Sie sind auf Seite 1von 61

Neoplastic Diseases of the

Ovary

Department of Obstetrics and
Gynecology
FEU-NRMF
Frequency of Ovarian Neoplasm
(WHO Classification)
Class Frequency (%)
Epithelial stromal (Common epithelial) tumors
Germ cell tumors
Sex cord-stromal tumors
Lipid (lipoid) cell tumors
Gonadoblastoma

Soft-tissue tumors (not specific to the ovary)
Unclassified tumors
Secondary (metastatic) tumors
Tumor-like conditions (not true neoplasm)
65
20-25
6
<0.01
<0.01
Differential Diagnosis of Adnexal Mass
Organ Cystic Solid
Ovary
Functional cyst
Neoplastic cyst
Benign
Malignant
Endometriosis
Neoplasm
Benign
Malignant
Fallopian tube
Tubo-ovarian abscess
Hydrosalphinx
Parovarian cyst
Tubo-ovarian abscess
Ectopic pregnancy
Neoplasm
Uterus
Intrauterine pregnancy in bicornuate
uterus
Pedunculated or intraligamentous
myoma
Bowel
Sigmoid or cecum distended with gas
or feces
Diverticulitis
Ileitis
Appendicitis
Colonic cancer
Miscellaneous
Distended bladder
Pelvic kidney
Urachal cyst
Abdominal wall hematoma or abscess
Retroperitoneal neoplasm

DiSaia et al, Clinical Gynecologic Oncology, 2007
Diagnostic Evaluation in the Presence
of an Adnexal Mass
Complete physical examination

Ultrasonography

Colonoscopy or Barium enema, if symptomatic

Intravenous pyelography, if indicated

CT Scan or MRI

Laparoscopy, Laparotomy
Epithelial Ovarian Neoplasms
Arise from inclusion cysts lined with surface
(coelomic) epithelium within the adjacent
ovarian stroma

Classified as:
Benign (adenoma)
Malignant (adenocarcinoma)
Intermediate (Boderline malignant or Low
malignant potential)

Epithelial Ovarian Tumor Cell Types

Tumor Cell Type
Approximate Frequency (%)
All Ovarian
Neoplasms
Ovarian
Cancers
Serous
Mucinous
Endometrioid
Clear cell (mesonephroid)
Brenner
20-50
15-25
5
<5

2-3
35-40
6-10
15-25
5

Rare
Scully RE: Atlas of Tumor Pathology, 1979
Serous Tumors
Composed of ciliated epithelial cells that
resemble those of the fallopian tube
Serous cystadenomas:
oOccur primarily during reproductive years
Boderline types:
oOccur in women 30-50 years
Serous cystadenocarcinoma:
oOccur in women older than 40 years
Benign Ovarian Tumors
Symptoms:
Initially are asymptomatic
Lower abdominal discomfort
Pelvic pain
Dyspareunia
Abdominal enlargement
Frequent urination
Constipation

Adnexal Tumors
Indications for Surgery:
Ovarian cystic structure >5 cm that has been
observed 6-8 weeks without regression
Any solid ovarian lesions
Any ovarian lesion with papillary vegetation on
the cyst wall
Any adnexal mass >10 cm
Palpable adnexal mass in premenarchal or
postmenopausal
Torsion or rupture suspected

Serous Cystadenoma
Grossly :
Papillary projections on the surface
Inner cyst wall are mostly smooth

Microscopic:
Low columnar epithelium with occasional cilia
Psammoma bodies
- small granules, end product of degeneration of
papillary implants
- indicative of functional immunologic response

Mucinous Tumors
Consist of epithelial cells filled with mucin,
resembling cells of the endocervix or intestinal
cells
Types:
Mucinous cystadenoma
Primarily during reproductive years
Borderline types
Mucinous cystadenocarcinoma
Usually in 30- to 60-year age range
Mucinous Cystadenoma
May become huge (>300 lbs)
Grossly:
Round or ovoid, smooth capsule usually
translucent or bluish to whitish gray
Interior divided by discreet septa into locule
containing clear, viscid fluid

