2 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 cancerousMass with complex features such as septation papillation and solid componant is more worrisome
3 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
4 CA -125 UNFORTUNATLY it is not specific for ovarean cancer It may be elevated in lung ;appendical and signetring cell carcinomasIn premenopausal elevated in :Leiomyomas;endometriosis;menstruation ;pregnancy ;and pelvic inflamatory .D
5 Should not be checked in the premenopausal patient with a pelvic mass THEREFOREShould not be checked in the premenopausal patient with a pelvic massHow ever in the post menopausal . P with a pelvic mass and elevated CA-125 ovarain cancers is diagnosed in 80% of these patients
6 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 indicatedIf there is a higher level of suspicion or the patient is menopausal oophorectomy is performed and frozen section histologic diagnosis is provided
9 EpidemiologyThe 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.
10 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.
11 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.
13 Early lesions largely asymptomatic Advanced tumors may produce only nonspecific symptoms such as early satiety, abdominal distention, and vague gastrointestinal symptoms.
14 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, omentalinvolvement, and ascites are the rule, rather than the exception, in these women.
15 TREATMENTIn 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.
16 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.
17 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.
18 STAGINGStaging 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 preventablerelapse.
19 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.
20 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.
21 If ascites is present, it should be aspirated and heparinized 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 abdominalcavity and submitted for cytologic evaluation after centrifugation and fixation.I
22 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 patientsexceeds 90%.
23 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, radiotherapyof the whole abdomen, or a single instillation of intraperitonealRADIO ACTIVE CHROMIC PHPSPHATE.
24 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.
25 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 resectionconsists 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.
26 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, patientswith suboptimal ovarian cancers must be treated with chemotherapy.Approximately 80% ofthese tumors will respond to platinum-based combination therapy;
27 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 abdomenwithout further surgical intervention.
28 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.
29 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
30 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.
31 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
32 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.
34 Second _look laparatomy Ovarian cancer often defies diagnosisbecause it does not produce symptoms and is detectable neither radiographically nor serologically, even in relatively advancedstages.The assessment of ovarian cancer during and after therapy is similarly difficult.
35 CA 125 is more sensitive than radiographic or magnetic scanning, Although CT or MRI may identify masses assmall as 2 to 3 em in diameter, neither technique can reliably detect smaller massesCA 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.,
36 The practice of performing exploratory surgery following chemotherapy originated during a time when alkylating agents wereused almost exclusively.Because acute nonmyelocytic leukemia isassociated with prolonged administration of such agents,a "secondlook“ operation was performed at an interval of 12 to 24 months following primery surgery
37 Presently, the duration of postoperative combination chemotherapy is often only 5 to 6 months, and the riskof leukemia is very low.In approximately 20 to 30% of patients who receive such treatment, no cancer will be identified at the timeof a second operation.These patients have an excellent long-term prognosisIn women who have persistent microscopic disease,the prognosis is also favorable,those with persistent gross tumors, the prognosis is relatively poor.
38 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 valuablein determining when therapy can be discontinued and when further treatment is indicated
39 Palliative surgeryIn 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.
40 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 shouldbe aggressive.Resection or bypass of the involved bowel is indicated; colonic resection also may be indicated.
41 When bowel obstruction occurs after chemotherapy, the prognosis is unfavorable. Women who develop such difficulties have alimited 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
42 Laparascopy in ovarian cancer At present,our ability to resect large ovarian cancers successfully using laparoscopic equipmentis limited
43 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,
44 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-oophorectomyOvarian cystectomy or nonextirpative resections commonly result in recurrences,
45 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.
46 Germ cell tumorThese tumors occur in women in the first three decades of lifeTypically 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.
47 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
48 But need not undergo hysterectomy Patients bearing dysgerminomas should undergo appropriate staging at the time ofthe primary resectionBut need not undergo hysterectomy(if fertility is to be preserved) or removal of the opposite ovary if it is normal in appearance,
49 Adjuvant therapy is unnecessary unless there is evidence of extraovarian spread, Either radiotherapy encompassing thewhole abdomen or systemic chemotherapy can be given to patients with metastases,The cure rate exceeds 90% even in patients with metastases
50 The other germ cell tumors, in order of frequency, are: Immature teratomaEndodermal sinus, or "yolk sac," tumorMixed tumorsEmbryonal carcinomasChoriocarcinomas
51 choriocarcinomas secrete hCG. Elevated AFP levels are found in all patients with endodermal sinus tumorsand mixed tumors that contain this componentEmbryonal carcinomas are associated with abnormal levels of both AFP and Hcg.choriocarcinomas secrete hCG.
52 These tumors are invariably unilateral but may spread by peritoneal, hematogenous, or lymphatic routes.Surgical therapy involves unilateral oophorectomy and appropriate stagingExcept 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
53 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 than50%, but prolonged chemotherapy may be necessary, These tumors are not sensetive to radiotherapy.
54 BENING OVARIAN TUMORS INCLODED: Non neoplastic cysts Non functioning tumorsFunctioning tumors
55 NON NEOPLASTIC CYSTBy definative a cystic enlargementof ovary should be at least 2.5 Cm in diameter to be termed cyst :Follicular cystCorpus luteum cystEndometriomasWolffian duct RemnantMullerian Dact Remnant
56 FULLICULAR CYST These are enlarge graafian folicle They grossly true symptomThey can rupture and peritoneal irritationIt can be spontaneosly regress
57 Corpus luteum cyst Mimic to pregnancy and delayed menses and spoting It may become as large as 10 to11 CmThey can rupture lead to sever hemorrhage and vascular collapseSYMPTOM :Mimic to pregnancy and delayed menses and spoting
61 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
62 two type of adenoma is there : They are adequatly treated by salpingo –oophorectomytwo type of adenoma is there :Serous cystadenomaMucinous cystadenoma
63 It is usally necessary to excise ovary completely M –cystadenoma are less likely to be malignant than S-cystadenomaapproximately 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
64 G 0- CARCINOMASome cystadenomase are classified as borderline by hystologic exam that called G 0 carcinomaseThese are excellent prognosisIf they are unilateral may treted by unilateral adnexectomy in reprodactive women
65 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.
66 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,
67 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.
68 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.
69 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.,
70 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).
71 If this material is spilled during surgery, a chemical peritonitis may result; therefore, it is important to removethese tumors intact.The opposite ovary should be inspected, but no further operative procedure is performed if the opposite ovaryappears normal.In approximately 12% of patients, these tumorsare bilateral.In patients of childbearing age, some functional ovariantissue should be preserved.Immature teratomas are treated as other malignant germ cell tumors, with conservative resection and appropriate adjuvant chemotherapy.
72 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.
73 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.
74 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 producea cytologically benign pleural effusion; in such cases, it is termed apseudo-Meigs' syndrome. Meigs' syndrome can be cured by excisingthe fibroma.
75 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,
76 In young girls, they are characteristically manifested by isosexual precocity, In elderly women, they are sometimes associated with postmenopausalbleeding or endometrial carcinoma. tumor
77 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,
78 TREATMENTIf 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 isindicated,
79 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.
80 TREATMENT In young patients with a single involved ovary: unilateral oophorectomy is adequatetherapy, 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.
81 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 theclinical picture of hyperthyroidism and is rarely malignant