MANAGEMENT OF PELVIC MASS ULTRA SOUND : When a pelvic mass is discovered on examination uitrasuond can be helpful in determining characteristic that are worrisome for malignancy: Asimple cyct in premenopusal patient will not be cancerous Mass with complex features such as septation papillation and solid componant is more worrisome
In a premenopausal with a simple cyct ultra sound should be repeated in 6to 8 weeks to see if it is corpus luteum. In post menopausal with complex massevaluation include CT to ruleout omental.D or other site of primery tumor. Barum enemais done to rule out involvement or primery colonic tumor
CA -125 UNFORTUNATLY it is not specific for ovarean cancer It may be elevated in lung ;appendical and signetring cell carcinomas In premenopausal elevated in : Leiomyomas;endometriosis;menstruation ;pregnancy ;and pelvic inflamatory.D
THEREFORE Should not be checked in the premenopausal patient with a pelvic mass How ever in the post menopausal. P with a pelvic mass and elevated CA-125 ovarain cancers is diagnosed in 80% of these patients
In patient with potential for carcinomatosis laparoscopy shouldn’t be done because of port site metastasis that occurs quickly and can make debulking difficult. If all indications are that the lesion is benign ovarian cystectomy or drainage is indicated If there is a higher level of suspicion or the patient is menopausal oophorectomy is performed and frozen section histologic diagnosis is provided
Epidemiology The majority of the 27,000 or more cases of ovarian cancer diagnosed annually in the United States are of the epithelial type. The median age at diagnosis for epithelial ovarian cancer is 61 years, Approximately 15,000 women die of this disease in the United States annually.
Approximately 5% of patients with epithelial tumors come from families where one or more first-degree relatives also have the disease. In such families, prophylactic oophorectomy may be considered at the completion of childbearing, especially if specific BRCA I or BRCA2 mutations are identified.
Primary peritoneal carcinomatosis has been reported in women who have undergone prophylactic surgery, however. Life-long screening with CA 125 levels, pelvic examination, and vaginal ultrasonography of women from affected families is important.
Early lesions largely asymptomatic Advanced tumors may produce only nonspecific symptoms such as early satiety, abdominal distention, and vague gastrointestinal symptoms.
cost-effective screening programs using serum markers such as CA 125 and vaginal ultrasound examination are being developed. Currently, the more than 70% of women with epithelial cancer have stage III tumors at the time of diagnosis. Widespread peritoneal dissemination, omental involvement, and ascites are the rule, rather than the exception, in these women.
TREATMENT In general, therapy for epithelial ovarian cancer consists of surgical resection and appropriate staging followed by adjuvant radiation or chemotherapy. Women with low-grade early stage (IA or IB) cancers who have undergone appropriate surgical staging may be treated with surgery without adjuvant therapy.
If the lesion is bilateral (stage IB), abdominal hysterectomy and bilateral salpingo-oophorectomy are sufficient. It is in the limited group of patients with unilateral histologic grade I or 2 lesions that fertility can be preserved by performing adnexectomy and staging biopsies without removing the uterus or contralateral ovary and fallopian tube.
In all other patients (stage lA, grade 3, and stage IC and above), appropriate initial surgery includes bilateral salpingo-oophorectomy, abdominal hysterectomy if the uterus has not been removed on a prior occasion, appropriate staging, and tumor resection.
STAGING Staging indicates surgical resection or biopsy of all potential areas of tumor spread.. Among patients whose cancer is confined to one or both ovaries at the time of gross inspection, occult metastases can be identified by careful surgical staging in one-third. If staging is improperly performed and adjuvant therapy omitted in patients whose tumors are apparently confined to the ovary, 35% will suffer preventable relapse.
Epithelial ovarian cancers disseminate along peritoneal surfaces and by lymphatic channels. The first site of spread is the pelvic peritoneum. Later the abdominal peritoneal surfaces and diaphragms are involved. The omentum is a common site for metastases, as are both the para-aortic and pelvic lymph nodes.
Because the abdominal cavity in its entirety is not accessible through a transverse pelvic incision, it is paramount that surgery for ovarian malignancies beperformed through a full-length midline abdominal incision. After the peritoneal cavity is entered, the visceral and parietal surfaces are inspected for metastatic disease, and any suspicious areas are biopsied.
If ascites is present, it should be aspirated and heparinized. Cytologic evaluation for metastatic cells or clusters is then performed. If no ascites is found, peritoneal washings with balanced salt solution or lactated Ringer's solution are obtained from the abdominal cavity and submitted for cytologic evaluation after centrifugation and fixation. I
Appropriately staged patients with histologic grade I or grade 2 tumors confined to one or both ovaries (stage IA or IB) require no postoperative therapy. Five-year survival in this group of patients exceeds 90%.
