Malign diseases of the ovary

Prof.Dr.Orhan Ünal
Department of Gynecological
Oncology
 OVARIAN CANCER

Ovarian cancer is the most common cause of

death among gynecological cancers.
• It constitutes 3% of all cancers
• Among cancer-related deaths (lung, breast,
colorectal, pancreas)is 5th.
• It is usually diagnosed at the advanced stage
and its prognosis is poor.
• Ovarian cancer average age was 63
 OVARIAN CANCER

• Eighty percent of the ovarian masses are

benign. 80% of malignant ovarian masses are
postmenopausal.
• Less than 1% of over cancer is seen before 20
years of age.
• Over cancer is diagnosed 80% of patients
progressed beyond the pelvis Despite new
treatment approaches, 5-year survival is only
39%
 EPİTHELİAL OVARIAN CA

• Of over cancer, 90% are epithelial type and other

forms are germ cell and sex-cord cell tumors.
• Incidence: seen at a frequency of 12.9 in 100
babies.  a woman's lifetime over-cancer risk is
1.4%.
•  Genetic conditions in epithelial ovarian cancers
(EOK) seen in young people should be considered
(BRCA carriage and Lynch syndrome)
 Ovarian cancer
• Serous cystadenom
• Mucinous cystadenom
• Brenner tm
• Borderline Over TM (BOT)
• Low Malignant Potential over Tm (DMP)
• Serous carcinoma
• Mucinous carcinoma
• Endometrioid carcinoma
• Clear cell carcinoma
• Mixed epithelial tm
• Indifferentiated carcinomas
 EOC

• Benign: Single ordered epithelium. Nuclear

stratification and no atype.
• Borderline: Papiller formation. Epithelial
proliferation, increased mitotic activity and
nuclear atypia. No stromal invasion.
• Malign: Stromal invasion.
 EPITHELIAL OVARIAN CANCER

• Family history
• A woman who develops over-cancer before
the age of 50 is more likely to be hereditary.
Hereditary over cancers can be seen 10 years
earlier than normal.
• There are gene analysis tests for BRCA 1 and 2
Genetic counseling should be given
 EOC
• Family History
• At the age of 70 with the hereditary BRCA I
mutation, the risk of developing breast cancer is
36-85%, the risk of developing over-cancer is 16-
63%, the risk of developing bilateral breast cancer
is 64%
• Similar percentages for repeated BRCA II
mutations. The risk of over-cancer is reduced in the
cases - 16-27%, the incidence of prostate,
pancreas, bladder, stomach and skin cancers is
increasing
• Lynch syndrome: Multiple adenocarcinomas are
observed in this syndrome (over, colon, endometrium,
stomach, upper urinary tract).;
• The risk of dysgerminoma and gonodoblastoma has
increased in Turner syndrome.
• Protective factors: Multiparity, OCS, Progesterone,
Hysterectomy and Tubal ligation, Breastfeeding
• 11% for 1 year use in OKS users
• 50 %, 5 years and over
• 10year and over, 80% risk is decreasing.
 EPITHELİAL OVER TM
• Symptoms are usually nonspecific.  
•  Abdominal symptoms are most common (gas,
bloating, nausea, constipation ..)
• Irregular bleeding in premenopause
• Some of the symptoms (pollakury, disuri ..) Lower
abdomen distension
• Dyspareunia
• Acute pain
• Acide-linked distension
• Omentum and intestinal metastasis-related distention
Postmenopausal bleeding
 EPITHELIAL OVARIAN TUMORS