Miscroscopic:
Lining epithelium is tall, pale staining secretory
type with nuclei at basal pole, rich in mucin
Mucinous cystadenoma
Pseudomyxoma peritinei
Transformation of peritoneal mesothelium to a
mucin secreting epithelium
Continuous secretion of mucus resulting in
accummulation in peritoneal cavity of gelatinous
material
Evacuation at operation is followed by
reaccummulation
Treatment: Repetitive surgical evacuation
Long-term nutritional support
Brenner Tumor
Grossly identical to a Fibroma of the ovary
Arise from Walthard cell rests
Microscopic:
Marked hyperplastic fibromatous matrix
interspersed with nest of epithelioid cells
Epithelioid cells show coffee bean pattern
caused by longitudinal grooving of nuclei
Scattered reports of malignant Brenner;
associated endometrial hyperplasia
Treament: Simple excision
Borderline Malignant Epithelial
Ovarian Tumors
Synonyms: Borderline Tumors, Proliferative
Cystadenomas
Epithelial ovarian tumors with histologic and
biologic features intermediate between clearly
benign and clearly malignant ovarian
neoplasms
The malignant cells do not invade the stroma of the ovary
Constitute approximately 15-20% of epithelial
ovarian cancers
Slower growth rate than invasive ovarian
carcinomas
Borderline Malignant Epithelial
Ovarian Tumors
Longer survival than invasive forms:
5-year survival rate of all stages = 97%
10-year survival rate of all stages = 89%
Leake and colleagues, Gynecol Oncol, 1992

Most common varieties:
Serous
Mucinous

Commonly found in younger women

Borderline Malignant Epithelial
Ovarian Tumors
Histologic criteria for diagnosis:
Stratification of the epithelial lining of the papilla
Formation of microscopic papillary projection or tufts arising
from the epithelial lining of the papillae
Epithelial pleomorphism
Atypicality
Mitotic activity
No stromal invasion present

Note: At least 2 of these features must be present to qualify as borderline
Janovski and Paramananthon: Ovarian tumors
Stuttgart, Georg Thieme Verlag, 1973

Borderline Malignant Epithelial
Ovarian Tumors
Management:
Complete surgical extirpation of the tumor

Unilateral involvement:
Salpingo-oophorectomy is preferred over Cystectomy
Thorough evaluation of the other ovary
Peritoneal fluid cytology
Partial omentectomy
Bilateral involvement:
Total abdominal hysterectomy with BSO
Peritoneal fluid cytology
Partial omentectomy

Borderline Malignant Epithelial
Ovarian Tumors
Management:

Criteria for Conservative Therapy:
Confirmed to be Stage IA
Extensive histologic sampling of the tumor confirms it to be
borderline tumor
Contralateral ovary appears normal
Biopsy specimens of areas of omental or peritoneal nodularity
are negative
Results of peritoneal cytologic tests are negative for tumor cells
Borderline Malignant Epithelial
Ovarian Tumors
Management:
Complete surgical extirpation of the tumor

Advanced stage:
Same as bilateral involvement plus:
Pelvic lymphadenectomy
Tumor debulking
Extensive biopsy of any peritoneal or omental implants
The role of chemotherapy is still controversial
Invasive Ovarian Carcinomas
Epithelial Ovarian Tumor Cell Types

Tumor Cell Type
Approximate Frequency (%)
All Ovarian
Neoplasms
Ovarian
Cancers
Serous
Mucinous
Endometrioid
Clear cell (mesonephroid)
Brenner
20-50
15-25
5
<5

2-3
35-40
6-10
15-25
5

Rare
Scully RE: Atlas of Tumor Pathology, 1979
Ovarian Cancer
The 2
nd
most common gynecologic malignancy
27% of gynecologic cancers
The most frequent cause of death from
gynecologic cancers
Due to advanced stage at the time of diagnosis
53% of all deaths from gynecologic cancers
Incidence increases with age, most marked
beyond 50 years, with increase continuing to
age 70 years, and decrease after age 80 years
Primary Ovarian Neoplasms
Related to Age
Type <20 yr (%) 20-50 yr (%) >50 yr (%)
Coelomic epithelium 29 71 81
Germ cell 59 14 6
Specialized gonadal-stromal 8 5 4
Non-specific mesenchyme 4 10 9
In general, more than half of ovarian carcinomas occur in women older than 50.