Those patients who have stage I, grade 3 lesions, stage IC tumors (malignant peritoneal washings, rupture of tumor, surface excrescences, or ascites), or stage II cancers that are completely resected may be treated equally well with systemic chemotherapy, radiotherapy of the whole abdomen, or a single instillation of intraperitonealRADIO ACTIVE CHROMIC PHPSPHATE.
Women with stages III and IV disease require systemic chemotherapy with cisplatin or carboplatin, generally in combination with a taxane such as paclitaxel. Survival at 5 years in such patients may exceed 20%, although this rate drops as low as 10% at 10 years.
It is widely accepted that patients in whom little or no residual disease remains after initial operation, on average, live longer than those in whom a great deal of tumor remains unresected. The terms debulking and cytoreduction indicate aggressive surgical removal of ovarian cancer. When disease remaining after surgical resection consists of nodules or plaques less than I to 2 cm in diameter, the surgical effort is termed optimal, and when a larger volume of residual disease remains, the surgical removal is termed suboptimal.
Resection of nodules involving the small or large bowel is warranted if the exercise results in complete removal of all observed disease. Such procedures are probably not indicated if tumor remains at other sites. After surgical extirpation of the tumor, patients with suboptimal ovarian cancers must be treated with chemotherapy. Approximately 80% ofthese tumors will respond to platinum-based combination therapy;
Resection of advanced tumor When advanced ovarian carcinoma is discovered at the time of exploratory laparotomy, the first reaction is often one of resignation. There has been a tendency to perform a diagnostic biopsy and close the abdomen without further surgical intervention.
In experienced hands, however, successful reduction of tumor volume to nodules 2 cm or less is possible in at least 50% of women with advanced ovarian cancer. If the primary surgeon is incapable of obtaining such results, the patient should be referred to one with sufficient expertise in this area. Survival following chemotherapy is inversely related to the volume of residual disease at the time of primary surgery.
Several techniques ensure adequate resection. First, most ovarian cancer is found on peritoneal surfaces and not invading viscera. A retroperitoneal approach thus facilitates mobilization of the involved mesothelium. The lateral aspects of the paracolic gutters may be incised and dissection carried medially to undermine tumors in these location
The ovarian artery and vein should be identified at this point and securely ligated before division. It is often useful to dissect the ureter from the underlying pelvic peritoneum and retract it laterally with a vessel loop. This allows access to the lateral pelvic peritoneum. Tumor nodules on anterior and posterior cul-de-sac peritoneum may be resected by developing planes in the retroperitoneal spaces and isolating the disease from the underlying bladder, sigmoid colon, and ureters. Opening the pararectal and paravesical spaces facilitates this dissection and also allows access to the uterine vessels, which then may be clamped, ligated, and divided. When the hysterectomy and adnexectomy are complete, the omentum may be resected.
Disease on the right diaphragm may be resected by transecting the falciform ligament and retracting the liver inferiorly. If it serves to remove all remaining tumor, splenectomy may be performed. Resection of small and large bowel may be performed if the operation removes all
Use of the ultrasound aspirator and argon beam coagulator have resulted in an increased ability to completely remove tumors, including those that are implanted on the serosal surfaces and mesentery of the bowel. With diligence it is often possible to remove all appreciable disease with these instruments.
Second _look operation
Second _look laparatomy Ovarian cancer often defies diagnosis because it does not produce symptoms and is detectable neither radiographically nor serologically, even in relatively advanced stages. The assessment of ovarian cancer during and after therapy is similarly difficult.
Although CT or MRI may identify masses as small as 2 to 3 em in diameter, neither technique can reliably detect smaller masses CA 125 is more sensitive than radiographic or magnetic scanning, but is also associated with a number of false positive results and may not be elevated in patients with mucinous tumors.,
The practice of performing exploratory surgery following chemotherapy originated during a time when alkylating agents were used almost exclusively. Because acute nonmyelocytic leukemia is associated with prolonged administration of such agents, a "secondlook“ operation was performed at an interval of 12 to 24 months following primery surgery
Presently, the duration of postoperative combination chemotherapy is often only 5 to 6 months, and the risk of leukemia is very low. In approximately 20 to 30% of patients who receive such treatment, no cancer will be identified at the time of a second operation. These patients have an excellent long-term prognosis In women who have persistent microscopic disease, the prognosis is also favorable, those with persistent gross tumors, the prognosis is relatively poor.
Second-look surgery is currently used primarily as a research tool. New treatment regimens can be evaluated quickly by performing a second-look operation,. Second-look surgery is also valuable in determining when therapy can be discontinued and when further treatment is indicated
Palliative surgery In most cases of advanced ovarian cancer, death is associated with bowel dysfunction or frank obstruction. Although invasion of the small bowel and colon is unusual, growth of the tumor adjacent to the bowel leads to mesenteric compromise and dysfunction usually heralded by distention, nausea, and vomiting.
