Ovarian Cancer

Zhai jianjun
Department of Obstetric &
Gynecolgy
Beijing tongren hospital
 Histological types vary
 Ovarian cancer: one of the three
common female genital carcinoma
 Usually found during later period
 Mortality of ovarian germ cell tumors
has dropped as a result of effective
chemotherapy
 Epithelial ovarian cancer has become
the major threaten to women's lives
Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Histological classification
 Coelomic epithelial origin(80%~85%)
"Common" epithelial tumor; benign,
borderline, malignant
Undifferentiated carcinoma
Carcinosarcoma or malignant mixed
mesodermal tumors

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Histological classification
 Germ cell origin(10%~15%)
Teratoma
Dysgerminoma
Endodermal sinus tumor
Embryonal sinus tumor
Choriocarcinoma
Gonadoblastoma
Mixed germ cell tumors

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Histological classification
 Specialized gonadal-stromal origin(3%~5%)
Granulosa-theca cell tumors
Sertoli-Leydig tumors
Gynandroblastoma
Lipid cell tumors

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Histological classification
 Nonspecific mesenchymal origin(fewer than 1%)
Fibroma, hemangioma, leiomyoma, lipoma
Lymphoma
Sarcoma

Differentiation Treatment Prognosis

Overview to ovarian cancer
 Risk of ovary cancer
 The patient characteristics found to be
associated with an increased risk for
epithelial ovarian cancer include white
race,late age at menopause,family history of
cancer of the ovary,breast or bowel,and
prolonged intervals of ovulation
uninterrupted by pregnancy.
 High risk of ovarian caner in nulliparous
women and those who have been infertile.
Benign or malignant ?
 1,age
 2,history
 3,sign
 4,B scan
 5,CA125,HE4,199,153,CEA,AFP,HCG
 LDH,
Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Divided into 3 referred to cell differentiation

 Differentiation 1:highly differentiated

 Differentiation 2:moderate differentiated
 Differentiation 3:low differentiated

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Clinical manifestations

Early-stage ovarian cancer

 Vague abdominal pain or bloating
 Symptom of a mass compressing the
bladder or rectum:urinary frequency or
constipation
 Menstrual irregularity

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Clinical manifestations
Advanced-stage ovarian cancer
 Abdominal pain
 swelling
 Abdomeinal mass

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Signs
A solid ,irregular ,fixed pelvic
mass ,sometimes combined with an
lower part abdominal mass ,
ascites,or both

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Complications

 Torsion
 Rupture
 Infection
 Malignancy

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Torsion
 Fallopian tube
 Pelvic ligament funnel
 Intrinsic ovarian ligament

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Rupture: spontaneous or external force

 Rupture because of torsion

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Metastasis of ovarian cancer

 Directly spread and peritoneal metastasis

 Lymph node metastasis
1, Along the ovarian vessels
2, Along ovarian lymphatic door to iliac
internal and external lymph nodes
3,Along round ligament to iliac external
and inguinal lymph nodes

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Aortic lymph nodes

Common iliac lymph nodes

Iliac internal lymph nodes

Inguinal lymph nodes

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Clinical stage of ovarian cancer

 Phase I: Growth limited to ovaries

Ia: Growth limited to one ovary; no ascites. No tumor
on the external surface; capsule intact
Ib: Growth limited to both ovaries; no ascites. No
tumor on the external surfaces; capsule intacts
Ic: Tumor either stage Ia or Ib but with tumor on the
surface of one or both ovaries or with capsule ruptured
or with ascites present containing malignant cells or with
positive peritoneal washings

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Clinical stage of ovarian cancer

 Phase II: Growth involving one or both ovaries

with pelvic extension
II a: Extension or metastases, or both, to the uterus
or tubes, or both
II b: Extension to other pelvic tissues
II c: Tumor either stage IIa or IIb but with tumor on
the surface of one or both ovaries or with capsule or
capsules ruptured or with ascites present containing
malignant cells or with positive peritoneal washings

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Clinical stage of ovarian tumors

 Phase III: Tumor involving one or both ovaries

with peritoneal implants outside the pelvis or
positive retroperitoneal or inguinal nodes, or
both. Supeficial liver metastasis equals stage III.
Tumor is limited to the true pelvis, but with
histologically proven malignant extension to
small bowel or omentum

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

IIIa: Tumor grossly limited to the true pelvis with

negative nodes but with histologically confirmed
microscopic seeding of abdominal peritoneal surfaces
IIIb: Tumor of one or both ovaries with histologically
confirmed implants of abdominal peritoneal surfaces,
none exceeding 2 cm in diameter. Nodes negative for
disease
IIIc: Abdominal implants >2 cm in diameter or
positive retroperitoneal or inguinal nodes, or both

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Clinical stage of ovarian tumors

 Phase IV: Growth involving one or both ovaries

with distant metastasis. If pleural effusion is
present, there must be positive cytologic test
results to allot a case to stage IV. Parenchymal
liver metastasis equals to stage IV.

