LALALA-LALAϋ

NEOPLASTIC DISEASES OF THE OVARY

Ovarian cancer
Second most common malignancy of the lower part of the female genital tract
DIAGNOSIS Other Ancillary Procedures/Work – ups
Possible Patient Profile: 1. History + PE  Paracentesis
o Pelvic Exam o May establish initial
Risk Factors Protective Factors
 See a normal – sized uterus diagnosis if malignant cells
1. > 50 years of age  Pregnancy
 Palpate an adnexal mass are found in the ascitic fluid
2. Frequent ovulation  Use of OCPs  Remember to always empty of patients who present
3. Nulliparity/nulligravidity o Make cycles
the urinary bladder first with ascites
4. Late childbearing anovulatory = lowers
because a distended  Chest x-ray
5. Infertility secondary to risk bladder may be mistaken for o To check for distant
anovulation o Remember: Protection
a mass metastases
Risk factor because this would from ovarian cancer is
 CT scan
require intake of ovulatory drugs not an indication for
 Transvaginal ultrasound + o To search for
which would increase frequency OCP intake color flow retroperitoneal node
of ovulation = increased risk for
enlargement and lymph
ovarian cancer node status in perineum
2. Transvaginal Ultrasound + Color Flow  Barium enema & Colonoscopy
 To evaluate the external & internal o Colon cancer is always
architecture of the mass considered in a patient who
Clinical Symptoms  The following are assessed for presents with an adnexal
 Abdominal enlargement prognosis & treatment planning: mass, especially in the
o Present as o Loculations older patient
pelvic/abdominal mass o Papillations o To evaluate GI symptoms
o An adnexal mass may o Solid vs cystic  Upper GI endoscopy or radiographic
indicate either a tumor of o Septa exam
the ovary or fallopian tube. o Excrescences o If px presents with GI
But statistically speaking,  Sassone’s scoring (based on inner bleeding or any sign of GI
tumors of the fallopian tube wall structure, wall thickness, septa, pathology
are very rare. echogenicity)  Tumor markers
 Non – specific gastrointestinal o > 9 = malignant o Not used for diagnosis but
symptoms o < 9 = benign may strengthen your
o Bloatedness, fullness diagnosis
 Urinary urgency 3. Histopathologic Examination o Used primarily to monitor
 Ascites  Diagnosis is established by histologic treatment
examination of the tumor tissue
removed at operation
Review muna  How do we differentiate a benign tumor from a malignant ovarian tumor?

BENIGN Features MALIGNANT

Slow Progression Rapid
Well – defined Definition of borders Ill – defined
Cystic Consistency Solid
Unilocular Loculation Multilocular
Mobile Mobility Fixed
(-) Ascites (+)
Reproductive age Age of patient > 50 y/o
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STAGING OF OVARIAN CARCINOMAS (FIGO)
 Remember that staging of ovarian CA is based on the results of operative exploration

TREATMENT

Operative exploration
Remove omentum, uterus, tubes, &
contralateral ovary
**exception: if grade 1 tumor & confined
to only 1 ovary

Remove all gross disease + uterus,

tubes, ovaries & omentectomy
(infracolic)
Pelvic & paraaortic node sampling

Maximal surgical resection

Bowel resection if necessary (not advisable if large
residual tumors would be left)
Serous surface papillary CA – respond well to
multiagent chemotherapy after max. surgical
debulking

OVARIAN TUMORS CLASSIFICATION

A. Epithelial Stromal Ovarian Neoplasms

 Most frequent ovarian neoplasms
 Arise from the surface (coelomic epithelium)
 Many are bilateral -> important consideration in therapy
 Nomenclature:
o “cyst” prefix (ex. cystadenoma): indicates a tumor with papillae or cystic structures
o “fibroma” suffix (ex. adenofibroma): indicates that ovarian stroma predominates
 Hereditary ovarian tumors are said to have better prognosis than those spontaneously occurring