• FINDİNG ;
• Most of the cases are diagnosed at Stage 3 - 4.
• Solid, irregular fixation mass on pelvic examination
• Upper abdominal mass
• Acid
• Palpable ovaries in postmenopausal patients
Pleural effusion
 Brenner tm
• It is usually asymptomatic.
• Transitional cell (transitionally epithelial cell tm) is
similar to the bladder epithelium. Of epithelial
ovarian tumors is the least seen in 1-2%
• 98% benign
• 1% malignant,
• usually small and solid.
• Histologically there is a view of coffee bean
(coffee bean) and walthard islets
Brenner tm
 Borderline over tm
• Compared to malignant tumors are seen at an earlier
age.(45-50 years)
• 70-85% in early stage during diagnosis.
• Even at the residual or recurrent level, the survey is
long (80%)
• Definitive diagnosis is made microscopically. Treatment
is surgery
• Chemo. and RT are in debate.
•
Surgical treatment:
• Laparotomy or laparoscopy according to tumor size
and clinic
 Borderline Over TM (BOT) Low
Malignant Potential over Tm (DMP)
• They form 10-15% of the whole epithelial
over tumors.
• The histological appearance and biological
behavior are between the benign and
malignant epithelial over tumors.
• No stromal invasion
• Stratification
• nuclear atypia
 SEROUS CARCİNOMA
• 50% of the epithelial over tumors.
• Average age 55-60
• Sixty percent of the cases are bilaterally.
• Most of the cases are advanced by about 70% during diagnosis.
• 5-year survival rate in most cases is 32%
• It is macroscopically 10-20 cm in diameter, contains cystic and solid
components.
• Internal and external papillary structures are characteristic. 60-70%
psammom bodies.
• There is stromal invasion in all cases.
• Ca125 is high.
 MUCINOUS CARCİNOMA
• 8-13% of the ovarıan epithelial ca.
• Average age 55
• It is 15-20% bilaterally.
• 90% of cases are diagnosed in early stage.
• It can be macroscopically 18-30cm,
• the multilocular is a cystic structure, contains solid and
papillary areas.
• The prognosis correlates with the number of mitosis in
an magnified area.
• Ca19,9, Ca125, CEA levels are high
 Endometrioid karsinom
• 15-20% of epithelial over ca.
• 10-20% of cases are accompanied by endometriosis.
• Average age 50-60 30% is bilaterally.
• Microscopically mimics the endometrium CA.
• It is usually well differentiated and localized.
• 20-50% of cases are accompanied by good
differentiation of endometrium ca,
• The prognosis is good in these cases.
•
 Clear Cell Carcinoma
• 5% of the epithelial over ca.
• Average age 50-60
• 50% of the cases are accompanied by endometriosis.
• 10-15% bilaterally.
• Generally cystic structure with thickened wall , 15-
25cm tall.
• The 5-year survival rate is lower rather than other
epithelial over-TM.
• The sensitivity to chemotherapy is lessKT is less.
 Mixed epithelial tm

• 1-2% of epithelial over tumors

• It contains two or more epithelial elements,
The second element should be about to 10%
of the surrounding area at least.
• It treats according to benign component.
• Most often; serous / endometrioid
• Followed by Endometrioid / clear cell
combinations followed.
 Indifferentiated carcinomas

• 10-15% of the epithelial ovar ca.

• Average age 55
• 50% is bilaterally.
• Most are little differentiated serous or endometrioid ca.
• The actual indifferentiated carcinomas seen in the ovaries are
small cell carcinomas;
• they are generally unilateral and seen in young patients (23
years old),
• solid in nature and capsule rupture is frequent.
• It spreads rapidly, the prognosis is poor, 90% will die within
a year.
• hypercalcemia is observed in 50% of cases
 DIAGNOSIS
•
ULTRASONOGRAPHY; is the most useful non-invasive test and is the
first test have to be performed in the presence of an adnexal mass. But the
actual examination is a pathological examination.
•
Radiological criteria for Malignant potential of Pelvic mass
• Solid component, nodular, papillary, isoechoic or hypoechoic appearance.
• The presence of septations and dense septations > 2-3mm
• The presence of current in the doppler in the solid component.
• Acid presence
• In case of overgrowth detection in USG
• Ovarian epithelial tumors,
• Ovarian non-epithelial tumors,
• Over metastasis,
• Tuba cancer,
• Overin benign tumors should be remembered in the differential diagnosis.
 EPITHELIAL OVARIAN TUMORS
• SCANNING
• In patients with familial over cancer syndrome annually,
• rectovaginal pelvic examination
•  TV USG
• CA 125 follow-up recommended
In patients with familial overcancer syndrome  
Genetic testing and counseling for BRCA 1 and 2
Prophylactic bilateral oophorectomy in women completing
child's wish (by explaining the menopause and osteoporosis risk)
Oral contraceptive use may be recommended
Chemoprophylaxis is still a research topic
 EPİTELYAL OVER TÜMÖRLERİ
TÜMÖR MARKERLARI
• CA 125
• CA 19-9
• CA 15-3
• CA 72-4
• LSAS (The lipid associated sialic acid)
• LPA (lysophosphatidic acid) OVX-1
osteopontin
• Recently, HE4 ((Human Epididymis Protein 4)
 Laboratuar
• CA125
•  Normal value <35
• The most commonly used tumor marker in ovarian
cancer evaluation
• is a glycoprotein in mucin structure with a high
molecular weight
• Elevated CA-125, in epithelial ovarian tumors   a good
marker for EOK, is normally <35 units / mL and is> 65 U
/ mL at 80% of EOC.
• While it is high in 50% of Stage 1 cases, higher 90% in
stage 2 cases and beyond.  
 HE-4

