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Ovarian neoplasms. Anita Chudecka - Głaz Ovarian neoplasms.

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Presentation on theme: "Ovarian neoplasms. Anita Chudecka - Głaz Ovarian neoplasms."— Presentation transcript:

1 Ovarian neoplasms. Anita Chudecka - Głaz Ovarian neoplasms.

2 Ovarian neoplasms. Anita Chudecka - Głaz Human ovarian neoplasms (especially epithelial ovarian cancer) presents a major challenge to oncological research, because they are frequently diagnosed late and show poor prognosis and low survival despite the apparent success of chemotherapy in achieving remission with no evidence of disease.

3 Ovarian neoplasms. Anita Chudecka - Głaz Epithelial ovarian cancer is the fourth most common cause of death from cancer in women and the most lethal of gynaecologic neoplasms. Epithelial ovarian cancer is the fourth most common cause of death from cancer in women and the most lethal of gynaecologic neoplasms.

4 Ovarian neoplasms. Anita Chudecka - Głaz The most important positive prognostic feature continues to be diagnosis at an early stage. BUT EARLY STAGE OVARIAN CANCERS DON’T PRODUCE SYMPTOMS !!!

5 Ovarian neoplasms. Anita Chudecka - Głaz The incidence of ovarian cancer is relatively high in Scandinavian (15/100000) countries, lower in western Europe and North America ( 10/ ) and low in Japan (3/100000).

6 Ovarian neoplasms. Anita Chudecka - Głaz ETIOLOGY Two hypotheses have been proposed to explain the biological mechanisms that increase the risk of ovarian cancer : u genetics ugonadotropin hypothesis

7 Ovarian neoplasms. Anita Chudecka - Głaz ETIOLOGY The involvement of gonadotropins in human ovarian carcinoma is backed by a number of epidemiological and experimental studies showing:  increase occurrence of disease with exposure to high levels of LH, FSH during menopause, after ovariectomy or during fertility treatment

8 Ovarian neoplasms. Anita Chudecka - Głaz ETIOLOGY  reduced risk of cancer associated with multiple pregnancies, oral contraceptives, breast - feeding  LH and hCG receptors are expressed in 40% of epithelial ovarian cancer  LHRH receptors are expressed in almost 80% of EOC

9 Ovarian neoplasms. Anita Chudecka - Głaz ETIOLOGY  deficit of cases of ovarian cancer among women with diagnosis of alcoholism in  animals ovarian cancer may be induced by gonadal radiation or chemical toxins that cause premature oocyte death, but hypophysectomized animals do not develop ovarian tumours after oocyte depletion which suggests a specific role of gonadotropins

10 Ovarian neoplasms. Anita Chudecka - Głaz ETIOLOGY other risk factors:  diet  talc  pelvic irradiation  viruses  age

11 Ovarian neoplasms. Anita Chudecka - Głaz ETIOLOGY other risk factors:  PID  endometriosis  blood group  legal status  education

12 Ovarian neoplasms. Anita Chudecka - Głaz SYMPTOMS EOC oftenest are asymptomatic until advanced stage, when the prognosis is poor and 5 year survival less then 40%. EOC oftenest are asymptomatic until advanced stage, when the prognosis is poor and 5 year survival less then 40%.

13 Ovarian neoplasms. Anita Chudecka - Głaz SYMPTOMS Irrespective of histology, most ovarian neoplasms when they have large size in advanced stage cause symptoms by exerting pressure on contiguous structures (urinary frequency, pelvic discomfort and constipation).

14 Ovarian neoplasms. Anita Chudecka - Głaz SYMPTOMS The most common :  abdominal swelling  fatigue  abdominal pain

15 Ovarian neoplasms. Anita Chudecka - Głaz SYMPTOMS Upper abdominal metastases or ascites cause nausea, heart burn, bloating, weight loss and anorexia. Acute abdominal pain secondary to haemorrhage, rupture or torsion can all result from tumour growth.

16 Ovarian neoplasms. Anita Chudecka - Głaz SYMPTOMS Biologically active hormones, including estrogen, progesterone, testosterone, corticosteroids and hCG can be produce by a variety of ovarian neoplasms and cause the predicted symptoms associated with each compound.

