CARCINOMA OVARYCARCINOMA OVARY

INTRODUCTION:INTRODUCTION: 22ndnd most common of all genital tumors most common of all genital tumors 10-15% of all gynecological tumors10-15% of all gynecological tumors Incidence – 1:70 to 1:100Incidence – 1:70 to 1:100 80% are primary & 20% secondary80% are primary & 20% secondary

PREDISPOSING PREDISPOSING FACTORSFACTORS

Low parityLow parity Delayed childbearingDelayed childbearing Genetic predisposition- Genetic predisposition-

BRCA1, BRCA2BRCA1, BRCA2 decreased fertility decreased fertility Familial predispositionFamilial predisposition

Multiple ovulation in Multiple ovulation in IVFIVF

occurance of mumps occurance of mumps prior to menarcheprior to menarche

Environmental factorsEnvironmental factors

-high dietry fat intake-high dietry fat intake

-use of talc on -use of talc on perineumperineum

-Industrial pollution -Industrial pollution

PROTECTING FACTORSPROTECTING FACTORS

MultiparityMultiparity AnovulationAnovulation Breast feeding Breast feeding Use of OCPs (reduce incidence by 40- Use of OCPs (reduce incidence by 40-

50%) 50%)

PROGNOSIS:PROGNOSIS: Generally poor d/tGenerally poor d/t -late diagnosis & early mets-late diagnosis & early mets - no satisfactory method of mass - no satisfactory method of mass

screening screening

At the time of diagnosis only 20% are At the time of diagnosis only 20% are confined to ovary & 80% are in stage III or confined to ovary & 80% are in stage III or stage IVstage IV

PATHOLOGYPATHOLOGY Histologically they are grouped as Epithelial and Non epithelial Histologically they are grouped as Epithelial and Non epithelial

tumorstumors

EPITHELIAL OVARIAN CANCEREPITHELIAL OVARIAN CANCER - 80 to 90%- 80 to 90% -Include-Include .Serous type (75%).Serous type (75%) .Mucinous type (20%).Mucinous type (20%) .Endometroid (2%).Endometroid (2%) .Brenner tumor.Brenner tumor .Clear cell Ca.Clear cell Ca .Undifferentiated Ca.Undifferentiated Ca .Border line tumors.Border line tumors

NON EPITHELIAL OVARIAN CANCERSNON EPITHELIAL OVARIAN CANCERS - Account for 10 to 20%- Account for 10 to 20%

- Include malignancies of - Include malignancies of - Germ cell origins - Germ cell origins - Sex cord stromal cell origin - Sex cord stromal cell origin - Metastatic cancers - Metastatic cancers - Rare malignancies like lipoid cell - Rare malignancies like lipoid cell

tumors, tumors, sarcoma. sarcoma.

. .

EPITHELIAL CA OF OVARY EPITHELIAL CA OF OVARY

Each tumor has histologic patterns similar to a part of Each tumor has histologic patterns similar to a part of upper genital tract. upper genital tract.

-- Serous or papillary – resembles the lining Serous or papillary – resembles the lining of of fallopian tube.fallopian tube.

-- Mucinous Mucinous - resembles the endocervical - resembles the endocervical glands glands

-- Endometroid Endometroid – endometrium. – endometrium. Secondary malignant change – 50% of benign serous Secondary malignant change – 50% of benign serous

epithelial tumor & 5% of mucinous cysts. epithelial tumor & 5% of mucinous cysts.

SEROUS PAPILLARY CARCINOMA

BILATERAL PAPILARY OVARIAN CARCINOMA

ENDOMETROID TUMOR

BILATERAL OVARIAN TUMOR

BORDERLINE TUMORS : BORDERLINE TUMORS : TUMOR OF LOW MALIGNANT POTENTIAL. TUMOR OF LOW MALIGNANT POTENTIAL. 10 to 20% of epithelial cancers. 10 to 20% of epithelial cancers. Remain confined to ovaries for long. Remain confined to ovaries for long. Incidence 30-50 yrs (Premenopausal). Incidence 30-50 yrs (Premenopausal). Good prognosis Good prognosis 5 yrs survival rate 90%. 5 yrs survival rate 90%. Criteria for diagnosis Criteria for diagnosis

- Epithelial proliferation with papillary formation & - Epithelial proliferation with papillary formation & pseudostratification. pseudostratification.

