OVARIAN CANCER

INTRODUCTION

I.Histologic Classification i.coelomic epithelium originating tumor accounts for 50-70% of primal ovarian tumor , 85-90% of ovarian malignace.developed from germinal epithelium→ primal coelomic epithelium →various muller,s epithelium →tubal epithelium,cervical mucosa epithelium,endometrium

the coelomic epithelial tumors include (i).serous tumor (ii).mucinous tumor (iii).endometrioid tumor (iv).clear cell tumor

(v).Brenner tumor/transitional cell tumor (vi).mixed epithelial tumor (vii).undifferentiated carcinoma

ii.germ cell tumor accounts for 20-40% of ovarian tumor.germ cells originate

from endogerm tissues.in the course of its origination, transformation and development the cellular heterogeneity may occur and form various tumors

germ cell tumors include (i).dysgerminoma (ii).endodermal sinus tumor

(iii).embryonic carcinoma (iv).polyembryonic tumor (v).choriocarcinoma (vi).teratoma i).immature type ii).mature type (a).solid teratoma (b).cystic teratoma a).dermoid cyst b).malignant change of dermoid cyst (c).monodermal and highly specialized tumors a).struma ovarii b).carcinoid (vii).mixed type

iii.ovarian gonadal sex cord stromal tumor accounts for 5% of ovarian tumor.sex cord stroma originates

from mesenchymal tissues of primal coelom female and male differentiation →epithelium differentiation→granulosa, Sertolic cell tumor functional tumor stromal differentiation →theca cell, Leydig cell tumor

sex cord stromal cells tumor includes (i).granulosa cell-stromal tumor i).granulosa cell tumor ii).theca cell tumor,fibroma

(ii).Sertolic-Leydig cell tumor i).androblastoma (iii).gynandroblastoma

iv.metastasized tumor

II.High risk factors of ovarian tumors i.hereditary and family factors about 20-25% malignant ovarian tumors have family history

ii.environmental factors the mobidity of ovarian cancer is high in industry developed countrys,this may be because of high cholesterol diet in these countrys

iii.endocrinic factors mobidity in less pregnant or infertile women is high(why), functional cancers may easily complicated with mammary andendometrial cancer

III.pathology i.epithelial ovarian tumors age:30-60 ;classification:benigh,borderline,malignant borderline tumor means: (i).serous cystadenoma mobidity :accounts for 25%benigh tumors macroexamination :unilateral,globular,different size,smooth

surface,cystic,thin wall and filled by clear light-yellow fluid section : simple type,monocystic,smooth wall;papillary type, multicystic,intracystic papilla microscopic exanination : tumor wall is composed of fibro- connective tissues and lined by a single layer of cuboid or columnar epithelium

borderline serous cystadenoma macroexamination : moderate size bilateral,more extracystic papilla microscopic examination :thin papillary branch,epithelium≤3 layers,slight cellular atypia,nuclear mitosis<1/HP,no stroma invasion 5 year survival rate :over 90%

serous cystadenocarcinoma morbidity :most common malignant ovarian tumor,40-50% macroexamination :bilateral,relatively large,semisolid,nodular or lobular,smooth surface,gray white color,papillary proliferation section :multicystic,filled by papilla,brittle,bleeding,necrosis, blurred cysticfluid

microscopic examination :obvious epithelial proliferation, 4-5layers,cuboid or columnar cancer cells,obvious cellular atypia,stromal invasion 5 year survival rate:20-30%

(ii).mucinous cystadenoma morbidity:20% of benign tumor macroexamination:unilateral,round or elliptic,smooth surface,gray white,large or giant section:multicystic,filled by tremellose mucus,less intracystic papilla

microscopic examination:fibroconective tissues wall,lined a single layer of high columnar epithelium,malignant change rate 5-10% peritoneal myxoma:2-5% of mucinous cystadenomas may develop,formation,histology

borderline mucinous cystadenoma macroexamination:relative large,more unilateral,smooth surface,multicystic section:thick walll,solid area,tiny soft papilla microscopic examination:epithelium≤3 layers,slight cellular heterogeneous,large dark stained nucleus,less mitosis,proliferated epithelium protrude into cavity and form papilla,no stromal invasion

mucinous cystadenocarcinoma morbidity:10% of malignant tumors macroexamination:unilateral,large size,papillary or solid area section:semicystic and semisolid,blurred or bloody fluid microscopic examination:dense gland,less stroma,glandular epithelium>3 layers,obvious cellular atypia,stromal invasion 5 year survival rate:40-50%,prognosis is better than serous cystadenocarcinoma

(iii).endometrioid tumor morbidity : less encountered,benign macroexamination : more unilateral,smooth surface microscopic examination : surface is a single layer of columnar epithelium which very like endometrial gland epithelium, cavity is lined by pavement epithelium borderline:rare endometrioid carcinoma morbidity :10-24% of primary malignant tumor macroexamination:more unilateral,moderate size section:cystic or solid,papilla,bloody fluid microscopic examination:very similar to endometrial cancer, more adenocarcinoma or adenoacanthoma,often complicated with endometrial carcinoma 5 year survival rate :40-50%

ii.ovarian germ cell tumors a group of ovarian tumors originated from primal germ cells, its morbidity is secondary to the epithelial tumors,most occurs in c

hildhood and adolescence,morbidity before adolescence accounts for 60-90%,while after menopause it only accounts4%

