximately 30% of ovariantumour.

* Commonest in the first two decade of

life.

* Sysgerminoma is the commonest

75% present in stage I disease10-15% Bilateral5-10% occur in female with abnormal

gonads


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Teratomas: drived from 2 -3embroyonic layers

Mature (Dermoid Cysts) Commonest

ovarian tumour

- Benign- Unilateral (10-15% Bilateral)

- Leading to torsion.- Contain teeth and hair in the cyst.- Malignant transformation 2%


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Immature Teratoma:

* 2nd commonest germ cell malignancy.

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

* Unilateral* classified according to differentiation

and quantity of immature tissue.


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Embryonic Markers:

* Yolk sac tumour AFP - (rare tumor)

* Ovarian choriocarcinoma secret BHCG(rare tumour)

* Normal level does not exclude diagnosis.

* Teratoma & dysgemenoma does notsecret this tumor marker.


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Secondary ovarian malignancy:

* Account up to 10%.

* Metastases form ColonStomachBreast

Female genitaltract


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Krukenberg Tumour: Bilateralenlarged ovaries

* Ovarian metastatic tumour fromgastric or colon cancer.

* Microscopic assessment signetring cells.

* CEA marker increase


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Eitology:

* Environmental Factors:

- Unknown- High fat diet

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

unclean.- Role of certain viral infection (Mumps,

rubella, influenza) inconclusive results.


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Reproductive and Hormonal factors:

* Contraceptive pill

* Pregnancy

* Breast feeding

* Tubal ligation and Hysterectomy

- early menarche- late menopause- nulliparity


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This suggest continous ovulation is

important factor.

* Using of ovulatory stimulants andsubsequent development of epithelial

ovarian cancer is currently lacking.

* Heriditary factors not more than 10% ofall ovarian cancer.

* BRCAI responsible for 5% of ovariancancer in young women < 40 years.


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Screening of ovarian cancer:

* No role of ovarian screening inasymptomatic population.

* Women at risk of developing ovarian

cancer based on family history 10%offered screening.

* Women risk vague pelvic abdominal

symptoms warrant complete history andexamination including vaginal and rectalexamination.


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Risk of Malignancy index (RMI)

Serum Ca 12.5

USS Score (0-3) calculated by:multilocular cystsSolid areaBilateral lessionMetastasis

Ascites

Menopausal status 1 for premenopausal3 for post menopausal


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This RMI to identify cases for referral

to Gynaecology Oncologist

Symptoms:

* Early stage Pressure symptom

* Late stage metastatic effect to bowel

mesentery and ascites.- Vaginal bleeding less

common.


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Clinical Signs:

* Supraclavicular, axillary, inguinal lymphnodes.

* Breast examination* Chest examination pleural effusion* Abdominal examination liver size* Pelvic & rectal examination Irregular

solid mass suggestive of malignancy.


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INVESTIGATIONS- For blood count

- Urea and electrolyte- Liver function test- Tumor marker- Ca 125

AFP & B-HCG

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

- MIR- CT Scan- Endometrial biopsy- Endoscopy


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Staging of primary ovarian cancer:

Stage Description 5 yearsurvival

(%)

I Confined to one/both ovariesIa Limited to a single ovary, no ascites; 89.9

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

capsule intact with no surface tumourIc One or both ovaries have ruptured 80

capsule or surface tumour, malignantascites or positive peritoneal washings

II Extension to pelvic structuresIIa Extension to uterus or fallopian tubes 69.9IIb Extension to other pelvic tissues 63.7IIc As for IIA or IIB but one or both ovaries 66.5

have ruptured capsule or surface tumour;malignant ascites or positive

peritoneal washings


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III As for stage I/II but also with peritonealImplants outside pelvis or with positiveretroperitoneal lymph nodes

IIIa Histologically confirmed microscopic58.5

seeding of abdominal peritoneal surfacesand negative retroperitoneal lymph nodes

IIIb Histologically confirmed implants of39.9

abdominal peritoneal surfaces


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Metastatic ovarian spread:

* Direct

tubes uterus - bladder* Trascoelmic along peritoneal surface.* Lymphatic spread pelvic and para

aortic lymph nodes.