• HUMAN EPIDIDIYMIS PROTEIN 4 (HE4): A

marker that has been approved for use since
2008, showing the recurrence of Over-cancer.
Studies on the distinction between Benign
and Malign are ongoing.
 RADYOLOGY

• USG: Abdominal and transvaginal USG is the

first noninvasive test to be performed.
• CT / MRI: Provides insight into both the
disease and the condition of the patient, both
before and during surgery.
• Acid is valuable in the display of metastases.  
• PET CT has recently been an increasing test of
popularity but is more expensive and more
diagnostic in terms of CT and MR.
 Exclusion of Non-Over-Malignancies

• GIS malignancy should be eliminated;

• Patient with anemia, dyspeptic complaint or defecation
complaint should undergo GIS screening by endoscopy and
colonoscopy.
• Gastric cancer may clinically mimic overcancer by performing
peritonitis carcinomatosis and krukenberg tumor.
• If there is a mass on physical examination, MAMOGRAPHY
should be performed before operation.
• Breast cancer can metastasize to over, or BRCA positive
people can have over-cancer and concurrent breast cancer.
Liquid sampling should be done in those with acid or pleural
effusion.
 EPITHELIAL OVER TUMOR

Metastasis pathways;
Transceolemic (most common)
Hematogen
Lymphatic system
 Epithelial Over Ca prognostic factors

•
Known prognostic factors
•
1-Stage: The most important prognostic factor is the
stage of the disease at the time of diagnosis.
•
It is directly related to the life span of 5 years. 2-Grade
•
3-Histological Type
•
4-Age, general situation
•
5-Rest tumor volume
•
6-Respond to Chemo., kind of chemo.
•
7-Ca125 levels: usually reflect the volume of the
disease.
•
8-Surgical factors
FIGO 2014 Ovarian Cancer Staging
 FIGO staging

Stage II: tumor invaded with one or two ovaries in

a pelvic extension
• Stage IIa; Uterine and / or tubal spread and / or
metastasis.      no malignant cells in acid or wash
liquid        
• Stage IIb; spreading to other pelvic tissues  no
acid or malignant cells in the wash fluid.       
• Stage IIc; IIa or IIb tumor together with ruptured
capsule and (+) cytology
 FIGO staging

Stage III:
•  Peritoneal invasion and / or (+)
retroperitoneal lymph node involvement of
the pelvis with a tumor containing one or two
ovaries.
• Histologically proven superficial spreading to
hepatic, small bowel or omentum
 FIGO staging

• Stage IIIa nodes are negative, microscopic

involvement of the peritoneal surfaces, limited
to small pelvis
• Stage IIIB nodes are negative, <2 cm implants
peritoneal surfaces.
• Stage IIIC retroperitoneal lymph nodes positive
or abdominal implants> 2 cm
 FIGO staging

