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Di Wen, M.D.,Ph.D
Ovarian tumors may arise at any age, but are commonest between 30 and 60. 1.Ovarian tumors are particularly liable to be or to become malignant. 2.In their early stages they are asymptomatic and painless. 3.They may grow to a large size and tend to undergo mechanical complications such as torsion and perforation.
CARCINOMA OF THE OVARY
In developed countries，women have a lifetime risk of developing ovarian cancer of about 1.4%，which is slightly greater than the risk of cervical or endometrial cancers, but well below the 7% average risk of breast cancer．
CARCINOMA OF THE OVARY
as in the Lynch Syndrome of familial breast colorectal and ovarian cancer．Ovulation induction with Clomiphene over more than year carries a l0-fold increased risk of ovarian cancer, Long-term ora1 contraceptive use reduces the incidence of ovarian cancers．
2003-10-27 Ovarian Cancer
Genetic factor are sometimes involved、
CARCINOMA OF THE OVARY Incidence Nearly 25% of all ovarian neoplasm are malignant．Approximately 80％ of them are primary growths of the ovary、the remainder being secondary，usually carcinomata． 2003-10-27 Ovarian Cancer 5 .
2003-10-27 Ovarian Cancer 6 .CARCINOMA OF THE OVARY Primary Carcinoma of the Ovary 80％ of all cases of primary carcinoma of the ovary arise in serous or mucinous cysts.
2003-10-27 Ovarian Cancer 7 .CARCINOMA OF THE OVARY Solid Carcinoma of the Ovary This accounts for 10% of primary carcinoma. The ovarian shape is retained for a time and there is a well-marked pedicle but soon the tumors become fixed. It is arise commonly bilateral but one tumor is usually larger than the other. Secondary deposits occur in the omentum and ascites develops.
CLINICAL FEATURES OF OVARIAN TUMOURS
Symptoms due to Size
Lack of any specific symptoms, ovarian tumors are often large by the time the doctor is consulted.
is seldom upset, and any irregularity is attributed to the patient’s ‘time of life’.
She may have noticed that her clothes are getting tight ant attributed this to weight gain or, if the abdominal swelling has coincided with amenorrhea she may believe herself to be pregnant.
CLINICAL FEATURES OF OVARIAN TUMOURS
These are commonly increased frequency of micturition, gastrointestinal symptoms and a dull pain in the lower abdomen. Very large tumors may cause respiratory embarrassment and edema or varicosities in the legs, and a characteristic ‘ ovarian cachexia’ develops, due perhaps to interference with alimentary function.
CLINICAL FEATURES OF OVARIAN TUMOURS 2003-10-27 Ovarian Cancer 12 .
CLINICAL FEATURES OF OVARIAN TUMOURS 2003-10-27 Ovarian Cancer 13 .
CLINICAL FEATURES OF OVARIAN TUMOURS 2003-10-27 Ovarian Cancer 14 .
CLINICAL FEATURES OF OVARIAN TUMOURS 2003-10-27 Ovarian Cancer 15 .
All abdominal swellings should be subjected to ultrasound and X-ray examination. in the circumstances.DIFFERENTIAL DIAGNOSIS General rule An experienced examiner will recognize an ovarian tumor mainly because ovarian tumor is. the most likely diagnosis. 2003-10-27 Ovarian Cancer 16 .
DIFFERENTIAL DIAGNOSIS 2003-10-27 Ovarian Cancer 17 .
and ascites and tumor may coexist. but as a rule the distinction should be easily made. 2003-10-27 Ovarian Cancer 18 .DIFFERENTIAL DIAGNOSIS ASCITES A fluid thrill may be elicited from an ovarian cyst.
DIFFERENTIAL DIAGNOSIS 2003-10-27 Ovarian Cancer 19 .
DIFFERENTIAL DIAGNOSIS Uterine Fibroids A large midline intramural fibroid may be impossible to distinguish from a solid ovarian tumor until the abdomen is opened and an entirely different surgical problem encountered. 2003-10-27 Ovarian Cancer 20 .