17 Ovarian neoplasms. Anita Chudecka - Głaz DIAGNOSIS 1. Physical examination-bimanual rectovaginal pelvic examination 2. Ultrasound investigation 3. Tumour markers 4. Ascites puncture 5. Biopsy the tumour 6. Laparoscopy 7. CT 8. NMR 9. Chest X ray

18 Ovarian neoplasms. Anita Chudecka - Głaz ULTRASONOGRAPHY  abdominal  transvaginal TVS  colour Doppler CDI ULTRASONOGRAPHY

19 Ovarian neoplasms. Anita Chudecka - Głaz TUMOR MARKERS epithelial ovarian cancer CA 125 CA 125 CA 19-9 CEA

20 Ovarian neoplasms. Anita Chudecka - Głaz TUMOR MARKERS endodermal sinus tumors embryonal carcinomas mixed germ cell tumors rarely immature teratoma and polyembryoma AFP

21 Ovarian neoplasms. Anita Chudecka - Głaz TUMOR MARKERS chorioncarcinoma embryonal carcinoma mixed germ cell tumors polyembryoma hCG

22 Ovarian neoplasms. Anita Chudecka - Głaz TUMOR MARKERS adult granulosa cell tumors thecomas ESTRADIOL

23 Ovarian neoplasms. Anita Chudecka - Głaz TUMOR MARKERS adult granulosa cell tumors INHIBIN

24 PREMENOPAUSAL OVARIAN MASS EXCLUDE NON-GYNAECOLOGICAL PROBLEM Surgical evaluation Solid or complex on US OR > 6 cm OR Elevated AFP/hCG/LDH OR Elevated CA 125 Simple on US AND < 6 cm AND Normal CA 125 Observation for 6-8 weeks and Gonadotrpopin suppression Peristent on US

25 POSTMENOPAUSAL OVARIAN MASS EXCLUDE NON-GYNAECOLOGICAL PROBLEM Surgical Evaluation SymptomaticOR Complex on USOR > 3 cmOR Elevated CA 125 AsymptomaticAND Simple on USAND < 3 cmAND Normal CA 125 Observe with Follow up US

26 Ovarian neoplasms. Anita Chudecka - Głaz DIFFERENTIAL DIAGNOSIS  gynaecologic  tuboovarian abscess  ectopic pregnancy  leiomyoma  fallopian tube neoplasia  luteal or follicular cysts

27 Ovarian neoplasms. Anita Chudecka - Głaz DIFFERENTIAL DIAGNOSIS  gynaecologic  ovarian hyperthecosis  pregnancy luteoma  theca-lutein cysts  endometrioma  simple cysts

28 Ovarian neoplasms. Anita Chudecka - Głaz DIFFERENTIAL DIAGNOSIS  nongynaecologic  diverticular disease  appendiceal abscess  Crohn’s disease  primary nongynaecological malignancy  pelvic kidney

29 Ovarian neoplasms. Anita Chudecka - Głaz CLASSIFICATION 1. Epithelial ovarian tumours - 70% of all ovarian neoplasms 2. Sex cord stromal tumours 5-10% 3. Germ cell tumours 15-20% 4. Metastatic 5 % 5. Other

30 Ovarian neoplasms. Anita Chudecka - Głaz Epithelial ovarian neoplasms malignantborderlinebenign

31 Ovarian neoplasms. Anita Chudecka - Głaz

32 SEX CORD STROMAL TUMOURS 1. Granulosa stromal cell k granulosa cell k thecoma-fibroma 2. Sertoli stromal cell 3. Lipid cell tumours 4. Gynanandroblastoma

33 Ovarian neoplasms. Anita Chudecka - Głaz GERM CELL TUMOURS 1. Dysgerminoma 2. Endodermal sinus tumour 3. Embryonal carcinoma 4. Polyembryoma 5. Chorioncarcinoma 6. Teratomas 7. Mixed forms 8. Gonadoblastoma

34 Ovarian neoplasms. Anita Chudecka - Głaz STAGE I Growth limited to the ovaries

35 Ovarian neoplasms. Anita Chudecka - Głaz STAGE II Growth involving one or both ovaries with pelvic extension

36 Ovarian neoplasms. Anita Chudecka - Głaz STAGE III Tumour involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperotoneal or inguinal nodes; superficial liver metastasis ; tumour is limited to the true pelvis but with histologically proven malignant extension to small bowel or omentum

37 Ovarian neoplasms. Anita Chudecka - Głaz STAGE IV Tumour involving one or both ovaries with distant metastases; if pleural effusion is present, there must be positive cytology to allot a case to stage IV

