OVARIAN CANCER

INTRODUCTION

I.Histologic Classification

i.coelomic epithelium originating tumor

accounts for 50-70% of primal ovarian tumor , 85-90% of

ovarian malignace.developed from germinal epithelium→

primal coelomic epithelium →various muller,s epithelium

→tubal epithelium,cervical mucosa epithelium,endometrium

the coelomic epithelial tumors include

(i).serous tumor

(ii).mucinous tumor

(iii).endometrioid tumor

(iv).clear cell tumor

(v).Brenner tumor/transitional cell tumor

(vi).mixed epithelial tumor

(vii).undifferentiated carcinoma

ii.germ cell tumor accounts for 20-40% of ovarian tumor.germ cells originate

from endogerm tissues.in the course of its origination,

transformation and development the cellular heterogeneity

may occur and form various tumors

germ cell tumors include (i).dysgerminoma

(ii).endodermal sinus tumor

(iii).embryonic carcinoma

(iv).polyembryonic tumor

(v).choriocarcinoma

(vi).teratoma

i).immature type

ii).mature type

(a).solid teratoma

(b).cystic teratoma

a).dermoid cyst

b).malignant change of dermoid cyst

(c).monodermal and highly specialized tumors

a).struma ovarii

b).carcinoid

(vii).mixed type

iii.ovarian gonadal sex cord stromal tumor accounts for 5% of ovarian tumor.sex cord stroma originates

from mesenchymal tissues of primal coelom

female and male differentiation

→epithelium differentiation→granulosa,

Sertolic cell tumor functional tumor

stromal differentiation →theca cell,

Leydig cell tumor

sex cord stromal cells tumor includes

(i).granulosa cell-stromal tumor

i).granulosa cell tumor

ii).theca cell tumor,fibroma

(ii).Sertolic-Leydig cell tumor

i).androblastoma

(iii).gynandroblastoma

iv.metastasized tumor

II.High risk factors of ovarian tumors

i.hereditary and family factors about 20-25% malignant ovarian tumors have

family history

ii.environmental factors

the mobidity of ovarian cancer is high in industry

developed countrys,this may be because of high

cholesterol diet in these countrys

iii.endocrinic factors

mobidity in less pregnant or infertile women is high(why),

functional cancers may easily complicated with mammary

andendometrial cancer

III.pathology

i.epithelial ovarian tumors age:30-60 ;classification:benigh,borderline,malignant

borderline tumor means:

(i).serous cystadenoma

mobidity :accounts for 25%benigh tumors

macroexamination :unilateral,globular,different size,smooth

surface,cystic,thin wall and filled by clear light-yellow fluid

section : simple type,monocystic,smooth wall;papillary type,

multicystic,intracystic papilla

microscopic exanination : tumor wall is composed of fibro-

connective tissues and lined by a single layer of cuboid or

columnar epithelium

borderline serous cystadenoma

macroexamination : moderate size bilateral,more extracystic

papilla

microscopic examination :thin papillary branch,epithelium≤3

layers,slight cellular atypia,nuclear mitosis<1/HP,no stroma

invasion

5 year survival rate :over 90%

serous cystadenocarcinoma

morbidity :most common malignant ovarian tumor,40-50%

macroexamination :bilateral,relatively large,semisolid,nodular

or lobular,smooth surface,gray white color,papillary

proliferation

section :multicystic,filled by papilla,brittle,bleeding,necrosis,

blurred cysticfluid

microscopic examination :obvious epithelial proliferation,

4-5layers,cuboid or columnar cancer cells,obvious

cellular atypia,stromal invasion

5 year survival rate:20-30%

(ii).mucinous cystadenoma

morbidity:20% of benign tumor

macroexamination:unilateral,round or elliptic,smooth

surface,gray white,large or giant

section:multicystic,filled by tremellose mucus,less

intracystic papilla

microscopic examination:fibroconective tissues wall,lined

a single layer of high columnar epithelium,malignant

change rate 5-10%

peritoneal myxoma:2-5% of mucinous cystadenomas may

develop,formation,histology

borderline mucinous cystadenoma

macroexamination:relative large,more unilateral,smooth

surface,multicystic

section:thick walll,solid area,tiny soft papilla

microscopic examination:epithelium≤3 layers,slight

cellular heterogeneous,large dark stained nucleus,less

mitosis,proliferated epithelium protrude into cavity and

form papilla,no stromal invasion

mucinous cystadenocarcinoma

morbidity:10% of malignant tumors

macroexamination:unilateral,large size,papillary or solid

area

section:semicystic and semisolid,blurred or bloody fluid

microscopic examination:dense gland,less stroma,glandular

epithelium>3 layers,obvious cellular atypia,stromal invasion

5 year survival rate:40-50%,prognosis is better than serous

cystadenocarcinoma

(iii).endometrioid tumor

morbidity : less encountered,benign

macroexamination : more unilateral,smooth surface

microscopic examination : surface is a single layer of columnar

epithelium which very like endometrial gland epithelium,

cavity is lined by pavement epithelium

borderline:rare

endometrioid carcinoma

morbidity :10-24% of primary malignant tumor

macroexamination:more unilateral,moderate size

section:cystic or solid,papilla,bloody fluid

microscopic examination:very similar to endometrial cancer,

more adenocarcinoma or adenoacanthoma,often complicated

with endometrial carcinoma

5 year survival rate :40-50%

ii.ovarian germ cell tumors

a group of ovarian tumors originated from primal germ cells,

its morbidity is secondary to the epithelial tumors,most occurs in childhood and adolescence,morbidity before adolescence accounts for 60-90%,while after menopause it only accounts4%

(i).teratoma

mature teratoma :also called dermoid cyst

morbidity :the most common benign ovarian tumor,10-20%

of ovarian tumors,85-97%of germ cell tumors,over 95% of

teratoma

age :occurs at any age,mostly between 20-40

macroexamination :more unilateral,moderate size,round or

elliptic,smooth and thin walll,

section :more nuicystic,filled by lipid and hair,occasionally

tooth and bone can be seen,scolex on the wall

components :endoderm,ectoderm and mesoderm

highly specialized teratoma : monoderm,such as struma ovarii

malignant change rate :2-4%,more in postmenopause,metasta-

sized by spreading and peritoneal implantation

prognosis :bad,5 year survival rate 15-31%

immature teratoma : malignant tumor

components :2-3germ layers,immature embryonic tissue

age:adolescence

macroexamination : more solid

malignance :dependent upon the ratio and differentiation of

immature tissue and the quantity of nervous epithelium

recurrent and metastatic rate : high,5year survival rate20%

(ii).dysgerminoma :mid malignant tumor

morbidity :5%of malignant ovarian tumors most in adolescence

and reproductive period

macroexamination :solid, more unilateral,round or elliptic,

moderate size,touching like eraser,smooth surface or lobular

section:light-brown color

microscopic examination :round or polygonal cells,lymphocyte

invasion in stroma

prognosis :very sensitive to radiotherapy,5year survival rate90%

(iii).endodermal sinus tumor :also called yolk sac tumo

morbidity : rarely encountered

age : mostly occurred in children and young women

macroexamination :unilateral,relatively large,round or elliptic

section:partially cystic,brittle tissue,bleeding and necrosis area,

gray-red or gray-yellow color

microscopic examination:endodermal sinus structure,flat or

cuboid or columnar tumor cells which produce AFP,AFP is

an important diagnostic and therapeutic marker

prognosis:average survival time is 1 year

iii.ovarian gonadal sex cord stromal tumor

accounts for 5-8%of malignant ovarian tumor

(i).granulosa-stromal cell tumor

i).granulosa cell tumor:low malignance

morbidity:3-6%of ovarian tumor,80%of sex cord stromal tumor

age:at any age,mostly between 45-55

feminization effect:secret estrogen

macroexamination:unilateral,different size ,round or elliptic,

lobular, smooth surface ,solid or partially cystic

section:brittle and soft tissue,bleeding and necrosis

microscopic examination :Call-Exner body

prognosis :better,5year survival rate over 80%

ii).theca cell tumor :benign tumor

feminization effect:secret estrogen,often coexist with granulosa

cell tumor

macroexamination : unilateral different size ,round or elliptic,

thin smooth fibrocapsule

section:solid ,gray white

microscopic examination :short spindal cells,lipid in cytoplasm

prognosis : malignant tumor is rare ,prognosis is better than

other ovarian cancer

iii).fibroma :common benign tumor

morbidity :2-5%of ovarian tumor

age : mostly in mid-aged women

macroexamination :unilateral, moderate size,smooth surface

or nodular

section:gray white,solid and hard

microscopic examination:composed of spindle cells

Meigs syndrome :accompanied with hydrothorax and ascites

(ii).Sertoli Leydig cell tumor:also called androblastoma

morbidity : rare

age : below40

macroexamination : unilateral,small,solid smooth surface

section :gray white accompanied by cystic degeneration,

bloody or serous or mucinous cystic fluid

virilism effect :secret androgen

prognosis :10-30% is malignant ,5year survival rate 70-90%

iv.ovarian metastatic tumor:all of the cancers in the human body can metastasize to the ovary,the common primary