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Diagnosis:
Screening for ovarian cancer—very difficulty
 Ultrasonography and available tumor markers
are not feasible
 For example, CA125 lack specificity and
sensitivity.

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

diagnosis
 Basic examination
 History, symptoms, pelvic examination, physical
examination
 Special examination
 B-mode ultrasound examination
Tumor markers
Laparoscopy
Diagnostic Radiology
Cytology

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

diagnosis

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Differentiation of benign and malignant

ovarian tumors

 Age
 Course of disease
 Nature and location of mass
 Ascites
 B-mode ultrasound
 Tumor markers:CA-125,CA199,CEA,AFP,HCG

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Benign, borderline and malignant giant

check to identify
benign borderline malignant

Papillae（乳头） Less,Small or Lot, Film-like Lot, Rough, cauliflower-

verrucous hairy like（菜花）
（疣）
Solid area no yes 2 / 3 semi-qualitative

Capsule rupture no yes beyond 51%

Peritoneal no yes more

Hemorrhage No, clear liquid yes more

and necrosis

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Benign, borderline and malignant microscopic identification

benign borderline malignant

Cell arrangement neat little loss of loss of polarity

polarity

Cell proliferation single layer 2-3 layers Above 4 layers

Cilia （纤毛） yes Can be no sometimes
Mitotic(有丝分裂) no less(<1/HP) more(> 1/HP)

back to back of the no yes The phenomenon

gland of wall
New glands No or less More, more cribriform
interstitial cavities
Interstitial infiltration no no yes

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Differential diagnosis of benign ovarian

tumors

 Ovarian tumor-like lesion

 Tubal ovarian cyst
 Uterine myoma
 Pregnant uterus
 Ascites

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Differential diagnosis of malignant

ovarian tumors

 Endometriosis
 Pelvic connective tissue inflammation
 Tuberculous peritonitis
 Tumors outside the reproductive tract
 Metastatic ovarian tumors

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

 Uterine myoma

Tubal ovarian cyst

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Preoprative evaluation
 Routine preoprative hematologic and
biochemical studies
 Chest radiograph
 Pelvic and abdominal CT scan
 Endometrial biopsy
 Endocervical curettage
 Abdominal radiograph
 Gastrointestinal endoscopy
 Pelvic ultrasonography
 Tumor markers

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Treatment of benign tumors

 Age
 Propertys and range of lesions
 Fertility requirements
 Surgery,espescialy micro-invasive
operation,such as laparoscopy

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Treatment of malignant tumors

 Surgery:
 Chemical treatment
 Radiation therapy
 Immunotherapy
 Thermal treatment

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

Follow-up and monitoring

 Time:After operation: monthly

After the second year: once every 3 months
After the third year: once every 6 months
More than three years: once a year
 Content:Clinical symptoms, signs,
Systemic and pelvic examination
B ultrasound, CT, MRI
PET-CT,
Tumor markers

Differentiation Treatment Prognosis

Classification Manifestation Complication Metastasis Clinical stage Diagnosis

prevention

 Prevention of risk factors

 To carry out survey :
 Early detection and treatment:B mode
ultrasound,

Differentiation Treatment Prognosis

Epithelial ovarian carcinomas Germ cell tumors Specialized gonadal-stromal tumors

Epithelial ovarian tumur

overview
 The most common ovarian tumors
 Age of onset is 30 to 60 years old
 Benign, borderline and malignant

metastatic cancers
Epithelial ovarian carcinomas Germ cell tumors Specialized gonadal-stromal tumors

Disease risk factors

 Genetic and familial factors:Pass breast - ovarian
cancer syndrome: BRCA1 BRCA2; site - specific
ovarian cancer syndrome: familial; II type Lynch
syndrome: endometrial, breast, ovarian, colon;
autosomal dominant feature
 Environmental factors and lifestyle:Asbestos, talc, high
doses of lactose, animal fat, whole milk powder, coffee,
low-iodine
 Endocrinefactors:Hormone,Menstrual,Marriag,Fertility,Br
east-feeding,Contraceptives
 Continued ovulation:Application of ovulation induction
drugs

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

Serous cystadenoma

 Resemble fallopian
tube epithelium
 Common.
Accounted for 25%
of benign ovarian
tumors.
 Mostly unilateral,
smooth surface,
cystic, capsule filled
with clear yellow
liquid .

