OVARIAN TUMOR

By Dr.Feng Quan LingBy Dr.Feng Quan Ling

CHARACTERSWHO CLASSIFICATION PATHOLOGY METASTASESHISTOLOGICAL GRADESSTAGINGCLINICAL MANIFESTATIONDIAGNOSISDIFFERENTIAL DIAGNOSISCOMPLICATIONRISK FACTORS & PREVENTIONMANAGEMENT

CHARACTERS • Common disease---comprise about

32% of all genital tumors in female

• Ovarian cancer is the 5th leading cause of cancer death in women and the leading cause of death from gynecologic malignancies.

• High mortality rate in malignant tumors?

Ovarian cancer is disproportionately deadly for a number of reasons:

• Symptoms are vague and non-specific

• Ovarian cancers shed malignant cells that frequently implant on the uterus, bladder, bowel and omentum (wangmo), and begin forming new tumor growths before cancer is even suspected.

• Because no cost-effective screening test for ovarian cancer exists, more than 50 percent of women with ovarian cancer are diagnosed in the advanced stages of the disease.

WHO CLASSIFICATION • WHO classification of ovarian tumor is according to t

he origination of ovarian tumor

• Epithelial tumors

surface epithelium of the ovary

• Sex cord tumors

sex cord cells of ovarian cortex

• Germ cell tumors

primordial germ cells

• Metastatic tumors

gastrointestinal or breast

PATHOLOGY • It is complicated.

• Pay attention to

_women age

_ unilateral or bilateral

_tumor size,shape,consistency,stiffness

lateral,cut surface

_character (benign or malignant)

_5-year survival rate

_prognosis

•Epithelial tumor of ovary It can be divided into

• benign,

• borderline malignant

• malignant tumors

Borderline malignant

_have some of the cellular characteristics of malignancy,

_grow slowly

_rate of metastasis is low and relapse is late

_clinical courses and prognosis are between B & M

PATHOLOGYPATHOLOGY

Epithelial tumor _serious tumor

• Serious cystadenoma

• Borderline serious cystadenomas

• Serious cystadenocarcinomas

PATHOLOGYPATHOLOGY

Serious cystadenoma• very common

• mostly unilateral

• smooth external surface

• content is generally a thin watery serosity

• usually one cavity

• divided into simple and papillary type

• Benign

• The rate of malignant change is 35%

PATHOLOGYPATHOLOGY

Serious cystadenocarcinomas• very common

• mostly bilateral

• large in size

• smooth surface or papilli growing

• content is turbid or hemorrhagic

• multiple cavity

• 5-year survival rate is only 20-30%

PATHOLOGYPATHOLOGY

Serious cystadenocarcinomas

mucinous cystadenoma• Common

• Benign

• unilateral

• bluish white surface

• huge size

• mucin fluid in cyst is thick contain mucoprotein or glycoprotein.

• rate of malignancy is 5-10%

PATHOLOGYPATHOLOGY

mucinous cystadenocarcinoma

• unilateral

• cut surface has both cystic and solid areas

• 5-year survival rate is only 40-50%

PATHOLOGYPATHOLOGY

•Ovarian germ cell tumor

• occur in children and young women in the reproductive age group

• only mature teratoma is benign

• others are all malignant

• except dysgerminoma, other malignancy are all high-malignant and prognosis is poor

PATHOLOGYPATHOLOGY

Teratoma (1)

• composed of 2-3 germ layers

• most part are cystic and few part is solid

• mature teratoma belongs to benign called mature cystic teratoma or dermoid cyst

• frequently unilateral

• filled with thick yellowish greasy fluid,hair,and sometimes tooth or bone

• rate of malignant change is 2-4%

PATHOLOGYPATHOLOGY

Teratoma (2)

• immature teratomas are unilateral solid body

• irregular surface

• cut surface is brittle and soft like cerebral tissue

• rate of metastases and recurrence is high

• 5-year survival rate is 20%.