- Nuclear atypia & - Nuclear atypia & mitotic activity. mitotic activity. - Absence of true stromal invasion. - Absence of true stromal invasion. -

NON EPITHELIAL MALIGNANCIES OF OVARY : NON EPITHELIAL MALIGNANCIES OF OVARY : A) GERM CELL MALIGNANCIES : A) GERM CELL MALIGNANCIES : 3 to 5% are malignant. 3 to 5% are malignant. Incidence – lower in Caucasian whites Incidence – lower in Caucasian whites Higher in Asians & Afro American Higher in Asians & Afro American Derived from primordial germ cells of ovary. Derived from primordial germ cells of ovary. Secrete biochemical substances tumor markers. Secrete biochemical substances tumor markers.

- Eg : - Eg : Embryonal ca – AFP, hCG Embryonal ca – AFP, hCG Endodermal Sinus tumor – AFP. Endodermal Sinus tumor – AFP. Choriocarcinoma - hCG. Choriocarcinoma - hCG. Dysgerminoma & Pure germinoma – donot Dysgerminoma & Pure germinoma – donot

secrete markers. secrete markers.

GERM CELL MALIGNANCIES INCLUDE : GERM CELL MALIGNANCIES INCLUDE : a)a) Dysgerminoma Dysgerminoma b)b) Teratoma Teratoma c)c) Endodermal Sinus tumor Endodermal Sinus tumor d)d) Embryonal carcinoma Embryonal carcinoma e)e) Polyembryoma Polyembryoma f)f) Choriocarcinoma Choriocarcinoma g)g) Mixed forms. Mixed forms.

DYSGERMINOMA : DYSGERMINOMA : - Corresponds to Seminoma testis - Corresponds to Seminoma testis - 3-5% of all ovarian tumors. - 3-5% of all ovarian tumors. - Average age of 20 yrs. - Average age of 20 yrs. - Genital abnormality associated - hypoplasia or absence - Genital abnormality associated - hypoplasia or absence of part of genital tract. of part of genital tract. - Reported in pseudohermophrodites. - Reported in pseudohermophrodites. - Gross : Solid, elastic rubbery consistency of smooth - Gross : Solid, elastic rubbery consistency of smooth

firm capsule. firm capsule. - Cut surface : - Cut surface :

Yellow or grey with areas of degeneration & Yellow or grey with areas of degeneration & hemorrhage. hemorrhage. - Microscopy : - Microscopy : Large cells arranged in bunches or alveoli. Large cells arranged in bunches or alveoli.

Lymphocytes & giant cells present – Lymphocytes & giant cells present – characteristic. characteristic.

- May undergo torsion. - May undergo torsion. - Tumor neutral – neither female or male sex - Tumor neutral – neither female or male sex

hormones secreted. hormones secreted.

- Secretes placental Alkaline phosphatase & - Secretes placental Alkaline phosphatase & LDH & Beta - hcg. LDH & Beta - hcg.

-Treatment : -Treatment : Highly radiosensitive but may lead to infertility. Highly radiosensitive but may lead to infertility. Chemotherapy preferred. Chemotherapy preferred.

TERATOMA TERATOMA

1)1) Mature , dermoid cyst Mature , dermoid cyst

2)2) Immature – Solid / cystic Immature – Solid / cystic

3)3) Monodermal teratoma like struma ovarii, Monodermal teratoma like struma ovarii, carcinoid, mixed. carcinoid, mixed.

DERMOID CYST : DERMOID CYST : - Incidence 5% to 10% of cystic tumor only 1.7% - Incidence 5% to 10% of cystic tumor only 1.7%

malignant. malignant. - Age : 20-30 yrs – combined, - Age : 20-30 yrs – combined,

40-50 yrs- simple. 40-50 yrs- simple. - Are unilocular with smooth surface. - Are unilocular with smooth surface. - Contain – Sebaceous material, hair & wall lined- Contain – Sebaceous material, hair & wall lined in part by Sq. epithelium .in part by Sq. epithelium .- Teeth, bone, cartilage, thyroid tissue, bronchial - Teeth, bone, cartilage, thyroid tissue, bronchial

mucus membrane are also present. mucus membrane are also present. - Inner surface is called a “focus” or embryonic node” - Inner surface is called a “focus” or embryonic node”

- May also have columnar & transitional - May also have columnar & transitional epithelial lining along with sq. epithelium. epithelial lining along with sq. epithelium.