When bowel obstruction occurs early in the clinical course of ovarian cance particularly if it occurs before the administration of chemotherapy, surgical intervention is warranted and should be aggressive. Resection or bypass of the involved bowel is indicated; colonic resection also may be indicated.
When bowel obstruction occurs after chemotherapy, the prognosis is unfavorable. Women who develop such difficulties have a limited survival following surgical correction. Laparotomy may be complicated by intestinal injury or fistula. Often the best approach in these patients is the use of a percutaneous or endoscopically positioned gastrostomy tube and intra venus fluids or conservative nutritional support
Laparascopy in ovarian cancer At present, our ability to resect large ovarian cancers successfully using laparoscopic equipment is limited
Tumor with low malignant potential These are epithelial tumors of malignant potential intermediate between benign lesions and frank malignancies, Histologically, most are of the serous type, Although these tumors may be associated with epithelial budding, atypia, mitoses, and stratification,
The median age of diagnosis is approximately 10years younger than that of patients with epithelial cancers, The vast majority occur in stage I and have a favorable prognosis, Surgery should include abdominal hysterectomy and bilateral salpingo-oophorectomy unless fertility is to be preserved in patients with unilateral lesions, These patients may undergo unilateral salpingo- oophorectomy Ovarian cystectomy or nonextirpative resections commonly result in recurrences,
Patients with stages III and IV lesions have 5-year survival rates that approach 85% after complete surgical resection. There is little evidence that chemotherapy or radiotherapy administered after surgery improves survival. on the other hand, deaths from chemotherapy-induced leukemia are not uncommon.
Germ cell tumor These tumors occur in women in the first three decades of life Typically grow rapidly, producing symptoms of distention and abdominal fullness, Torsion may occur, producing an acute abdomen, Most are unilateral, and all have a tendency to spread to the paraaortic lymph nodes, as well as throughout the peritoneal cavity.
Dysgerminoma, the female equivalent of testicular seminoma, is composed of pure, undifferentiated germ cells. It is bilateral in 10 to 15% of patients and is occasionally associated with elevated levels of hCG or lactate dehydrogenase (LDH). It is the most common ovarian malignancy diagnosed during pregnancy
Patients bearing dysgerminomas should undergo appropriate staging at the time of the primary resection But need not undergo hysterectomy (if fertility is to be preserved) or removal of the opposite ovary if it is normal in appearance,
Adjuvant therapy is unnecessary unless there is evidence of extraovarian spread, Either radiotherapy encompassing the whole abdomen or systemic chemotherapy can be given to patients with metastases, The cure rate exceeds 90% even in patients with metastases
The other germ cell tumors, in order of frequency, are: Immature teratoma Endodermal sinus, or "yolk sac," tumor Mixed tumors Embryonal carcinomas Choriocarcinomas
Elevated AFP levels are found in all patients with endodermal sinus tumors and mixed tumors that contain this component Embryonal carcinomas are associated with abnormal levels of both AFP and Hcg. choriocarcinomas secrete hCG.
These tumors are invariably unilateral but may spread by peritoneal, hematogenous, or lymphatic routes. Surgical therapy involves unilateral oophorectomy and appropriate staging Except for those with completely resected stage I, grade I immature teratomas and those with stage I dysgerminoma, all patients with germ cell tumors require systemic chemotherapy
Three courses of a platinum and etoposide- containing combination suffice in those patients whose tumors are completely resected, Cure rates in these patients approach 90%. In women with incompletely resected nondysgerminomatous germ cell tumors, cure may still be expected in more than 50%, but prolonged chemotherapy may be necessary, These tumors are not sensetive to radiotherapy.
BENING OVARIAN TUMORS INCLODED: Non neoplastic cysts Non functioning tumors Functioning tumors
NON NEOPLASTIC CYST By definative a cystic enlargementof ovary should be at least 2.5 Cm in diameter to be termed cyst : Follicular cyst Corpus luteum cyst Endometriomas Wolffian duct Remnant Mullerian Dact Remnant
FULLICULAR CYST These are enlarge graafian folicle They grossly true symptom They can rupture and peritoneal irritation It can be spontaneosly regress
Corpus luteum cyst It may become as large as 10 to11 Cm They can rupture lead to sever hemorrhage and vascular collapse SYMPTOM : Mimic to pregnancy and delayed menses and spoting
Endometriomas These account CHOCOLATE CYSTthat detail preview
Wolffian duct remnant They are ovarean cyst but mimic tumor of ovary They are small but may enlarge and infarct These are incidental finding at laparotomy and cause no difficult or symtom
cystadenomase -Appear as cyst with trans lucent wall and clear fluid and lined by ciliated epithelium -They are usaly on pedicle and may torsion leading pain and infarct
They are adequatly treated by salpingo – oophorectomy two type of adenoma is there : Serous cystadenoma Mucinous cystadenoma
M –cystadenoma are less likely to be malignant than S-cystadenoma approximately 20% of S-cystadenoma and 5% m-cysadenoma are bilateral-cystic lesion with solid componant not alwase bining or malignant so : It is usally necessary to excise ovary completely
G 0- CARCINOMA Some cystadenomase are classified as borderline by hystologic exam that called G 0 carcinomase These are excellent prognosis If they are unilateral may treted by unilateral adnexectomy in reprodactive women
Frozen-section examination of the tumor at the time of surgical intervention is necessary to determine the proper course of therapy for patients in the reproductive age group. The opposite ovary should be inspected.
