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OVARIAN MALIGNANCY

OVARIAN MALIGNANCY. Ovarian cancers are a clinical challenge because the majority are asymptomatic until late in the disease process. So 70% women will present with an advanced stage at diagnosis. It has the highest mortality among all the gynecological malignancies.

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OVARIAN MALIGNANCY

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  1. OVARIAN MALIGNANCY

  2. Ovarian cancers are a clinical challenge because the majority are asymptomatic until late in the disease process. • So 70% women will present with an advanced stage at diagnosis. • It has the highest mortality among all the gynecological malignancies.

  3. About 30% of ovarian tumors in postmenopausal women are malignant. • Whereas only 7% in premenopausal women are malignant.

  4. WHO (Scully 1999) • Epithelial tumors (benign, borderline or malignant) • Serous • Mucinous • Endometroid • Clear cell (mesonephroid) • Brenner • Mixed epithelial • Undifferentiated • Unclassified

  5. Sex cord stromaltumours • Granulosastromal cell tumour • Androblastoma or Sertoli-Leydig cell tumour • Gynandroblastoma • Unclassified • Lipid cell tumors

  6. Germ cell tumours • Dysgerminoma • Endodermal sinus tumour • Embryonal cell tumour • Polyembryoma • Choriocarcinoma • Teratoma • Mixed tumours

  7. Gonadoblastoma • Soft tissue tumours not specific to ovary • Unclassified tumours • Metastatic tumours

  8. Incessant ovulation : • Nulliparity • Early menarche • Late menopause • Infertility • Regarding the relation with infertility, ovulation-inducing drugs are supposed to be a risk factor by resulting in multiple ovulation, but the evidence is still not clear.

  9. Genetic factors Inheritance has a very important role : • BRCA1 and BRCA2 genes are implicated • 50% risk of ovarian cancer. • the other familial syndrome is hereditary Nonpolyposis Colon cancer (HNPCC) or • Lynch II syndrome • It includes multiple adenocarcinomas, colon cancer, ovarian, endometrial and breast cancers.

  10. Pathology • Most common epithelial tumours • 50-60% of all ovarian tumours • Malignant epithelial tumours comprise 90% of all ovarian tumours. • Epithelial tumours can be • Benign, • Borderline • malignant Serous tumours commonest – 75% Mucinous 20% Endometroid, clear cell, and transitional

  11. Serous tumours • Serous tumours resemble the glandular epithelium of the fallopian tubes. • They are cystic • Psammoma bodies are characteristic • Papillary ingrowths may be present • Mucinous tumours

  12. Papillary serous cyst adeno carcinoma

  13. Muscinous cyst adenoma

  14. Multilocular thin-walled cysts • Contain mucinous fluid • They are the largest ovarian tumours • Cells lining may resemble endo cervical cells • 10% bilateral

  15. Pseudomyxoma peritonei is a term used to describe the presence of mucoid material in the abdomen and pelvis surrounded by fibrous tissue. • It can result secondary to a ruptured mucinous tumour of the ovary, • a well differentiated appendiceal carinoma, • any other gastrointestinal primary tumour or a mucocele of the appendix. • Care should be taken to avoid rupture during surgery

  16. Borderline tumours • Low malignant potential • 10% of all epithelial tumours • Commoner in young women between 30 and 50yrs. Histological criteria • Epithelial hyperplasia • Nuclear atypia and increased mitotic activity • Detached cell clusters • Absence of stromal invasion • Metastases are uncommon • They have very good prognosis

  17. Direct or transcoelomic spread : • Omentum (most common) • Posterior cul de sac • Paracolic gutters • Right hemidiaphragm • Capsule of the liver • Peritoneal surface of small and large intestines • Mesenteries • Parietal peritoneum

  18. Lymphatic spread : • Para-aortic nodes • Pelvic nodes • Supraclavicular nodes • Retroperitoneal nodes

  19. Para-aortic node metastases are 20% in stages I and II and 65% in stage IV. Pelvic lymph nodes are seen in 30% of stage I and II and 67% of stage III and IV.

  20. Haematogenous : late stages • Lungs • Liver (Parenchymal) • Bone and brain (rarely)

  21. Clinical features : • Malignancies are more common in extremes of age group – younger and older age • Malignancy 50-60yrs • Borderline between 30 & 50 yrs. • Younger age group germ cell tumours are more common • Older age group epithelial tumours

  22. Symptoms : • Majority of epithelial ovarian tumours are asymptomatic • They are diagnosed in late stages • Abdominal distension and pain • Feeling of a lump in the abdomen

  23. Dyspepsia, • Bloating • Abdominal discomfort • Loss of appetite and loss of weight • Pressure symptoms like urinary frequency, retention or constipation • Abnormal uterine bleeding or postmenopausal bleeding in feminising tumour

  24. Advanced stage symptoms may be due to • ascites • Omental deposits • Bowel – altered bowel habits • Pulmonary metastases – cough and haemoptysis

  25. Signs • General examination • Cachexia • Supraclavicular lymph nodes • Breast lumps • Thyroid nodules • Pleural effusion