origination is at breast,intestine,stomach,reproductive tract,

urinary tract and other organs

morbidity:5-10%of ovarian tumor

Krukenberg tumor :a special metastatic adenocarcinoma,its

primary origination is in the gastrointestinal tract

macroexamination:bilateral,renal shape, no adhesion,often

accompanied by ascites

section:solid

microscopic examination:signet-ring cell which produce mucus

prognosis:very bad

• IV.Metastatic Path• i.metastatic character:there is subclinical metastasis on

• omentum,peritoneum,retroperitoneal LN and diaphragm

• although the tumor is localized from its apparence

• ii.metastatic path:

• (i).directly spreading:this is the chief metastatic path.the

• tumor cells may directly invade the capsule,involve

• the neighbour organs and extensively implant on the

• peritoneum and omentum

• (ii).lymphetic vessels metastasis:this is an important

• metastatic way which includes

• i).spread along the ovarian blood vessels and is metastasized

• to para-aortic LN through ovarian lymphetic vessels

• ii).from ovarian hilus lymphetic vessels to internal and

• external iliac LN,and then from the common iliac LN

• to para-aortic LN

• iii).along the round ligament enters the external iliac and

• inguinal LN.diaphragm is the place to which the cancer

• is easily metastasized,especially the right diaphragm is

• the most easily invaded because of its dense lymphetic

• plexus

• (iii).blood metastasis is very rare.but at very late stage it may

• metastasize to the liver and lung

• V.Histologic grades• the WHO standards of histologic grading is chiefly• according to the histologic structure and cellular• differentiation.• Grade I:means the cell is well differentiated• Grade II:means moderate differenation• Grade III:means undifferenation• the effects of histologic grade on the prognosis is • more important than that of the histologic types

• VI.Clinical stage:the FIGO(1986) clinical stage is

• adopted• stage I tumor is localized in the ovary

• Ia tumor is localized in one ovary,the capsule is integrated,

• no tumor on ovary surface,no ascites

• Ib tumors are localized in bilateral ovarys,integrated capsule

• no tumor on surface,no ascites

• Ic based on Ia or Ib,there is tumor on the surface(unilateral

• or bilateral);or capsule is ruptured;or there is malignant

• cells in ascites ;or the abdominal cavity irrigating fluid

• is positive

• Stage II unilateral or bilateral ovarian tumor with pelvic

• metastasis

• IIa spread to uterus and (or)fallopian tube

• IIb spread to other tissues in pelvis

• IIc based on the IIa or IIb, there is implantation on

• unilateral or bilateral ovarian surface;or the capsule is

• ruptured;or the ascites contains malignant cells;or the

• abdominal cavity irrigating fluid is positive

• Stage III unilateral or bilateral ovarian tumor.there is

• extrapelvic peritoneal implantation and (or) the

• retroperitoneal or inguinal LN is positive,liver

• surface metastasis is stage III

• IIIa macroexamination shows that the tumor is loca-

• ted in the true pelvis,LN is negative but there is

• microscopic peritoneal implantation

• IIIb unilateral or bilateral ovarian tumor,there is

• peritoneal surface implantation and its diameter

• is<2cm, LN is negative

• IIIc the peritoneal surface implantation is>2cm and

• (or) retroperitoneal or inguinal LN is positive

• stageIV unilateral or bilateral ovarian tumor with telemetastasis,

• hydrothorax contains cancer cells,and there is liver

• parenchyma metastasis

VII.Clinical Manifestation

i.benign ovarian tumor

(i).at early stage

(ii).when tumor is moderate size

(iii).when tumor is large enough to occupy the full pelvis

or abdominal cavity

ii.malignant ovarian tumor (i).at early stage

(ii).once there are symptoms

(iii).the severity of the symptoms depends ouon

i).the tumor size,location and whether there is neighbour

tissues or organs invasion

ii).the histologic type of the tumor

iii).whether there is complication

(iv).at late stage

i).symptoms

ii).body signs

VIII.Diagnosis

i.cytologic examination

ii.B-Ultrasound

iii.radiodiagnosis:

(i).abdominal plain film

(ii).intravenous pyelography,barium meal,barium double

contrast radiography or mammary soft tissue X-ray

(iii).CT

(iv).laparoscopy

(v).tumor marker

i).CA-125

ii).AFP

iii).HCG

iv).sexual hormone

IX.Differential Diagnosis * *i.differential diagnosis between the benign and

malignant ovarian tumor

Differential contents benign tumor malignant tumor

History long clinical course short clinical course and

and gradually enlarge rapidly enlarge

Body sign often unilateral,movable, often bilateral,fixed solid

cystic,smooth surface or semisolid,rough surface,

no ascites bloody ascites with cancer

cells

General condition better cachexia is gradually developed

B-Ultrasound dark fluid echo area,there echo group or points exist

may be intracystic diaph- in the dark fluid area tumor

ragm,tumor outline is outline is not clear

clear

ii.differential diagnosis of benign ovarian tumor i.ovarian tumor like condition:may disappear within 2 month

ii.tubo-ovarian cyst

iii.uterine myoma

iv.pregnant uterus

v.large quantity ascites

iii. differential diagnosis of malignant ovarian tumor

i.endometriosis:symptoms,body signs,B-Ultrasound and laparoscopy

ii.pelvic connective tissues inflammation:history,symptoms,and

body signs,B-Ultrasound

iii.TB peritonitis:history,general symptoms,body signs, B-Ultrasound

and gastrointestinal X-ray

iv.extra-reproductive tract tumors: B-Ultrasound,Barium meal and

intravenous pyelography

v.metastatic ovarian tumor:generally no primary tumor history

X.Complications of ovarian tumor

i.pediculotorsion:common gynecologic acute abdomen

(i).mechanism

(ii).components of the pedicle

(iii).pathologic change

(iv).typical symptoms

(v).body signs

(vi).management

ii.tumor rupture:accounts for about 3% of ovarian tumor

(i).traumatic and spontaneous rupture

(ii).symptoms depends on the length of rupture,the quantity and

the quality of the cystic fluid flowing into abdominal cavity

(iii).body signs

(iv).management

iii.infection:rarely encountered

(i).cause of the infection

(ii).clinical manifestation

(iii).management

iv.malignant change

(i).at early stage of malignant change

(ii).suspicious manifestation

(iii).management principle of ovarian tumor

XI.Prevention

i.prevention of high risk factors : suggesting high protein

and vitamin A diet and avoiding high cholesterol diet

ii.popularizing the regular examination and treatment

iii.early diagnosis and treatment

XII.Treatment of ovarian tumor i.benign ovarian tumor:once the diagnosis is confirmed

operation should be performed

(i).young patient with unilateral tumor

bilateral tumor

(ii).perimenopausal patient with benign ovarian tumor

(iii).manipualtion principle of operation

ii.malignant tumor:the treating principle is chiefly by

operation and the chemotherapy and radiotherapy is as

the accessory treatment

(i).operation:operation play the key role for the treatment

especially the first time of operation

i).probe during operation

ii).operating range:(a).for stage Ia or Ib

(b).for stage Ic or over Ic

(c).cytoreductive operation

iii).the indications of reserving contralateral ovary

(a).stage Ia,well differentiated

(b).borderline or low malignant tumor

(c).no tumor is found in the contralateral ovary

(d).has the condition of closely postoperative follow up

(ii).chemotherapy

chemotherapy is a chief accessory therapy.malignant

ovarian tumor is relatively sensitive to the chemotherapy,

the chemotherapy has certain effect even if the tumor has

extensively metastasized

the chemotherapy may be either for the prevention of

recurrence or for the postoperative treatment in the patient

whose tumor can not be thoroughly removed

for late stage patient who does not fit for the operation,the

chemotherapy can shrink the tumor and create the condition

for afterwards operation

(iii).radiotherapy:the accessory treatment for the operation

and chemotherapy

dysgerminoma is very sensitive to the radiotherapy,

granulosa cell tumor is moderate sensitive to the

radiotherapy

epithelial ovarian cancer also has certain sensitivity

to the radiotherapy

XIII.Prognosis:

prognosis is associated with the clinical stage,

histologic type,age and treating methods among

which the clinical stage is the most important

XIV.follow up

i.time of follow up:once a time within 1 year after

operation;once every 3 month in the second year after

operation;once every 6 month in the third year and once a

year over 3 years after operation

ii.contents:symptoms body signs ,pelvic and general examination

B-ultrasound,CT,MRI and tumor marker