Benign and malignant

ovarian tumors
 Benign Tumors of the Ovary

 The human ovary has a striking propensity to develop

a wide variety of tumors, most of which are benign.
 90% of all ovarian tumors are benign, although this
varies with age.
 Clinical presentation:

 Asymptomatic
 Pain
 Abdominal swelling
 Pressure effects
 Menstrual disturbance
 Abnormal cervical smear
 Cont…..

 Many benign ovarian tumors are found incidentally

during a routine examination.
 Ultrasound was used in trials of screening for ovarian

cancer, the majority of tumors detected were benign.

 Functional ovarian cyst

 A functional ovarian cyst is a fluid-filled sac that forms

on an ovary.
 A sac normally forms during ovulation to hold a maturing
egg.
 Usually the sac goes away after the egg is released.
 But if an egg isn't released, or if the sac closes up after the
egg is released, the sac can swell up with fluid.
 Cont….

 During the normal monthly menstrual cycle, one of

two types of functional cysts may form.

 A follicular cyst. This type occurs when a sac on the

ovary doesn't release an egg and the sac swells up
with fluid.

 A luteal cyst. This type occurs when the sac releases

an egg and then reseals and fills with fluid.
 What causes them?

 A functional ovarian cyst is caused by slight changes in

the way the ovary makes or releases an egg.
 A cyst may form when a sac on the ovary doesn't release
an egg, and the sac swells with fluid.
 Or the sac may release an egg and then reseal and fill
with fluid.
 What are the symptoms?

 Most functional ovarian cysts don't cause symptoms.

The larger the cyst is, the more likely you'll have
symptoms.
 Symptoms include pelvic pain, pain with intercourse,
lower belly pain, and changes to your period.
 How are functional ovarian cysts treated?

 Most functional ovarian cysts go away without treatment.

 Your doctor may suggest using heat and medicine to
relieve minor pain.
 Surgery can remove a large cyst that bleeds or causes
severe pain.
 Your doctor may suggest that you take birth control pills,
which stop ovulation.
 This may prevent new cysts from forming.
Cont…..
 Benign Ovarian Tumors

 Ovarian tumors may be divided generally by cell type

of origin into three main groups:
 Epithelial
 Stromal
 Germ cell
 Taken as a group, the epithelial tumors are by far the
most common.
 Epithelial ovarian tumors

 Serous cystadenomas
 Commonest cystic ovarian tumors.
 Multilocular
 Mucinous cystadenomas

 The second most common epithelial tumor

 Unilateral and multilocular cysts

 About 85% are benign

 The fluid content consists of mucin and the only treatment is to

remove the tumor surgically.
 Cont….

Gross appearance of a mucinous (A) and serous (B) cystadenoma of the ovary. The
mucinous type is generally multiloculated and can be quite large
 Brenner cell tumors

 The Brenner cell tumors are commonly solid and occur in women

after the age of 50 years.

 It is a small, smooth solid ovarian tumor, usually benign and

occasionally bilateral.

 Treated by local excision.

Sex cord stromal ovarian tumor

 Hormone secreting tumors of the ovary.

 These tumors include fibromas, granulosa-theca cell tumors, and

Sertoli-Leydig cell tumors

 Granulosa–theca cell tumor

 The granulosa-theca cell tumors are arising from ovarian granulosa

cells, these tumors produce oestrogens.

 They occur in any age but more commonly in the postmenopausal

years.

 Promotes feminizing signs and symptoms, if arising before puberty

produce precocious menarche or pre menarchal uterine bleeding

during infancy and childhood (precocious sexual development)

 Sertoli-Leydig cell tumor

 Androgen secreting tumor

 Less frequent
 It generally occurs in women under 30 years of age.
 These tumors are comprised of Sertoli cells which are normally
found in testes and Leydig cells which secrete testosterone.
 The clinical manifestations include the onset of amenorrhea,
loss of breast tissue, virilizing effects, such as hirsutism,
deepening of the voice, clitoromegaly, and a defeminizing
change in body habitus to a muscular build.
 Ovarian fibroma