DIFFERENTIAL DIAGNOSIS 2003-10-27 Ovarian Cancer 21 .
DIFFERENTIAL DIAGNOSIS 2003-10-27 Ovarian Cancer 22 .
DIFFERENTIAL DIAGNOSIS 2003-10-27 Ovarian Cancer 23 .
DIFFERENTIAL DIAGNOSIS 2003-10-27 Ovarian Cancer 24 .
DIFFERENTIAL DIAGNOSIS 2003-10-27 Ovarian Cancer 25 .
TORSION of the PEDICLE Complications of Ovarian Tumors This is the commonest complication and may occur with any tumor except those with adhesions. Very rarely the pedicle atrophies and the tumor obtains a new blood supply through its adhesions to surrounding viscera (parasitic tumor). and if not treated gangrene will occur. As a result there is hemorrhage into the tumor and into the peritoneum. 2003-10-27 Ovarian Cancer 26 . The thin-walled veins of the pedicle are obstructed first while the arterial supply continues.
TORSION of the PEDICLE 2003-10-27 Ovarian Cancer 27 .
There is a rise in pulse and temperature during the bleeding. and over a period anemia develops.TORSION of the PEDICLE Clinical Features Subacute The patient complains of recurrent abdominal pain which passes off as the pedicle untwists. 2003-10-27 Ovarian Cancer 28 .
The problem becomes one of differential diagnosis to exclude those conditions in which laparotomy is not needed and laparoscopy may be useful. Pain tends continuous.TORSION of the PEDICLE Clinical Features Acute The signs and symptoms are those of an acute abdominal condition. to be intense and 2003-10-27 Ovarian Cancer 29 .
e.) Acute appendicitis Meckel’s diverticulitis Obstruction of bowel Diverticulitis 2003-10-27 Ovarian Cancer 30 .TORSION of the PEDICLE Clinical Features Differential Diagnosis ‘Surgical Conditions’ (i. those conditions commonly seen and dealt with by a general surgeon.
Rupture is not particularly upsetting to the patient unless the contents are irritant.TORSION of the PEDICLE Ruptured Cyst This may occur alone or in conjunction with torsion. 2003-10-27 Ovarian Cancer 31 .
TORSION of the PEDICLE 2003-10-27 Ovarian Cancer 32 .
TORSION of the PEDICLE 2003-10-27 Ovarian Cancer 33 .
RUPTURE OF OVARIAN CYST 2003-10-27 Ovarian Cancer 34 .
RUPTURE OF OVARIAN CYST RUPTURE OF OVARIAN CYST RUPTURE OF OVARIAN CYST 2003-10-27 Ovarian Cancer 35 .
or secretion is faster than absorption. The epithelial cells implant on the peritoneum and continue to secrete a gelatinous pseudomucin which is not absorbed.RUPTURE OF OVARIAN CYST PSEUDOMYXOMA PERITONEI This rare condition occasionally but not inevitably follows mthe rupture of a mucinous cystadenoma. 2003-10-27 Ovarian Cancer 36 . The abdominal cavity is eventually filled with the jelly. while the secreting cells spread over the parietal and visceral peritoneum.
or may occur as an accompaniment of a lung tumor. The so-called Meigs’ syndrome describes the specific condition of ascites and hydrothorax in conjunction with benign ovarian fibroma.RUPTURE OF OVARIAN CYST HYDROTHORAX Hydrothorax may accompany ascites due to any cause. 2003-10-27 Ovarian Cancer 37 .
Age. If the patient is over 50 the chance of malignancy is over 50% as opposed to less than 15% in premenopausal women.Features suggestive of malignancy 1.Ascites. Tumors in childhood are usually malignant.Rapid growth. 2. 3. 2003-10-27 Ovarian Cancer 38 .
but a normal level does not exclude malignancy. may be measured in the blood.Features suggestive of malignancy 4. 5. such as CA125. Pressure pain can occur with any tumor. 2003-10-27 Ovarian Cancer 39 .Multilocular cysts with solid areas. 6. (At least 10% of cysts are malignant).Solid tumours. but referred pain suggests malignant involvement of nerve roots.Tumor markers. 7. especially when bilateral.Pain.
