1. Chapter 21 Female Genital Tumor
6. Ovarian Tumor
Women’s Hospital, School of Medicine, Zhejiang university
Xiaodong Cheng

2. Ovarian tumor Common gynecologic malignant tumors
Occur in females of all ages
but different histological types in different age-periods
Epithelial ovarian carcinoma with poor prognosis
5-year survival rate about 30-40%
the mortality rate ranks first in gynecological malignancies

3. General Introduction Histological classification very complicated
Most histological types in body organs
The current classification
issued by WHO in 1973

4. Histologic types of ovarian tumor
Ovarain epithelial tumor
Germ cell tumor
Sex-cord stromal cell tumor
Lipid (lipoid) cell tumor
Gonadal blastoma
Non-specific ovarian soft tissue tumor
Unclassified tumor
Metastatic tumor
Tumor-like lesions

5. Symptoms and signs Benign tumors No symptoms as tumor is small
Abdominal distention or pelvic mass as tumor is medium size
Gynecological examinations
A spherical mass on one side of the uterus, cystic, smooth surface, movable

6. Symptoms and signs Ovarian cancer early stage
asymptomatic, often found occasionally by gynecological examinations
Late stages
Abdominal distention, abdominal mass, ascites
End-stage
Weight loss, severe anemia, cachexia
Transvagina-rectnum examination
Pelvic masses: bilateral , solid or semi-solid, not movable

7. Complications pedicel retortion Common gynecological emergency
Frequency about 10%
Usually occur in mass with a longer pedicle, medium size, good movability, and center deflection
Blood flow blocked and tumor necrosis after retortion
Symptoms: one side of lower abdomen pain concomitant nausea and vomit,
Signs: Mass with high tension and tenderness
Treatment emergency surgery once diagnosed

8. Complications Rupture Frequency about 3% Traumatic and spontaneous
Symptom
lower abdominal pain
related to the size of rupture
the quality and quantity of cyst fluid
Signs
abdominal tenderness
muscle intensity
ascites
Treatment
emergency surgery

9. Complications Infection Malignant change
Due to rupture, retorsion or the near organs’ infection
Symptoms
fever, abdominal pain
Signs
mass, abdominal tenderness,
muscle intensity
Treatment
anti-infection, surgery
Malignant change
surgery as soon as possible

10. Diagnosis Benign tumors Ovarian cancer No specific symptoms
A mass found occasionally by physical examination
Ovarian cancer
Gynecological examination
bilateral pelvic mass, solid , poor movability, with ascites, uterus rectum nest nodules

11. Diagnosis Adjuvant examinations Imaging techniques Ultrasonography ：
mainly used to diagnose primary lesion
accuracy rate above 90%
difficult to measure the diameter <1cm lesion
Radiology (X-Ray, CT, MRI)
mainly used to diagnose the metastatic lesion

12. Ultrasound: ovarian cancer

13. Diagnosis Adjuvant examinations Tumor markers §CA125
rise up in 80% epithelial cancers
more used for disease monitoring and prognosis evaluation
§AFP
rise in endodermal sinus tumor
§hCG
ovarian choriacarcinoma
§Sex hormone
sex-cord stromal cell tumor
Laparoscopy
Ascitic cytology

14. Metastatic pathway Features pathways
Widely disseminated in abdominal cavity
Subclinical metastasis
pathways
spread directly and
abdominal cavity plant
lymph metastasis
blood vessel metastasis

15. Clinical surgical-pathology staging (2000，FIGO)
Stage I
Growth limited to ovaries
　 　 　 IA
Growth limited to one side ovaries; no ascites. No tumor on external surface; capsules intact IB
Growth limited to both ovaries; no ascites. No tumor on external surface; capsules intact IC
Tumor either IA or IB but with tumor on surface of one or both ovaries;or with capsule ruptured; or with ascites containing malignant cells, or with positive peritoneal washings II
Growth involving one or both ovaries with pelvic extension.
IIA
Extension and/or metastasis to the uterus and/or tubes.
IIB
Extension to other pelvic tissues.
IIC
Tumor either Stage IIA or IIB, but with tumor on surface of one or both ovaries; or with capsule ruptured; or with ascites containing malignant cells, or with positive peritoneal washings.
III
Tumor involving one or both ovaries with peritoneal implants outside pelvis and/or positive retroperitoneal or inguinal nodes. Superficial liver metastasis equals Stage III.
IIIA
Tumor grossly limited to true pelvis with negative nodes, but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces.
IIIB
Tumor of one or both ovaries with histologically confirmed implants to abdominal peritoneal surfaces, none exceeding 2 cm in diameter Nodes are negative.
IIIC
Abdominal implants >2 cm in diameter and/or positive retroperitoneal or inguinal nodes. IV
Growth involving one or both ovaries with distant metastasis. If pleural effusion present, must be positive cytology to assign a case to Stage IV. Parenchymal live metastasis equals Stage IV.

