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Ovarian Cancer: Di Wen, M.D.,PH.D
Ovarian Cancer: Di Wen, M.D.,PH.D
Di Wen, M.D.,Ph.D
OVARIAN TUMOURS
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.
Definition
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Definition
In developed countrieswomen 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
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Risk Factor
as in the Lynch Syndrome of familial breast colorectal and ovarian cancerOvulation 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
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Incidence
Nearly 25% of all ovarian neoplasm are malignantApproximately 80 of them are primary growths of the ovarythe remainder being secondaryusually carcinomata
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Primary Carcinoma of the Ovary 80 of all cases of primary carcinoma of the ovary arise in serous or mucinous cysts.
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is seldom upset, and any irregularity is attributed to the patients time of life.
Menstrual
function
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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.
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Pressure Symptoms
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.
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DIFFERENTIAL DIAGNOSIS
General rule
An experienced examiner will recognize an ovarian tumor mainly because ovarian tumor is, in the circumstances, the most likely diagnosis. All abdominal swellings should be subjected to ultrasound and X-ray examination.
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
ASCITES
A fluid thrill may be elicited from an ovarian cyst, and ascites and tumor may coexist; but as a rule the distinction should be easily made.
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DIFFERENTIAL DIAGNOSIS
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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.
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
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Clinical Features
Subacute
The patient complains of recurrent abdominal pain which passes off as the pedicle untwists. There is a rise in pulse and temperature during the bleeding; and over a period anemia develops.
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Clinical Features
Acute
The signs and symptoms are those of an acute abdominal condition. The problem becomes one of differential diagnosis to exclude those conditions in which laparotomy is not needed and laparoscopy may be useful.
to
be
intense
and
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Clinical Features
Differential Diagnosis
Surgical Conditions (i.e. those conditions commonly seen and dealt with by a general surgeon.) Acute appendicitis Meckels diverticulitis Obstruction of bowel Diverticulitis
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Ruptured Cyst
This may occur alone or in conjunction with torsion. Rupture is not particularly upsetting to the patient unless the contents are irritant.
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PSEUDOMYXOMA PERITONEI
This rare condition occasionally but not inevitably follows mthe rupture of a mucinous cystadenoma. The epithelial cells implant on the peritoneum and continue to secrete a gelatinous pseudomucin which is not absorbed, or secretion is faster than absorption. The abdominal cavity is eventually filled with the jelly, while the secreting cells spread over the parietal and visceral peritoneum.
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HYDROTHORAX
Hydrothorax may accompany ascites due to any cause, 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.
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OVARIAN TUMOURS
Histological Classification
Most tumors arise from the ovarian stroma and germinal epithelium. The embryonic coelom from which that epithelium develops also gives rise to the Mullerian duct from which develop the structures of the genital tract, and it is this common origin which explains the great variety of epithelial patterns which are met with.
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OVARIAN TUMOURS
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.Fibroma or sarcoma. .Dysgerminoma. .Teratoma. .Gonadoblastoma. .Yolk sac tumour. .Carcinoid .Thyroid tumour Choriocarcinoma
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OVARIAN TUMOURS
HORMONE-PRODUCING TUMORS
Estrogen-producing:
Granulosa cell tumour. Thecoma. Sertoli-Leydig cell tumour (Arrhenoblastoma). Hilar cell tumour. Lipoid cell tumour.
Androgen-prodicing:
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OVARIAN TUMOURS
krukenberg tumour
There is one well-known secondary tumour of the ovary, the krukenberg tumour, a secondary of a stomach carcinoma.
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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, occupying the whole peritoneal cavity and compressing other organs. It may occur at any age.
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Definition
This is only a third as common as the serous variety. Malignancy in a mucinous cyst is characterised by the formation of areas of solid carcinoma in the wall. The cells are columnar, show mitoses and tend to form glandular structures.
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Definition
A unilocular or multilocular cyst lined by epithelium similar to the fallopian tube. They are the most common benign epithelial tumors and form 20% of all ovarian neoplasm. In 10% of cases they are bilateral. It is uncommon to find them large than a fetal head.
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Definition
This is by far the commonest primary carcinoma, accounting for 60% of all cases, and in over half the cases it is bilateral. The cysts are always of papillary type and the epithelium burrowing through the capsule produces papillary processes on the serous surface. Extension of the growth to the pelvis and adjacent organs fixes the tumor. Ascites is always present.
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It is now recognized that carcinoma of the ovary may be of endometrial type, sometimes arising in endometrioma. Attacks of pain, unusual with ovarian cancer, are common. Sometimes there is uterine bleeding in post-menopausal cases.
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Usually the lesion is cystic and chocolate brown in color. If such a cyst ruptures spontaneously, malignancy should be suspected. The histology varies as in uterine carcinoma. It may be a welldifferentiated adenocarcinoma, an adenoacanthoma, mucinous adenocarcinoma or clear-celled carcinoma.
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Ovarian metastases from extragenital tumors are not uncommon. The commonest sites of primary growth are breast, stomach and large intestine.
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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. The fibroma is believed by many to be a thecoma which has undergone fibrous transformation. It is sometimes associated with Meigs syndrome.
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.Dysgerminoma; .Tumours of tissues found in the embryo or adult ---- the teratomata; .Tumours of dysgenetic gonads ---- commonly a gonadoblastoma; .Tumours of extra-embryonic tissues such as choriocarcinoma or yolk sac tumour.
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Dysgerminoma
This is the only solid ovarian tumor of characteristic appearance. Usually ovoid with a smooth capsule, it is of rubbery consistency and greyish colour. It is commonest in younger age groups, under 30 years as a rule, and is often bilateral. Sometimes it is found in cases of intersex.
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Estrogen-producing Tumors
These belong to the granulosatheca cell group and are found at all ages. They account for 3% of all solid tumors of the ovary.
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Estrogen-producing Tumors
In childhood there is accelerated skeletal growth and appearance of sex hair. 5% occur in children precocious puberty. 60% occur in child-bearing years irregular menstruation. 30% occur in post-menopausal women post-menopausal bleeding.
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ANDOROGEN-PRODUCING TUMOURS Three distinct types of masculinising ovarian tumor are recognised: a) SertoliLeydig cell tumor (Arrhenoblastoma), b) Hilar cell tumor, c) Lipoid cell tumor. All three cause amenorrhoea.
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Direct
The first spread is directly into neighbouring structures peritoneum, uterus, bladder, bowel and omentum.
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Lymphatics
Ovarian drainage is to the para-aortic glands, but sometimes to the pelvic and even inguinal groups. 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.
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Blood stream
Blood spread is usually late, to the liver and lungs.
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General Principle
1.To classify the growth according to its extent of spread (staging) as accurately as possible. 2.To remove as much cancerous tissue as possible (surgical debulking;cytoreductive treatment).
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General Rule
Benign ovarian over 10 cm in diameter must be removed, 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.
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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:
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General Principle
Ovarian carcinoma is staged surgically, so laparotomy is an essential part of management for most patients. Surgical removal of as much malignant tissue as possible, even if this should call for resection of structures outside the normal field of the gynecologist.
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General Principle
Follow-up with intensive chemotherapy, using various combinations of antineoplastic drugs. Taxanes, probably combined with platinum compounds, are an appropriate first choice. 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, so should only be performed with informed consent in clinical trials.
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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.
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Cytology
Before handling the tumour, take specimens of ascitic fluid or peritoneal saline washings for cytological examination, and a cytology smear from the underside of the diaphragm.
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