- Frequently arise in association with mucinous - Frequently arise in association with mucinous cystadenoma. cystadenoma.

- Malignant changes to dermoid carcinoma - Malignant changes to dermoid carcinoma sarcomatous changes. sarcomatous changes.

- Usually a Sq. cell Ca develops from ectodermal - Usually a Sq. cell Ca develops from ectodermal tissue mammary Ca and malignant thyroid tissue mammary Ca and malignant thyroid tumours have been described. tumours have been described.

SOLID TERATOMA: SOLID TERATOMA:

- Most of these are malignant due to - Most of these are malignant due to

Sarcomatous change. Sarcomatous change.

- Only 20% benign - Only 20% benign

- Rare tumors - Rare tumors

- Mostly solid & have peculiar trabeculated - Mostly solid & have peculiar trabeculated appearance on cut surface & have large loculi. appearance on cut surface & have large loculi.

- Solid part has cartilage & bone mostly & cystic - Solid part has cartilage & bone mostly & cystic part has hair & seabceous material. part has hair & seabceous material.

IMMATURE TERATOMA

SOLID TERATOMA

STRUMA OVARII : STRUMA OVARII : - Consists of thyroid tissue similar to that of - Consists of thyroid tissue similar to that of

thyroid adenoma. thyroid adenoma.

- Gross – Resembles small mucinous - Gross – Resembles small mucinous cystadenoma. cystadenoma.

- Most of the tumors are benign but malignant - Most of the tumors are benign but malignant thyroid tumors recorded. thyroid tumors recorded.

CARCINOID TUMORS : CARCINOID TUMORS : - Occurs as malignant change in a benign Occurs as malignant change in a benign

dermoid dermoid - Sometimes primary & sometimes metastatic Sometimes primary & sometimes metastatic - Argentaffinoma Argentaffinoma - Solid yellow tumour. Solid yellow tumour. - Produces 5 – hydroxytryptamine – attacks of Produces 5 – hydroxytryptamine – attacks of

flushing & cyanosis. flushing & cyanosis.

ENDODERMAL SINUS TUMOR : ENDODERMAL SINUS TUMOR : - Rare, 2- Rare, 2ndnd common of germ cell tumors common of germ cell tumors - Age : young women - Age : young women - Arises from multipotential embryonal tissue. - Arises from multipotential embryonal tissue. -Histology : Characteristically has papillary projections. -Histology : Characteristically has papillary projections.

Composed of central core of blood vessels enveloped Composed of central core of blood vessels enveloped immature epithelial. immature epithelial.

- Young women present with abd pain & pelvic mass. - Young women present with abd pain & pelvic mass. - Tumour markers – AFP. Also Secretes alpha antitrypsin. - Tumour markers – AFP. Also Secretes alpha antitrypsin. - Highly malignant & respond to chemotherapy. - Highly malignant & respond to chemotherapy.

ENDODERMAL SINUS TUMOR

CHORIOCARCINOMA : CHORIOCARCINOMA : Presents as a part of mixed germ cell tumor. Presents as a part of mixed germ cell tumor. Highly vascular & malignant. Highly vascular & malignant. Histology has dimorphic population of Histology has dimorphic population of

syncytiotrophoblasts & Cytotrophoblasts. syncytiotrophoblasts & Cytotrophoblasts. Secretes hCG – tumor marker for diagnosis & Secretes hCG – tumor marker for diagnosis &

management management Highly malignant. Highly malignant. Mets to the lungs, brain, bone & other viscera via Mets to the lungs, brain, bone & other viscera via

blood. blood.

EMBRYONAL CELL CARCINOMAEMBRYONAL CELL CARCINOMA Rare tumorRare tumor Incidence: Prepubertal associated with Incidence: Prepubertal associated with

precocious puberty & menstrual irregularity. precocious puberty & menstrual irregularity. Highly malignant. Highly malignant. May undergo torsion, rupture & H’age. May undergo torsion, rupture & H’age. Tumour Markers : AFP & Beta hCG. Tumour Markers : AFP & Beta hCG.