 A solid, encapsulated, smooth-surfaced tumor made up of

interlacing bundles of fibrocytes.
 It is associated with ascites caused by the transudation of
fluid from the ovarian fibroid.
 The flow of this ascitic fluid through the trans
diaphragmatic lymphatics into the right pleural cavity
may result in Meigs' syndrome (ascites and hydrothorax
in association with an ovarian fibroma).
 GERM CELL TUMORS

 Tumors of germ cell origin may replicate stages

resembling the early embryo.
 Germ cell tumors can occur at any age.
 They make up about 60% of ovarian tumors occurring in
infants and children.
 The most common ovarian tumor is the Benign cystic
teratoma, a germ cell tumor that can take on a great variety
of forms.
 Benign cystic teratoma

 Commonly referred to as a Dermoid cysts which are the commonest solid

ovarian tumor found in young women.

 Is composed primarily of ectodermal tissue (such as sweat and sebaceous

glands, hair follicles, and teeth), with some mesodermal and rarely
endodermal elements.

 Commonly asymptomatic unless they undergo torsion or rupture and

releases sebaceous material that causes chemical peritonitis.

 Dermoid cysts are bilateral in 12% of cases, and becomes malignant in

approximately 2%.

 Treatment: Excision of the Dermoid cyst

 Cont…..

Gross appearance of a cut-open dermoid cyst.

Note the presence of hair-bearing skin.
 Diagnosis of benign ovarian tumors

 Bimanual examination involves palpating the organs

between both hand
 Pelvic ultrasonography
 Tumor markers, such as  Serum CA 125,  may help to
distinguish between benign and malignant masses
 Laparoscopy
 Laparotomy
 Management

• The definitive treatment will depend on the type of

tumor, the patient's age, and her desire for future
childbearing.
• Benign epithelial ovarian tumors are generally treated
by Unilateral Salpingo-oophorectomy.
• The contralateral ovary must be carefully inspected to
exclude a bilateral lesion.
 Cont…..

 If the patient is young and nulliparous, the ovarian

tumor is unilocular, an Ovarian Cystectomy with
preservation of the ovary may be performed.
 In an older woman, a Total Abdominal
Hysterectomy and Bilateral Salpingo-oophorectomy.
 Cont…..

For some very early tumors (stage 1, low
grade or low-risk disease), only the involved
ovary and fallopian tube may be removed
(called a “Unilateral Salpingo-
Oophorectomy," USO), especially in young
females who wish to preserve their fertility
and have children.
If all of these structures are removed, the
surgery is called a “Total Abdominal
Hysterectomy and Bilateral Salpingo-
Oophorectomy”
(TAH-BSO).
 Ovarian cancer
 Ovarian cancer is a cancer that forms in or on an ovary. 
 It results in abnormal cells that have the ability to invade or 
spread to other parts of the body. 
 When this process begins, there may be no or only little
symptoms. 
 Symptoms become more noticeable as the cancer
progresses. 
  Common areas to which the cancer may spread include the 
lining of the abdomen, lymph nodes, lungs, and liver.
 Cont……

 The most common GYN cancer (uterine more

common)

 Most common cause of GYN cancer related death

and ovarian cancer is the 5th leading cause of
cancer related death among females
 Ovarian Cancer – subtypes

 The majority (95%) of ovarian cancers originate from

the surface epithelium of the ovary which is epithelial
type
 Serous histology ~75%
 Other types are less common
 Sex cord stromal tumors

 Germ cell tumors

 Cont…..

Germ cell and sex cord-stromal tumors are rare gynecologic

malignancies, comprising less than 15% of ovarian cancers

combined.

In general, these types of tumors affect young women and present

in early stage disease, which governs the treatment rationale.

Each group is composed of a variety of histologic subtypes, but

despite this variation, they are treated using the same general

clinical and surgical principles.

 Cont….

 The most common types of germ cell tumors are

dysgerminomas, endodermal sinus tumors (otherwise
known as yolk-sac tumors), and immature teratomas.
 The most common types of sex cord-stromal tumors
include granulosa cell and Sertoli-Leydig tumors.
 Cont…..