The risk of malignancy in a primary ovarian tumor increases to approximately 33% in
women older than 45, whereas it is less than 1 in 15 for women 20-45 years of age.
Putative Associations of Increasing and Decreasing
Risks of Ovarian Epithelial Carcinoma
Increases Decreases
Age
Diet
Family history
Industrialized country

Infertility
Nulliparity
Ovulation
Ovulatory drugs
Talc (?)
Breast-feeding
Oral contraceptives
Pregnancy
Tubal ligation and hysterectomy with
ovarian conservation
Herbst et al: Am J Obstet Gynecol, 1994
Characteristics in Benign and Malignant
Ovarian Tumors
Clinical Finding Benign Malignant
Unilateral +++ +
Bilateral + +++
Cystic +++ +
Solid + +++
Mobile +++ ++
Characteristics of Benign and Malignant
Ovarian Tumors
Clinical Finding Benign Malignant
Fixed + +++
Irregular + +++
Smooth +++ +
Ascites + +++
Cul-de-sac
Nodulations
- +++
Most Frequent Presenting
Symptoms of Ovarian Cancer
Symptom Relative frequency
Abdominal swelling XXXX
Abdominal pain XXX
Dyspepsia XX
Urinary frequency XX
Weight change X
Note:- Symptoms are vague and not specific for ovarian cancer
- A high index of suspicion is warranted in all women between the ages of
40 to 69 years who have persistent gastrointestinal symptoms that
cannot be diagnosed.
Non-ovarian causes of Apparent
Adnexal Mass
Diverticulitis

Tubo-ovarian abscess

Carcinoma of the colon or sigmoid

Pelvic kidney

Uterine or intraligamentous myoma
Ovarian Carcinoma
Screening and Early Detection Tools:
Periodic pelvic Examination
Sonography
Biomarkers (e.g. CA 125)

Conclusion: There is NO evidence available yet
that the current screening modalities can be
used effectively for widespread screening for
ovarian cancer
Ovarian Cancer
Diagnostic techniques:

Routine pelvic examination detect only 1
ovarian cancer in 10,000 asymptomatic
women
Routine laboratory test are not of great value
in the diagnosis of ovarian tumors
The major value of laboratory tests is in ruling
out other pelvic disorders
Surgical exploration is the ultimate test as to
the nature of the disorder.
Tumor Markers in Ovarian Cancer
CA-125

Carcino-embryonic antigen (CEA)

Alpha-feto protein (AFP)

Lactic dehydyhrogenase (LDH)

Human chorionic gonadotrophin (hCG)


CA 125 and Ovarian Cancer
Carcinoma Antigen (CA) 125 is expressed in
approximately 80% of ovarian epithelial
cancers but less frequently by mucinous types
Also increased in tubal, endometrial, lung,
breast and pancreatic cancers
Also increased in benign conditions
The specificity appears better for increased
values in postmenopausal patients
Benign Conditions with Elevated
CA 125
Endometriosis
Peritoneal inflammation, including PID
Leiomyoma
Pregnancy
Hemorrhagic ovarian cysts
Liver disease
Role of Ultrasound in Ovarian Cancer
Ultrasound helped to define criteria to allow
conservative follow-up and the risk of
malignancy of some adnexal masses
Scoring systems have been proposed
Parameters used:
Unilocular or complex cysts
Papillary projections
Regular and smooth septa and/or cytstic walls
Echogenicity
Doppler color-enhanced flow
Used to characterize ovarian mass as benign
or malignant, rather than for screening
Ovarian Cancer
Additional diagnostic methods:
CT scan

MRI

Barium enema or Colonoscopy



Case 1
A 55 y/o, postmenopausal woman consulted because of rapid
abdominal enlargement associated with weight loss of 8 lbs of
2 months duration. Pertinent PE findings are: palor,
abdominal girth of 89 cm with positive fluid wave and shifting
dullness, with a vague pelvoabdominal mass. Pelvic exam:
Normal external genitalia, cervix: firm, close and slightly
movable, the lower pole of a mass is palpable at the cul-de-
sac which seems solid and slightly movable. The uterus and
adnexa can not be fully assessed because of the massive
ascites.

