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OVARIAN TUMOR

By Dr.Feng Quan Ling


CHARACTERS
WHO CLASSIFICATION
PATHOLOGY
METASTASES
HISTOLOGICAL GRADES
STAGING
CLINICAL MANIFESTATION
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
COMPLICATION
RISK FACTORS & PREVENTION
MANAGEMENT
CHARACTERS
• Common disease---comprise about
32% of all genital tumors in female
• Ovarian cancer is the 5th leading cause
of cancer death in women and the
leading cause of death from
gynecologic malignancies.
?
• High mortality rate in malignant tumors
Ovarian cancer is disproportionately
deadly for a number of reasons:
• Symptoms are vague and non-specific
• Ovarian cancers shed malignant cells that frequently
implant on the uterus, bladder, bowel and omentum
(wangmo), and begin forming new tumor growths
before cancer is even suspected.
• Because no cost-effective screening test for ovarian
cancer exists, more than 50 percent of women with
ovarian cancer are diagnosed in the advanced stages
of the disease.
WHO CLASSIFICATION
• WHO classification of ovarian tumor is according to
the origination of ovarian tumor
• Epithelial tumors
surface epithelium of the ovary
• Sex cord tumors
sex cord cells of ovarian cortex
• Germ cell tumors
primordial germ cells
• Metastatic tumors
gastrointestinal or breast
PATHOLOGY
• It is complicated.
• Pay attention to
_women age
_ unilateral or bilateral
_tumor size,shape,consistency,stiffness
lateral,cut surface
_character (benign or malignant)
_5-year survival rate
_prognosis
PATHOLOGY
PATHOLOGY

•Epithelial tumor of ovary


It can be divided into
• benign,
• borderline malignant
• malignant tumors
Borderline malignant
_have some of the cellular characteristics of malignancy,
_grow slowly
_rate of metastasis is low and relapse is late
_clinical courses and prognosis are between B & M
PATHOLOGY
PATHOLOGY

Epithelial tumor _serious tumor


• Serious cystadenoma
• Borderline serious cystadenomas
• Serious cystadenocarcinomas
PATHOLOGY
PATHOLOGY

Serious cystadenoma
• very common
• mostly unilateral
• smooth external surface
• content is generally a thin watery
serosity
• usually one cavity
• divided into simple and papillary type
• Benign
• The rate of malignant change is 35%
PATHOLOGY
PATHOLOGY

Serious cystadenocarcinomas
• very common
• mostly bilateral
• large in size
• smooth surface or papilli growing
• content is turbid or hemorrhagic
• multiple cavity
• 5-year survival rate is only 20-30%
Serious cystadenocarcinomas
PATHOLOGY
PATHOLOGY

mucinous cystadenoma
• Common
• Benign
• unilateral
• bluish white surface
• huge size
• mucin fluid in cyst is thick
contain mucoprotein or
glycoprotein.
• rate of malignancy is 5-10%
PATHOLOGY
PATHOLOGY

mucinous cystadenocarcinoma
• unilateral
• cut surface has both cystic and solid areas
• 5-year survival rate is only 40-50%
PATHOLOGY
PATHOLOGY

•Ovarian germ cell tumor


• occur in children and young women in
the reproductive age group
• only mature teratoma is benign
• others are all malignant
• except dysgerminoma, other
malignancy are all high-malignant and
prognosis is poor
PATHOLOGY
PATHOLOGY

Teratoma (1)
• composed of 2-3 germ layers
• most part are cystic and few part is solid
• mature teratoma belongs to benign called
mature cystic teratoma or dermoid cyst
• frequently unilateral
• filled with thick yellowish greasy fluid,hair,and
sometimes tooth or bone
• rate of malignant change is 2-4%
PATHOLOGY
PATHOLOGY

Teratoma (2)
• immature teratomas are unilateral solid body
• irregular surface
• cut surface is brittle and soft like cerebral
tissue
• rate of metastases and recurrence is high
• 5-year survival rate is 20%.
PATHOLOGY
PATHOLOGY

