Rahimullah Khattak Final Year MBBS

 Anatomy of the Ovary  Classification  Incidence  Risk Factors  Spread and Screening  Signs and Symptoms  Investigations  Staging  Differential Diagnosis  Treatment and Management

 Cancer that arises in the epithelium, the tissue that lines the skin and internal organs of the body, and has a malignant potential as well.

 Surface Epithelial Tumors Serous Tumor Mucinous Tumor Endometrioid Tumor Clear-cell Tumor Brenner Tumor Cystadenofibroma

 Germ-cell Tumors  Teratoma  Dysgerminoma  Yolk sac Tumor  Choriocarcinoma  Sex Cord Stromal Tumors  Fibroma  Granulosa-theca cell Tumor  Sertoli-Leydig cell Tumor  Metastasis to Ovaries

 In general ovarian malignancy accounts for 25% of gynaecological cancers.  Among ovarian tumors only 10% are malignant.

1. Nulliparity 2. Family history There is a higher incidence of carcinoma in unmarried women and married women with low parity. Interestingly, prolonged use of oral contraceptives reduces the risk somewhat.

. Direct spread.  Neighbouring organs like fallopian tube, uterus, bladder and pelvic peritonium.  Lymphatic spread.  Via lymphatic channel to the diaphragm, omentum, peritonial surfaces of small and large bowel, liver and parietal peritonium throughout the abdominal cavity.  Blood metastasis.  to the liver, lungs, bones and brain but occurs late in the course of the disease

 Limited by two factors;  Ovary is not an accessible organ.  A premalignant stage of ovarian cancr has not yet been recognized.  Screening includes, bimanual pelvic examination, ultrasonography and tumour markers.

 Abdominal Pain or discomfort  Distention or feeling a lump  Indigestion  Urinary frequency  Abnormal menses

 Ultrasound.  Radiological Investigations.  Chest x-ray  Barium studies to assess bowel involvement.  Imaging techniques.  CT scan  MRI  Lymphangio-graphy

 Cytology.  Fine needle aspiration done in clinically suspicious lymph nodes in the groin and neck.  Tumor markers.  CA-125 (<35 IU/mL)  Haematological investigations.  Full blood count, urea, creatinine, electrolytes and liver function tests.

 The Federation Internationale de Gynecologie et d'Obstetrique (FIGO) and the American Joint Committee on Cancer (AJCC) have designated staging.

 Limited to the ovaries.  Stage IA: tumour limited to 1 ovary, the capsule is intact, no tumour on ovarian surface and no malignant cells in ascites or peritoneal washings.  Stage IB: tumour limited to both ovaries, capsules intact, no tumour on ovarian surface and no malignant cells in ascites or peritoneal washings.  Stage IC: tumour is limited to 1 or both ovaries with any of the following: capsule ruptured, tumour on ovarian surface, malignant cells in ascites or peritoneal washings.

 Tumors involving 1 or both ovaries with pelvic extension and/or implants.  Stage IIA: extension and/or implants on the uterus and/or fallopian tubes. No malignant cells in ascites or peritoneal washings.  Stage IIB: extension to and/or implants on other pelvic tissues. No malignant cells in ascites or peritoneal washings.  Stage IIC: Pelvic extension and/or implants (stage IIA or stage IIB) with malignant cells in ascites or peritoneal washings.

 Tumours involving 1 or both ovaries with microscopically confirmed peritoneal implants outside the pelvis. Superficial liver metastasis equals stage III.   Stage IIIA: microscopic peritoneal metastasis beyond pelvis (no macroscopic tumour).  Stage IIIB: macroscopic peritoneal metastasis beyond pelvis less than 2 cm in greatest dimension.  Stage IIIC: peritoneal metastasis beyond pelvis greater than 2 cm in greatest dimension and/or regional lymph node metastasis.

Tumours involving 1 or both ovaries with distant metastasis. Parenchymal liver metastasis equals stage IV.

 Distended urinary bladder  Pregnancy  Uterine swelling and displacements  Fallopian tube swelling  Pelvic abscess  Endometriosis, adenomycosis  Ascites  Broad ligament cyst

 History  GPE  Per Abdominal Examination  Per Vaginal Examination  Surgery is main stay for treatment and diagnosis.

 Hormone therapy is the use of hormones or drugs that block hormones to fight cancer.  Hormone therapy is rarely used to treat epithelial ovarian cancer. It is more often used to treat ovarian stromal tumors.

 BENIGN TUMOURS  Cystectomy  Unilateral oopherectomy  Salpingo-oopherectomy  In post-menopausal…TAH  BORDERLINE TUMOURS  Young patients: conservative treatment and follow up  Older patients: TAH  MALIGNANT TUMOURS  Depends upon staging and grading

Stage IA and IB/Grade I TAH No need for further treatment Close follow up In young patients who wish to preserve fertility, conservative surgery of preserving uterus and contralateral ovary can be performed. Stage IA and IB with Grade 2 and 3/and stage IC TAH and BSO followed by chemotherapy and radiotherapy Stage II,III and IV Same as above. Has to be modified according to: General health Extent of disease and residual disease after surgery If growth cannot be removed completely: Debulking Cytoreduction

 Radiation to whole abdomen is given after removal of most disease by operation.  Restricted to those who are most likely to get benefit.

 Prolongs remission and survival  Also used for palliative treatment in advanced and recurrent disease.  Administered in all cases beyond stage Ia.  Earlier single agents were used, nowadays combination therapy is favoured.

 The drugs used are;  Alkylating agents.  Cyclophosphamide, chlorambucil  Anti-metabolites.  5-florouracil, methotrexate  Platinum compounds.  Cisplatin, carboplatin  Toxoid compounds  Paclitaxil (taxol)  Anti tumour antibiotics.

 Combination therapy is most beneficial.  Drugs are given at 3 weeks intervals  Intraperitoneal chemotherapy is also done but is very effective.

 Overall 5-year survival in ovarian epithelial carcinoma is low because of the preponderance of late-stage disease at diagnosis.  Stage I and II: %  Stage III: 15-20%  Stage IV: 5%  Patients under 50 in all stages have considerably better 5-year survival than older patients (40% compared to 15%)