•
Stage IV:
• The tumor has ınvased to one or two
ovaries, distant metastases as well. 
• Display of cytolysis in the pleural effusion
(+) Presence of hepatic parenchymal
metastases Distant organ metastases
 TREATMENT

Primary treatment of over cancer is SURGICAL. Aims

of the surgeon:
Confirm diagnosis
Staging
Removal of tumor
Surgical treatment can only be cured in early stage
(stage 1a and 1b)
Beyond to stage 1c, adjuvant CT to surgery should be
added.
 TREATMENT

• Surgical
• Chemotherapy
• Radiotherapy
• Immunotherapy
• Hormone therapy
 TREATMENT OF BORDERLİNE TUMORS

• The main treatment for borderline tumors is

the resection of the primary tumor
• Surgery is sufficient in stage Ia and Ib G1
tumors (fertility surgery can be performed)
Surgery + chemotherapy in stage Ia and Ib G
2-3 and
• In advanced stages, cyto-reductive surgery
(debulking) + chemotherapy
 TREATMENT

• Cytoreduction;
•  Without any tumor so that no tumor remains
larger than 1cm masses  is the best indication
of survival in advanced stage disease
• Not the volume of tumor cells left behind, The
diameter of the largest rest tumor determines
the prognosis
 CYTOREDUCTIVE SURGERY
• TAH + BSO
• Total omentectomy
• PPLND
• Bowel resection
• Splenectomy (often intraabdominal advanced tm)
• Hepatic resection
• Diaphragmatic peritoneal resection
• VATS
 TREATMENT

Advanced phase epithelial ovarian cure standard therapy;

• Optimal cytoreduction + CT.
• Classic approach to epithelial ovarian cancer, even in
early stages: TAH + BSO + surgical staging
•
Conservative treatment; demand of the baby, optimal
staging, FİGO stage 1a,
• Serous, mucinous, endometrioid ca
• To be informed of the patient and approving of patient
may be considered if appropriate for close follow-up
and the surgery is completed when the number of
children is complete
 GERM CELL TUMORS
• They originate from primordial germ cells
• 20-25% of all benign and malignant ovarian
tumors are germ cell tumors
• 3% of germ cell tumors are malignant
• 70% of over tumors detected in the first two
decades are germ cell tumors and 1/3 of them
is malignant (mean age is 19)
• 75% of the cases are stage I.
 Classification of Germ Cell Tumors by
WHO
I - Germ cell tumors   b. Cystic Teratom
a. Dysgerminoma   i.Mature cystic teratoma
b. Endodermal sinus tumor     ii. mature cystic teratoma with
c. Embryonal carcinoma   malignant transformation
  d .Poliyembryoma 3. Monodermal Teratoma
  e. Choriocarcinoma        a. Stroma ovarii   
  f. Teratoma    b. Carcinoid tumor
         1- Immature         c. Neuroectodermal
       2- Mature             d. Others
     a. Solid teratom g. Mixed germ cell tumor
 MATURE TERATOM
• Includes elements originating from 3 germ sheets (endoderm,
ectoderm, mesoderm).
• There are two types of cystic and solid.
•
Maturic Cystic teratoma 'dermoid cyst';
• Usually between the ages of 20-30 (75%)
• 10-15% is bilaterally.
•
Microscope:
•
Ectodermal tissues is essential. It may contain fat, sweat
glands, hair, nerve tissue of epidermis. These elements are
mature.
•
Endodermal elements: thyroid, bronchial, intestinal tissue
Mesodermal; bone, cartilage, smooth muscle elements.
Selim germ cell over tm: Mature
Teratom (Dermoid cyst)
 DERMOID CYST
• Torsion;
• is the most common complication.
• In general children and teenagers.
• Quite often during pregnancy and puerperium.
• Acute abdominal pain is the first symptom, rupture is rare 1%
• Chemical peritonitis may develop after the rupture of the cyst
contents into the peritoneum.
• Granulomatous reaction causes widespread and tight
adhesions in the peritoneal cavity.
• Infection is rarely seen in 1%, the causative agent is coliform
bacteria.
 DERMOİD CYST

