Ovarian Cancer

Ovarian Cancer
Of all gynecologic cancers, ovarian
cancer most challenging
Highest case-fatality ratio
Usually present in advanced stages
Require extensive surgery and intensive
chemotherapy
Need for increased awareness about
early signs and symptoms
Mostly sporadic in occurrence
Ovarian Cancer
Clinical Variants
Epithelial ovarian cancer - 85 %
Germ cell tumors - 5%
Sex cord stromal tumors - 5%
Metastaic tumors - 5%
Rare tumors
Lipoid tumors
Ovarian sarcomas
Epithelial ovarian cancer
Types
Invasive Borderline
Serous 75 % Younger age group
Mucinous 20 % Mostly confined to
Endometrioid ovary
2% Better prognosis
Brenner 20-25 % show
Clear cell metastasis
Undifferentiated
Epithelial ovarian cancer
Primary Peritoneal
Carcinoma
Indistinguishable from serous ovarian
tumors

May occur in predisposed women even after

bilateral oophorectomy

Clinical behaviour just like ovarian cancers

Management like serous ovarian cancers

Epithelial ovarian cancer
Etiology
Low parity
Infertility
Early menarche
Late menopause
Talc use
Galactose consumption
Epithelial ovarian cancer
Prevention
Pregnancies are protective

OCPs - > 5 years of use reduces risk by 50

%

Role of prophylactic oophorectomy in high

risk women

Fenretinide a Vitamin A derivative offers

some protection
Epithelial ovarian cancer
Screening
Screening of use only in high risk
population

Screening Modalities
CA 125
Transvaginal sonography (TVS)
Pelvic examination in postmenopausal
women
Epithelial ovarian cancer
Symptoms
Asymptomatic for long periods of time

Symptoms in early stage

Irregular menses if premenopausal
Pressure symptoms:frequency/constipation
Lower abdominal distension
Pain
Acute symptoms from rupture or torsion
Epithelial ovarian cancer
Symptoms
Symptoms in Advanced Stage
Due to ascites, omental metastasis or bowel
metastasis
Distension
Bloating
Constipation
Nausea
Anorexia and early satiety
Epithelial ovarian cancer
Signs
Solid, irregular and fixed pelvic mass very
suggestive of malignancy

If ascites and upper abdominal mass also

present then diagnosis certain

Supraclavicular lymph nodes may be found

enlarged

Pleural effusion may be present

 Epithelial ovarian cancer
Differential Diagnosis
Gynecologic Tumors Non-gynecologic
Benign ovarian Tumors
neoplasms Diverticular
Functional ovarian disease
cysts
PID Colonic cancer
Endometriomas
Pedunculated fibroids Pelvic kidney
Epithelial ovarian cancer
Diagnosis
Establishing the diagnosis in early stage
disease usually requires an Exploratory
Laparotomy

Investigations that aid in diagnosis

Ultrasonography
Colour Doppler
Tumour Markers
Ascitic Fluid Cytology
Epithelial ovarian cancer
Diagnosis
Prudent to exclude
Colonic Cancer

Stomach cancer

Breast cancer

Cervical cancer
Epithelial ovarian cancer
Patterns of spread
Transcoelomic

Direct extension

Lymphatic

Hematogenous
Epithelial ovarian cancer
Prognostic factors
Histologic type
Histologic grade
Stage of disease
Biologic behaviour
Volume of residual disease after surgery
Presence of malignant ascites
Performance status
Epithelial ovarian cancer
Surgical staging procedure
Midline incision
Collect ascitic fluid/peritoneal washings
for cytology
Remove the mass for frozen section
Meticulous abdominal survey
Biopsy suspicious areas/adhesions
Infracolic omentectomy
TAH+BSO if fertility not desired
In advanced stages Debulking surgery
Epithelial ovarian cancer
Staging
StageIa Confined to one ovary
Ib Confined to both ovaries
Ic Ia or Ib + malignant ascites or
positive peritoneal cytology or tumor on the
surface or breach in capsule
Stage IIa Extension to uterus or tube
IIb Extension to other pelvic tissues
IIc IIa or IIb + malignant ascites or positive
peritoneal cytology or tumor on the surface
or breach in capsule
Epithelial ovarian cancer
Staging
Stage IIIa Microscopic peritoneal deposits
IIIb Peritoneal deposits < 2 cm in size
IIIc Peritoneal deposits > 2 cm in size

Stage IV Distant metastasis

Epithelial ovarian cancer
Role of chemotherapy
Vital role in ovarian cancers
Adjuvant chemo in Stage Ic and beyond
Neoadjuvant chemo in clinically advanced
stages to achieve chemical debulking
followed by interval cytoreductive surgery
followed by adjuvant chemotherapy
Standard Chemo : Paclitaxel + Carboplatin
Alternative :Cyclophosphamide +
Cisplatinum
Epithelial ovarian cancer
Follow-up
Every 3 months for 2-years, then every
6 months

Method
Symptoms
Signs
Imaging studies
Tumor markers
Epithelial ovarian cancer
Management of recurrence

Secondary cytoreduction

Second-line chemotherapy
Ovarian Cancer
Germ Cell Tumors
Common in younger age groups

Grow rapidly hence present early with pain,

pelvic mass or pressure symptoms

AFP and hCG are important tumor markers for

germ cell tumors

USG very helpful in diagnosis any solid tumor

or tumor > 8 cm deserves exploration
Germ cell tumors
Types
Dysgerminoma Commonest GCT
Teratoma
Endodermal sinus tumor
Embryonal cell cancer
Polyembryoma
Choriocarcinoma
Mixed germ cell tumor
Germ cell tumors
Management principles
Primary surgery with tumor resection and
surgical staging
Attempt preservation of fertility in
younger patients
Chemotherapy with BEP for all except
those dysgerminomas confined to one
ovary
Radiotherapy used rarely though very
effective in dysgerminoma
Ovarian Cancer
Sex Cord-stromal tumors
Uncommon tumors of the ovary
Usually low-grade cancers
Usually produce hormones that lead to
symptoms
Surgical treatment with tumor resection
and surgical staging
Tend to have late recurrences
Role of adjuvant therapy
Thank you