Tumours of the ovary

• Internationally agreed classification is needed

for proper analysis of
-The trend of there incidence
- Proper and meaningful comparison of
there treatment.
 Tumour Cont.
• FIGO( International Federation of Gynaecology
and Obstetrics)
• WHO( World Health Organisation) recognised
pathological classification of Ovarian tumour as
-Benign
-Borderline
-Malignant &
Primary and
secondary
 Tumour cont.
• Classification based on Histological cell of
origin.
• Full classification is complex and is split into
Nine main group.
 Classification
• Epithelial – serous
- mucinous
- endometroid
- clear cell tumour
- brener tumour
- mixed epithelial tumour
 Cont.
• Sex cord stromal tumour
- granulosa-theca cell tumour
- androblastoma(sartoli-leydig cell tumour)
-gynandoblastoma
-unclassified
• Germ cell tumour
-dysgerminoma
-endodermal sinus tumour
-embryonal carcinoma
-polyemryoma
-choriocarcinoma
-teratoma
 Cont.
• Gonadoblastoma
• Soft tissue tumour not specific to ovary
• Unclssiffied tumour
• Secondery ( metastetic)
• Tumour like condition.
 Incidence
• Epithelial – 70%-80%
• Stromal - 10%
• Germ cell - 5%
• Remainder- 5%
 Pathology
• Epithelial ovarian tumour

serous : macroscopy
-papillary, cystic or adenofibrometus
-usually unilocular with single cyst
-20 To 30 cm diameter
-translucent and contain clear fluid
: microscopy
-lined by single layer of cubiodal epi.
 Cont.
mucinous : macroscopy
-unlateral, multi-locular
-can attain huge diameter
-contain thick mucous material
-white grey or silvery blue colour
: microscopy
-lined by tall columner cell
 Cont.
• Germ cell tumour :
teratoma- embryonic differentiation
choriocarcinoma-extraembryonic
differentiation
dysgerminoma-no evidence of embryonic or
extra-embryonic line of
differentiation.
 Cont.
• Sex cord stomal tumour :
- smooth surface, round, solid yellowish
-rarely larger than an orange
-produces hormone and
become functional ovarian tumour
 Tumour of Borderline Malignancy
• Predominantly in pre menopause
• Confined to ovary for long time
• Have a very good prognosis
• Epi. Proliferation with nuclear atypia
• Increase mitotic activity
• Absence of stromal invasion
 Clinical Feature
• Age
germ cell - < 20 yrs
benign -earlier ag
borderline - 30-50 yrs
invasive - post menopause

