Malignant Ovarian Tumors

1. Malignant Ovarian Tumors Dr.Omaraldabbas Assisstantprof. MUTA university OBGYN specialist

2. Introduction • The second most common malignancy of the genital system. • The most common cause of death from malignancy due to late diagnosis • Most of the tumors are of epithelial origin. Occurs after the age of 35 years with increasing incidence with advancing age. • Only 3% occurs before 35 years of age and they are mostly non-epithelial in origin as germ cell tumors.

3. Aetiology • Ovulation theory: more common in nulliparity, early menarche and late menopause. Oral contraceptive pills reduces the risk. • Infertility treatment: there is a link between prolonged ovulation induction and ovarian malignancy. • Genetic factors: strong family history of breast, colorectal and ovarian cancer.

4. Epithelial tumors: 1- Serous carcinoma 2- Mucinous car. 3- Endometrioid car. 4- clear cell car. 5- Brenner tumor. 6- undifferentiated car. Sex cord stromal tumor: 1- Granulosa cell tumor 2- Androblastoma. 3- Gynandroblastoma. Germ cell tumors: 1- Dysgerminoma. 2- Endodermal sinus tumor (Yolk sac tumor) 3- Embryonal cell tumor 4- Choriocarcinoma 5- Malignant teratoma. 6- Mixed tumors. Metastatic tumors (Krukenberg tumors) Histologic classification of ovarian tumors

5. Epithelial malignant tumors • Well-differentiated epithelial tumors tend to be associated will early stage disease. • There is no difference in survival between different epithelial types. • Mucinous and endometrial lesions have better prognosis than serous cystadeno carcinoma.

6. Serous cystadenocarcinoma • Has both solid and cystic elements. • Has a papillary pattern with stromal invasion. • Psammoma bodies are often present. • Glandular tissue may be present. • The tumor could be at any stage of differentiation.

7. Mucinous cystadenocarcinoma • Account for 10% of malignant ovarian tumors. • Usually multilocular, thin-walled cysts containing mucinous fluid. • They are the largest tumors of the ovary. • A cyst diameter of 25 cm is common.

8. Endometrioid carcinoma • Resemble to endometrial carcinomas. • Mostly they are cystic, unilocular, and contain turbid brown fluid. • They could occurs in association with endometriosis and endometrial tumors of the body of the uterus.

9. Clear cell carcinoma (mesonephroid) • The lest common (5%). • On histopathology, they have a clear cell pattern. • It has a strong association to ovarian endometriosis and endometrioid cancer.

10. Borderline epithelial tumors • 10% of ovarian tumors are borderline malignant. • They show varying degree of nuclear atypia and increased mitotic activity. • There is no stromal invasion. • They remain confined to the ovary. • Rarely, peritoneal metastasis occurs.

11. Staging for primary ovarian carcinoma Stage I: Growth limited to ovaries Ia: One ovary,no ascites,capsule intact. Ib: Two ovaries, no ascites, capsule intact. Ic: one or both ovaries with ascites containing malignant cells and/or invasion through the capsule.

12. Staging for primary ovarian carcinoma Stage II: Stage one with pelvic extension. Stage III: Peritoneal implants outside the pelvis or positive lymph node or superficial liver metastasis. Stage IV: Distant metastasis, pleural effusion with positive malignant cells, Deep liver involvement.

13. Clinical history • In two-thirds of patients presents at late stages. • This is due to late symptoms and difficult early diagnosis. • Some of the tumors are rapidly growing.

14. Clinical Diagnosis • Abdominal pain, discomfort and distension. • Feeling of a lump. • Indigestion, urinary frequency, weight lost and rarely abnormal menses or post menopausal bleeding. • On examination, hard mass arising from the pelvis. Ascites may be present. The tumor is fixed and tender. Irregular pelvic masses may be felt on vaginal or rectal exam which suggest metastesis. Palpable inguinal or neck nodes.

15. Investigations • Full blood count, renal and liver function tests, electrolytes,blood sugar and chest x-ray. • Barium enema or colonoscopy to exclude bowel involvement. • IVU for renal and ureteric involvement. • Ultrasonography for mass and ascites. • Ca125 estimation. • Laparotomy.

16. Screening for ovarian cancer • Because of late diagnosis, much effort has been made to screen for ovarian cancer. • Till now no specific tumor marker has been found for epithelial tumors. • Ultrasonography and Ca125 are in use. • Inhibin for granulosa cell tumor. • Beta-hCG for choriocarcinoma. • Alpha -fetoprotien in germ cell tumors.

17. Surgery • Is the mainstay for both diagnosis and treatment. • Vertical incision is required. • A sample of ascitic fluid or peritoneal wash send for cytology. • The abdomen should be inspected for metastasis and lymph node involvement.

18. Surgery • The main is to remove the whole tumor (stage I and II) or to remove as much as possible from the tumor (debulking operation). • The operation in early stages includes TAH+BSO and infracolic omntectomy. • In young nulliparous women with stage Ia , unilateral salpingo-oophorectomy can be done. This is also applied to borderline malignancy.

19. Surgery • After debulking operation, chemotherapy should be used. • Interval debulking surgery: a second surgery after chemotherapy for residual tumor. • Surgery is the only treatment for stage I. All others need further treatment.

20. Chemotherapy • This treatment is for stages II to IV. • The drugs in common use are: Carboplatin or cisplatin and taxol. • Chemotherapy is used to prolong clinical remission and for palliation in advanced and recurrent disease. • It is given for 5-6 cycles at 3-4 weekly intervals.

21. Prognosis • Borderline tumors have a good long-term prognosis. • Stage I have a 5 year survival rate of 90%. • For stage III and IV is only 10%. • The overall survival rate is around 23%.

22. Non-epithelial malignant tumors • This constitute around 10% of all malignant ovarian tumors. • The staging is similar to epithelial tumors. • The treatment is similar. • Radiotherapy is hardly used in the treatment of ovarian cancer.

23. Thank you