EPITHELIAL STROMAL OVARIAN NEOPLASMS

Neoplasm Description Symptoms Major cell type
SEROUS Most frequent ovarian epithelial tumor Borderline tumors: seen in women 30 – 50y/o Endosalpinx
Usually not detected until there is widespread Carcinomas: > 40 y/o
metastasis already More commonly bilateral than mucinous
Poorly differentiated
Worst prognosis
Serous Surface Papillary Carcinoma Aggressive tumor
Small ovaries (< 4 – 5cm)
Extensive disease on ovarian surface + metastases in
the abdomen
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Primary Peritoneal Serous Adenocarcinoma Normal sized ovaries with surface metastatic tumor
deposits
Associated with BRCA1 and BRCA2 mutations
MUCINOUS Consists of epithelial cells filled with mucin Benign: usually seen in reproductive years Endocervix
Most are benign Carcinoma: 30 – 60 y/o
Resemble cells of the endocervix or may mimic
intestinal cells
ENDOMETRIOID Consists of epithelial cells that resemble cells in Occur in 40 – 50 y/o Endometrium
endometrium Rarely associated with endometriosis
Less frequent than serous/mucinous
CLEAR CELL (mesonephroid tumors) Contain abundant glycogen & hobnail cells (nuclei
protrude into glandular lumen)
Not related to DES exposure
Aggressive tumor with tendency to recur even in stage I
BRENNER TUMOR Consists of cells that resemble the transitional
epithelium of the bladder
TREATMENT
Prognostic Factors:
1. Tumor stage Borderline Ovarian Tumors: Ovarian Carcinomas of Low Malignant Invasive Epithelial Carcinomas
2. Tumor grade Potential  Primary treatment: removal of all resectable gross disease
 Ploidy of tumor (aneuploidy = negative prognostic  Do not invade stroma of the ovary o Before removal, do cytologic exam of ascitic fluid (if
factor)  Slower growth rate than invasive ovarian CA present), pelvis, upper abdomen, right & left paracolic
3. Cell type gutters
4. Amount of residual tumor after resection  Treatment options: o If no gross disease outside pelvis -> do paraaortic &
o Conservative therapy - unilateral oophorectomy (w/ pelvic lymph node sampling + removal of enlarged
Worse prognosis: invasive epithelial cancers, serous carcinomas preservation of childbearing function) if: nodes
Better prognosis: mucinous, endometrioid, clear cell tumors  Tumor is stage IA
 Contralateral ovary is normal  Criteria for treatment with conservative therapy in a young
 Biopsy specimens of omental/peritoneal px with stage IA ovarian epithelial carcinoma
EXTRA NOTES 
Post – op Management of Stage I & II nodularity are negative o Tumor confined to 1 ovary
 No benefit for adjuvant therapy in completely excised stage I and II  Results of peritoneal cytologic tests negative o Grade 1 tumor w/ no invasion of capsule, lymphatics,
tumors for tumor cells mesovarium
o With irradiation + chemotherapy o Peritoneal washings negative
Chemotherapy for Ovarian Cancer
 Paclitaxel – first line therapy for ovarian CA  Tumors beyond stage I o Young woman of childbearing years w/ desire to
 Paclitaxel – carboplatin: recommended outpatient regimen o Operative removal of all gross disease – most preserve function
o Both drugs are neurotoxic (dose limiting toxicity) important and best treatment for borderline tumors 
o Commonly used program: Paclitaxel 175mg/m2 over 3
hrs & carboplatin 1 – 2 hr infusion every 3 weeks
 G – CSF given to combat neutropenia
 Evaluation of results:
o Watch out for severe neutropenia w/ fever and an ANC SUMMARY OF TREATMENT FOR OVARIAN EPITHELIAL CANCERS:
< 500cells/ul -> need antibiotics to prevent septic
complications 1. Standard of treatment is removal of gross disease + sampling of areas with high risk of spread
o If CT scan shows a tumor, fine needle biopsy may 2. Post op therapy
identify recurrent/persistent disease  No benefit for stage I and II
o CA 125 may be used to monitor course of px
 Multiagent chemo (Paclitaxel + Carboplatin) for:
Second – Look Procedures o Poorly differentiated stage I (grade 3) tumors or stage II tumors
 Method of evaluating disease status after primary therapy o High stage tumors
 Goal: perform surgical reassessment in a woman who is clinically free of o w/ residual disease after primary operation
disease
o Normal PE, imaging findings, CA 125 levels
**adverse effect of chemo: leukemia
 High stage tumors (III or IV) are most likely to have (+) second look 3. External irradiation – no proven benefit; compromises bone marrow function
procedures
 Not recommended for those with low stage tumors because they rarely
have (+) second look procedures
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GERM CELL TUMORS
 Derived from germ cells of the ovary
 Second most frequent ovarian neoplasm
 Always think of a germ cell tumor in a young patient!
 Usually unilateral except for:
o Dysgerminoma
o Teratomas

