Metastatic Tumors of Ovary

METASTATIC TUMOR FROM BREAST CANCER both ovaries replaced by pale, rather nodular tumor, with breast cancer cells arranged in long lines perpendicular to the surface of the ovarian cortex

METASTATIC TUMOR FROM GASTRIC CANCER (Krukenberg ) gastric carcinoma of the fundus, with secondary ovarian tumor (Mucus-secreting signet-ring cells)

Krukenberg Tumor:

Neoplastic Ovarian Tumours Surface epithelial – 65-70% Germ cell tumors – 15-20% stromal – 10-15% Metastatic tumors – 5%

Epidemiology 15,900 deaths annually 4th common cause of cancer mortality Most (70%) diagnosed at advanced stage where cure is uncommon. 23,000 cases annually Ranks 3 r d among gynecologic cancers Ranks 5 th among women cancers.

Risk Factors Personal H : Any age ( common >40ys). Nulliparous. Late age 1 st preg History of breast or colon cancer. Gonadal Dysgenesis Talcum powder –Increased risk in women who use talc powder on genital area

Risk Factors M.H: –E arly menarche. –Late menopause –prolonged use of fertility drugs without achieving pregnancy –Hormone replacement therapy > 10 years –Uninterrupted ovulation. F.H –Mother, sister or daughter with ovarian cancer.

Protective factors Multiparity: First pregnancy before age 30 Oral contraceptives. Hysterectomy Lactation Bilateral oopherectomy

complications of benign ov Tumours torsion hemorrhage rupture infection incarceration malignant change complications during pregnancy

Diagnostic tools History Exam (including rectal) Investigations:- –TVS – masses and mass characteristics –Tumor markers – CA-125, LPA (plasma lysophosphatidic acid) –CT – assess spread to LN, pelvic and abdominal structures –MRI – best for distinguishing malignant from benign tumors

Clinical picture of benign ov tumors Symptoms: –functioning tumors –nonfunctioning tumors swelling pressure symptoms pain menstrual disturbances ovarian cachexia Signs small ov tumors large ov tumors DD: from other pelvic swellings from other abdominal swellings

Clinical picture cancer ovary Benign ovarian Tumours + The following suggest malignancy age:mostly postmenopausal pain: chronic and persistent rapid course bilaterality Solidity ( variegated consistency ) fixity metastases :nodules in DP, lymph nodes ascitis edema LL cachexia

Staging: Vertical incision. Aspirate, or saline washing. Careful assessment., Liver, rt hemidaphragm, All other organs as omentum, intestine, …. Para aortic LN sampling. Proper staging, for prognosis, selection of adjuvant therapy …..

Ovarian Cancer Staging Stage 1 –1A: One ovary –1B: Both ovaries –1C: with malignant ascites, rupture surface tumor

Ovarian Cancer Staging Stage 2 –2A: Reproductive organs –2B: Other pelvic organs –2C: with malignant ascites or washings

Ovarian Cancer Staging Stage 3 –3A: microscopic upper abdominal disease –3B: upper abdominal metastasis less than 2 centimeters –3C: upper abdominal metastasis greater than 2 centimeters

Ovarian Cancer Staging Stage 4 is disease outside the peritoneal cavity –Liver parenchymal metastasis. –Pleural effusion –Supraclavicular nodes

Treatment Depends on –Staging –Tumor type –Age – Desire for future fertility Include surgery, chemotherapy and/or radiation therapy

Surgery for ov. cancer Complete surgery: TAH/BSO +omentectomy+lymphadenectomy –other cases of stage Ia Conservative surgery: unilateral adnexectomy indicated: –stage Ia: intact capsule, negative peritoneal washing, free omentum, –well differentiated T, –young patient with low parity –Stage Ib,c

Surgery for ov. Cancer cont… Cytoreductive surgery: for all other stages –optimum cytoreduction leaving no macroscopic lesion or one less than 1.5 cm. –consist of TAH/BSO +omentectomy+lymphadenectomy+may be bowel resection & anastmosis. Second look surgery after chemotherapy

Surgical treatment Primary debulking and cytoreduction; may include: –Bilateral salpingo-oopherectomy –Hysterectomy –Lymphadenectomy (Para-aortic, inguinal) –Omentectomy –“ brushing ” of diaphragm –Examination of liver

Chemotherapy & radiotherapy for ov cancer Chemotherapy: –adjuvant to surgery to improve prognosis in early stages –induce remission in advanced cases –agents: alkylating agents,platinum: single drug and multible drug regimens

Chemotherapy & radiotherapy for ov cancer cont……… Radiotherapy : –has less place in modern practice, replaced by chemotherapy –was given for cases with small residual lesions (< 2 cm) –forms are: radioactive isotope: intraperitoneal 32 P, external-beam radiotherapy

Chemotherapy and Radiation Usually 6 cycles of chemotherapy Cisplatin (or Carboplatin) plus Paclitaxel most commonly used combination therapy XRT