L/O/G/O. Ovarian Tumor. Xiaoyu Niu Obstetrics and Gynecology Department Sichuan University West China Second Hospital

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1 L/O/G/O Ovarian Tumor Xiaoyu Niu Obstetrics and Gynecology Department Sichuan University West China Second Hospital

2 Essentials classification of ovarian tumor clinical manifestation of ovarian tumor metastatic routes of malignant ovarian tumor diagnosis and differential diagnosis complication of ovarian tumor treatment of ovarian tumor

3 Background clinical dilemma -- 7th most common cancer, 8th most common cause of death from cancer ,000 death in 239,000 ovarian cancer women (2012, worldwide) late discovery -- 70% quick spread months poor prognosis -- 5 ys'sr 30%-40% difficult treatment choice

4 outlines of ovarian tumor

5

6 Histologic Classification germ cell sex cord stroma epithelium metastatic nonspecific sex cord stroma (very rare)

7 Histologic Classification epithelium sex cord stroma germ cell secondary serous mucinous endometrioid clear cell Brenner tumor mixed tumor undifferentiated

8 serous cystadenoma common, account for 25 % in benign unilateral, smooth surface, cystic,filled with light yellow clear fluid.

9 borderline serous cystadenoma medium size, more bilateral, few papilloma inside the cyst microscopy: stratified epithelium less than 3 layers, no stroma invasion. 5 years' SR >90%

10 serous cystadenocarcinoma most common type bilateral, solid, large volume multilocular, filled with papilloma obvious cellular atypia, with stroma invasion 5 years' SR 20~30%

11 mucinous cystadenoma account for 20% in benign tumor unilateral, huge volume, smooth surface multilocular, filled with jelly like fluid

12 borderline mucinous cystadenoma thickened wall, with solid or tiny papilloma area, soft microscopy: stratified epithelium less than 3 layers, no stroma invasion

13 mucinous cystadenocarcinoma cystic-solid or papilloma area microscopy: typical cellular atypia, with stroma invasion 5 years' SR 40~50% Pseudomyxoma peritonei

14 endometrioid tumor few benign tumor more malignant: most unilateral, medium size, cystic or solid, with papilloma growth 5 years' SR 40~50%

15 epithelium sex cord stroma germ cell secondary dysgerminoma endodermal sinus tumor embryonal polyembryoma choriocarcinoma teratoma immature mature

16 germ cell tumor mature teratoma(benign) filled with oil fragment and hair, sometimes tooth or bone struma ovarii -- secret thyroxine -- hyperthyroidism immature teratoma(malignant) mainly rudimentary nervous tissue

17 germ cell tumor Dysgerminoma solid, less aggressive adolescence and early adult round, medium size, rubber like texture sensitive to radiation and chemotherapy

18 germ cell tumor endodermal sinus tumor(yolk sac tumor) highly malignant adolescence and early adult unilateral, big volume, round shape may have heamorrhage or necrosis inside the tumor and cause acute abdomen

19 epithelium sex cord stroma germ cell secondary granulosa cell 1. granulosa cell 2. thecal cell fibroma Sertoli-Leydig cell tumour Gynandroblastoma

20 sex cord stroma tumor granulosa cell tumor: low grade malignancy, secret oestrogen, Call-Exner body, granulosa cell arranged around cyst, like chrysanthemum thecal cell tumor: benign, secretory function, solid tumor, sliced surface show greywhite color

21 sex cord stroma tumor fibroma: Meig s syndrome: accompanied with ascite and pleural effusion androblastoma (sertoli-leydig cell tumor) with bloody serous and mucin fluid, may show masculinization

22 epithelium sex cord stroma germ cell secondary breast, intestine, stomach, genital tract or urinary tract

23 Secondary ovarian tumor Krukenberg tumor: originated from digestive tract, bilateral, accompanied with ascite, with signetring cells

24 Histologic Grade according to cell differenciation and mitosis(histochemistry-- P53): Low Grade 12 mitosis /10 high scope high Grade > 12 mitosis /10 high scope

25 etiology (risk factor) genetics environment hormone ovulation Hereditary breast ovarian cancer syndromes (HBOC) BRCA1 BRCA2 site-specific ovarian cancer syndrome family heritage type II Lynch syndrome endometrium, breast, ovary, colon autosomal dominant

26 Hereditary breast ovarian cancer syndromes (HBOC) : BRCA1 breast cancer 50%-85% bilateral primary breaset ca 40%-60% ovarian ca 20%-60% Adapted from ASCO

27 Hereditary breast ovarian cancer syndromes (HBOC) BRCA2 breast ca (50%-85%) ovarian ca (10%-20%) male breast ca (6%) risk factor for prostate ca, melanoma, pancreatic ca

28 genetics environment hormone asbestos, French chalk high dose of lactose animal fat whole milk powder caffee, low iodine ovulation