What is your diagnosis? Basis of your diagnosis?
What diagnostic work-up/s will you request and why?
Comparison between Surgical Findings of
Benign and Malignant Ovarian Neoplasm
Findings Benign Malignant
Surface papilla Rare Very common
Intracystic papilla Uncommon Very common
Solid areas Rare Very common
Bilaterality Rare Common
Adhesions Uncommon Common
Ascites (100 ml or more) Rare Common
Necrosis Rare Common
Peritoneal implants Rare Common
Capsule intact Common Infrequent
Totally cystic Common Rare
Epithelial Ovarian Cancers
Constitute 85-90% of ovarian cancers

Histologic distribution in USA:
Serous cystadenocarcinomas =
42%
Mucinous cystadenocarcinoma = 12%
Endometrioid carcinoma = 15%
Undifferentiated carcinoma = 17%
Clear cell carcinoma = 6%
Copeland LJ, Clin Gyneco Oncol, 7
th
Ed, 2007
Ovarian Cancer
Routes of spread:
Ceolomic spread
Spread through the peritoneal surfaces of both the
parietal and intestinal areas, as well as the under surface
of the diaphragm.

Lymphatic route
Para-aortic nodes are at risk through lymphatics that run
parallel to the ovarian vessels

Hematogenous spread
Staging of Ovarian Cancer
Staging is surgical and based on the operative
findings at the commencement of the
procedure
Staging Laparotomy:
Midline longitudinal incision
Peritoneal fluid cytology
Systematic exploration of the abdominal cavity
Total abdominal hysterectomy with bilateral salpingo-
oophorectomy
Lymphadenectomy or lymph node evaluation
Random biopsy of abdominal peritoneum and
suspicious areas
FIGO Staging Classification of
Ovarian Cancer
FIGO Stage Description
I Growth limited to the ovaries
Ia Growth limited to one ovary; no ascites present containing malignant
cells; no tumor on the external surfaces; capsule intact
Ib Growth limited to both ovaries; no ascites present containing
malignant cells; no tumor on the external surfaces; capsule intact
Ic Tumor stage Ia or Stage Ib but with tumor on the external surface of
one or both ovaries; or with capsule ruptured; or with ascites present
containing malignant cells or positive peritoneal washings
FIGO Staging Classification of
Ovarian Cancer
FIGO Stage Description
II Growth involving one or both ovaries with pelvic extension
IIa Extension and/or metastases to uterus and/or tubes
IIb Extension to other pelvic tissues
IIc Tumor stage IIa or Stage Iib but with tumor on the surface of one or
both ovaries; or with capsule(s) ruptured; or with ascites present
containing malignant cells or positive peritoneal washings
FIGO Staging Classification of
Ovarian Cancer
FIGO Stage Description
III Tumor involving one or both ovaries with peritoneal implants outside
the pelvis and/or positive retroperitoneal or inguinal nodes;
superficial liver metastasis equals stage III; tumor is limited to the
true pelvis but with histologically verified malignant extension to
small bowel or omentum
IIIa Tumor grossly limited to the true pelvis with negative nodes with
histologically confirmed microscopic seeding of abdominal peritoneal
surfaces
IIIb Tumor of one or both ovaries; histologically confirmed implants of the
abdominal surfaces, none exceeding 2 cm in diameter; nodes are
negative
IIIc Abdominal implants 2 cm in diameter and/or positive retroperitoneal
or inguinal nodes
FIGO Staging Classification of
Ovarian Cancer
FIGO Stage Description
IIV Growth involving one or both ovaries with distant metastasis; if
pleural effusion is present, there must be positive cytologic test
results to allot a case to stage IV; parenchymal liver metastasis equals
stage IV
Carcinoma of the Ovary
Survival by FIGO Stage
(Patients treated 1990-1992)
Stage Number 5-year Survival (%)
IA 342 86.9
IB 49 71.3
IC 352 79.2
IIA 64 66.6
IIB 92 55.1
IIC 136 57.0
IIIA 129 41.1
IIIB 137 24.9
IIIC 1,193 23.4
IV 360 11.1
Case 2
A 60 y/o nulligravid underwent exploratory laparotomy
because of an ovarian mass. Intraoperative finding were: the
ovary was enlarged to 12 x 9 cm with papillary excricences on
the surface; the uterus, both tubes and contralateral ovary
was grossly normal; omentum was studded with 1 cm nodular
lesions; the abdominal peritoneum, liver and diapragm are
free of tumor.

What is the Stage of Ovarian Cancer?
Case 3
A 45 y/o G1P1 underwent exploratory laparotomy because of
an ovarian mass. Intraoperative finding were: the ovary was
enlarged to 20 x 11 cm with smooth external surface, which
on cut section showed multiple papillary growths; the uterus,
both tubes and contralateral ovary was grossly normal;
omentum was grossly normal but showed metastatic cells on
microscopic examination; the abdominal peritoneum, liver
and diapragm are free of tumor. PFC was positive for
malignant cells.