38 Ovarian neoplasms. Anita Chudecka - Głaz Five - year survival rates for epithelial ovarian cancer Stage IA82,3% IB74,9% IC67,7% IIA 60,6% IIB&IIC53,8% III22,7% IV 8 %

39 Ovarian neoplasms. Anita Chudecka - Głaz PREDICTORS OF SURVIVAL  stage  grade  age  residual disease  max. cytoreductive surgery  histopathology  others ( protein p53, CA 125, EGF-R)

40 Ovarian neoplasms. Anita Chudecka - Głaz TREATMENT surgical chemotherapy radiotherapy hormonal treatment postoperative procedures

41 Nowotwory jajnika. Anita Chudecka - Głaz SURGICAL TREATMENT cytoreductive operation: " hysterectomy " bilateral oophorectomy " omentectomy " appendectomy " lypmphadenectomy ??

42 Ovarian neoplasms. Anita Chudecka - Głaz CHEMOTHERAPY CT PC PAC Vepesid or Ifosfamid with CDDP as II LINE CHT. Hycamptin or Gemzar as III LINE CHT. I LINE CHEMOTHERAPY

43 Ovarian neoplasms. Anita Chudecka - Głaz SURGICAL TREATMENT - EOC  benign In young women conservative surgery usually including cystectomy or oophorectomy. In postmenopausal women TAH/BSO should be considered to avoid the risk of cancer in the future.  borderline In young women conservative surgery oophorectomy or USO can be performed. In women who have completed their child bearing a TAH/BSO/Omentectomy is appropriate always with very precise surgical staging.

44 Ovarian neoplasms. Anita Chudecka - Głaz SURGICAL TREATMENT - EOC  malignant In all cases we have to carry out cytoreductive surgery. It includes TAH/BSO complete omentectomy with resection of any metastatic lesions. In some cases bowel resection and retroperitoneal lymphadenectomy are necessary in order to obtain optimum cytoreduction. Optimum cytoreduction is achieved when the largest residual tumour mass measures less then 1,5 cm.

45 Ovarian neoplasms. Anita Chudecka - Głaz POSTOPERATIVE TREATMENT - EOC  chemotherapy Platinum-based combination with paclitaxel chemotherapy is now the standard postoperative treatment for patient with ovarian cancer  radiation therapy It is useful method especially in patient who have positive second-look laparoscopy or laparotomy after chemotherapy treatment but the residual mass are less than 2 cm.  hormonal treatment

46 Ovarian neoplasms. Anita Chudecka - Głaz FOLLOW - UP  second-look laparoscopy every year during first 5 year to detect early microscopic relapse  CA 125 every 3 to 4 month  complete medical history  physical examination  rectovaginal pelvic examination

47 Ovarian neoplasms. Anita Chudecka - Głaz SCREENING Screening is recommended in women with HOCS and HBOCS and include: Ø rectovaginal pelvic examination Ø CA 125 determination Ø TVS Ø prophylactic TAH/BSO

48 Ovarian neoplasms. Anita Chudecka - Głaz MALIGNANT GERM CELL TUMOURS  Dysgerminoma most common germ cell malignancy, in 10-15% is bilateral, survival rate for early stage is 95% and even in advanced stage grater then 80% when appropriate adjuvant therapy is given. LDH is useful tumour marker. hCG levels is elevated in small number of patients. In young women and stage I unilateral oophorectomy is recommended with inspection and biopsy of opposite ovary and staging with retroperitoneal lymphadenectomy. In other women TAH/BSO. Adjuvant therapy should be given in all patients radiotherapy and/or chemotherpy.

49 Ovarian neoplasms. Anita Chudecka - Głaz MALIGNANT GERM CELL TUMOUR  Embryonal carcinoma is quite rare, rarely bilateral and trends to spread intraperitoneally, survival is slightly better then with EST using the same platinum based chemotherapy regiments. Both AFP and hCG can serve as tumour markers. Surgical treatment depend on age and stage. Adjuvant therapy ( chemotherapy) is recommended in all cases.

50 Ovarian neoplasms. Anita Chudecka - Głaz MALIGNANT GERM CELL TUMOURS  Immature teratoma represents approximately 20% of all malignant germ cell tumours and 25 % in girls under 10. After grade surgicopathologic stage is the most prognostic factors. Fortunately most patient are diagnosed with early stage. Occasionally immature carcinoma produce AFP as tumour marker but hCG is never produced. Surgical treatment depend on age and stage. Chemotherapy is kind of adjuvant therapy but only in immature teratoma of all malignant germ cell tumours chemotherapy in stage IA grade I does not benefit.