• Infrequently, autoimmune hemolytic anemia

can be seen among the complications of the
cyst.
• Malign transformation is rare in 1-2%, before
age 40 years.
• Diagnosis: USG and MR
• Treatment: cystectomy / oophorectomy with
surgical LT / LS
 DYSGERMINOM
• 30-45% of all germ cell tumors , 1-3% of ovarian tumors
• 20-30% of ovarian cancers seen during pregnancy
• 75% are between the ages of 10-30.
• The other germ cell tm may be associated with immature
teratoma mostly.
• Since 5% may be associated with abnormal gonads,
karyotyping should be performed before premenarcheal.
• 10-15% is bilaterally.
• 75% is diagnosed at stage 1.
• They are radiosensitive.
 Disgerminom

• Outline of treatment: optimal surgical staging

USO, CT
• If there is suspected lesion on the other over-
biopsy
• In the presence of the disgenetic gonad, BSO
at stage 1, uterus can also be saved. 5 years
survey is 75-90% in all stages
 CHORIOCARCINOMA
• Very rare.
• The average age is 13, mostly associated with
P.prexox.
• 50% develops before puberty.
• POLİEMBRİOMA
• A rare tumour made of all-embryoid body.
Malignancy is high, even in the early period,
adjacent organ and peritoneal surface invasion.
• If it contains sinsiotrophoblast, hCG is elevated.
 gonadoblastom
• Composed of Germ and gonadal stroma hc.
• It occurs very rarely.
• Tm is always found in dysgenetic gonads, 90% of patients have Y
chromosome.
• In the presence of Y chromosome, the risk of developing cancer is
25%, so both ovaries should be removed.
• 80% of patients are phenotype female, 20% are male.
• If the phenotype is male; cryptorchidism, hypospadias, internal
female sex organs are detected.
• Primary amenorrhea, virilization, or genital organ anomalies are
common.
• 60% of the cases are disgerminomas and 10% of the cases are with
malignant germ cell tumors.
• The prognosis is very good when both ovaries are removed.
 Sex-cord stromal tumors
• They form 5-8% of all ovarian malignancies
• Very rare before menarche,
• They constitute 5% of childhood cancers.
• They consist of sex cords, mesenchim and
stroma of ovaries,
• Functional tumors (estrogen, progesterone,
testosterone, cortisone are released)
 Sex-cord stromal tumors
•

A-Granulosa-stromal cell
a) Granulosa cell tumor                          
b) Tekoma-fibroma group
 B- Androblastoma (Sertoli-leydig cell tumors)
 C- Gynandroblastoma  
 D- Uncategorized
 Granulosa Cell Tumor

• It can be seen at any age and has hyperestrogenism

(juvenile and adult form)
• It has a low grade biology and develops slowly (80-90
% is stage I at the time of diagnosis)
• The probability of being bilateral is 2%
•

Solid, yellow, soft

 Granulosa Cell Tumor
• Fractional curettage is essential in the
perimenopausal and postmenopausal period.
• If fertility is to be protected: USO + Surgical
staging  
• 5 year survival in GHT
• Stage I: 92% -100%
• Stage II - III: 33% - 53%
 Sertoli-leydig Cell Tumors

• It occurs mostly in 3rd and 4th decades.

• 75% is under 40 years old
• They constitute 0.2% of over tumors
• Reinke crystals are seen in pathology
preparations.
• % 1 biteral
 Sertoli-leydig Cell Tumors
• Androgen producers and in 75-80% of them are seen
virilization (oligomenore, amenorrhea, breast atrophy, acne,
hirsutism, voice thickening and male hairline type)
• Generally, low grade and unilateral,
• Treatment  is planned similar to the granulosa cell tumors
average 10cm
Yellow-brown
Necrosis- bleeding areas
 Fertility Preserving Treatment
• Even If not all genital organs are possible, at
least one ovary or uterus may preserve for
fertility.
• After fertility treatment is accelerated, the
treatment for cancer should be completed.
THANK YOU