Ovarian Malignancy

 Constitutes about 15-20% of genital malignancy

 Leading cause of death from malignancy
 Prevalent in USA and Scandinavian countries but much less
in Oriental or Latin America and Asian countries
 Life time risk-1 in 70
 Incidence -22 per 1,00,000
 5yrs survival rate is 30%
 Etiology –incompletely understood

Factors reducing risk of ovarian cancer

 OC pills- 50%reduction after 5yrs of use

 Mechanical sterilization and hysterectomy
 Child birth -1child :risk reduction of 0.3-0.4
 Breast feeding, pregnancy
Factor increasing risk of ovarian cancer
 Early menarche and late menopause
 Family history
 Infertility
 Talc use, clomid use
 Age – rare before 40, peaks at 65-75yrs
1.Theory of incessant ovulation
 Riskof epithelial ovarian cancer is directly related to
the number of uninterrupted ovulatory cycle
ovulation

Ruptured surface epithelium

Rapid proliferation and repair

Spont mutation → oncogenic phenotype

 ovulation

Invagination of surface epithelium into the

underlying stroma

Inclusion cyst
Oncogenic factors
Neoplastic transformation
 2. Exposure of ovarian epithelium to persistantly
high level of pituitary gonadotropins
elevated gonadotropin

Estrogen biosynthesis

Abnormal proliferation of adjacent epithelium

Breastfeeding
Pregnancy
OC pills
Family history
 familial or hereditary patterns account for 5% to 10% of
all malignancies
 Lifetime risk

5% in women with one first degree

7% in women with ≥ 2 relative
Epithelial Ovarian Cancer
 90% of ovarian cancers

 Derived from the coelomic epithelium or

mesothelium. which can undergo metaplasia.

 Each tumor type has a histologic pattern that

reproduces the mucosal features of a section of the
lower genital tract.
 Classification of Epithelial Ovarian Tumors
Serous Tumors
 develop by invagination of the surface ovarian epithelium
 secrete serous fluid (as do tubal secretory cells).
 associated with Psammoma bodies,
 Papillary ingrowths are common, in the wall of the
mesothelial invaginations.
Malignant Serous Carcinomas
stromal invasion
Grading
 well-differentiated adenocarcinomas
papillary and glandular structures

 poorly differentiated neoplasms

solid sheets of cells, nuclear pleomorphism, and high
mitotic activity;

 Moderately differentiated carcinomas

intermediate between these two lesions.
Mucinous Tumors
 8% to 10% of epithelial ovarian tumors
 loculi lined with mucin-secreting epithelium
 The lining epithelium contain intracytoplasmic mucin
 resemble those of endocervix, gastric pylorus, or
intestina
 May reach enormous size, filling the entire abdominal
cavity
Malignant Mucinous Carcinomas
 Bilateral tumors occur in 8% to 10% of cases
 Histology resembles GIT
 rarely metastasize to the mucosa of the bowel
 They commonly involve the serosa,
Pseudomyxoma Peritonei
 Abundant mucoid or gelatinous material in the pelvis
and abdominal cavity surrounded by fibrous tissue
 Commonly secondary to a well-differentiated
appendiceal carcinoma
Endometrioid Tumors
 6% to 8% of epithelial tumors
 Cell type resemble of uterine endometrium
 Can develop from either pre – exiting ovarian
endometriosis / from surface epithelium of ovary
 Usually large (10 -25cm )
 Solid /cystic
 Contain clear /mucoid/ haemorrhagic fluid
 1/3rd a/w endometrial adenocarcinoma
Clear cell ( mesonephroid) tumor
 1% of epithelial tumor
 Benign tumor uncommon
 Made up of clear cell & hob nail cells
 Focal areas of endometriosis & endometriod CA
sometimes occur

Brenner tumor
 Transitional cell lining
 Always benign
 Small ,even microscopic in size
Peritoneal Carcinomas
 Histologically indistinguishable from primary ovarian
serous tumors.

 Tumors affect predominantly the uterosacral

ligaments, pelvic peritoneum, or omentum.

 The overall prognosis for borderline serous peritoneal

tumors is excellent
 Peritoneal carcinoma simulates ovarian cancer
clinically
 ovarian cancer can arise in a patient whose ovaries
were surgically removed many years earlier
Clinical features
 80% found in postmenopausal
 Peak incidence- 56-60yrs

Stage 1&2 ovarian cancer- non specific symptoms

-abdominal bloating and pain
-indigestion, constipation
-urinary frequency, dyspareunia
Advanced disease –
 Abdominal swelling, fatigue, weight loss
 Nausea, anorexia, early satiety
 Shortness of breath
 Vaginal bleeding- metastatic involvement of
the uterus
 Endometrial hyperplasia and AUB- excess
estrogen from an ovarian stromal tumor
 Malignant pleural effusion
 Signs

Pelvic mass on physical examination

b/l, solid, irregular, fixed
Ascitis, upper abdominal mass
Size >8-10cm
Diagnosis
 Ovarian epithelial cancers must be differentiated
from benign neoplasms and
functional cysts of the ovaries.
Serum CA125-
 used to distinguish malignant from benign pelvic mass
 In postmenopausal – adnexal mass with
high CA125 (>200U/ml)

96% positive predictive value

 For premenopausal – low specificity

 The size of the lesion is important.

 If a cystic mass is >8 cm in diameter, the probability is
high that the lesion is neoplastic.
 USG

Adnexal pelvic mass with areas of

complexity s.a irregular boarder,
multiple echogenic pattern within mass
and dense multiple irregular septae
 Screening
Tumor marker and USG –not established

1. USG – limited specificity

 Advances in TVS have been shown to have a

very high (>95%) sensitivity for the detection of

early-stage ovarian cancer.