 Granulosa cell tumors, which account for approximately 70% of sex

cord-stromal tumors, mostly affect women who are peri or post-
menopausal.
 Juvenile granulosa cell tumors typically affect younger women, but
only account for a fraction of the total number of granulosa cell tumors.
 Sertoli-Leydig tumors, like germ cell tumors, also are noted more
frequently in younger women.
 Other quite rare malignant histologic sex cord-stromal tumor subtypes
include gynandroblastoma, sex cord tumor with annular tubules.
 Cont….

 Various tumor markers have been validated in germ cell

and sex cord-stromal tumors.
 Lactate dehydrogenase (LDH) is commonly elevated in
patients with dygerminomas;
 if syncytiotrophoblasts are present within a
dysgerminoma, b-hCG may also be elevated.
 Endodermal sinus tumors and immature teratomas can
secrete alpha fetoprotein.
 Conti….
 A combination of these markers may be elevated
in mixed germ cell tumors, depending on the
composition of the tumor.
 Inhibin B and anti-Müllerian hormone are usually
elevated in patients with granulosa cell tumors,
and testosterone is elevated in approximately 40%
of patients with Sertoli-Leydig tumors
 Cont….

 Given that the majority of women who are affected by germ cell
tumors are less than 30 years of age at the time of diagnosis, future
fertility is generally a significant consideration when planning
treatment.
 Conservative surgery has been shown to preserve reproductive
potential without increasing cancer-related mortality.
 Removal of just the affected ovary in the young ovarian germ cell
cancer patient desiring future fertility, along with appropriate
staging is an important component of the management of germ cell
tumors.
 Cont……

 In contrast, sex cord-stromal tumors rarely metastasize to

the lymph nodes, even in advanced stage disease.
 Therefore, lymphadenectomy can be safely omitted.
 Debulking of advanced stage disease improves outcome
for women with either germ cell or sex cord-stromal
tumors.
 Signs and Symptoms of Ovarian Cancer

 Ovarian cancer may cause several signs and symptoms. Women

are more likely to have symptoms if the disease has spread, but
even early-stage ovarian cancer can cause them.
 The most common symptoms include:
• Bloating
• Pelvic or abdominal (belly) pain
• Trouble eating or feeling full quickly

• Urinary symptoms such as urgency (always feeling like you have

to go) or frequency (having to go often)
 Cont…..

 These symptoms are also commonly caused by benign

(non-cancerous) diseases and by cancers of other organs.
 When they are caused by ovarian cancer, they tend to be

persistent and a change from normal they occur more often

or are more severe.
 These symptoms are more likely to be caused by other
conditions, and most of them occur just about as often in
women who don’t have ovarian cancer.
 Risk factors
• Ovarian cancer is related to the amount of time spent ovulating. Thus not

having children is a risk factor for ovarian cancer, likely because ovulation is

suppressed via pregnancy.

• During ovulation, cells are constantly stimulated to divide while ovulatory

cycles continue.

• Therefore, people who have not borne children are at twice the risk of ovarian

cancer than those who have.

• A longer period of ovulation caused by early first menstruation and

late menopause is also a risk factor.  

• Both obesity and hormone replacement therapy also raise the risk.
 Cont…..

 The risk of developing ovarian cancer is less for women

who have fewer menstrual cycles, no menstrual
cycles, breast feeding, take oral contraceptives, and
have a pregnancy at an early age.
 The risk of developing ovarian cancer is reduced in
women who have had tubal ligation, both ovaries
removed, or hysterectomy.
 Age is also a risk factor
 Tests for Ovarian Cancer

 If we find something suspicious during a pelvic

exam, or if you have symptoms that might be due to
ovarian cancer, different exams and tests are
recommended to find the cause.
 Medical history and physical exam

 Ask about medical history to learn about possible

risk factors, including family history. also be asked
if having any symptoms,
 When they started, and how long you've had them
 Ultrasound

 Ultrasound is often the first test done if a problem with

the ovaries is suspected.
 It can be used to find an ovarian tumor and to check if it
is a solid mass (tumor) or a fluid-filled cyst.
 It can also be used to get a better look at the ovary to
see how big it is and how it looks inside.
 Computed tomography (CT) scans