Psudo myxoma peritonei Occasionally, a condition known as pseudomyxoma peritonei isencountered; this is a locally infiltrating tumor composed of multiple cysts containing thick mucin. These tumors arise either from ovarian mucinous cystadenomas or from mucoceles of the appendix,
Histologically, they are benign,but by local spread and infiltration they compromise surrounding vital structures. Localized tumors should be excised completely, if possible. Both ovaries and the appendix are removed, even though they grossly appear to be normal.
Mature Teratoma These germ cell tumors are thought to arise from the totipotential germ cells of the ovary. The tumors often contain calcified masses, and, occasionally, either teeth or pieces of bone can be seen on abdominal radiographs.
If a teratoma (dermoid) is encountered in a young woman, it is preferable to shell it out from the ovarian stroma preserving functioning tissue in the affected ovary.,
Mature teratomas occur at any age but are more frequent in patients between 20 and 40 years old. They are benign dermoid cysts. The occasional solid teratoma is usually malignant (immature teratoma).
If this material is spilled during surgery, a chemical peritonitis may result; therefore, it is important to remove these tumors intact. The opposite ovary should be inspected, but no further operative procedure is performed if the opposite ovary appears normal. In approximately 12% of patients, these tumors are bilateral. In patients of childbearing age, some functional ovarian tissue should be preserved. Immature teratomas are treated as other malignant germ cell tumors, with conservative resection and appropriate adjuvant chemotherapy.
Brener tumor These are rare epithelial tumors that usually do not secrete hormones. Histologically, the epithelial elements are similar to Walthard rests and are believed to arise from them. These tumors occur primarily in later life and have a small malignant potential. Simple oophorectomy is usually sufficient therapy, and the prognosis is excellent.
Meigs syndrome This pertains to ascites with hydrothorax, seen in association with benign ovarian tumors with fibrous elements, usually fibromas. It is more common to see fluid accumulation with ovarian fibromas that are more than 6 cm in size.
The cause of the condition is unknown, but the ascitic fluid may originate from the tumor, as a result of lymphatic obstruction of the ovary. Frequently, this clinical picture is encountered with other ovarian tumors, especially ovarian malignancies, which can produce a cytologically benign pleural effusion; in such cases, it is termed apseudo-Meigs' syndrome. Meigs' syndrome can be cured by excising the fibroma.
Granulosa cell tumor Pure theca cell tumors (thecomas) are benign, but those with granulosa cell elements may be malignant It is often impossible to predict their behavior from the histologic features,and prolonged follow-up is necessary in order to judge the nature. Usually, granulosa cell tumors elaborate estrogen, but some of these tumors have no hormone production,
In young girls, they are characteristically manifested by isosexual precocity, In elderly women, they are sometimes associated with postmenopausal bleeding or endometrial carcinoma. tumor
The tumor can occur at all ages from childhood to the postmenopausal period, most common in later life, with maximal occurrence between the ages of 40and 60 years,
TREATMENT If the tumor is discovered in the reproductive years and confined to one ovary without signs of surface spread or dissemination: simple oophorectomy may be sufficient therapy, IFIt is discovered in later life : removal of both ovaries with the uterus is indicated,
SERTOLI-LEYDIG CELL TUMOR (ARRHENOBLASTOMAS) These rare, but potentially malignant, Tumors are associated with androgen output and masculinization. Rarely, they elaborate estrogen. They usually occur in the reproductive age group and appear to contain tubular structures as well as Leydig-type cells.
TREATMENT In young patients with a single involved ovary: unilateral oophorectomy is adequate therapy, provided there is no extension of the tumor. For older patients or for those with bilateral involvement: total hysterectomy and bilateral salpingo- oophorectomy are performed.
STROMA OVARII This term refers to the presence of grossly detectable thyroid tissue in the ovary, usually as the predominant element in dermoid cysts. This tissue occasionally may produce the clinical picture of hyperthyroidism and is rarely malignant