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Ovarian Cancer

Ovarian Cancer. Prof. Mohammed Addar gyneoncologist. Introduction. Fifth most common cancer in women Fifth most frequent cause of cancer death 1 in 70 newborn girls will develop cancer during her lifetime Disease of postmenopausal women and all ages Year 2000 23000 new cases

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Ovarian Cancer

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  1. Ovarian Cancer Prof. Mohammed Addar gyneoncologist

  2. Introduction • Fifth most common cancer in women • Fifth most frequent cause of cancer death • 1 in 70 newborn girls will develop cancer during her lifetime • Disease of postmenopausal women and all ages • Year 2000 • 23000 new cases • 14000 deaths

  3. Etiology • Cause is unknown • Predisposing factors • Repeated ovulation • Infertility treatment • PCO 2.5 fold increase • Unopposed estrogen therapy

  4. Etiology • Increase risk by • High diet in saturated animal fats • Alcohol and milk (never confirmed) • Exposure to talk powder

  5. Etiology • Protective factors • Chronic anovulation • Multiparty • Breast feeding • Pregnancy -reduction 13-19% per pregnancy • COC Pills decrease by 50% for 5 years and more of use

  6. Over 90% develop sporadically • 10% of epithelial based on genetic predisposition • Turner syndrome(45,XO) dysgerminoma and gonadoplastoma • Two first degree relatives –risk 50%

  7. hereditary • In two forms • Breast and ovarian syndrome (BOC) • Germline mutation in BRCA1 gene on chromosome 17(28-44%) • Less common BRCA2 on chromosome 13 (1/800) • Lyncy II syndrome (hereditary nonpolyposis colorectal cancer syndrome )HNPCC

  8. Histopathology • Divided to three categories according to cell type of origin • Epithelia neoplasms • Germ cell neoplasms • Sex cord and stromal neoplasms • May be the site of metastatic disease • Neoplasms metastatic to the ovary

  9. 1-Epithelia neoplasms • Tend to occur in the sixth decade of life • Derived from the ovarian surface mesothelial cells , six types: • Serous • Mucinous • endometroid • clear cell • Transitional cell • undifferentiated • Account for over 60% of all ovarian neoplasms • More than 90% of malignant ovarian tumors

  10. Ovarian serous cystadenocarcinoma • Most common 35-50% of all epithelial tumors • Bilateral in 40-60% • 85% with extra ovarian spread at diagnosis • Over 50% exceeds 15 cm, solid areas, hemorrhage, cyst wall invasion • Most poorly dfferentiated

  11. Mucinous neoplasms • 10-20% of epithelial ovarian tumor • Second most common type of epithelial ovarian carcinoma • Bilateral in less than 10% • Average size is 16-17 cm (large) ,multilocular ,viscous mucus

  12. Pseudomyxoma peritonei • Unusual condition • Associated with mucinous neoplasms of ovary • Progressive accumulation of mucinous in abdominal cavity • May be associated with appendix • Benign • Potentially morbid ,intestinal obstruction • Mortality rate approaches 50%

  13. Endometroidal neoplasm • Adenometroidal pattern • Bilateral in 30-50% • 30% of patients will have endometrial carcinoma of uterus as primary

  14. Clear cell carcinoma • Called mesonephroid carcinoma • 5% of epithelial ovarian cancer • Small size • Aggressive ,hypercalcimeia ,hyperpyrexia • Cystic and solid

  15. Transitional cell carcinoma • Brenner • Newly described • Present with advanced stage • Poorer prognosis

  16. Undifferentiated carcinoma • Accounts for less than 10% of epithelial • Absence of any distinguishing microscopic features that permit its placement in one of the other histologic categories.

  17. 2-Germ cell neoplasms • Tend to occur in second and third decade of life • Better prognosis • Many produce biological markers • Types: • Dysgerminoma • Young females (Seminoma in male) • 30-40% of germ cell tumors • Unilateral in 85-90% • Solid

  18. Endometrial sinus tumor • Was called yolk sac tumor • Second most common germ cell tumor • Occurs in 20% of cases • Bilateral in less than 5% • Commonly present with acute abdomen • Produces AFP

  19. Immature teratomas • Malignant counterpart of mature cystic teratoma • 20% of germ cell neoplasms • Bilateral in less than 5% • Elevated serum AFP • Three germ layers • Immature neuroectodermal element • Mature teratomas • Common at age 20 to 30 • Most common neoplasm diagnosed during pregnancy • Less than 2% goes malignant after age of 40

  20. Embryonal carcinoma • Very rare in pure form • HCG and AFP are usually elevated • Choriocarcinoma • rare germ cell tumor unrelated to pregnancy • Lower elevation HCG • May cause precocious puberty, uterine bleeding or amenorrhea

  21. Gonadoblastoma • Rare • More common on the right than left ovary • Occur in second decade of life • Associated with presence of Y chromosome • Mixed germ cell tumors • Accounts for 10% of germ cell tumor • Contains two or more germ cell elements • dysgerminoma and endometrial sinus tumor ocurs together

  22. 3-Sex Cord-Stromal tumors • Granulosa cell tumor • 1-2% of all ovarian neoplasms • Most common malignant tumor of sex cord-sromal • Associated with hyperestrogenism • May cause precocious puberty(girls) ,adenomatous hyperplasia and vaginal bleeding(postmenopausal women)