16. Therapy Surgery Objectives To confirm the diagnosis To resect tumor
To determine surgical-pathology staging of malignancy
Chemotherapy and radiation
for malignancy
follow-up
ovarian cancer is easy to recurrent and should be long-term follow-up

17. Epithelial tumors The most common histological type
accounting for 50-70% of the primary tumor
85-90% of malignant tumor
Derived from ovarian germinal epithelium
belong to the primitive body cavity epithelium
have potential to differentiate into a variety of
Mullerian epithelia
More common in older women
Can be divided into benign, borderline, malignant tumors

18. Epithelial tumors Borderline tumors low malignant potential tumors
pathological features of malignant tumor cells but no stromal invasion
clinically slower development, fewer metastasis and more later recurrence

19. Histological classification
Epithelial tumors
Serous tumors
Mucinous tumors
Endometrioid tumor
Brenner tumor
Mixed epithelial tumors
Undifferentiated carcinoma
Changing: New classification—2014 (WHO)

20. Pathology Serous tumors
cancer cell differentiate into oviduct epithelial
Serous cystadenoma
Mostly unilateral, spherical, smooth, cystic, serous fluid Microscope: simple columnar epithelium
serous cystadenocarcinoma
Mostly bilateral, semi-substantive, multiple antrum cystoid, cavity filled with papilla, crisp, bloody cyst fluid
Microscope: cubic or columnar epithelium, stratified, arranged in ≥4 layers, cellular atypia, stromal invasion

21. Serous
tumors
Serous cancer

22. Pathology Mucinous tumors
cancer cell differentiate into enteric or cervical endometrial
Mucinous cystadenoma
Mostly unilateral, large size, cystic, and often have more capsules with the jelly-like mucus
Microscope: simple columnar epithelium, can see goblet and argyrophil cells
If tumor rupture, tumor cells seed in peritoneal to form peritoneal myxoma
Mucinous cystadenocarcinoma
Mostly unilateral, cystic, cystic see the papilla, bloody cyst fluid
Microscope: columnar epithelium, stratified, arranged in ≥ 3 layers, cellular atypia, stromal invasion

23. Mucinous tumors
Mucinous cancer

24. Pathology Endometrioid tumor Endometrioid carcinoma
Benign, borderline tumor is few
Endometrioid carcinoma
Mostly unilateral, cystic or solid, with papilla, bloody cyst fluid.
Microscope: similar to endometrial cancer
Often concomitant with endometrial cancer

25. Endometrioid cancer

26. Pathology Clear cell tumors Benign tumors are few Clear cell carcinoma
Mostly unilateral, cystic or solid
Microscope: alveolar tumor cells with abundant cytoplasm , atypia nuclear
Easy to lymph node and liver metastasis
Often concomitant with endometriosis and hypercalcemia
Brenner tumor
Differentiate and formate from transitional epithelum
Most are benign, unilateral, diameter <5cm, hardware quality

27. Clear cell tumors

28. Brenner tumor

29. Epithelial Tumors Treatment benign tumors
Once diagnosed, surgical extension
reproductive period women
ovarian tumor resection or oophorectomy
perimenopausal and postmenopausal women
● adnexectomy
● hysterectomy and bilateral salpingo-oophorectomy
Notices in surgery
① differentiate the benign and malignant tumors
during surgery (grossly, frozen section )
② take out the tumor integrally

30. Epithelial Tumors Treatment malignancy
Principle: surgery combined with chemotherapy and radiotherapy
surgery
Early stage:
Staging surgery
Cytology for ascites or peritoneal washings
Complete pelvic and abdominal exploration
Omentectomy
Back peritoneum lymph nodes excision
Hysterectomy + bilateral salpingoophorectomy
Conservative surgery
only for eligible young women desiring childbearing

31. Epithelial Tumors Treatment surgery malignancy Advanced stage:
Cytoreductive surgery (debulking surgery)
Resect primar and metastatic tuomrs as much as possible , to minimize diameter of residual tumor (<1cm)