SEX CORD STROMAL TUMORS : SEX CORD STROMAL TUMORS : Both benign & malignant. Both benign & malignant. - Account for 5 to 8% of all ovarian malignant. Account for 5 to 8% of all ovarian malignant.

GRANULOSA CELL TUMORS : GRANULOSA CELL TUMORS : Secrete oestrogen. Secrete oestrogen. Cause precocious puberty, menometrorrhagia & Cause precocious puberty, menometrorrhagia &

DUB,post menopausal bleeding. DUB,post menopausal bleeding. Endometrial hyperplasia occurs in 25-50% & in 5% of Endometrial hyperplasia occurs in 25-50% & in 5% of

cases Endometrial Ca occurs.cases Endometrial Ca occurs.

ANDROBLASTOMA OR ARRHENOBLASTOMA : ANDROBLASTOMA OR ARRHENOBLASTOMA : Sertoli leydig cell tumors. Sertoli leydig cell tumors. Incidence 30-40 yrs of age. Incidence 30-40 yrs of age. 0.2% of all ovarian neoplasms. 0.2% of all ovarian neoplasms. Secrete androgen & cause defeminisation Secrete androgen & cause defeminisation

followed by masculinization. followed by masculinization. oligomenorrhea followed by amenorrhea, oligomenorrhea followed by amenorrhea,

flattening of breast, acne, hirsutism, enlargement flattening of breast, acne, hirsutism, enlargement of clitoris & change in voice. of clitoris & change in voice.

On removal of tumor – changes revert back except On removal of tumor – changes revert back except voice changes. voice changes.

UNCOMMON OVARIAN CA:UNCOMMON OVARIAN CA: Comprise 0.1% of all ovarian malignancies. Comprise 0.1% of all ovarian malignancies.

TYPES :TYPES : Lipoid cell tumor Lipoid cell tumor Sarcoma of ovary Sarcoma of ovary ChorioepitheliomaChorioepithelioma

Often benign & of low grade malignancy. Often benign & of low grade malignancy. Associated with virilisation, , hypertension & glucose Associated with virilisation, , hypertension & glucose

intolerance. intolerance.

SARCOMA : SARCOMA : Very rare Very rare Often misdiagnosed histologically & are Often misdiagnosed histologically & are

granulosa cell tumors or anaplastic Ca. granulosa cell tumors or anaplastic Ca. Arise after menopause & in particular Arise after menopause & in particular

multipara. multipara. Have multiple mets. Have multiple mets. Rhabdomyosarcoma of ovary has also been Rhabdomyosarcoma of ovary has also been

described described

METASTATIC CARCINOMAS : METASTATIC CARCINOMAS : Mets commonly from GIT – Pylorus Mets commonly from GIT – Pylorus Small bowel Small bowel Colon Colon Gall bladderGall bladder PancreasPancreas Breast Breast Uterus (10%) Uterus (10%) Cervix (1%) Cervix (1%) 20% are secondary deposits from primary growths else 20% are secondary deposits from primary growths else

where. where.

Two forms of secondary Ca of ovary recognized. Two forms of secondary Ca of ovary recognized.

FIRST FIRST Growth corresponds in its histology with the Growth corresponds in its histology with the

primary growth. primary growth. Spread either by implantation from peritoneal cavity Spread either by implantation from peritoneal cavity

or retrograde lymphatic spread. or retrograde lymphatic spread. Are solid, with irregular surface. Are solid, with irregular surface. Bilateral Bilateral Ascites & peritoneal mets present. Ascites & peritoneal mets present.

KRUKENBERG TUMOR : KRUKENBERG TUMOR : Second type of Secondary ovarian cancer. Second type of Secondary ovarian cancer. Diagnostic features : Diagnostic features : - Almost always bilateral. Almost always bilateral. - Have smooth & slightly bossed surface Have smooth & slightly bossed surface - Freely mobile in the pelvis. Freely mobile in the pelvis. - No tendency to form adhesions. No tendency to form adhesions. - No infiltration through the capsule. No infiltration through the capsule. - It retains the shape of normal ovary. It retains the shape of normal ovary.

