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Chapter 21 Female Genital Tumor

Chapter 21 Female Genital Tumor. 6. Ovarian Tumor. Women’s Hospital, School of Medicine, Zhejiang university Xiaodong Cheng. Ovarian tumor. Common gynecologic malignant tumors Occur in females of all ages

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Chapter 21 Female Genital Tumor

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  1. Chapter 21 Female Genital Tumor 6. Ovarian Tumor Women’s Hospital, School of Medicine, Zhejiang university Xiaodong Cheng

  2. Ovarian tumor • Common gynecologic malignant tumors • Occur in females of all ages • but different histological types in different age-periods • Epithelial ovarian carcinoma with poor prognosis 5-year survival rate about 30-40% the mortality rate ranks first in gynecological malignancies

  3. General Introduction • Histological classification very complicated • Most histological types in body organs • The current classification issued by WHO in 1973

  4. Histologic types of ovarian tumor • Ovarain epithelial tumor • Germ cell tumor • Sex-cord stromal cell tumor • Lipid (lipoid) cell tumor • Gonadal blastoma • Non-specific ovarian soft tissue tumor • Unclassified tumor • Metastatic tumor • Tumor-like lesions

  5. Symptoms and signs • Benign tumors • No symptoms as tumor is small • Abdominal distention or pelvic mass as tumor is medium size • Gynecological examinations A spherical mass on one side of the uterus, cystic, smooth surface, movable

  6. Symptoms and signs • Ovarian cancer • early stage asymptomatic, often found occasionally by gynecological examinations • Late stages Abdominal distention, abdominal mass, ascites • End-stage Weight loss, severe anemia, cachexia Transvagina-rectnum examination • Pelvic masses: bilateral , solid or semi-solid, not movable

  7. Complications • pedicel retortion Common gynecological emergency • Frequency about 10% • Usually occur in mass with a longer pedicle, medium size, good movability, and center deflection • Blood flow blocked and tumor necrosis after retortion Symptoms: one side of lower abdomen pain concomitant nausea and vomit, Signs: Mass with high tension and tenderness Treatment emergency surgery once diagnosed

  8. Complications • Rupture • Frequency about 3% • Traumatic and spontaneous • Symptom lower abdominal pain related to the size of rupture the quality and quantity of cyst fluid • Signs abdominal tenderness muscle intensity ascites • Treatment emergency surgery

  9. Complications • Infection • Due to rupture, retorsion or the near organs’ infection • Symptoms fever, abdominal pain • Signs mass, abdominal tenderness, muscle intensity • Treatment anti-infection, surgery • Malignant change surgery as soon as possible

  10. Diagnosis • Benign tumors No specific symptoms A mass found occasionally by physical examination • Ovarian cancer No specific symptoms Gynecological examination bilateral pelvic mass, solid , poor movability, with ascites, uterus rectum nest nodules

  11. Diagnosis • Adjuvant examinations Imaging techniques • Ultrasonography : mainly used to diagnose primary lesion accuracy rate above 90% difficult to measure the diameter <1cm lesion • Radiology (X-Ray, CT, MRI) mainly used to diagnose the metastatic lesion

  12. Ultrasound: ovarian cancer

  13. Diagnosis • Adjuvant examinations • Tumor markers §CA125 rise up in 80% epithelial cancers more used for disease monitoring and prognosis evaluation §AFP rise in endodermal sinus tumor §hCG ovarian choriacarcinoma §Sex hormone sex-cord stromal cell tumor • Laparoscopy • Ascitic cytology

  14. Metastatic pathway • Features • Widely disseminated in abdominal cavity • Subclinical metastasis • pathways • spread directly and abdominal cavity plant • lymph metastasis • blood vessel metastasis

  15. Clinical surgical-pathology staging (2000,FIGO)

  16. Therapy • Surgery Objectives • To confirm the diagnosis • To resect tumor • To determine surgical-pathology staging of malignancy • Chemotherapy and radiation for malignancy • follow-up ovarian cancer is easy to recurrent and should be long-term follow-up

