DR.UMA DEVI OBS GYN PG 2nd YEAR

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1 DR.UMA DEVI OBS GYN PG 2nd YEAR

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3 Ovaries are paired gonads in female. Shape: oval in shape Colour:pinkish grey. It measures about: 3cm 2cm 1cm.

4 Premenopause 3.5 x 2 x 1.5 cm Early menopause 1-2 years 2 x 1.5x0.5cm Late menopause 2-5 years 1.5x0.75x0.5cm

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6 posterior layer broad ligament by mesovarium, lateral pelvic wall by infundibulo pelvic ligament, uterus by ovarian ligament.

7 Ovary is covered by single layer of germinal epithelium. It consists of outer cortex and inner medulla.

8 Cortex consists of stromal cells studded with numerous follicular structures - primordial -maturing -graffian follicles -corpus luteum.

9 It consists of loose connective tissue, few unstriped muscles, blood vessels and nerves. Hilus cells are small collection of cells homologous to interstitial cells of testes.

10 Arterial supply ovarian artery,a branch of abdominal aorta. Venous drainage- pampiniform plexus to form ovarian veins which drain into inferior vena cava on the right side and left renal vein on left side. Nerve supply-sympathetic supply comes down along ovarian artery from T10 segment.

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13 Germ cell maturation,storage and its release. Steroidogenesis.

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15 OVARIAN CYSTS CAN BE CLASSIFIED AS FOLLOWS: Functional benign Neoplastic borderline malignant

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17 FUNCTIONAL OVARIAN CYSTS INCLUDES: a. Follicular cysts b. Corpus luteum cysts c. Theca lutien cysts

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20 FUNCTIONAL CYSTS Usually asymptamatic. Unilocular. can reach up to 6 to 8cm in diameter. Lining epithelium corresponds to functional epithelium of the unit from which it arises. These are cysts related to the process of ovulation. They are the most common detected cysts in the reproductive age group. Resolve spontaneously.

21 Follicular cysts results from the growth of a follicle that does not rupture. Corpus luteum cyst results from Haemorrhage inside a corpus luteum. Theca luteum cysts over stimulation of the ovary by HCG. common in molar pregnancy, choriocarcinoma and assisted reproductive technology.

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24 A follicular cyst<_3cm requires no investigations. A simple cyst <8cm unilocular with no solid areas and normal CA 125. Low dose oc pills are given for 2 months and Patient is reviewed after 2 months for USG

25 If cysts persists or grow, cystectomy should be performed by laparoscopy/laparotomy.

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27 Epithelial cells derived from celomic epithelium. Oocytes derived from primitive germ cells. Mesenchymal cells derived from gonadal stroma.

28 1.Epithelial tumour 2.Sex cord stromal tumour 3.Lipoid cell tumour 4.Germ cell tumour 5.Gonadoblastoma 6.Soft tissue tumour not specific to ovary 7.Unclassified 8.Secondary tumour(metastatic) 9.Tumour like conditions

29 Epithelial tumours are classified as -Serous cystadenoma -Mucinous cystadenoma -Endometroid tumours -Clear cell tumour -Brenner tumour -Mixed epithelial -Undifferentiated carcinoma -Unclassified epithelial tumours

30 I.EPITHELIAL TUMORS A)Serous tumours 1.Benign a.cystadenoma and papillary cystadenoma b.surface papilloma c.adeno fibroma & cystadeno fibroma 2.Boderline malignant a.cystadenoma & papillary cystadenoma b.surface papilloma c.adenofibroma and cystadenofibroma 3.Malignant a.adenocarcinoma and papillary adenocarcinoma b.surface papillary carcinoma c.malignent adenofibroma and cystadenofibroma

31 B.mucinous tumors 1.Benign a.cystadenoma and papillary cystadenoma b.surface papilloma c.adeno fibroma & cystadeno fibroma 2.Boderline malignant a.cystadenoma & papillary cystadenoma b.surface papilloma c.adenofibroma and cystadenofibroma 3.Malignant a.adenocarcinoma and cyst adenocarcinoma b.malignent adenofibroma and cystadenofibroma

32 C.ENDOMETRIOID TUMORS 1.BENIGN a.adenoma and cystadenoma b.adenofibroma and cystadenofibroma 2.Borderline malignant a.adenoma and cystadenoma b.adenofibroma and cystadenofibroma 3.Malignant a.carcinoma I.Adenocarcinoma II.Adenocanthoma III.Malignant adenofibroma and cystadenofibroma b.endometriod stromal sarcoms c.mixed mularian mesodermal tumors,homologous and heterologous