Dysgerminoma
• malignant
• bilateral
• common in right
• round or ovoid, moderate size with smooth
surface
• cut surface is solid and grayish pink.
• very sensitive to radiation therapy
• the 5-year survival rate can reach 90%
Dysgerminoma
PATHOLOGY
PATHOLOGY

Endodermal sinus tumor


• tissue structure is very similar to endodermal sinus of the rat's
placenta
• their morphology resemble yolksac of human's embryo,so it's
also called yolk sac tumor
• highly malignant
• Unilateral, round or ovoid
• cut surface is solid and brittle
• tumor cells can produce AFP,which can be identified,its
concentration is parallel to growth and decline of tumor, has
become an important mark in diagnosis,treatment and monitor.
• mean survival time was only 12-18 months in the past.
Endodermal sinus tumor
PATHOLOGY
PATHOLOGY

•Sex cord-stromal tumors of ovary

• Granulosa-stromal cell tumor.


1-granulosa cell tumor.
2- theca cell tumor
3-fibroma
• Sertoli-leydig cell tumors
PATHOLOGY
PATHOLOGY

granulosa cell tumor.


• low-malignant
• functional tumors
• frequently occur in women of 50 years old.
• tumor cell can secret estrogen
• generally prognosis is good
• 5-year survival rate may reach about 80%
• because these tumors recur after a long
interval, prolonged follow up is necessary
PATHOLOGY
PATHOLOGY

theca cell tumor


• mostly benign
• usually diagnosed in postmenopause
women, rarely in women below 40 years
old
• have more obvious symptoms of
femininity
• prognosis is better than ovarian
carcinoma
PATHOLOGY
PATHOLOGY

fibroma
• occur in middle aged women,
• solid,benign ,unilateral,moderate in size.
• smooth surface
• Occasionally these tumors will be associated with
ascites and pleural effusions, a situation that is
called MEIGS syndrome. These ascites and
pleural effusions will go down spontaneously after
removal of tumor.
fibroma
PATHOLOGY
PATHOLOGY

Sertoli-leydig cell tumors


• also called androblastoma,
• found in young women
• mostly benign
• with abnormal masculinization symptoms
• 10-30% tumors are malignant
• 5 year survival rate is 70-90%
PATHOLOGY
PATHOLOGY

•Secondary of metastatic
carcinoma of ovary.
• primary lesion usually in GIT (gastrointestinal),
breast, genitalia(uterus,oviduct).
• Krukenberg tumor is a special metastatic
adenocarcinoma from GIT.
It is solid moderate in size.
prognosis is poor
most patients die a year after operation.
Krukenberg
tumor
PATHOLOGY
PATHOLOGY

•Tumor-like conditions of ovary


• solitary follicle cyst
• corpus luteum cyst
• multiple luteinized follicular cyst
• polycystic ovary
• endometriosis of ovary
Metastases of the malignant ovarian tumor

Direct spreading and peritoneal


implantation
Lymphatic spreading
Blood Matastases
METASTASES OF THE
MALIGNANT OVARIAN TUMOR
• some malignant ovarian tumors look
localized but in fact a sub-clinical
metastases have occured always to
peritoneal, post peritoneal lymphonodi,
omentum,diaphragm etc.
• the metastatic ways mainly are directly
spreading and peritoneal implantation.
• metastases through blood vessels are rare.
HISTOLOGICAL GRADES
OF MALIGNANT TUMOR
1)Highly differentiated
2)moderately differentiated
3)lowly differentiated
STAGING
• stage 1=growth limited to ovaries
• stage 2=growth involving one or both ovaries
with pelvic extension.
• stage 3=tumors involving one or both ovaries
with peritoneal implants outside pelvis and/or
positive retroperitoneal or inguinal nodes
• stage 4=growth involving one or both ovaries
with distant metastases
I期 II 期