  17. Epithelial tumors • The most common histological type accounting for 50-70% of the primary tumor 85-90% of malignant tumor • Derived from ovarian germinal epithelium belong to the primitive body cavity epithelium have potential to differentiate into a variety of Mullerian epithelia • More common in older women • Can be divided into benign, borderline, malignant tumors

  18. Epithelial tumors • Borderline tumors • low malignant potential tumors • pathological features of malignant tumor cells but no stromal invasion • clinically slower development, fewer metastasis and more later recurrence

  19. Histological classification Epithelial tumors • Serous tumors • Mucinous tumors • Endometrioid tumor • Brenner tumor • Mixed epithelial tumors • Undifferentiated carcinoma Changing: New classification—2014 (WHO)

  20. Pathology Serous tumors cancer cell differentiate into oviduct epithelial • Serous cystadenoma Mostly unilateral, spherical, smooth, cystic, serous fluidMicroscope: simple columnar epithelium • serous cystadenocarcinoma Mostly bilateral, semi-substantive, multiple antrum cystoid, cavity filled with papilla, crisp, bloody cyst fluid Microscope: cubic or columnar epithelium, stratified, arranged in ≥4 layers, cellular atypia, stromal invasion

  21. Serous tumors Serous cancer

  22. Pathology Mucinous tumors cancer cell differentiate into enteric or cervical endometrial • Mucinous cystadenoma Mostly unilateral, large size, cystic, and often have more capsules with the jelly-like mucus Microscope:simple columnar epithelium, can see goblet and argyrophil cells If tumor rupture, tumor cells seed in peritoneal to form peritoneal myxoma • Mucinous cystadenocarcinoma Mostly unilateral, cystic, cystic see the papilla, bloody cyst fluid Microscope:columnar epithelium, stratified, arranged in ≥ 3 layers, cellular atypia, stromal invasion

  23. Mucinous tumors Mucinous cancer

  24. Pathology • Endometrioid tumor • Benign, borderline tumor is few • Endometrioid carcinoma • Mostly unilateral, cystic or solid, with papilla, bloody cyst fluid. Microscope: similar to endometrial cancer • Often concomitant with endometrial cancer

  25. Endometrioid cancer

  26. Pathology Clear cell tumors • Benign tumors are few • Clear cell carcinoma • Mostly unilateral, cystic or solid • Microscope:alveolar tumor cells with abundant cytoplasm , atypia nuclear • Easy to lymph node and liver metastasis • Often concomitant with endometriosis and hypercalcemia • Brenner tumor • Differentiate and formate from transitional epithelum • Most are benign, unilateral, diameter <5cm, hardware quality

  27. Clear cell tumors

  28. Brenner tumor

  29. Epithelial Tumors Treatment • benign tumors • Once diagnosed, surgical extension • reproductive period women ovarian tumor resection or oophorectomy perimenopausal and postmenopausal women ● adnexectomy ● hysterectomy and bilateral salpingo-oophorectomy Notices in surgery ① differentiate the benign and malignant tumors during surgery (grossly, frozen section ) ② take out the tumor integrally

  30. Epithelial Tumors Treatment • malignancy • Principle: surgery combined with chemotherapy and radiotherapy • surgery Early stage: Staging surgery • Cytology for ascites or peritoneal washings • Complete pelvic and abdominal exploration • Omentectomy • Back peritoneum lymph nodes excision • Hysterectomy + bilateral salpingoophorectomy • Conservative surgery only for eligible young women desiring childbearing

  31. Epithelial Tumors Treatment • malignancy • surgery Advanced stage: Cytoreductive surgery (debulking surgery) Resect primar and metastatic tuomrs as much as possible , to minimize diameter of residual tumor (<1cm)