Solid waxy consistency along with cystic spaces. Solid waxy consistency along with cystic spaces. Histologically – Cellular or myxomatous stroma Histologically – Cellular or myxomatous stroma

among which are scattered large signet ring cells. among which are scattered large signet ring cells. Primary carcinoma is in stomach (70%) Primary carcinoma is in stomach (70%)

Large bowel (15%) Large bowel (15%) Breast (6%). Breast (6%).

Retrograde lymphatic spread. Retrograde lymphatic spread. Cells pass from stomach to the superior gastric Cells pass from stomach to the superior gastric

lymphatic glands which also receive lymphatic from lymphatic glands which also receive lymphatic from the ovary. the ovary.

KRUKENBERG TUMOUR - OVARY

KRUKENBERG TUMOUR SIGNET RING CELLS

SPREAD : SPREAD : Hematological spread – Rare Hematological spread – Rare Lymphatic spread – Lymphatic spread – -Through regional lymphatic glands -Through regional lymphatic glands

.Para aortic nodes.Para aortic nodes . Superior gastric nodes. Superior gastric nodes-May permeate to mediastinal glands. -May permeate to mediastinal glands.

Ulcerates Ulcerates Pleural cavity Pleural cavity

Pleura effusion Pleura effusion - Nodes in post triangle of (L) clavicle – Via - Nodes in post triangle of (L) clavicle – Via lymphatic ducts in mediastinum. lymphatic ducts in mediastinum.

-Pelvic lymph nodes by mets. -Pelvic lymph nodes by mets.

CLINICAL FEATURES :CLINICAL FEATURES : Age Age Family historyFamily history Initially asympatomatic Initially asympatomatic Characteristic features:Characteristic features: -Abdominal discomfort & pain -Abdominal discomfort & pain -Abnormal or post menopausal bleeding -Abnormal or post menopausal bleeding -Abdominal lump -Abdominal lump

ADVANCE STAGE : ADVANCE STAGE : - Wt loss - Wt loss - Cachexia - Cachexia - Anaemia - Anaemia

ON EXAMINATION : ON EXAMINATION : U/l non pitting oedema of leg, pleural effusion.U/l non pitting oedema of leg, pleural effusion.P/A :P/A : B/l tumor B/l tumor Ascites present Ascites present Fixed mass (late stage) Fixed mass (late stage) Intra peritoneal mets Intra peritoneal mets Hepatomegaly – (Late stage) Hepatomegaly – (Late stage)

P/V : Fixed nodule in POD P/V : Fixed nodule in POD Adnexal masses felt separate from uterus. Adnexal masses felt separate from uterus.

STAGING : FIGO STAGING OF OVARIAN CA. STAGING : FIGO STAGING OF OVARIAN CA.

STAGE I : Tumor restricted to one or both ovaries. STAGE I : Tumor restricted to one or both ovaries. IA : Restricted to one ovary. No tumor on ext. IA : Restricted to one ovary. No tumor on ext.

surface, capsule intact. No malignant ascites. surface, capsule intact. No malignant ascites. IB : Limited to both ovaries. No tumor on ext surface, IB : Limited to both ovaries. No tumor on ext surface,

capsule intact. No Malignant ascites. capsule intact. No Malignant ascites. IC: Tumor IA or IB positive for surface malignant IC: Tumor IA or IB positive for surface malignant

growth, capsule ruptured, malignant ascites or growth, capsule ruptured, malignant ascites or positive washing. positive washing.

STAGE II : Tumor involves one/ both ovaries with STAGE II : Tumor involves one/ both ovaries with pelvic extension pelvic extension

IIA : Extension / mets to uterus tubes and / or IIA : Extension / mets to uterus tubes and / or pelvic ext. No malignant cells in ascites/ washings. pelvic ext. No malignant cells in ascites/ washings.

IIB: Extension to other pelvic organs. No IIB: Extension to other pelvic organs. No malignant cells in ascites or washing. malignant cells in ascites or washing.

IIC: Tumor IIA & II B with surface growth, IIC: Tumor IIA & II B with surface growth, capsule ruptured at / or prior to surgery, malignant capsule ruptured at / or prior to surgery, malignant ascites or positive washings. ascites or positive washings.