51 Ovarian neoplasms. Anita Chudecka - Głaz MALIGNANT GERM CELL TUMOURS  Endodermal sinus tumour also known as “yolk sac tumour” is an extremely aggressive malignancy. Almost never is bilateral. Intraperitoneal and hematogenous spread is common. Commonly patients present with acute abdomen secondary to spontaneous rupture and haemorrhagiae. Platinum based chemotherapy significantly improves the survival. AFP is useful tumour marker.

52 Ovarian neoplasms. Anita Chudecka - Głaz MALIGNANT GERM CELL TUMOURS  Chorioncarcinoma nongestational is extremely rare, 50% is diagnosed in prepuberatal females, produced hCG as tumour marker. Although gestsational chorioncarcinoma is treated successfully in most patients with platinum based chemotherapy, remission is less common in patients with nongestational type.  Polyembryoma  Mixed

53 Ovarian neoplasms. Anita Chudecka - Głaz BENIGN GERM CELL TUMOURS  Gonadoblastoma is almost always found in patients with gonadal dysgenesis associated with chromosome Y. In 50% coexist with malignant germ cell tumours  Teratomas 25-40% of all ovarian neoplasms. The most common is cystic teratoma - “dermoid cysts”. Most cases diagnosed in premenopausal women. Most patients are asymptomatic and often dermoids are diagnosed by usg. This tumours can be bilateral in 15%. The risk of malignancy is 1-2% and most commonly occurs in postmenopausal women.  Struma ovarii it is dermoid where thyroid tissue comprises greater than 50% of teratomas. This is unusual and accounts for only 2,7% of ovarian teratomas.

54 Ovarian neoplasms. Anita Chudecka - Głaz SEX CORD STROMAL TUMOURS  Adult granulosa cell tumours (GCTs) excess estrogen production is often found causing precocious puberty and menometrorrhagia in menstruating or postmenopausal. Endometrial hyperplasia or carcinoma is at 60% in patients with this tumour.50% occur in postmenopausal women and only 5% in prepubertal girls. It is interestin that this king of tumour may relapse after many years ( even above 20 ) after primary diagnosis. Estardiol and in nowadays inhibin are useful tumour marker.

55 Ovarian neoplasms. Anita Chudecka - Głaz SEX CORD STROMAL TUMOURS  Juvenile granulosa cell tumours in 50% occur in prebubertal girls, rare relapse after many years from diagnosis, typically is early recurrence. Rarely lethal as GCTs.  Fibroma unilateral, diagnosed in 5 decade of life. Hormone production is unusual, eventually estrogen. It is benign tumour, when 1 to 3 mitoses are present is called cellular fibroma, if greater then 3 it is considered as fibrosarcoma.  Thecoma very similar to fibroma but more commonly produce etsrogen which causes postmenopausal bleeding, menorrhagia, endometrial hyperplasia or cancer.

56 Ovarian neoplasms. Anita Chudecka - Głaz SEX CORD STROMAL TUMOURS  Sertoli stromal cell tumours 1 % of all ovarian neoplasms, many of these tumours androgen producing, many are hormonally inert and some occasionally may produce estrogen. Diagnosed of pure Sertoli tumours is unlikely in the presence of virilization. Rarely is malignant.  Sertoli-Leydig cell tumours are the most common in these group, 40% have evidence of estrogen or androgen production, unilateral and occur in 3 decade of life. Rather frequently is malignant.  Sex cord tumour with annular tubules (SCTAT) in 30% associated with Peutz-Jegers syndrome.

57 Ovarian neoplasms. Anita Chudecka - Głaz SEX CORD STROMAL TUMOURS  Lipid cell tumour are typically virilizing with increased serum levels of testosteron and androstendione. Occasionally produce estrogen, estron and cortisol and in 10% cases Cushing Syndrom in found. In 20 % develop metastases.  Gynanroblastoma is rare ovarian tumours which contain granulosa stromal cell and Sertoli stromal cell tumours.  Leydig cell tumours mean age is 50 and almost always behaves in benign fashion. Testosterone is commonly produced resulting in mild virilization.


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