33 D.Clear cell(mesonephroid )tumors 1.benign:adenofibroma 2.Borderline malignant 3.malignant:carcinoma and adenocarcinoma E.Brenner tumor 1.Benign 2.Borderline malignant 3.Malignant F.Mixed epithelial tumor 1.Benign 2.Borderline malignant 3.Malignant G.Undiffrentiated carcinoma H.Unclassified epithelial tumors

34 II.SEX CORD STROMAL TUMOURS A.Granulosa cell tumors 1.Granulosa cell tumors 2.Tumors of thecoma and fibroma group B.androblastromas:sertoli-leydig cell tumors 1.Well diffrentiated 2.Of intermediate differentiation 3.Poorly differentiated 4.With heterologous elements C.Gynandroblastoma D.unclassified

35 III.Lipoid cell tumor IV.germ cell tumors A.Dysgermioma B.Endodermal sinus tumor C.Embryonal carcinoma D.Polyembrioma E.Chorio carcinoma F.Teratomas 1.Immature 2.Mature a.solid b.cystic I.Dermoid cyst II.Dermoid cyst with malignant transformation 3.Monodermal and highly specialised a.struma ovarii b.carcinoid c.struma ovarii and carcinoid and others G.Mixed forms

36 V.gonadoblastoma A.Pure B.Mixed with dysgerminoma or other forms of germ cell tumor VI.Soft tissue tumors not specific to the ovary VII.Unclassified tumors VIII.Secondary tumors(metastatic) tumours IX.Tumor-like conditions

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38 1. Serous cystadenoma 2. Mucinous cystadenoma 3. Endometrioma 4. Dermoid cysts 5. Fibroma

39 Benign ovarian neoplasia Incidence 80% of ovarian neoplasm are benign The incidence of ovarian tumour varies from 1-3%. - Benign ovarian neoplasm can be solid or cystic

40 1.Age-younger 2.Slow growth 3.Unilateral 4.Cystic 5.Smooth surface 6.Small 7.Mobile 8.TVS-regular vascular branching and flow 9.Cut section-cystic

41 A brief discription about few common tumours seen clinically

42 I. Serous Cystadenoma (Commonest) - Arises from totipotent surface epithelium of ovary. - Accounts for 40% of ovarian tumours. - It is bilateral, unilocular or multilocular - smooth surface - fluid filled

43 II. MUCINOUS CYSTADENOMA - May reach very large size. -Arises from totipotent surface epithelium of ovary. -Accounts for 20-25% of all ovarian tumours. - Chance of malignancy 5 to 10%. - Filled with thick mucinous material - Perforation may lead to a serious condition called pseudomyxoma peritonei for which chemotherapy may be needed. III. ENDOMETRIOMA (Chocolate cysts) -Associated with endometriosis

44 IV. DERMOID CYSTS OR BENIGN CYSTIC TERATOMA - Contains elements from endoderm mesoderm and ectoderm - Usually small and may be bilateral - Contains sebum, hair, teeth etc. - Can change into malignant teratoma - Avoid spilling of contents which leads to chemical peritonitis

45 V. FIBROMA - Firm in consistency * Meigs syndrome Ovarian fibroma + ascites, hydrothorax following removal of fibroma, there is spontaneous resolution of ascites and hydrothorax

46 Clinical features of ovarian mass: Symptoms 1. Asymptomatic, incidentally diagnosed 2. Abdominal discomfort 3. Pressure symptoms- bowel and bladder 4. Acute abdomen due to - Haemorrhage - Rupture - Torsion 5.cardiorespiratory embarassment by huge tumour 6.Gastrointestinal symptoms like nausea or indigestion 7.Menstrual pattern unaffected-unless associated with hormone producing tumours.

