Ovarian Tumour

OVARIAN DEVELOPMENT

 Surface epithelium

 Germ cells

 Specialised mesenchymal cells

 Ordinary connective tissue

OVARIAN ENLARGEMENT
 Functional cyst
 Endometriotic cyst
 PCOD
 Hyperstimulation of ovaries
 Neoplastic
 benign
 borderline malignant (lmp)
 malignant
CLINICAL FEATURES
 Asymptomatic
 Infertility
 Lump abdomen
 Distension of abdomen
 Pain
 torsion
 rupture
 haemorrhage
 infection
 Anaemia
 Weight loss
 Cachexia
 Virilising features
 Feminising features
SIGNS
 Abdomino-pelvic mass
 Size
 Consistency
 Mobility
 Ascites
 fluid thrill
 shifting dullness
SIGNS
 Per vaginum
 Adnexal mass
 felt separate from uterus
 Nodularity in pod
 Mobility
 Lymphadenopathy
INVESTIGATIONS
 Haematological
 Ultrasonography
 Colour Doppler
 CT / MRI scan
 Ascitic fluid analysis
 cytology
 biochemistry
INVESTIGATIONS
 Tumour markers
 CA - 125
 B-HCG
 AFP
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%
 Metastatic 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 2 % ovary
 Brenner  Better prognosis
 Clear cell  20-25 % show
 Undifferentiated metastasis
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
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 disease
 Functional ovarian 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
Stage Ia 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