* Haematogenous spread - liver- lung


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Technique for Surgical Staging:

* Midline incision adequate access forsurgical staging and full inspections.

1. Sending ascites or peritoneal washing2. Performing total hystrectomy andbilateral salpingo ophorectomy.

3. Omentectomy

4. Peritoneal biopsy all suspicious area.5. Diaphragmatic biopsy or scraping.6. Sampling of pelvic and a paraaortic

lymph nodes.

S i l M t f O i


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Surgical Management of Ovarian

Cancer:

* Primary surgery in early epithelialovarian cancer.

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

diagnosis and staging* Frozen section is useful.* Delaying procedure until histopathology

is available regardin further surgicalmanagement to be made in consultation

with patient and cancer team.


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Primary surgery in advanced epithelium

ovarian cancer.

* Primary cytoreductive surgery followed

by chemotherapy is current goldstandard.

* Cytoreductive surgery remove all

primary cancer and if possiblemetastatic disease to tumor load toachieve optimal status.

Ch th


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Chemotherapy:

* Additional therapy in early stage diseasewith high risk factor.

* Standard adjuvant depending involve IVchemotherapy single agent active in

epithelial ovarian cancer.

Include: Alkalizing agent (cyclophosophomide)- platinuim compound (cisplatin)

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

of care in advanced ovarian cancer.- pallative surgery bowel obstruction involve

bowel resection and intestinal bypass.

G ll t


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Germ cell tumour:

* Adequate surgical staging.* Cytoreduction and adjuvantchemotherapy is the standard therapy.

* Usually occur in young patient so

conservative of contralateral ovary anduterus is appropriate.

* In dysgeminoma and Immature tertomastage I ovarian cancer further therapy.

From all after patient 2-3 cycles ofcombination therapy.

* Tumor marker useful in monitoringdisease and planning management.


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Sex cord stromal tumour:

Surgery is the gold standard but

early stage can be managed byunilateral oophorectomy and

endometrial biopsy when fertility isimportant.


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Treatment of ovarian Cancer

The principle of Treatment

1. Surgical staging Laparotomy to classify thegrowth to its extent of spread.

2. Surgical removal of as much malignant

tissue as possible( surgical debulking; cyto-reductive treatment), may involve partialresection of bladder and bowel.

3. Follow up with intensive chemotherapy using

various combination of drugs Toxanes withplatinium are first choice of treatment.4. Second look laparatomy or laparoscopy to

determine effectiveness of chemotherapyonly performed for clinical trails.


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- Cooperation with general surgeon and

experience in field of chemotherapy andradiotherapy.

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

cancer and used to assess response tochemotherapy.

Chemotherapy:

- Act by inhibiting cell deviation

* Alkalyting agent preventing replication of DNA- cyclophosphoamide- Chloraambucil


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*Antimitotic antibiotic Prevent DNAprotein synthesis actinomycin DAntimetabolites: Preventing the synthesisof nucleoprotein

Methotrexate:

Other Non Alkylating agent

* Cisplatin-Carboplatin

* Taxanes Paclitaxel


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Toxicity:

- Bone marrow depression- gastrointestinal- neurotoxic- nephrotoxic- alopecia- candiatoxic- liver failure

- regular check up for marrow and liverfunction


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Prognosis for epithelial ovarian cancer

Stage 5 years survival

I 60 70%II 40 - 50%III 5 - 10%IV nil


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Borderline epithelial Tumour - hasexcellent prognosis

- 5 years 90 95%- 15 years survival 70-85%- For serous

tumour- 5-10% for mucinous

- Chemotherapy is effective in the in frequentgerm cell tumour


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Thank you andGood Luck!

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Malignant Ovarian Tumour- By Nukesh