IIa 期
Ia 期 Ib 期

或 IIb 期

腹水阳性

Ic 期 IIc 期
III 期 IV 期
前锁骨淋巴结

种植性肝转移

恶性胸膜细胞

腹腔腹膜转移
肝实质性转移
CLINICAL MANIFESTATION(1)
benign tumors
• grow slowly.
• In early stage have no symptoms, usually discovered in
gynecological examination on occasion.
• During gynecological examination we can touched
mass :
in unilateral or bilateral,
cystic or solid,
smooth surface,
moved freely,
no adhesion.
• Large tumors can push adjacent organs.
CLINICAL MANIFESTATION(2)
malignant tumors
• very insidious and silent in terms of
signs and symptoms
• appearance of symptoms often indicated
advanced stage of tumor
• grow rapidly
• symptoms generally depend on size,
histological types and complications
DIAGNOSIS
Depend on
Antigen
• age history markers
• local signs AFP
Hormone
• ultrasonic examination
markers β-
• radiological examination HCG
• cytological examination Enzyme
LDH
• laparoscopy
• tumor markers (AFP,CA-125,hCG)
R

R
DIFERENTIAL DIAGNOSIS

• benign ovarian tumor


• malignant ovarian tumors
benign ovarian tumor
• tumor like disease of ovary
follicle cyst and corporalutum are the commonest
diameter less than 5cm
generally unilateral
thin walls disappear spontaneously in 2 months
• leiomyoma
• gestational uterus
• plentifull bladder
• ascites
malignant ovarian tumors

• secondary tumors of ovary


• endometriosis
• pelvic cellulitis
• TB peritonitis
• tumors except genital system
COMPLICATION
• 1) torsion of pedicle
these tumors have moderate size, long
pedicle, great mobility and partiality, e.g
dermoid cyst.
• 2) rupture of cyst
divided into spontaneous and traumatic types.
• 3) infection
• 4) malignantation
RISK FACTOR & PREVENTION
Risk factors Prevention
• hereditary and • avoid above risk
family factors factors
• environmental • General survey of
factors age >30
• endocrine factors • find and treat as
• virus factors early as possible
• Repeated • Oophorectomy
ovulation
• oral contraceptive
MANAGEMENT
1. Treatment of benign ovary tumors
• a) Principles : surgical therapy
• b) Range of remove :
• c) Notes during operation
2. Treatment of malignant ovary tumor
• a) Surgical therapy
• b) Chemical therapy
• c) Radiation therapy
Torsion of pedicle
b) Range of remove
• related to :
the age of patients ,
demand of fertility ,
condition of opposite ovary
• i) Unilateral oophorectomy (or only excise
tumour) (shell out of their ovarian beds)
• ii) Bilateral oophorectomy
• iii) Hysterectomy
c) Notes during operation

• Distinguish the benign tumor from the


malignant tumor
• Histological examination (frozen section
biopsy)
• Remove completely
2-a) Surgical therapy
• careful exploration of organs in
abdominal cavity including diaphragm
• range of operation: hysterectomy and
Bilateral salpingo-oophorectomy
• cytoreductive surgery
• removal of lymph nodes in
reteroperitoneal space
2-b) Chemical therapy
• Postoperative chemical therapy is helpful in
preventing of replace of ovarian tumor
• Platinum- type drug and taxane
• Common drugs : alkylating agents, Anti-metabolic
groups, Anti-biotic groups.
• Combined chemical therapy is better than therapy with
single drug
• Choose effective chemical therapy according to the
tumor histological type
• Neoadjuvant chemotherapy: prior to any attempt to
perform cytoreductive suegery
2-c) Radiation therapy
Sensitivity of different histological type
tumors is different
• Dysgerminoma is the most sensitive
• Granulosa cell tumor has moderate
sensitivity
• Epithelial tumor has also a certain
sensitivity
cytoreductive surgery
• Even for advanced stage cases, the
masses that can be found grossly should
be removed to decrease the quantity of
tumor cells as few as possible.
• Leaving residual disease at the initial
surgery that has a maximum diameter
less than 1 cm at any site in the
abdominal cavity.