STAGE III : STAGE III : Tumor involving one / both ovaries with Tumor involving one / both ovaries with

microscopic implants outside the pelvis, and / or microscopic implants outside the pelvis, and / or positive nodes ( inguinal, retroperitoneal). positive nodes ( inguinal, retroperitoneal). Tumor limited to true pelvis but with histological Tumor limited to true pelvis but with histological evidence of spread to bowel, omentum presence evidence of spread to bowel, omentum presence of superficial mets on the liver. of superficial mets on the liver.

IIIA: Tumor grossly limited to pelvis, nodes neg IIIA: Tumor grossly limited to pelvis, nodes neg but microscopic seeding of peritoneum of the but microscopic seeding of peritoneum of the abdominal wall. abdominal wall.

IIIB : IIIB : Tumor with abdominal peritoneal implants of less Tumor with abdominal peritoneal implants of less than 2.0 cm size & nodes negative. than 2.0 cm size & nodes negative.

IIIC : IIIC : Abd implants of more than 2.0 cm size & / or positive Abd implants of more than 2.0 cm size & / or positive nodes. nodes.

STAGE IV :STAGE IV : Growth involving one or both ovaries with distant Growth involving one or both ovaries with distant

mets in liver, lungs & pleura. Tap fluid for cytology. mets in liver, lungs & pleura. Tap fluid for cytology.

INVESTIGATIONS : INVESTIGATIONS : 1.Routine investigations – Hb, Blood sugar, serum create, 1.Routine investigations – Hb, Blood sugar, serum create,

LFT, CXR, ECG. LFT, CXR, ECG. 2. Ultrasound abdomen 2. Ultrasound abdomen 3. Doppler ultrasound ( low pulsatile index < 1 & resistance 3. Doppler ultrasound ( low pulsatile index < 1 & resistance

index less than 0.4 suggest malignancy). index less than 0.4 suggest malignancy). 4. CT & MRI 4. CT & MRI 5. Tissue markers 5. Tissue markers CEA > 5 ngl ml ( (N) 2.5 – 5 ng / ml) CEA > 5 ngl ml ( (N) 2.5 – 5 ng / ml) Endometrioid, Brenner tumor, Mucinous, Colonic, liver, Endometrioid, Brenner tumor, Mucinous, Colonic, liver,

breast & lung mets. breast & lung mets. CA 125 – Used for follow up of treatment (N) < 35 MIU / CA 125 – Used for follow up of treatment (N) < 35 MIU /

ML. ML.

6.Barium meal, barium enema, breast 6.Barium meal, barium enema, breast examination. examination.

7. Chest X- ray 7. Chest X- ray

8. AFP, hCG, NB/ 70K; placental alkaline 8. AFP, hCG, NB/ 70K; placental alkaline phosphatase & lactase dehydrogenase are phosphatase & lactase dehydrogenase are tissue markers for germ cell tumors. tissue markers for germ cell tumors.

Inhibin in granulosa cell tumor. Inhibin in granulosa cell tumor.

9. FNAC & Ascitic fluid cytology. 9. FNAC & Ascitic fluid cytology.

MANAGEMENT : MANAGEMENT :

1.1. SURGERY SURGERY

2.2. CHEMOTHERAPY CHEMOTHERAPY

3.3. RADIO THERAPY RADIO THERAPY

4.4. IMMUNOTHERAPY IMMUNOTHERAPY

5.5. COMBINED APPROACH COMBINED APPROACH

SURGERY :SURGERY : Laparotomy & Maximal reduction – 1Laparotomy & Maximal reduction – 1oo gold standard treatment. gold standard treatment. Surgical staging followed by definitive surgery or debulking Surgical staging followed by definitive surgery or debulking

followed by chemo or RT. followed by chemo or RT.

SURGICAL STAGING : SURGICAL STAGING : Systemic exploration of under surface of diaphragm, liver, Systemic exploration of under surface of diaphragm, liver,

stomach, bowel & omentum. stomach, bowel & omentum. Para aortic nodes should be palpated. Para aortic nodes should be palpated. Ascitic fluid & peritoneal wash collected in heparinised bottles. Ascitic fluid & peritoneal wash collected in heparinised bottles. Ovaries & uterus should be studied for planning definitive Ovaries & uterus should be studied for planning definitive

surgery. surgery.