  26. Abdominal examination : • Mass in the pelvis or abdomen • Bilateral tumours • Boders vague and ill-defined • Hard or varying consistency • Fixity or restricted mobility • Ascites • Hepatomegaly • Other abdominal masses suggestive of lymph node metastases

  27. Bimanual examination : • Hard fixed mass • Uterus may be felt separate • Nodules in the cul de sac due to secondary deposits

  28. Differential diagnosis : • Benign ovarian tumour • Gastrointestinal problems like colonic cancer and stomach cancer (history of altered bowel habits, bleeding per rectum and other gastrointestinal symptoms should warrant a search for the same) and diverticulitis • Lymphoma (presence of other lymph node enlargement is suggestive)

  29. Retroperitoneal sarcoma • Pedunculated fibroids • Pelvic inflammatory disease • Endometriosis • Pelvic kidney • Functional cysts

  30. Investigations : • Routine investigation like blood count, urine routine • RFT, LFT • Tumour markers • Chest X-ray • Ultrasound scan

  31. Colonoscopy • Gastroscopy • Barium enema / barium swallow • Pap smear • Endometrial biopsy • Intravenous pyelogram • CT and MRI

  32. TAS followed by TVS done Ultrasound features of malignancy • Solid or echogenic areas • Multilocularity • Thick and fronded septations • Bilaterality

  33. Papillary projections • Doppler may show increased vascularity • Ascites • It also detects liver parenchymal metastases • Enclarged pelvic and para-aortic nodes • Detects hydroureter and hydronephrosis

  34. CT and MRI • They detect the extend of invasion, lymph node involvement, retroperitonial or omental involvement • So that surgery can be planned

  35. Tumour markers : • CA 125 levels are useful in differentiating malignant from benign neolplasms. • Useful tumour marker in epithelial ovarian cancer • More useful in postmenopausal woman • The cut off value is 30 U/mL • The test has a sensitivity of 81% and a specificity of 75% • Above 95 U/mL is taken as significant • RMI is calculated from CA 125 level • Age and ultrasound

  36. Premenopausal women in endometriosis and pelvic tuberculosis CA 125 level may be raised. • More than 200 U/mL indicate malignancy

  37. Tumour markers in ovarian cancer

  38. Screening : • At the present moment screening with ultrasound is only indicated in high risk women. • High risk women need to undergo genetic screening, use of oral contraceptives for chemoprophylaxis and can be offered prophylactic oophorectomy STAGING • Ovarian epithelial tumours are staged according to the FIGO system • Essentially a surgical staging • Histological and cytological finding also taken in account

  39. FIGO staging for carcinoma ovary

  40. Management • Staging laparotomy • Ascites or peritoneal washings (50-100ml saline) taken cytology • Washing from cul de sac, paracolic gutter and beneath hemidiaphragm • Exploration of the abdomen and pelvis in a clockwise manner from the caecum cephalad

  41. Any suspicious areas should be biopsied • Diaphragm can be sampled either by biopsy or by scraping • Infracolicomentectomy • Retroperitoneal space dissection to evaluate the pelvic and para-aortic nodes • Enlarged nodes must be submitted for frozen section • If there are no metastases a pelvic lymphadenectomy must be performed. • Careful documentation of the operative findings

  42. Surgery : • Stage I & II total hysterectomy, bilateral salpingo-oophorectomy and infracolic omentectomy • After a thorough surgical staging must be performed. • In advanced cases maximal cytoreductive surgery must be attempted. • Fertility sparing surgery – rarely there is also a place for conservative surgery in stage Ia grade-I in those younger women who mare anxious to conceive

  43. They should be under regular follow up • After childbearing is completed • Definitive surgery is done • High risk cases surgery followed by adjuvant chemotherapy with carboplatin and paclitaxel for 3-6 cycles is desirable.

  44. Advanced disease : • Maximal cytoreductive or debulking surgery • Residual disease should be less than 1cm. • The surgery typically consists of a total abdominal hysterectomy, • Bilateral salpingo-oophorectomy and omentectomy • In addition it may include resection of any metastatic lesions from the peritoneal surfaces or intestines • Sometimes resection of part of the bladder or removal of the sigmoid and rectum may be necessary. • If optimal cytoreduction has been achieved, chemotherapy for 6-8 cycles is usually given.

  45. Interval cytoreductive surgery • Second look surgery • Postoperative management of advanced disease • Intravenous carboplatin and paclitaxel every 3 weeks for 6-8 cycles • Intraperitoneal cisplatin and paclitaxel is an acceptable alternative to intravenous route.

  46. Neoadjuvant chemotherapy : • Advanced disease preoperative chemotherapy for about 3 cycles followed by cytoreductive surgery. • After cytoreductive surgery chemotherapy followed • This is useful in patients with massive ascites and pleural effusions

  47. Immunotherapy : • Cytokines have been used such as interferons and interleukin – 2 in combination with chemotherapy as second-line therapy. Survival rates : • The survival rates in each stage depend on the grade of the tumour • Stage I 76-93% • Stage II 60-74% • Stage III 23-41% • Stage IV 11%

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