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Overview of Ovarian Cancer - Types, Pathology, and Clinical Features

This article provides an overview of ovarian cancer, including the different types, pathology, and clinical features. It highlights the importance of early detection and emphasizes the need for further research.

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Overview of Ovarian Cancer - Types, Pathology, and Clinical Features

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  1. بسم الله الرحمن الرحيم

  2. Ovarian cancer Dr. T Allameh Associated professor of Ob & Gyn of IUMS

  3. Ovarian cancer • Epithelial 90% • Germ cell tumors (20-25% of all benign and malignant ovarian neoplasms, only 3% of these are malignant ) • Sex cord stromal tumor 5-8%

  4. Epithelial cancers are the most common ovarian malignancies • Usually asymptomatic until they have metastatized patients have advanced disease at diagnosis in more than 2/3 of cases • It has the highest fatality –to case ration of all the gynecologic malignancies

  5. Epithelial ovarian cancer • APPROXIMATELY 90% OF OVARIAN CANCERS ARE DERIVED FROM TISSUES THAT COME FROM THE COELOMIC EPITHELIUM OR MESOTHELIUM

  6. pathology of invasive cancer • 75% of epithelial cancers are of the serous histologic type • Mucinous 20% • Endometriosis 2% • Clear cell 1%, • Brenner 1% • Undifferentiated 1% • Occur more often in ages of 50-70

  7. Border line tumors • Are lesions that tend to remain confined to the ovary for long periods • Occur predominantly in premenopausal women ( 30-50 y ) • Good prognosis

  8. Borderline tumors • Epithelial proliferation with papillary formation and pseudostratification • Nuclear atypia and increased mytotic activity • Absence of true stromal invasion ( without tissue distraction ) • 20-25% of borderline malignant tumors spread beyond the ovary

  9. Serous tumors • Develop by invagination of the surface ovarian epithelium • Psammoma bodies (focal of foreign material )

  10. Borderline serous tumors • 10% of all ovarian serous tumors • 50% occur before the age of 40 y • 10% have extra ovarian implans (invasive and non invasive) • The invasive implants resemble well differentiated serous carcinoma

  11. Malignant serous carcinoma • Stromal invasion is present • Well differentiated ( papillary and grandular structures predominant ) • Moderately differentiated • Poorly differentiated (solid sheets of cells , nuclear pleomorfism and highly mitotic activity ) • Calcified psammoma bodies in 80%

  12. Mucinous tumors • Have loculi lined with mucin secreting epithelial • 8-10% of epithelial of ovarian tumors • May reach enormous size

  13. Bordeline mucinous tumors • Often a diagnosis difficult to make • Well differentiated mucinous epithelium may be seen adjacent to a poorly differentiated focus

  14. Malignant mucinous carcinoma • 8-10% are bilateral • 95-98% are intraovarian • Most ovarian mucinous carcinomas contain intestinal type cells • Can not be distinguished from metastasis carcinoma of the GI (basis of histology alone ) • Primary ovarian neoplasm rarely metastasized to the mucosa of the bowel ( commonly involved the serous )

  15. Pseudomyxoma peritoneal The neoplastic epithelium secrets large amount of gelatinous mucinous material , most commonly secondary to : a well differentiated appendiceal carcinoma an ovarian mucinous carcinoma A mucocell of the appendix

  16. Endometriod tumors • 6-8% of epithelia tumors • Similar to those seen in uterine cavity • A malignant potential of endometriosis is very low

  17. Borderline endometriod tumors • Wide morphologic spectrum • Resemble an endometrial polyp or complex endometrial hyperplasia • Some have a prominent fibromatus component (adenophibroma)

  18. Malignant endometrial carcinoma • Are characterized by adenomatos pattern with all the potential variations of epithelial found in the uterus • Greatest opportunity to multifocal disease • Entometriod tumors of the ovary are often associated with similar lesions in the endometrium

  19. Mutifocal disease • Metastatic from the uterus to the ovaries have a 30-40% five year survival • Synchronous multifocal disease have a 75-80% five year survival

  20. Clear cell carcinoma • The tumors are made up of clear cells and hobnail cells • The tall clear cells have abundant clear or vacuolated cytoplasm ,hyperchromatic irregular nuclear and nucleoli of various size • Is the histlogically identical to that seen in the uterus or vagina of the young patient who has been exposed to DES in uterus

  21. Brennr tumors Borderline • the epithelium dose not invade the stroma • Resemble low grade papillary transitional cell carcinoma of the urinary bladder

  22. Malignant brenner tumors • The tumor infiltrates the tissue with associated destruction

  23. Transitional cell tumors • Resemble transitional cell carcinoma of the urinary bladder • An appointment finding is that those ovarian carcinomas that contain more than 50% of transitional cell carcinoma are more sensitive to chemotherapy and have a more favorable prognosis • Differ from malignant Brenner tumor in that they are more frequently diagnosed in advanced stage ( poorer survival rate )