29 genetics environment hormone ovulation HRT IVF early first menstruation late menopause endometriosis give birth breast feeding oral contraceptives IUD

30 genetics environment hormone ovulation nulliparous, OCs

31 Clinical Manifestation Benign tumor no obvious synptom blotting or swelling pressure

32 Malignant tumor Swelling abdominal mass ascites (severity of synptom lies on 1tumor size, location, degree of invasion to nearby organ 2histologic type 3 complicaton )

33 complication ovarian torsion cyst rupture infection malignancy

34 complication ovarian torsion cyst rupture infection malignancy

35 Metastatic routes Direct spread or peritoneum seeding lymphatic channel along with ovarian blood supply from hilum ovarii to internal and external iliac LN. through round ligment to inguinal LN.

36 Metastatic routes Direct spread or peritoneum seeding lymphatic channel along with ovarian blood supply from hilum ovarii to internal and external iliac LN. through round ligment to inguinal LN.

37 Clinical stage (Malignancy) Stage Description I Cancer is completely limited to the ovary IA involves one ovary, capsule intact, no tumor on ovarian surface, negative washings IB involves both ovaries; capsule intact; no tumor on ovarian surface; negative washings IC tumor involves one or both ovaries IC1 surgical spill IC2 capsule has ruptured or tumor on ovarian surface IC3 positive ascites or washings

38 Clinical stage (Malignancy) II pelvic extension of the tumor (must be confined to the pelvis) or primary peritoneal tumor, involves one or both ovaries IIA IIB tumor found on uterus or fallopian tubes tumor elsewhere in the pelvis

39 Clinical stage (Malignancy) III cancer found outside the pelvis or in the retroperitoneal lymph nodes, involves one or both ovaries IIIA metastasis in retroperitoneal lymph nodes or microscopic extrapelvic metastasis IIIA1 metastasis in retroperitoneal lymph nodes IIIA1(i) the metastasis is less than 10 mm in diameter IIIA1(ii) the metastasis is greater than 10 mm in diameter IIIA2 microscopic metastasis in the peritoneum, regardless of retroperitoneal lymph node status

40 IIIB metastasis in the peritoneum less than or equal to 2 cm in diameter, regardless of retroperitoneal lymph node status; or metastasis to liver or spleen capsule IIIC metastasis in the peritoneum greater than 2 cm in diameter, regardless of retroperitoneal lymph node status; or metastasis to liver or spleen capsule

41 Clinical stage (Malignancy) IV distant metastasis (i.e. outside of the peritoneum) IVA pleural effusion containing cancer cells IVB metastasis to distant organs (including the parenchyma of the spleen or liver), or metastasis to the inguinal and extra-abdominal lymph nodes

42 Diagnosis primary: medical history, symptom, physical examinantion specific: B ultrasound tumor markers(ca125,he4,ca199,cea,β- HCG,AFP) laparoscopy imaging scan ascites cytology tissue biopsy

43 Differential diagnosis age course of disease mass feature and location ascite or not B ultrasound tumor marker

44 benign and malignant tumor differential diagnosis benign malignant age <20 or >50 history long,slow growth short,quickly enlarged sign one side, cystic, movable, smooth surface, no ascite two sides, solid or cystic-solid, fixed, irregular shape, bloody ascite may find cancer cell B ultrasound clear margine, fluid area unclear margine, solid and cystic fluid area mixed g e n e r a l appearance good CA125 <35u/ml > 35u/m l skinny, may cachexia

45 benign ovarian tumor differential diagnosis ovarian functional cyst tubo-ovarian cyst uterous fibroma pregnant uterus ascite

46 malignant ovarian tumor differential diagnosis endometrioma tuberculous peritonitis metastatic ovarian tumor tumor outside the genital tract

47 treatment of benign ovarian tumor age lesion feature and extent reproduction requirement

48 epithelium tumor treatment benign tumor: surgery after diagnosis borderline tumor: early stage: fertility reserve surgery or hystorectomy+bilateral salpingoophorectomy late stage: as ovarian cancer malignant tumor: mainly surgery, combined with chemotherapy, may use radiation, hormonal therapy, immunotherapy, Palliative care (combined therapy)

49 surgery of ovarian cancer: total hysterectomy+bilateral salpingooophorectomy+omentectomy + appendectomy + pelvic and paraaortic lymph nodes dissection tumor reduction

50 Non epithelium tumor treatment benign tumor: surgery malignant tumor:(gc reserve fertility surgery) surgery chemotherapy radiation secondary ovarian tumor:surgery and chemotherapy

51 prognosis age clinical stage treatment mode histologic type and grade residual tumor during first operation

52 prognosis

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54 Follow up time point content 1st year: every month 2nd year:every 3 month 3rd-5th year: every 6 month >5year: every year symptom, physical exam B ultrasound, CT MRI tumor marker

55 May you healthy foreve