32. Epithelial Tumors Chemotherapy Radiotherapy Prognosis
Major adjuvant therapy, post-surgery
Commonly used drugs
cisplatin, carboplatin, paclitaxel, CTX, others.
Preferred to platinum-based combination chemotherapy
“Gold standard”: carboplatin and paclitaxel combination
Radiotherapy
For metastasis and recurrence
Others immunotherapy
Prognosis
5-year survival rate of Ia stage >90％
5-year survival rate of advanced stage <30％

33. Ovarian germ cell tumor
Features
From primitive germ cells in embryonic gonad
Ability to produce diversity organizations
Frequency: account for 20~40% in all ovarian tumors
More common in young women and girls
Sensitive to chemotherapy ，most can be reserved for reproductive function
Abnormal tumor markers: AFP, HCG

34. Histologic classification
Germ cell tumors
dysgerminoma
endodermal sinus tumor
embryonal tumor
polyembryoma
choriocarcinoma
teratomas
mixed tumor

35. Pathology Teratomas Comprised of multi-germ layer , rarely one layer
Mostly are mature , few are immature
Mature teratomas（dermoid cyst）
benign tumor，the most common germ cell tumor
frequently single side, cystoid with smooth surface,
contains tissues of fat, hair, teeth and bone
microscopy： scolex contains three layers
malignant transformation: squamocarcinoma in
scolex epilithium

36. Mature Cystic Teratoma
Immature ovarian teratoma

37. Pathology Dysgerminoma Moderate malignant tumor
Mostly occurs at puberty and child-bearing perild
Single side, solid
Microscopy ：rotundity or mostly cornual cells
Extraordinary sensitive to radiotherapy

38. dysgerminoma

39. Pathology Endodermal sinus tumor Common in children and young women
Highly malignant, poor prognosis
Single side with large mass, fragile, obvious bleeding and necrosis;
Microscopy：loose reticulate and endothelial sinus structure
Produce AFP

40. Endodermal sinus tumor

41. Treatment Benign tumor Malignant tumor The same as epilithial tumors
Surgery
Lateral salpingoophorectomy regardless any stage as long as opposite side ovary and uterus are not involved
Chemotherapy
Sensitive to chemotherapy : BEP BVP VAC
Radiotherapy
sensitive for Dysgerminoma，seldom used for young ages

42. Sex cord-stromal tumors
From sex cord and stromal tissues of embryonic gonad
Frequency: account for 5％ in all ovarian tumors
Comprised or uni- or multi-cell components
Mostly are benign or low malignant tumor
Produce steroid hormones, with endocrine funtion, produce female or male features, also called “functioning ovarian tumor ”

43. Histologic classification
Sex cord-stromal tumors
Granulosa cell -stromal cell tumors
Sertoli-stromal cell tumors
Granudroblastoma

44. Pathology Granulosa cell tumors Adult form and child form Adult form
common
low malignant，produce E2，female features
solid or partly cystic
microscopy: Granulosa cell, Call-Exner body
Child form
seldom, highly malignant

45. Granulosa cell
tumor
Granulosa cell
tumor
Call–Exner bodies
(sex cord-stromal
tumors )
Granulosa cell
tumor
Granulosa cell
tumor
stromal cell
tumors

46. Pathology Ovarian thecoma (theca cell tumor) Benign，seldom malignant
Single side, solid.
Microscopy
short spindle cells, spiral arrangement
Female features

47. Ovarian thecoma

48. Pathology Fibroma Benign Single side, solid, hardness Microscopy
short spindle cells, knitting arrangement.
Meigs syndrome
fibroma combination with ascites or hydrothorax, naturally disappear after tumor excision

49. Fibroma

50. Treatment Benign tumor Malignant tumor
surgery as same as epithelial tumor
Malignant tumor
Surgery
Conservative surgery for young women with stage I, desiring childbearing
Radical surgery for others
Chemotherapy
Combinated Chemotherapy
Regimens: as same as germ cell or epilithelial tumors

51. Ovarian metastatic tumors
Origin
any organs’ tumors
commonly from breast, gastrointestinal and genital tract
Krukenberg tumors (signet ring cell tumor)
From gastrointestinal
Bilateral, solid, median size, without adhension
ovary –shape or kidney-shape
microscopy：signet ring cells
Surgery combined with chemotherapy and radiotherapy
Poor prognosis

52. Krukenberg tumors

53. Thank you !