SPECIFIC MANAGEMENT : SPECIFIC MANAGEMENT : BORDERLINE MALIGNANCY : BORDERLINE MALIGNANCY : If peritoneal wash is negativeIf peritoneal wash is negative -TAH & BSO in older women -TAH & BSO in older women -Conservative ovariotomy in young women -Conservative ovariotomy in young women -No post OP chemo required-No post OP chemo required -Follow up mandatory. -Follow up mandatory.

STAGE I & II : STAGE I & II : Operable - TAH & BSO with omentectomy. Operable - TAH & BSO with omentectomy.

STAGE III & IV STAGE III & IV Debulking surgery & removal of tumor Debulking surgery & removal of tumor Post op chemo & RT Post op chemo & RT Preop Cisplatin followed by surgery is lately Preop Cisplatin followed by surgery is lately

employed. employed. Post OP chemo & RT depends on staging & Post OP chemo & RT depends on staging &

type of tumor. type of tumor. Duration of chemo is judged by level of tissue Duration of chemo is judged by level of tissue

markers. markers.

SECOND LOOK SURGERY : SECOND LOOK SURGERY : To detect presence of any residual tumor To detect presence of any residual tumor

following course of chemo & decide if further following course of chemo & decide if further chemo required. chemo required.

Following 3-6 m course of chemo in Following 3-6 m course of chemo in inoperable cases, this may enable TAH & BSO inoperable cases, this may enable TAH & BSO or debulking. or debulking.

In recurrent tumor – this procedure is In recurrent tumor – this procedure is alterative to laparotomy. alterative to laparotomy.

RECURRENT TUMOR : RECURRENT TUMOR : If tumor recurs the following option applicable If tumor recurs the following option applicable

depending on the type & size & histology of depending on the type & size & histology of tumor. tumor.

For single site recurrence – Second look For single site recurrence – Second look surgery & removal of the lesion. surgery & removal of the lesion.

For visceral mets – chemotherapy For visceral mets – chemotherapy For nodal mets – Radiotherapy. For nodal mets – Radiotherapy.

CHEMOTHERAPY : CHEMOTHERAPY : Given for 6 m once in 3 wks Given for 6 m once in 3 wks Cisplastin & taxol are main drugs used. Cisplastin & taxol are main drugs used. Carboplatin – Superior to cisplatin with less Carboplatin – Superior to cisplatin with less

nephrotoxicity & less emetic but nephrotoxicity & less emetic but myelosuppresion is the myelosuppresion is the limiting factor. limiting factor.

Second line drugs Second line drugs Cyclophosphamide, Cyclophosphamide, Topotecan Topotecan Ifosfamide Ifosfamide Doxycycline Doxycycline

MONITOR FOR : MONITOR FOR :

1) Regression disease 1) Regression disease

2) Myelosuppression 2) Myelosuppression

3) Vomiting 3) Vomiting

4) Diarrhoea 4) Diarrhoea

5) Nephro & neurotoxicity & renal toxicity 5) Nephro & neurotoxicity & renal toxicity

NEOADJUVANT CHEMOTHERAPY OR NEOADJUVANT CHEMOTHERAPY OR INTERVAL DEBULKING INTERVAL DEBULKING

3 cycles of chemo 3 cycles of chemo Sx Sx 3 more cycles of chemo. 3 more cycles of chemo.

RADIOTHERAPY : RADIOTHERAPY : Moving strip technique of ext RT is applied to para Moving strip technique of ext RT is applied to para

aortic lymphnodes & abd mets. aortic lymphnodes & abd mets. Dysgerminoma & granulosa cell tumors are highly Dysgerminoma & granulosa cell tumors are highly

radiosensitive. radiosensitive.

IMMUNOTHERAPY : IMMUNOTHERAPY : Host immunity – known to alter the behaviour of Host immunity – known to alter the behaviour of

tumors. tumors.

IMMUNOPOTENTIATORSIMMUNOPOTENTIATORSBCG BCG Corynebacterium parvum Corynebacterium parvum Levamisole Levamisole Interferon Interferon

Still under research. Still under research.

PROGNOSIS : PROGNOSIS :

FIGO staging FIGO staging 5 yr survival rate 5 yr survival rate Stage O Stage O 90-100%90-100%Stage IStage I 70% 70% Stage II Stage II 25-30% 25-30% Stage III Stage III 10%10%Stage IV Stage IV 0 - 5%0 - 5%