The embryonic coelom from which that epithelium develops also gives rise to the Mullerian duct from which develop the structures of the genital tract.OVARIAN TUMOURS Histological Classification Most tumors arise from the ovarian stroma and germinal epithelium. and it is this common origin which explains the great variety of epithelial patterns which are met with. 2003-10-27 Ovarian Cancer 40 .
Endometrium).Endometrioma or Endometrioid carcinoma (of.Clear cell carcinoma. 5. Cervical epithelium).OVARIAN TUMOURS PRIMARY EPITHELIAL TUMOR 1. tubal epithelium).Brenner tumour.Serous cystadenoma or cystadenocarcinoma (of . 4.Mucinous cystadenoma or cystadencarcinoma (of. 3. 2. 2003-10-27 Ovarian Cancer 41 .
Fibroma or sarcoma.Dysgerminoma. . .Teratoma.Gonadoblastoma.Yolk sac tumour. . . .OVARIAN TUMOURS STROMATOUS TUMOURS GERM CELL TUMOURS .Carcinoid .Thyroid tumour Choriocarcinoma 2003-10-27 Ovarian Cancer 42 .
Androgen-prodicing: 2003-10-27 Ovarian Cancer 43 . Sertoli-Leydig cell tumour (Arrhenoblastoma). Thecoma. Hilar cell tumour.OVARIAN TUMOURS HORMONE-PRODUCING TUMORS Estrogen-producing: Granulosa cell tumour. Lipoid cell tumour.
a secondary of a stomach carcinoma. 2003-10-27 Ovarian Cancer 44 .OVARIAN TUMOURS krukenberg tumour There is one well-known secondary tumour of the ovary. the krukenberg tumour.
OVARIAN TUMOURS --MUCINOUS CYSTADENOMA Definition A unilocular or multilocular cyst of ovary lined by tall columnar epithelium resembling that of the cervix or large intestine. It is usually large and may reach immense proportions. 2003-10-27 Ovarian Cancer 45 . occupying the whole peritoneal cavity and compressing other organs. It may occur at any age.
OVARIAN TUMOURS --MUCINOUS CYSTADENOMA 2003-10-27 Ovarian Cancer 46 .
Rupture may occur and seeding of the epithelium on the peritoneal surface may cause pseudomyxoma peritonei.OVARIAN TUMOURS --MUCINOUS CYSTADENOMA signs and symptoms The signs and symptoms are those generally associated with any nonfunctioning ovarian tumor. 2003-10-27 Ovarian Cancer 47 .
show mitoses and tend to form glandular structures.OVARIAN TUMORS --MUCINOUS CYSTADENOCARCINOMA Definition This is only a third as common as the serous variety. 2003-10-27 Ovarian Cancer 48 . Malignancy in a mucinous cyst is characterised by the formation of areas of solid carcinoma in the wall. The cells are columnar.
2003-10-27 Ovarian Cancer 49 . In 10% of cases they are bilateral.OVARIAN TUMORS --SEROUS CYSTADENOMA Definition A unilocular or multilocular cyst lined by epithelium similar to the fallopian tube. It is uncommon to find them large than a fetal head. They are the most common benign epithelial tumors and form 20% of all ovarian neoplasm.
OVARIAN TUMORS --SEROUS CYSTADENOMA 2003-10-27 Ovarian Cancer 50 .
Ascites is always present. Extension of the growth to the pelvis and adjacent organs fixes the tumor. The cysts are always of papillary type and the epithelium burrowing through the capsule produces papillary processes on the serous surface.OVARIAN TUMORS --SEROUS CYSTADENOCARCINOMA Definition This is by far the commonest primary carcinoma. and in over half the cases it is bilateral. accounting for 60% of all cases. 2003-10-27 Ovarian Cancer 51 .