47 General condition-unaffected Pitting edema of legs may be present-when huge tumour presses on vessels. Abdominal examination- Inspection-Abdominal wall moves freely with respiration - Mass placed centrally or one side - Umbilicus-everted - Veins-visible under skin Palpation-Feel is cystic or tense cystic -Freely mobile -Upper and lateral borders-well defined -Surface smooth-grooved in lobulated tumor

48 Percussion-note is dull in centre,resonant in flanks -fluid thrill elicited-walls are thin Auscultation-friction rub present over tumour Bimanual examination- -uterus felt seperate from mass -groove felt between uterus and mass -movement of mass/abdomen fails to move cervix If cyst anterior to uterus-most likey to be dermoid

49 Ultrasonography-uterus and tumour(unilocular or multilocular,solid ares,metastasis,ascitis,bilateral) CT-adnexal mass,fat,calcification and tooth MRI-Benign or Malignant CA-125-value>35 U/ML suggestive of epithelial ovarian cancer. X-RAY-errect abdomen-outline of soft tissue -Teeth or bones

50 1.Full bladder 2.Pregnancy 3.Fibroid 4.Chocolate cyst of ovary 5.Encysted peritonitis 6.Asitis 7.Functional ovarian cyst 8.Pregnancy with fibroid

51 Torsion of the pedicle Intracystic haemorrhage Infection Rupture Pseudomyxoma peritonei Malignancy

52 COMMON SONOGRAPHIC FEATURES OF BENIGN OVARIAN MASSES: 1. Unilocular 2. Smooth surface 3. No solid elements 4. No external or internal outgrowth 5. No ascites 6. Unilateral 7. Normal doppler flow

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54 Contributes to 4% of all cancers More than 90 % are epithelial cancers % present in stages III and IV Most non-epithelial tumours present in early stage Nonspecific symptoms make early diagnosis difficult

55 Less than 1% of Ovarian Ca occur before the age of 21, 2/3rds of Ovarian Ca in these pts are Germ cell tumours 30% of Ovarian neoplasms in postmenopausal are malignant 7% of Ovarian epithelial tumours in premenopausal women are frankly malignant

56 Epithelial Cancers Serous - 75% Mucinous - 20% Endometroid - 2% Clear Cell Brenner Undifferentiated

57 Tumour of Low Malignant Potential (Borderline Tumours) Criteria for Diagnosis Epithelial proliferation with papillary formation and pseudostratification Nuclear atypia and increased mitotic activity Absence of stromal invasion

58 1.Patient Age-older 2.Fixed 3.Solid 4.Irregular surface 5.Ascitis-present 6.Growth-rapid 7.Bilateral Nodules in POD-Present Adhesions-present USG-Cystic areas with irregular heterogenous solid part>50%total tumour volume Neovascularisation,low resistence flow with pulsatality index<1.0

59 No symptoms for long periods of time Vague and non-specific Irregular menses if premenopausal Pressure symptoms on bladder or rectum Lower abdominal distension, pressure or pain Acute symptoms- Pain due to rupture, torsion, haemorrage. Late, advanced disease Pelvic mass, pain Abdominal distension, bloating, constipation, nausea, anorexia, or early satiety

60 Pelvic mass on physical examination Solid, irregular, fixed is highly suggestive Upper abdominal mass Ascites Postmenopausal palpable ovary is potentially malignant Only about 3% of palpable masses < 5cm in postmenopausal women are malignant

61 Differential Benign Tumour Endometriosis Pedunculated uterine myomas Neoplastic colonic mass, pelvic kidney Other primary cancers metastatic to Ovary Breast & GI malignancy Occult blood in stool Upper Gi Endoscopy Double contrast Ba enema X-ray Mammography

62 Transcoelomic Lymphatic Haematogenous

63 Pathologic Histologic type Histologic grade Biologic Ploidy HER-2/neu oncogene Clonogenic growth Clinical factors Dense adhesions Tumour rupture

64 STAGE I Growth limited to Ovaries IA Growth limited to one ovary; no ascitespresent containing malignant cells. NO tumour on external surface;capsule intact. IB Growth limited to both ovaries; no ascites present containing malignant cells. No tumour on external surfaces;capsules intact. IC Tumour either IA or IB, but with tumour on surface of one or both ovaries, or with capsule rupture, or with ascites present containing malignant cells, or with positive peritoneal washings

65 StageII Growth involving one or both ovaries with pelvic extension. IIA Extension and/or metastases to the uterus and/or tubes. IIB Extension to other pelvic tissues. IIC Tumour either stage IIA or IIB, but with tumour on surface of one or both ovaries, or with capsule(s) rupture; or with ascites present containing malignant cells or with positive peritoneal washings.