  32. Epithelial Tumors • Chemotherapy Major adjuvant therapy, post-surgery Commonly used drugs cisplatin, carboplatin, paclitaxel, CTX, others. Preferred to platinum-based combination chemotherapy “Gold standard”: carboplatin and paclitaxel combination • Radiotherapy For metastasis and recurrence • Others immunotherapy Prognosis 5-year survival rate of Ia stage >90% 5-year survival rate of advanced stage <30%

  33. Ovarian germ cell tumor Features • From primitive germ cells in embryonic gonad • Ability to produce diversity organizations • Frequency: account for 20~40% in all ovarian tumors • More common in young women and girls • Sensitive to chemotherapy ,most can be reserved for reproductive function • Abnormal tumor markers: AFP, HCG

  34. Histologic classification Germ cell tumors • dysgerminoma • endodermal sinus tumor • embryonal tumor • polyembryoma • choriocarcinoma • teratomas • mixed tumor

  35. Pathology Teratomas • Comprised of multi-germ layer , rarely one layer • Mostly are mature , few are immature • Mature teratomas(dermoid cyst) • benign tumor,the most common germ cell tumor • frequently single side, cystoid with smooth surface, contains tissues of fat, hair, teeth and bone • microscopy: scolex contains three layers • malignant transformation: squamocarcinoma in scolex epilithium

  36. Mature Cystic Teratoma Immature ovarian teratoma

  37. Pathology Dysgerminoma • Moderate malignant tumor • Mostly occurs at puberty and child-bearing perild • Single side, solid • Microscopy :rotundity or mostly cornual cells • Extraordinary sensitive to radiotherapy

  38. dysgerminoma

  39. Pathology Endodermal sinus tumor • Common in children and young women • Highly malignant, poor prognosis • Single side with large mass, fragile, obvious bleeding and necrosis; • Microscopy:loose reticulate and endothelial sinus structure • Produce AFP

  40. Endodermal sinus tumor

  41. Treatment • Benign tumor The same as epilithial tumors • Malignant tumor Surgery Lateral salpingoophorectomy regardless any stage as long as opposite side ovary and uterus are not involved Chemotherapy Sensitive to chemotherapy : BEP BVP VAC Radiotherapy sensitive for Dysgerminoma,seldom used for young ages

  42. Sex cord-stromal tumors • From sex cord and stromal tissues of embryonic gonad • Frequency: account for 5% in all ovarian tumors • Comprised or uni- or multi-cell components • Mostly are benign or low malignant tumor • Produce steroid hormones, with endocrine funtion, produce female or male features, also called “functioning ovarian tumor ”

  43. Histologic classification Sex cord-stromal tumors • Granulosa cell -stromal cell tumors • Sertoli-stromal cell tumors • Granudroblastoma

  44. Pathology Granulosa cell tumors • Adult form and child form • Adult form • common • low malignant,produce E2,female features • solid or partly cystic • microscopy: Granulosa cell, Call-Exner body • Child form • seldom, highly malignant

  45. Granulosa cell tumor Granulosa cell tumor Call–Exner bodies (sex cord-stromal tumors ) Granulosa cell tumor Granulosa cell tumor stromal cell tumors

  46. Pathology Ovarian thecoma (theca cell tumor) • Benign,seldom malignant • Single side, solid. • Microscopy short spindle cells, spiral arrangement • Female features

  47. Ovarian thecoma

  48. Pathology Fibroma • Benign • Single side, solid, hardness • Microscopy short spindle cells, knitting arrangement. • Meigs syndrome fibroma combination with ascites or hydrothorax, naturally disappear after tumor excision

  49. Fibroma

  50. Treatment • Benign tumor surgery as same as epithelial tumor • Malignant tumor Surgery Conservative surgery for young women with stage I, desiring childbearing Radical surgery for others Chemotherapy Combinated Chemotherapy Regimens: as same as germ cell or epilithelial tumors

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