What is the Stage of Ovarian Cancer?
Ovarian Cancer
Prognostic Factors
Tumor stage

Tumor grade

Cell type

Amount of residual tumor after resection
Ovarian Cancer
Treatment options:
Surgery
Removal of all resectable disease

Post-operative or Adjuvant therapy
Chemotherapy
Radiation therapy
immunotherapy
Ovarian Cancer
Staging Laparotomy:
Midline longitudinal incision
Peritoneal fluid cytology
Systematic exploration of the abdominal cavity
Total abdominal hysterectomy with bilateral salpingo-
oophorectomy
Lymphadenectomy or lymph node evaluation
Random biopsy of abdominal peritoneum and
suspicious areas

Surgery in Ovarian Cancer
Standard surgical procedure:
Total abdominal hysterectomy with bilateral salpingo-
oophorectomy
Bilateral lymph node dissection
Paraaortic lymph node dissection/ sampling/palpation
Infracolic omentectomy
Random biopsy of abdominal peritoneum in early-stage
disease
Tumor debulking in advanced disease

Surgery in Ovarian Cancer
Conservative surgery: Unilateral Salpingo-
Oophorectomy
Criteria:
Stage IA
Well-differentiated tumor
Peritoneal fluid cytology is negative for malignant cells
Omentum and peritoneal biopsies are negative for metastasis
Young woman desirous of pregnancy
Ovarian Cancer
Adjuvant therapy:
Chemotherapy
The most common adjuvant used
The chemotherapeutic agent used depends on the
histologic type
Limiting factor: Toxicity
Radiotherapy
For early stage disease confine to the pelvis
Immunotherapy
Still in the experimental stage
Germ Cell Tumors of the Ovary

Classification of Germ Cell Neoplasms of
the Ovary
Dysgerminoma
Endodermal sinus tumor
Embryonal carcinoma
Polyembryoma
Choriocarcinomas
Teratomas
Immature (Solid, Cystic, or both)
Mature
Solid
Cystic
Mature cystic teratoma (Dermoid cyst)
Mature cystic teratoma (dermoid cyst) with malignant transformation
Monodermal or highly specialized
Struma ovarii
Carcinoid
Struma ovarii and carcinoid
Others
Mixed forms (tumors composed of types in any combination)
Germ Cell Tumors of the Ovary
Ninety-seven percent (97%) are benign and
only 3% are malignant
Most occur in young women
Mostly in the 2
nd
and 3
rd
decades of life
Staged surgically as with epithelial types
Certain histologic types secretes a specific
tumor marker
A single tumor may contain a mixture of
histologic types
Germ Cell Tumors of the Ovary
Treatment options:
Surgery:
Extent of primary surgery is dictated by the findings at surgery
and the reproductive desires
USO = if preservation of fertility is desired
THBSO = if childbearing has been completed
Chemotherapy :
Tremendous advances have been made that even in advanced
malignancies an excellent chance at long term control cure
Radiotherapy:
Rarely used today
Case 4
A 19 year old nulligravid consulted because of abdominal
enlargement of 1 month duration. Pertinent PE findings:
abdomen is globularly enlarged with a solid, movable non-
tender mass about 8 x 10 cm. Rectal exam showed an
unenlarged uterus with a right adnexal mass, predominantly
solid with cystic areas, movable and nontender.

What is your impression?
What work-up/s is/are necessary to arrived at a proper
diagnosis?
What is the management?
Sex Cord-Stromal Tumors of the
Ovary
Originate from the ovarian matrix
Consist of cell from the mebryonic sex cord
and mesenchyme
Incidence increasing in the 5
th
, 6
th
and 7
th

decades
Approximately 90% of hormonally active
ovarian tumors
Have propensity for indolent growth, tend to
recur late
Sex Cord-Stromal Tumors of the
Ovary
Management:
Surgery is adequate treatment in most cases
USO = for those who are desirous of fertility
preservation and are Stage Ia
THBSO = for advanced stage and older women
Stage Ic or higher:
Adjuvant therapy: Radiation or Chemotherapy

Das könnte Ihnen auch gefallen