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

Borderline serous cystadenoma

 Medium size, mostly

bilateral. Intracystic
papillary growth in the
less.
 Microscope, no more
than three-stratified
epithelium, no
Interstitial infiltration
 5-year survival rate of
90%

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

Serous cystadenocarcinoma

 The most common

ovarian cancer
 Mostly bilateral, larger,
semi-substantial.
 Multi-room section,
cavity filled nipple.
 Significant cellular
atypia, and to
interstitial infiltration.
 5-year survival rate of
20 to 30%

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

Mucinous cystadenoma

 Resemble endocervical
epithelium
 Common, accounting for
20% of benign ovarian
tumors
 Mostly unilateral, round
or oval, smooth, larger
or huge.
 Section for multi-room,
filled with jelly-like
mucous cysts.

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

Borderline mucinous cystadenoma

 Section wall thickening, parenchyma and

nipple shape, nipple is small and soft.
 Microscopically, the epithelium is not
more than three cells with mild atypia
 No Interstitial infiltration

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

Mucinous cystadenocarcinoma

 Nipple visible wall

or parenchyma, cut
half-solid half-sac
 Significantly
abnormal cells, and
interstitial infiltration
 5-year survival rate
of 40 to 50%

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

Endometrioid ovarian tumors

 Rare benign tumor.

 Malignant:Mostly
unilateral, of
moderate size,
cystic or solid, with
nipple growth.
 5-year survival rate
of 40 to 50%

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

treatment
 Early stage tumors：the standard operation is
total abdominal hysterectomy, bilateral salpingo-
oophorectomy, infracolic omentectomy, and
thorough surgical staging.
 People who wish to preserve fertility may have a
unilateral salpingo-oophorectomy
 No further treatment is necessary in patients
with grade 1 or 2 tumors confined to one or both
ovaries after surgical stage
 Patients with grade 3 tumors are subsequently
treated with systemic chemotherapy

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

treatment
 Advanced stage tumors: cytoreductive
surgery("debulking")—to remove the primary
tumor and all of the metastases,if possible.
 If all macroscopic disease cannot be removed,
an attempt should be made to reduce individual
tumor nodules to 1cm or less in diameter.
 In patient who are medially unfit or have a poor
performance status, give two or three
neoadjuvant chemotherapy before radical
surgery.
 Not respond to chemotherapy—palliative care.

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

treatment

 Combination chemotherapy after

cytoreductive surgery—most commonly
intravenous carboplatin and paclitaxel, or
intraperitoneal cisplatin and paclitaxel.
 Single-agent therapy with paclitaxel, or
carboplatin, is only for frail or elder people.

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

treatment
Second-Look Laparotomy(if necessay)
To determine whether the patient, who are
clinically free of disease after completing
chemotherapy, has had a complete
response to chemotherapy

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

Prognosis

 Almost all patient with stage Ia gradeⅠare

cured surgically.
 5-year survival rate for poor differentiated
bilateral lesions of stage Ia is 75%
 5-year survival rate for stage II is 65%
 5-year survival rate for stage III is 20%
 A prolonged survial is expected in patients
of borderline ovarian tumors

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

Ovarian germ cell tumors

 Mature teratoma
(benign):Cavity full of grease
and hair, teeth and bones are
sometimes visible.
Ovarian goiter - thyroid
hormone secretion –
hyperthyroidism
 Immature teratoma(malignant)
:Mainly the original nerve
tissue

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

Ovarian germ cell tumors

 Dysgerminoma
 Medium malignant
solid tumors.
 Occur in
adolescence and
childbearing women.
 Round or oval,
medium sized, solid,
such as rubber-like
touch.

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

Ovarian germ cell tumors

 Endodermal sinus
tumor
 Rare, highly malignant

 More common in
children and young
women
 Mostly unilateral, large
Tumors, round or oval

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

Ovarian gonadal-stromal tumors

 Myeloid tumor:
Low grade, can secrete estrogen, Call-
Exner bodies, surrounded by granulosa cells
into small round cysts, arrange cauliflower
 Theca cell tumor:
With endocrine function, often co-exist
with the granulosa cells, solid cut surface, white

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

Ovarian gonadal-stromal tumors

 Fibroma:
Meig's syndrome: often
accompanied by pleural
effusion
 Sertoli cell - Leydig
cell tumor (testicular
neuroblastoma):
Body with bloody serous and
mucus, a masculine role
Tumor cells produce
estrogen .

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

Metastatic ovarian tumors

 Breast, bowel, stomach,

reproductive tract,
urinary tract

 Krukenberg tumor:
The primary site
is gastrointestinal tract,
bilateral, multi-ascites,
showing signet-ring cell

metastatic cancers
 Epithelial ovarian tumors Germ cell tumors Specialized gonadal-stromal tumors

treatment
 Benign tumors: surgery
 malignant tumors:
Surgery
Chemotherapy
Radiation therapy
 Metastatic ovarian Tumors: surgery,
chemotherapy

metastatic cancers
Summary
 Hard to find ,poor prognosis
 Stage
 Surgery is the major choice , combine with
chemotherapy and radiotherapy
 5 year survive is still poor