• Genetic factor
site specific familial ovarian cancer
breast/ovarian familial cancer syndrome
lynch II syndrome
BRCA I and BRCAII gene of 17q chromosome are
associated
 C/F cont.
• Symptoms
- may be amasingly quiet and rarely produce
any symptom
- abdominal lump/swelling
- indigestion, vomiting, dyspepsia
- frequency of micturation,
- urinary retension and obstructed labour if
impacted
- menestrual upset if hormone producing
- cachecxia, edema of leg, vulva, vericocities
 C/F cont.
• Sign :
-small ovarian tumour lies in pelvis.
-when emerge from pelvis it produce an
abdominal lump which displace intestine
above and to side, the uterus lies below
and behind.
 C/F cont.
• Character of lump :
size-small( size of an orange) to huge which
fill whole abdomen
shape- round
concistancy- soft, cystic
mobility-mobile in all direction
tenderness- non-tender otherwise
torsion/impaction
• Bimanual ex.- a cleft b/w uterus and lower
pole of tumour.
cervix moves up when tumour moves upwards
 Attention should be paid
• Do not neglect history and symptom eg.
menstrual problem goes against OT
• Bladder should be evacuate by catheter
• Percussion note exclude ascites
• Auscultation exclude pregnancy
• Think of pelvic kidney
 Investigation
• USG – origin of tm. size, unilateral/bilateral,
unilocular/bilocular, septed, thin/ thick
wall, solid or cystic.
• Collour Dopler-high peak velocity & low
resistance index in malignancy
• X-Ray – diagnose Dermoid cyst
• Tumour marker- CA-125, CEA, CA19-9, hCG
LDH, Alpha-fetoprotien, estrogen
androgen and inhibin.
 Investigation cont.
• IVU- exclude pelvic kidney
• CT scan and MRI to evaluate tumour, its
extent
of spread, monitoring prognosis.
• Laparoscopy- if nature of tumour is in doubt,
treatment can be given at same time.
 Feature suggesting malignancy
• Age- prepuberty, postmenopause
• Pain and tenderness
• Rapidity of growth
• Consistancy –solid, nodular and irregular
• Number- 75% malignant Tm. are bilateral
• Fixation- is an omnious sign
otherwise impacted or endometriosis
• Ascites , oedema of leg and vulva, varicosities
• Metastases
 Complication
• Torsion of pedicle
• Haemorrhage into or from a cyst
• Rupture of cyst
• Degeneration
• Infection
• Intestinal obstruction
• Malignant transformation
 Staging of Ovarian Cancer
• Whenever malignancy is suspected a staging
laparotomy should be done.
• The steps of staging laparotomy are as follows –
-any free fluid collected , send for cytology
-exploration of all abdominal organ done systemeticaly
-biopsy from suspecious area and adhesion
-retroperitoneal space explore to evaluate
lymph node
-an infracolic omentectomy done and
- ovarian tumour preferably remove intact
 Staging
• Surgical staging following laparotomy
• FIGO recommended staging are as follows-
Stage I : limited to ovaries
A. Limited to one ovary; capsule intact;
no tumour on surface; no malignant
cell in ascitic fluid or peritoneal washing
B. as IA; limited to both ovaries
C. limited to one or both ovaries; capsul
ruptured; tm. Cell on surface; ascitic fluid +
 Staging cont.
• Stage II: tumour involving one or both ovaries
with pelvic extention
A. extention to, or metastases in the uterus/
tubes; no malignant cell in ascitic fluid or
peritoneal washing
B. extension to other pelvic tissue,uterus/tube
C. as in IIA or IIB with malignant cell in ascitic
fluid or peritoneal washing
 Staging cont.
• Stage III: Tm. Involving one or both ovaries
with microscopically confirmed peritoneal
metastases beyond pelvis & / or regional
L/N metastases; liver capsule metastases
A. microscopic peritoneal metastases
beyond pelvis
B. macroscopic metastases beyond
pelvis(<2cm)
C. peritoneal metastases beyond pelvis ( >2cm), and/or
regional L/N metastases
 Staging cont.
• Stage IV ; distant metastases
(excluding peritoneal metastases)
Liver parenchyma metastases or
Positive cytological confirmation of
plural fluid
 Treatment
• Surgery
• Chemotherapy
• Radiotherapy
 Tx. Cont.
• Surgery- depends on
-age
-whether it is benign or malignant
Rx option- for benign
-cystectomy
-ovariotomy and salpingo-oophorectomy
-TAH with BSO
-laparoscopic surgery
 Tx. Cont.
• Surgery- for malignant ovarian tumour
TAH BSO with infracolic-omentectomy
 Tx. Cont.
• Conservative surgery for ovarian tumour
-germ cell tumour
-young pt. with stage IA (well differentiated)
 Tx. Cont.
• Chemotherapy
-for all case beyond stage IA
-following surgery
-as soon as healing complete
-single / combination therapy
-5-6 cycle 3-4 weeks intervals
- CAP
(cysplatin,doxorubicin,cyclophosphamide)
- CP ( cysplatin, cyclophosphamide)
 Tx. Cont.
• Radiotherapy-
-palliative for metastatic bone or brain lesion
-local recurrence to alleviate pain
 Tx. For borderline tumour
• Surgical resection of primary tumour
 Follow up
• Every 3-4 month for first 2yrs
• Then 6 monthly for 5yrs
• At each visit physical and pelvic examination
• Serum CA-125 should be done
 Prognosis
• For benign tumour result of surgery is good
• For malignant tumour prognosis depend
-cell type and activity
-extent of growth
-involvement of peritonium, omentum
-amount of residual tissue
 Prognosis cont.
• 5yr survival rate
Stage I and II - 80-100%
Stage IIIA - 30-40%
Stage IIIB -20%
Stage IIIC & IV - <5%