Sometimes there is uterine bleeding in post-menopausal cases. unusual with ovarian cancer. are common.CARCINOMA OF THE OVARY Endometrioid Carcinoma of the Ovary It is now recognized that carcinoma of the ovary may be of endometrial type. Attacks of pain. 2003-10-27 Ovarian Cancer 52 . sometimes arising in endometrioma.
2003-10-27 Ovarian Cancer 53 . The histology varies as in uterine carcinoma. malignancy should be suspected.CARCINOMA OF THE OVARY Endometrioid Carcinoma of the Ovary Usually the lesion is cystic and chocolate brown in color. If such a cyst ruptures spontaneously. It may be a welldifferentiated adenocarcinoma. mucinous adenocarcinoma or clear-celled carcinoma. an adenoacanthoma.
CARCINOMA OF THE OVARY Clear Cell Carcinoma It is doubtful if this exists as a distinct entity. 2003-10-27 Ovarian Cancer 54 . usually solid. consists almost entirely of polygonal cells with clear cytoplasm. It behaves in the same way as any other solid carcinoma and has the same prognosis. Clear cells may be seen in almost any variety of ovarian carcinoma. but occasionally a carcinoma.
CARCINOMA OF THE OVARY Secondary Carcinoma of the Ovary The ovary may be the site of secondary deposits from growths arising in other parts of the genital tract. These are usually overshadowed by the clinical manifestations of the primary growth. 2003-10-27 Ovarian Cancer 55 .
stomach and large intestine. 2003-10-27 Ovarian Cancer 56 . The commonest sites of primary growth are breast.CARCINOMA OF THE OVARY Secondary Carcinoma of the Ovary Ovarian metastases from extragenital tumors are not uncommon.
2003-10-27 Ovarian Cancer 57 .CARCINOMA OF THE OVARY FIBROMA This is composed of fibrous tissue and resembles fibromata found elsewhere. It is most common in the elderly and accounts for 4-5% of all ovarian neoplasm. It is sometimes associated with Meig’s syndrome. The fibroma is believed by many to be a thecoma which has undergone fibrous transformation.
Dysgerminoma. 2003-10-27 Ovarian Cancer 58 .the teratomata.commonly a gonadoblastoma. . .Tumours of tissues found in the embryo or adult ---.Tumours of dysgenetic gonads ---.CARCINOMA OF THE OVARY GERM CELL TUMOURS There are four main types of gern cell tumour: . .Tumours of extra-embryonic tissues such as choriocarcinoma or yolk sac tumour.
it is of rubbery consistency and greyish colour.CARCINOMA OF THE OVARY Dysgerminoma This is the only solid ovarian tumor of characteristic appearance. under 30 years as a rule. and is often bilateral. It is commonest in younger age groups. 2003-10-27 Ovarian Cancer 59 . Sometimes it is found in cases of intersex. Usually ovoid with a smooth capsule.
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2003-10-27 Ovarian Cancer 62 . It has a variable histological structure and is highly malignant. The main interest lies in the fact that it produces alphafetoprotein and the blood levels can be used as a diagnostic test and as a means of monitoring response to treatment.CARCINOMA OF THE OVARY Yolk sac tumor This is a rare tumor found in children and young adults.
CARCINOMA OF THE OVARY 2003-10-27 Ovarian Cancer 63 .
2003-10-27 Ovarian Cancer 64 . They account for 3% of all solid tumors of the ovary.CARCINOMA OF THE OVARY Estrogen-producing Tumors These belong to the granulosatheca cell group and are found at all ages.
30% occur in post-menopausal women post-menopausal bleeding.CARCINOMA OF THE OVARY Estrogen-producing Tumors In childhood there is accelerated skeletal growth and appearance of sex hair. 2003-10-27 Ovarian Cancer 65 . 5% occur in children precocious puberty. 60% occur in child-bearing years irregular menstruation.