 The CT scan is an x-ray test that makes detailed cross-

sectional images of your body.
 The test can help tell if ovarian cancer has spread to other
organs.
 CT scans do not show small ovarian tumors well, but they can
see larger tumors, and may be able to see if the tumor is
growing into nearby structures.
 A CT scan may also find enlarged lymph nodes, signs of cancer
spread to other organs
 Magnetic resonance imaging (MRI) scans

 MRI scans also create cross-section pictures of your

insides. But MRI uses strong magnets to make the
images – not x-rays.
 MRI scans are not used often to look for ovarian cancer,
but they are particularly helpful to examine the brain and
spinal cord where cancer could spread.
 Chest x-ray

 An x-ray might be done to determine whether ovarian

cancer has spread (metastasized) to the lungs.
 This spread may cause one or more tumors in the lungs

and more often causes fluid to collect around the lungs.

 This fluid, called a pleural effusion, can be seen with
chest x-rays as well as other types of scans.
 Blood tests

 Tumor marker protein CA-125 test.

 CA-125 – a protein in the blood that is commonly

elevated in ovarian cancer
 Most commonly followed tumor marker
 Approximately 1 of 4 patients will have normal CA-125
at diagnosis
 Non-specific – many things can elevate
 Cont……

 HE4 – an alternative biomarker, may be elevated in

patients with normal CA-125
 May be elevated in endometrioid subtype
 Some germ cell cancers can cause elevated blood levels
of the tumor markers human chorionic gonadotropin
(HCG), alpha-fetoprotein (AFP), and/or lactate
dehydrogenase (LDH).
 Ovarian Cancer Stages

 After a woman is diagnosed with ovarian cancer, doctors

will try to figure out if it has spread, and if so, how far.
This process is called staging.

 The stage of a cancer describes how much cancer is in

the body. It helps determine how serious the cancer is
and how best to treat it

 Ovarian cancer stages range from stage I through IV

 Criteria to stage ovarian cancer

 The extent (size) of the tumor (T): Has the cancer spread
outside the ovary? Has the cancer reached nearby pelvic
organs like the uterus or bladder?
 The spread to nearby lymph nodes (N): Has the cancer
spread to the lymph nodes in the pelvis or around the aorta
 The spread (metastasis) to distant sites (M): Has the
cancer spread to fluid around the lungs (malignant pleural
effusion) or to distant organs such as the liver or bones.
 Stage I

 The cancer is only in the ovary (or ovaries) (T1). It has

not spread to nearby lymph nodes (N0) or to distant sites
(M0).
 Stage I A The cancer is in one ovary, and the tumor is
confined to the inside of the ovary. There is no cancer on
the outer surfaces of the ovary(T1A) .
 It has not spread to nearby lymph nodes (N0) or to
distant sites (M0).
 Cont……

 Stage I B The cancer is in both ovaries but not on their

outer surfaces. No cancer cells are found in the abdomen
and pelvis (T1b)
• It has not spread to nearby lymph nodes (N0) or to
distant sites (M0)
 Stage IC The cancer is in one or both ovaries.
 Cancer is on the outer surface of at least one of the
ovaries.
 Stage II

• The cancer is in one or both ovaries and has spread to

other organs (such as the uterus, bladder, the sigmoid
colon, or the rectum) within the pelvis (T2).
• It has not spread to nearby lymph nodes (N0) or to
distant sites (M0).
 Cont…..
• Stage II A
 The cancer has spread to or has invaded (grown into) the uterus or
the fallopian tubes, or the ovaries(T2A) .
 It has not spread to nearby lymph nodes (N0) or to distant sites (M0).
• Stage II B
 The cancer is on the outer surface of or has grown into other nearby
pelvic organs such as the bladder, the sigmoid colon, or the
rectum(T2B)
 It has not spread to nearby lymph nodes (N0) or to distant sites
(M0).
 Stage III

 The cancer is in one or both ovaries(T1) and it may have

spread or grown into nearby organs in the pelvis (T2).
 It has spread to the retroperitoneal (pelvic and/or para-
aortic) lymph nodes only(N1).
 It has not spread to distant sites (M0).
 Stage III A