  24. Small cell carcinoma • Mainly in young women who may have symptoms of hypercalcemia • Immunohystochemichal stains are helpful to differentiate this tumor from a lymphoma , leukemia

  25. Clinical features • Peak incidence of invasive epithelial ovarian cancer is at 56-60 y • Fewer than 1% occur before 21 y • 30% of ovarian neoplasms in post menopausal women are malignant • 7% of ovarian epithelial tumors in premenopausal patients are malignant

  26. Borderline tumors • Average age 46 y • The chance that a primary epithelial tumor will be of borderline or invasive malignancy before 40 y is 1/ 10 , after that age it rises 1/3

  27. Etiology • Low parity • Infertility • Talk use • Galactose consumption • Early menarche • Late menopause Repetitive disruption and repair of the surface epithelium may lead to mutation

  28. Prevention • 1 child RR 0.3- 0.4 • OC for 5 or more years RR 0.5 • (50% reduction in ovarian cancer ) • 2 children and OC for 5 or more years RR 0.3 ( 70% reduction in ovarian cancer ) • Fenertidine ( 4hydroxyretinoic acid ) . A vitamin A derivative

  29. Screening • BME • Ultrasound : TVS : > 95% sensitivity for the detection of early stage of ovarian cancer ( 10-15 laparatomy for each ovarian cancer ) Trans abdominal + CA 125>30 u/ml (4 laparatomy for each ovarian cancer ) Transvaginal color flow • CA- 125 ( 50% in stage I , 60% in stage II )

  30. Genetic risks of epithelial ovarian cancer • The life time risk of ovarian carcinoma for women in the USA is about 1.4% • Most epithelial ovarian cancer is sporadic • Familial or hereditary patterns in 5-10%

  31. Hereditary ovarian cancer • BRCA 1 mutations (chromosome 17 ) 28- 44 % life time risk • BRCA2 mutations (chromosome 13 ) 27 % life time risk • The mutations are inherited in an autosomal dominant fashion • Full pedigree analysis( maternal and paternal ) • The risk of breast cancer in BRCA1 or BRCA2 mutation is 56-87% .

  32. Hereditary ovarian cancers in general occur in women approximately 10 years younger than those with nonhereditary tumors

  33. Pedigree analysis • In familis with 2first degree relatives (mother ,sister, or daughter ) with premenopausal epithelial ovarian cancer , the risk that a female first degree relative has an affected gene could be 35-40% . • In familis with a single degree relative and single second degree relative (grandmother ,aunt , first cousin , or grandaughter ,) with epithelial ovarian cancers the risk that a woman has an affected gene increase 2-10 fold higher than others.

  34. 3- In families with a single post menopausal first degree relative with epithelial ovarian carcinoma a woman may not have an increased risk . • if the ovarian cancers occurs in a premenopausal relative , could be significant and a full pedigree analysis should be undertaken .

  35. 4-women with a primary history of breast cancer have twice the expected incidence of ovarian cancer

  36. Linch 2 syndrome • Multiple adenocarcinoma : familial colon cancer (lynch 1) high rate of ovarian endometrial and breast cancers other malignancies of GI and GU • The mutations are MSH2 , MLH 1, PMS 1 and PMS 2 • RR 3 for ovarian cancers

  37. Management of women at high risk for ovarian cancers • Genetic counseling • TVS every 6 months • OC in young women who have completed their families may undergo prophylactic BSO (peritoneal carcinomas occasionally can occur ) • in women also have a strong family history of breast cancer , annual mammographic screening should be performed beginning at age 30 • Women with a HNPCC syndrome should undergo periodic screening mammography , colonoscopy , and endometrial biopsy

  38. Symptoms • Most have no symptoms for long periods of time • Symptoms are vague and non specific • (Irregular menses urinary frequency or constipation, lower abdominal distention, pressure or pain ) • In advance stage : ascites,abdominal distention , bloating ,constipation , nausea , anorexia or early satiety

  39. Signs • Pelvic mass • Upper abdominal mass • Ascites

  40. Diagnosis • CA 125 levels have been shown to be useful in distinguishing malignant from benign pelvic masses • For a postmenopausal patients with an adnexal mass and CA125 > 95u/ml there is a 96% PPV for malignancy • For premenopausal patients the specificity of the test is low

  41. If a cystic mass is > 8cm • Solid • Fixed • Irregular

  42. Pattern of spread • Transcoelomic • Lymphatic • Hematogenous

  43. Treatment Complete surgical staging • Peritoneal washing • TAH- BSO • Pelvic lymphnod Dysection • Paraaortic sampling • Omentectomy Chemotherapy • Taxol • carbopelatin

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