66 Stage III Tumour involving one or both ovaries with peritoneal implants outside the pelvis and/or positive RP or inguinal LN. Superficial liver mets equals stage III IIIA Tumour grossly limited to the true pelvis with neg nodes but with histologically confirmed microscopic seeding of abdo peritoneal surfaces IIIB Histologically confirmed implants none exceeding 2 cm in dia. Nodes neg. IIIC - Abdominal implants>2cm in dia and/or positive RP or inguinal LN.

67 Stage IV -Growth involving one or both ovaries with distant mets. -Pleural effusion with positive cytology allots the case to stage IV. - Parenchymal liver metastasis equals stage IV

68 Midline incision Anatomical tour of abdomen -Free fluid/peritoneal washings for cytology Biopsy of suspicious areas or adhesions of peritoneum Multiple intraperitoneal Bx cul-de-sac, paracolic gutter,bladder peritoneum, intestinal mesentery and diaphragm Infra-colic omentectomy Para-aortic & pelvic LN assessment

69 Stages IA & IB, Gd 1 TAH + BSO The uterus and contralateral ovary can be preserved who desire to preserve fertility Stages IA & IB (Grades 2&3) and Stage IC TAH + BSO Omentectomy Adjuvant Therapy Stages II, III & IV Primary Surg / NACT / Cytoreductive Surg Adjuvant Chemotherapy

70 The adjuvant modalities, which have been administered to, the post-op patients of early stage ovarian cancer have been: Intra peritoneal radio-colloid. Pelvic radiation. Abdomino-pelvic radiation (API). Chemotherapy: Over the past three decades, these have been the subjects of various clinical trials. Their efficacy, toxicity, resultant disease free survival and overall survival have been evaluated.

71 Melphalan Cyclophosphamide Cisplatin / Carboplatin Paclitaxel Cisplatin + Cyclophosphamide Carboplatin + Paclitaxel 6#

72 Logic Bulky tumours have areas that are poorly vascularized which will be exposed to sub optimal conc. of CT agents Larger proportion of cells in resting phase (G 0 cells) which are resistant to CT. (Low growth fraction) Goals Remove all of the primary disease and if possible, all metastatic disease Reduce tumour burden by resection of all individual metastatic nodules to < 5mm

73 Surgery BSOH +Omentectomy + Resection of metastatic lesions from peritoneal surfaces or from intestines Interval Cytoreduction 3# Ct Assess Response Surgery No RCT Prospective trial Demonstrated a survival benefit for patients who had an optimal resection (performed after 3# of platinum combination CT)of their disease at that time as compared with those who did not

74 Radiation Whole abdomen Inappropriate for macroscopic disease Immunotherapy Used in salvage setting Alpha interferon Interleukin-2 Hormonal Well differentiated endometroid Ca

75 Second look Laparoscopy/ Laparotomy A second look opn is one performed on a pt who has no clinical evidence of disease after a prescribed course of CT to determine the response to therapy 35% False negative rate in Laparoscopy Ca125 Predictive value of Pos test 100% Predictive value of Neg test 56% USG CT Scan FNAC

76 Technique same as Staging Laparotomy Fluid for cytology, Bx of peritoneal surfaces. Bx of areas from previous documented tumours 30% of pts with no evidence of macroscopic disease will have micromets Second look laparotomy have not shown to influence patient survival. They should only be performed in a research setting, in which salvage/ 2 nd line therapies are undergoing trials

77 Secondary Cytoreduction Second line CT Intraperitoneal therapy Whole abdominal radiation Experimental combination CT regimens

78 Stage I & II % Stage IIIA 30-40% Stage IIIB 20% Stage IIIC & IV 5% Gd 1 40% Gd 2 20% Gd % Borderline tumours yr survival ranges are from 95-90%

79 CA125, Transvaginal USG False positive results, not cost effective, not routinely used for screening Genetic risk for Ov Cancer Site-specific Familial Ov Cancer Two first degree relatives :-affected gene upto 50% Single first degree relative and single second degree relative : fold higher risk Single first degree relative :- 2-4 fold risk Breast/Ovarian Familial Cancer Syndrome Lynch II Syndrome

80 Wish to preserve reproductive function TVS every 6 months Oophorectomy after completes childbearing OC pills Do not wish to maintain fertility BRCA1 testing Offered bilateral oophorectomy Can still develop Primary Peritoneal Ca Lynch II syndrome Periodic mammography, colonoscopy and EB