 During surgery, no cancer is visible in the abdomen

(outside of the pelvis) to the naked eye, but tiny deposits
of cancer are found in the lining of the abdomen when it
is examined in the lab.
 The cancer might or might not have spread to
retroperitoneal lymph nodes (N0 or N1), but it has not
spread to distant sites (M0).
 Stage III B

 The deposits of cancer are large enough for the

surgeon to see, but are no bigger than 2 cm (about 3/4
inch) across.
 It may or may not have spread to the retroperitoneal
lymph nodes (but it has not spread to the inside of the
liver or spleen or to distant sites (M0).
 Stage III C

 The deposits of cancer are larger than 2 cm (about 3/4

inch) across and may be on the outside (the capsule)
of the liver or spleen.
 It may or may not have spread to the retroperitoneal
lymph nodes, but it has not spread to the inside of the
liver or spleen or to distant sites (M0).
 Stage IVA

 Cancer cells are found in the fluid around the lungs (called a
malignant pleural effusion) with no other areas of cancer spread
such as the liver, spleen, intestine, or lymph nodes outside the
abdomen (M1A).
 Stage IVB

 The cancer has spread to the inside of the spleen or liver, to lymph

nodes other than the retroperitoneal lymph nodes, and/or to other

organs or tissues outside the peritoneal cavity such as the lungs and

bones (M1B).
 Ovarian Cancer management

Once it is determined that ovarian cancer is present,

treatment is scheduled by a gynecologic oncologist (a

physician trained to treat cancers of a woman's

reproductive system).

Treatment usually involves surgery and chemotherapy,

and sometimes radiotherapy, regardless of the subtype

of ovarian cancer.
 Cont…..

 Surgical treatment may be sufficient for well-differentiated

malignant tumors and confined to the ovary.

 Addition of chemotherapy may be required for more

aggressive tumors confined to the ovary.

 For patients with advanced disease, a combination of

surgical reduction with a combination chemotherapy

regimen
 Surgery

 The surgery depends upon the extent of nearby invasion

of other tissues by the cancer when it is diagnosed
 The extent of the cancer is described by assigning it a
stage. It may remove one (unilateral oophorectomy) or
both ovaries (bilateral oophorectomy).
 TheFallopiantubes(salpingectomy),uterus (hysterectomy)
may also be removed. Typically, all of these organs are
removed.
 Cont…..

 For low-grade, unilateral stage-IA cancers, only the

involved ovary will be removed.
 This can be done especially in young people who wish
to preserve their fertility. However, a risk of microscopic
metastases exists and staging must be completed.  
 If any metastases are found, a second surgery to remove
the remaining ovary and uterus is needed
 Cont….

 For low-grade, unilateral stage-IA cancers, only the

involved ovary and Fallopian tube will be removed.
 This can be done especially in young people who wish to
preserve their fertility.
 However, a risk of microscopic metastases exists and
staging must be completed.
  If any metastases are found, a second surgery to remove
the remaining ovary and uterus is needed
 Chemotherapy

 Chemotherapy is used after surgery to treat any residual disease, if appropriate.

 In some cases, there may be reason to perform chemotherapy first, followed by

surgery.

 This is called "neoadjuvant chemotherapy", and is common when a tumor

cannot be completely removed or optimally debulked via surgery.

 It can reduce the risk of complications after surgery.

 If a unilateral salpingo-oophorectomy or other surgery is performed, additional

chemotherapy, called "adjuvant chemotherapy", can be given

 Cont…..

 Chemotherapy in ovarian cancer typically consists of 

platins, a group of platinum-based drugs, combined with
non-platins. 
 Common therapies

include paclitaxel, cisplatin, topotecan, doxorubicin, 
epirubicin, and gemcitabine. Carboplatin is typically given
in combination with either paclitaxel or docetaxel; the
typical combination is carboplatin with paclitaxel
 Prognosis

 Ovarian cancer usually has a relatively poor prognosis.

 It is disproportionately deadly because it lacks any clear
early detection or screening test, meaning most cases are not
diagnosed until they have reached advanced stages.
 Ovarian cancer metastasizes early in its development, often
before it has been diagnosed.
 The five-year survival rate for all stages of ovarian cancer is
46%; the one-year survival rate is 72% and the ten-year
survival rate is 35%.
THANK YOU