PATHOLOGYPATHOLOGY

Dysgerminoma

• malignant

• bilateral

• common in right

• round or ovoid, moderate size with smooth surface

• cut surface is solid and grayish pink.

• very sensitive to radiation therapy

• the 5-year survival rate can reach 90%

PATHOLOGYPATHOLOGY

Dysgerminoma

Endodermal sinus tumor• tissue structure is very similar to endodermal sinus of the ra

t's placenta

• their morphology resemble yolksac of human's embryo,so it's also called yolk sac tumor

• highly malignant

• Unilateral, round or ovoid

• cut surface is solid and brittle

• tumor cells can produce AFP,which can be identified,its concentration is parallel to growth and decline of tumor, has become an important mark in diagnosis,treatment and monitor.

• mean survival time was only 12-18 months in the past.

PATHOLOGYPATHOLOGY

Endodermal sinus tumor

•Sex cord-stromal tumors of ovary

• Granulosa-stromal cell tumor.

1-granulosa cell tumor.

2- theca cell tumor

3-fibroma

• Sertoli-leydig cell tumors

PATHOLOGYPATHOLOGY

granulosa cell tumor.

• low-malignant

• functional tumors

• frequently occur in women of 50 years old.

• tumor cell can secret estrogen

• generally prognosis is good

• 5-year survival rate may reach about 80%

• because these tumors recur after a long interval, prolonged follow up is necessary

PATHOLOGYPATHOLOGY

theca cell tumor

• mostly benign

• usually diagnosed in postmenopause women, rarely in women below 40 years old

• have more obvious symptoms of femininity

• prognosis is better than ovarian carcinoma

PATHOLOGYPATHOLOGY

fibroma • occur in middle aged women,

• solid,benign ,unilateral,moderate in size.

• smooth surface

• Occasionally these tumors will be associated with ascites and pleural effusions, a situation that is called MEIGS syndrome. These ascites and pleural effusions will go down spontaneously after removal of tumor.

PATHOLOGYPATHOLOGY

fibroma

Sertoli-leydig cell tumors

• also called androblastoma,

• found in young women

• mostly benign

• with abnormal masculinization symptoms

• 10-30% tumors are malignant

• 5 year survival rate is 70-90%

PATHOLOGYPATHOLOGY

•Secondary of metastatic carcinoma of ovary.

• primary lesion usually in GIT (gastrointestinal), breast, genitalia(uterus,oviduct).

• Krukenberg tumor is a special metastatic adenocarcinoma from GIT.

It is solid moderate in size.

prognosis is poor

most patients die a year after operation.

PATHOLOGYPATHOLOGY

Krukenberg tumor

•Tumor-like conditions of ovary

• solitary follicle cyst

• corpus luteum cyst

• multiple luteinized follicular cyst

• polycystic ovary

• endometriosis of ovary

PATHOLOGYPATHOLOGY

Metastases of the malignant ovarian tumor

Direct spreading and peritoneal implantationLymphatic spreadingBlood Matastases

METASTASES OF THE MALIGNANT OVARIAN TUMOR

• some malignant ovarian tumors look localized but in fact a sub-clinical metastases have occured always to peritoneal, post peritoneal lymphonodi, omentum,diaphragm etc.

• the metastatic ways mainly are directly spreading and peritoneal implantation.

• metastases through blood vessels are rare.

HISTOLOGICAL GRADES OF MALIGNANT TUMOR

1)Highly differentiated2)moderately differentiated3)lowly differentiated

STAGING• stage 1=growth limited to ovaries

• stage 2=growth involving one or both ovaries with pelvic extension.

• stage 3=tumors involving one or both ovaries with peritoneal implants outside pelvis and/or positive retroperitoneal or inguinal nodes

• stage 4=growth involving one or both ovaries with distant metastases

IaIa 期期

Ic Ic 期期

腹水阳性 腹水阳性

或

IbIb 期期

I 期 II 期

IIa IIa 期期

IIb IIb 期期

IIc IIc 期期

III 期

种植性肝转移

腹腔腹膜转移腹腔腹膜转移肝实质性转移

恶性胸膜细胞

前锁骨淋巴结

IV 期

CLINICAL MANIFESTATION(1)benign tumors

• grow slowly.