2. Pelvic examination
 Lacks sufficient sensitivity and specificity
3. Tumor markers :
-CA125
-elevated in 50% of stage 1 , 90% of stage 2
-cutoff value of 30 IU/ml – lacks specificity
- Elevated in variety of other condition – fibroids,
endometriosis, mensturation, endometrial ca,
colitis, pancreatitis, SLE
Patterns of Spread

Transcoelomic
 Most common and earliest mode
 The cells tend to follow the circulatory path of the
peritoneal fluid.
 The fluid tends to move with the forces of respiration
from the pelvis, up the paracolic gutters, especially on
the right, along the intestinal mesenteries, to the right
hemidiaphragm.
Metastases are typically seen on
 The posterior cul-de-sac,
 paracolic gutters,
 right hemidiaphragm,
 liver capsule,
 the peritoneal surfaces of the intestines and their
mesenteries,
 and the omentum
 progressively agglutinates loops of bowel, leading to a
functional intestinal obstruction.
This condition is known as carcinomatous ileus
Lymphatic
 dissemination to the pelvic and para-aortic lymph
nodes
 dissemination to the supraclavicular lymph nodes
occurs through the lymphatic channels of the
diaphragm and through the retroperitoneal lymph
nodes
Hematogenous
 uncommon.
 Spread to vital organ parenchyma, such as the lungs
and liver, occurs in only about 2% to 3% of patients
Staging

 subsequent treatment will be determined by the stage

of disease
 Staged according to the FIGO system, based on
findings at surgical exploration
 Technique for Surgical Staging
 a midline or paramedian abdominal incision
 Any free fluid, especially in the pelvic cul-de-sac,
should be submitted for cytologic evaluation
 If no free fluid is present, peritoneal washings should
be performed
 A systematic exploration of all the intra-abdominal
surfaces and viscera is performed
 Any suspicious areas or adhesions on the peritoneal
surfaces should be biopsied
 The diaphragm should be sampled either by biopsy or
by scraping with a tongue depressor and obtaining a
sample for cytologic assessment

 The omentum should be resected from the transverse

colon, a procedure called an infracolic omentectomy

 The retroperitoneal spaces should be explored to

evaluate the pelvic and paraaortic lymph nodes
Pre operative evaluation
Routine hematological and biochemical assessment
CxR, ECG
EC – endometrial carcinoma
PAPS smear
CT/MRI: ascitis in absence of ovarian tumor
Colonoscopy in >45yrs with occult blood in stool
UGI endoscopy
Stage I
 The primary surgical treatment –
total abdominal hysterectomy, bilateral
salpingo-oophorectomy with para aortic
lymphadenectomy and surgical staging

 Based on the findings at surgery and the pathologic

evaluation, patients with stage I ovarian cancer can be
grouped into low-risk and high-risk categories
Stage I Low-risk
 The uterus and the contralateral ovary can be
preserved in women with stage Ia, grade 1 to 2
disease who desire to preserve fertility

 Monitor with routine periodic pelvic examinations

and determinations of serum CA125 levels

 The other ovary and the uterus are removed at the

completion of childbearing.
Stage I High-risk
 complete surgical staging must be performed

 most patients are treated with chemotherapy

 Advanced-Stage Ovarian Cancer
 Cytoreductive Surgery
 To remove as much of the tumor and its metastases as
possible
 TAH with BSO along with a complete omentectomy
and resection of any metastatic lesions from the
peritoneal surfaces or from the intestines.
Goals of Cytoreductive Surgery
 Removal of all of the primary cancer and, if
possible, all metastatic disease.

 The removal of bulky tumor masses may reduce the

volume of ascites present

 surgical removal of these bulky tumors eliminate

areas that are most likely to be relatively resistant to
treatment with chemo or radiotherapy
 Patients whose disease has been completely resected to
no macroscopic
(microscopic only) residual disease have the best overall
survival.

 Approximately 60% of patients in this category will be

free of disease at 5 years.

 The performance of a pelvic and para-aortic

lymphadenectomy in patients with stage III disease
does not prolong survival
Omentectomy
 Ascites will completely disappear after removal of the
primary tumor and a large omental “cake.”
 Also, removal of the omental cake alleviates the nausea
and early satiety
“interval” cytoreductive surgery
-primary attempt at cytoreduction was
suboptimal
-performed after three cycles of platinum-
combination chemotherapy
-demonstrated a survival benefit
Chemotherapy

Stage I Epithelial Ovarian Cancer

 Early-stage, Low-risk

-no adjuvant chemotherapy is recommended for these

patients
 Early-stage, High-risk
-single agent or multiagent.
cisplatin, carboplatin, cyclophosphamide, and paclitaxel

-carboplatin and paclitaxel for 3-6 cycles seems desirable

in these patients.

- whereas a short course of a single agent may be

preferable for older women.
Advanced-stage Epithelial Ovarian
Cancer
 Systemic multiagent chemotherapy is the standard
treatment

 combination of cisplatin (75 mg/m2) and paclitaxel (135

mg/m2) was superior to cisplatin (75 mg/m2) and
cyclophosphamide (600 mg/m2), each given for six cycles

 paclitaxel should be included in the primary treatment

Intraperitoneal Chemotherapy
 Is an acceptable therapeutic alternative to
intravenous chemotherapy with carboplatin and
paclitaxel
 Is more cumbersome and has a higher morbidity than
intravenous therapy
Neoadjuvant Chemotherapy

 Massive ascites and large pleural effusions

 Two or three cycles of chemotherapy before

cytoreductive surgery may be helpful

 It may dry up the effusions,

 Improve the patient's performance status,
 Decrease postoperative morbidity, particularly chest
morbidity
Survival
 Patients younger than 50 years of age have a 5-year
survival rate of about 40%, compared with about 15% for
patients older than 50 years.