2003-10-27 Ovarian Cancer 66 .CARCINOMA OF THE OVARY ANDOROGEN-PRODUCING TUMOURS Three distinct types of masculinising ovarian tumor are recognised: a) SertoliLeydig cell tumor (Arrhenoblastoma). b) Hilar cell tumor. All three cause amenorrhoea. c) Lipoid cell tumor.
bladder. bowel and omentum. 2003-10-27 Ovarian Cancer 67 . uterus.Spread of Ovarian Cancer Direct The first spread is directly into neighbouring structures – peritoneum.
but sometimes to the pelvic and even inguinal groups.Spread of Ovarian Cancer Lymphatics Ovarian drainage is to the para-aortic glands. 2003-10-27 Ovarian Cancer 68 . Cells seeded on to the peritoneum are drained via the lymphatic channels on the underside of the diaphragm into the subpleural glands and thence to the pleura.
2003-10-27 Ovarian Cancer 69 . to the liver and lungs.Spread of Ovarian Cancer Blood stream Blood spread is usually late.
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To remove as much cancerous tissue as possible (‘surgical debulking’. 2003-10-27 Ovarian Cancer 72 . 2.’cytoreductive treatment’).To classify the growth according to its extent of spread (staging) as accurately as possible.SURGICAL PROCEDURES IN OVARIAN CANCER General Principle 1.
SURGICAL TREATMENT OF OVARIAN TUMMOURS General Rule Benign ovarian over 10 cm in diameter must be removed. 2003-10-27 Ovarian Cancer 73 . but clinical and ultrasonically diagnosed cysts under 10 cm (the size of a lemon) in women under 35 years may be reviewed in a few months if there is no suspicion of malignancy. A follicular or luteral cyst may resolve spontaneously.
SURGICAL TREATMENT OF OVARIAN TUMMOURS 2003-10-27 Ovarian Cancer 74 .
SURGICAL TREATMENT OF OVARIAN TUMMOURS 2003-10-27 Ovarian Cancer 75 .
SURGICAL TREATMENT OF OVARIAN TUMMOURS 2003-10-27 Ovarian Cancer 76 .
TREATMENT OF OVARIAN CANCER General Principle Much attention is being directed towards the treatment of epithelial ovarian cancer which is now the most frequent cause of death from gynecological malignancy. The principles of treatment are: 2003-10-27 Ovarian Cancer 77 .
so laparotomy is an essential part of management for most patients. Surgical removal of as much malignant tissue as possible. 2003-10-27 Ovarian Cancer 78 . even if this should call for resection of structures outside the normal field of the gynecologist.TREATMENT OF OVARIAN CANCER General Principle Ovarian carcinoma is staged surgically.
A ‘second look’ laparotomy or laparoscopy operation (SLO). to determine the actual effectiveness of the chemotherapy and to decide whether it should be stopped does not affect prognosis. 2003-10-27 Ovarian Cancer 79 . Taxanes. using various combinations of antineoplastic drugs. are an appropriate first choice.TREATMENT OF OVARIAN CANCER General Principle Follow-up with intensive chemotherapy. so should only be performed with informed consent in clinical trials. probably combined with platinum compounds.
2003-10-27 Ovarian Cancer 80 .SURGICAL PROCEDURES IN OVARIAN CANCER Incision A vertical incision which can be extended is essential to allow a full inspection. Reduction of a cyst by tapping and extraction through a suprapubic incision is not acceptable practice.
and a cytology smear from the underside of the diaphragm. take specimens of ascitic fluid or peritoneal saline washings for cytological examination. 2003-10-27 Ovarian Cancer 81 .SURGICAL PROCEDURES IN OVARIAN CANCER Cytology Before handling the tumour.
SURGICAL PROCEDURES IN OVARIAN CANCER 2003-10-27 Ovarian Cancer 82 .
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