• In early stage have no symptoms, usually discovered in gynecological examination on occasion.

• During gynecological examination we can touched mass :

in unilateral or bilateral,

cystic or solid,

smooth surface,

moved freely,

no adhesion.

• Large tumors can push adjacent organs.

CLINICAL MANIFESTATION(2)malignant tumors

• very insidious and silent in terms of signs and symptoms

• appearance of symptoms often indicated advanced stage of tumor

• grow rapidly

• symptoms generally depend on size, histological types and complications

DIAGNOSISDepend on

• age history

• local signs

• ultrasonic examination

• radiological examination

• cytological examination

• laparoscopy

• tumor markers (AFP,CA-125,hCG)

Antigen markers AFPHormone markers β-HCGEnzyme LDH

R

R

DIFERENTIAL DIAGNOSIS

• benign ovarian tumor

• malignant ovarian tumors

benign ovarian tumor• tumor like disease of ovary

follicle cyst and corporalutum are the commonest

diameter less than 5cm

generally unilateral

thin walls disappear spontaneously in 2 months

• leiomyoma

• gestational uterus

• plentifull bladder

• ascites

malignant ovarian tumors

• secondary tumors of ovary

• endometriosis

• pelvic cellulitis

• TB peritonitis

• tumors except genital system

COMPLICATION• 1) torsion of pedicle

these tumors have moderate size, long pedicle, great mobility and partiality, e.g dermoid cyst.

• 2) rupture of cyst

divided into spontaneous and traumatic types.

• 3) infection

• 4) malignantation

RISK FACTOR & PREVENTION

Risk factors• hereditary and

family factors• environmental

factors• endocrine

factors• virus factors• Repeated

ovulation

Prevention

• avoid above risk factors

• General survey of age >30

• find and treat as early as possible

• Oophorectomy

• oral contraceptive 

MANAGEMENT

1. Treatment of benign ovary tumors

• a) Principles : surgical therapy

• b) Range of remove :

• c) Notes during operation

2. Treatment of malignant ovary tumor

• a) Surgical therapy

• b) Chemical therapy

• c) Radiation therapy

Torsion of pedicle

b) Range of remove • related to :

the age of patients ,

demand of fertility ,

condition of opposite ovary

• i) Unilateral oophorectomy (or only excise tumour) (shell out of their ovarian beds)

• ii) Bilateral oophorectomy

• iii) Hysterectomy

c) Notes during operation

• Distinguish the benign tumor from the malignant tumor

• Histological examination (frozen section biopsy)

• Remove completely

2-a) Surgical therapy

• careful exploration of organs in abdominal cavity including diaphragm

• range of operation: hysterectomy and Bilateral salpingo-oophorectomy

• cytoreductive surgery

• removal of lymph nodes in reteroperitoneal space

2-b) Chemical therapy• Postoperative chemical therapy is helpful in preventi

ng of replace of ovarian tumor

• Platinum- type drug and taxane

• Common drugs : alkylating agents, Anti-metabolic groups, Anti-biotic groups.

• Combined chemical therapy is better than therapy with single drug

• Choose effective chemical therapy according to the tumor histological type

• Neoadjuvant chemotherapy: prior to any attempt to perform cytoreductive suegery

2-c) Radiation therapy

Sensitivity of different histological type tumors is different

• Dysgerminoma is the most sensitive

• Granulosa cell tumor has moderate sensitivity

• Epithelial tumor has also a certain sensitivity

cytoreductive surgery

• Even for advanced stage cases, the masses that can be found grossly should be removed to decrease the quantity of tumor cells as few as possible.

• Leaving residual disease at the initial surgery that has a maximum diameter less than 1 cm at any site in the abdominal cavity.