Neoplasm Description Patient Profile Treatment

Immature teratomas Consist of immature embryonic structures mixed with Usually occur in young women (do not occur in women If opposite ovary normal: unilateral salpingo –
mature elements after menopause) -> preservation of childbearing oophorectomy alone
Opposite ovary rarely involved function is important
For metastatic tumors, stage I (grade 2 and 3) tumors:
add multiagent chemotherapy (VBP regimen:
vincristine, bleomycin, cisplatin)
Dysgerminoma Most frequent malignant germ cell tumor Usually diagnosed in women < 30 y/o TREAT CONSERVATIVELY 
A relatively friendly tumor ;) May be discovered during pregnancy
Homologous counterpart in male testes: seminoma If only 1 ovary affected: unilateral salpingo –
Consist of primitive germ cells with stroma infiltrated by oophorectomy + exploration of abdomen
lymphocytes
Bilateral Always ask for a frozen section to guide you as you
choose your tx plan.
If frozen section shows pure dysgerminoma (no spread
outside primary tumor): unilateral salpingo –
oophrectomy only

Only ovarian malignancy that is RADIOSENSITIVE.

Endodermal Sinus Tumor (Yolk sac tumors) Secretes alpha – fetoprotein Occur in females 13 months – 45 yrs of age Stage IA: unilateral adnexectomy
Rapidly growing
Remember: ALL patients with this tumor should
undergo postop chemotherapy (VAC regimen:
vincristine, actinomycin, cyclophosphamide or VBP
regimen)
Choriocarcinomas Highly malignant resembling extraembryonic tissues Usually < 20 y/o Multiagent chemotherapy
Consists of malignant cytotrophoblasts &
sycnytiotrophoblasts
hCG as tumor marker
Embryonal Carcinoma Secrete both hCG and AFP Seen in females 4 – 28 y/o
Mixed Germ Cell Tumors Combination of any of the germ cell tumors of the ovary Multiagent chemotherapy
Most common: teratomas + dysgerminomas
Gonadoblastoma (Germ Cell Sex – Cord Stromal Germ cells resemble dysgerminoma; sex – cord stromal Usually occurs in patients with abnormal (dysgenetic) Removal of both gonads
tumors) elements consist of immature granulosa & Sertoli cells gonads
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SEX – CORD STROMAL TUMORS (Functioning Tumors)
 Called “functioning” because they are hormonally active
 Sex cord component: granulosa cell
 Stromal component: theca cell/fibroblast

Neoplasm Description Patient Profile Treatment

Granulosa – Theca Cell Tumors
Consists primarily of granulosa cells + varying
proportions of theca cells/fibroblasts
Call – Exner bodies: eosinophlic bodies surrounded by
granulosa cells (microscopic finding)
Patient may present with precocious puberty. Why? Operative removal of tumor
Because the patient may not even be ovulating yet. But
because of estrogen produced by the tumor, she may Stage IA: unilateral adnexectomy
present with bleeding & may undergo precocious
puberty.

For menstruating women: may cause abnormal

Sertoli – Leydig Cell Tumors (Androblastoma)
menstrual patterns, menorrhagia, amenorrhea
Remember that this is also a risk factor for endometrial
cancer due to the production of estrogen which will be
unopposed and stimulate the endometrium to become
hyperplastic -> may become endometrial CA
Known as masculinizing tumors Usually in young women of reproductive age

Present as a pelvic/ovarian mass plus

1. Defeminizing signs first
- Amenorrhea/oligomenorrhea, breast
atrophy, change in fat distribution that is
like the males
2. Masculinzing/virilising signs
- Clitoromegaly, deepening of voice,
hirsutism
- These usually regress after tumor removal

METASTATIC OVARIAN TUMORS

 Primary tumors that originate elsewhere in the female reproductive tract (usually endometrium or fallopian tube)
 Distant sites of origin usually: breast & GI tract REMEMBER!!!
o If GI tract: usually have estrogenic manifestations
o Krukenberg’s tumor
 Contains nests of mucin filled signet ring cells in the cell stroma
 Most common site of origin: 1) stomach, 2) large intestine

Source: Because this is the last lalala ever

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Comprehensive Gyne, 6 ed for OB/Gyne, I wish that we all
Dra. Punsalan’s lec  answer our quizzes tomorrow with
smiles on our faces because last na
Dra. Dee notes 
to!!:))!
Thank you for being my inspiration,
I could have never done it without
all of you 3A and 3B :)