  23. Ovarian thecoma • Associated with hyperesrogenism • Benign tumor • Ovarian fibroma • Benign tumor • Associated with Meig’s syndrome • Sertoli-stromal cell tumors • Rare • consist of testicular structures • Occur during third decade • Usually virilizing • Rarely bilateral

  24. 4-Neoplasms metastatic to the ovary • Accounts for 25% of all ovarian malignancy • Mimic primary ovarian cancer • Present as bilateral adnexal masses • 25% unilateral • Common primary cancers • Breast (40%_ • Stomach (Krukenberg tumors) • Colon • endometrium

  25. Diagnosis of ovarian Cancer • Insidious disease • Non specific GIT complains • Abdominal distention • Pelvic weight • Menstrual abnormalities in 15% • Rarely excessive estrogens or androgens

  26. Screening • Routine pelvic examination • Ultrasound examination • Tumor markers • CA-125 antigen from fetal amniotic and coelomic epithelium • TAG 72 ,M-CSF ,OVX1

  27. Evaluation of the patient with suspected ovarian neoplasm • Child and postmenopausal women at great risk of malignancy • Reproductive women is likely to have functional cyst or endometrioma • Differential diagnosis is influenced by • Age • Characteristic of the mass on pelvic examination • Radiographic appearance

  28. Physical Examination • Comprehensive examination • Lymph node , Sister Mary Joseph’s nodule • Abdomen examination • Pelvic examination

  29. Radiographic Evaluation • Trans abdominal ultrasound • Trans vaginal ultrasound • Color flow Doppler

  30. Radiographic Evaluation,,,, • Computed tomography (CT) • Pelvic organs and Retroperitoneal structures • Magnetic resonance imaging (MRI) • Nature of ovarian neoplasm • X ray chest • Barium enema • mammogram

  31. Laboratory Evaluation • CBC • Serum electrolytes • hCG (pregnancy) • AFP ,LDH lactate dehydrogenase (young girls) • CA-125

  32. Surgical Treatment of Epithelial Cancer • Surgery is the corner stone of therapy • Surgical staging to • Reduce amount of disease • Evaluate the extent of spread • Debulking or cytoreduvtive surgery is removal • Primary tumor • Associated metastasis disease

  33. Intra operative differentiation

  34. Most common location of metastases • Peritoneum 85% • Omentum 70% • Liver 35% • Pleura 33% • Lung 25% • Bone 15%

  35. Procedures in staging • Sample of ascites or peritoneal washings from Para colic gutters , pelvic and sub • diaphragmatic for cytology • Complete abdominal exploration • Intact removal of tumor • Infracolic omentectomy • Biopsies of abdominal peritoneal implants • Pelvic and Para aortic lymph node biopsies • Cytoreduvtive surgery to remove all visible disease

  36. International Federation of Gynecology & Obstetrics (FIGO) Staging • Stage I. growth limited to the pelvis • Ia- One ovary • Ib- both ovaries • Ic- Ia or Ib and ovarian surface tumor ,rupture capsule, malignant ascites, peritoneal cytology positive. • Stage II. Extension to the pelvis • IIa- extension to the uterus or fallopian tube • IIb- extension to the other pelvic tissues • IIc- IIa or IIb and ovarian surface tumor ,rupture capsule, malignant ascites, peritoneal cytology positive.

  37. International Federation of Gynecology & Obstetrics (FIGO) Staging • Stage III. Extension to abdominal cavity • IIIa - abdominal peritoneal surfaces with microscopic metastases • IIIb- tumor metastases <2cm in size • IIIc- tumor metastases >2cm or metastatic disease in pelvic para aortic or inguinal lymph nodes • Stage IV. Distant metastases • Malignant pleural effusion • Pulmonary parenchymal metastases • Liver or splenic paranchyml metastases • Metastases to thr supraclavicular lymph nodes or skin

  38. Surgical treatment of Germ Cell Neoplasms • Most are at early stage on young women • Removal of involved adnexia • Same complete surgical staging

  39. Chemotherapy of epithelial cancer • Stage Ia and grade I, don’t need treatment • Agents ,cisplatin, carboplatin, cyclophosphamide, paclitaxel • Compinationpaclitaxel 175mg/m2 and cisplatin 75mg/m2 or carboplatin for 6 cycles at 3 week intervals • Toxic effects • Vomiting ,diarrhea ,alopecia, nephro and ototoxicity and myelosuppression.

  40. Chemotherapy of Germ Cell Neoplasms • Curable • Dysgerminoma most radiation sensitive • Preserve future reproductive potential with chemotherapy • Regimens ,vinblastine-bleomycin-cisplatin , vincristin-actinomycin, D-cyclophsphomide, bleomycin-etoposide-cispltin

  41. Complications of chemotherapy • Nausea vomiting alopecia

  42. Radiation therapy and alternative • Very limited role in epithelial cancer • Dysgerminoma • Immunotherapy • Gen therapy

  43. prognosis • Related to • Response to chemotherapy • Differentiation of tumor • Germ cell better than epithelial • Stage of the disease -5 year survival rate (epithelial) • Stge I -75-93% • stageII- 65-74% • Stage III- 23-41% • Stage IV- 11%

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