(i).teratoma mature teratoma :also called dermoid cyst morbidity :the most common benign ovarian tumor,10-20% of ovarian tumors,85-97%of germ cell tumors,over 95% of teratoma age :occurs at any age,mostly between 20-40 macroexamination :more unilateral,moderate size,round or elliptic,smooth and thin walll,

section :more nuicystic,filled by lipid and hair,occasionally tooth and bone can be seen,scolex on the wall components :endoderm,ectoderm and mesoderm highly specialized teratoma : monoderm,such as struma ovarii malignant change rate :2-4%,more in postmenopause,metasta- sized by spreading and peritoneal implantation prognosis :bad,5 year survival rate 15-31% immature teratoma : malignant tumor components :2-3germ layers,immature embryonic tissue age:adolescence macroexamination : more solid malignance :dependent upon the ratio and differentiation of immature tissue and the quantity of nervous epithelium recurrent and metastatic rate : high,5year survival rate20%

(ii).dysgerminoma :mid malignant tumor morbidity :5%of malignant ovarian tumors most in adolescence and reproductive period macroexamination :solid, more unilateral,round or elliptic, moderate size,touching like eraser,smooth surface or lobular section:light-brown color microscopic examination :round or polygonal cells,lymphocyte invasion in stroma prognosis :very sensitive to radiotherapy,5year survival rate90%

(iii).endodermal sinus tumor :also called yolk sac tumo morbidity : rarely encountered age : mostly occurred in children and young women macroexamination :unilateral,relatively large,round or elliptic section:partially cystic,brittle tissue,bleeding and necrosis area, gray-red or gray-yellow color microscopic examination:endodermal sinus structure,flat or cuboid or columnar tumor cells which produce AFP,AFP is an important diagnostic and therapeutic marker prognosis:average survival time is 1 year

iii.ovarian gonadal sex cord stromal tumor accounts for 5-8%of malignant ovarian tumor (i).granulosa-stromal cell tumor i).granulosa cell tumor:low malignance morbidity:3-6%of ovarian tumor,80%of sex cord stromal tumor age:at any age,mostly between 45-55 feminization effect:secret estrogen macroexamination:unilateral,different size ,round or elliptic, lobular, smooth surface ,solid or partially cystic section:brittle and soft tissue,bleeding and necrosis microscopic examination :Call-Exner body prognosis :better,5year survival rate over 80%

ii).theca cell tumor :benign tumor feminization effect:secret estrogen,often coexist with granulosa cell tumor macroexamination : unilateral different size ,round or elliptic, thin smooth fibrocapsule section:solid ,gray white microscopic examination :short spindal cells,lipid in cytoplasm prognosis : malignant tumor is rare ,prognosis is better than other ovarian cancer iii).fibroma :common benign tumor morbidity :2-5%of ovarian tumor age : mostly in mid-aged women

macroexamination :unilateral, moderate size,smooth surface or nodular section:gray white,solid and hard microscopic examination:composed of spindle cells Meigs syndrome :accompanied with hydrothorax and ascites

(ii).Sertoli Leydig cell tumor:also called androblastoma morbidity : rare age : below40 macroexamination : unilateral,small,solid smooth surface section :gray white accompanied by cystic degeneration, bloody or serous or mucinous cystic fluid virilism effect :secret androgen prognosis :10-30% is malignant ,5year survival rate 70-90%

iv.ovarian metastatic tumor:all of the cancers in the human body can metastasize to the ovary,the common primary

origination is at breast,intestine,stomach,reproductive tract, urinary tract and other organs morbidity:5-10%of ovarian tumor Krukenberg tumor :a special metastatic adenocarcinoma,its primary origination is in the gastrointestinal tract macroexamination:bilateral,renal shape, no adhesion,often accompanied by ascites section:solid microscopic examination:signet-ring cell which produce mucus prognosis:very bad

• IV.Metastatic Path• i.metastatic character:there is subclinical metastasis on• omentum,peritoneum,retroperitoneal LN and diaphragm• although the tumor is localized from its apparence• ii.metastatic path:• (i).directly spreading:this is the chief metastatic path.the • tumor cells may directly invade the capsule,involve• the neighbour organs and extensively implant on the• peritoneum and omentum• (ii).lymphetic vessels metastasis:this is an important• metastatic way which includes• i).spread along the ovarian blood vessels and is metastasized• to para-aortic LN through ovarian lymphetic vessels

• ii).from ovarian hilus lymphetic vessels to internal and• external iliac LN,and then from the common iliac LN• to para-aortic LN• iii).along the round ligament enters the external iliac and• inguinal LN.diaphragm is the place to which the cancer• is easily metastasized,especially the right diaphragm is• the most easily invaded because of its dense lymphetic• plexus• (iii).blood metastasis is very rare.but at very late stage it may• metastasize to the liver and lung

• V.Histologic grades• the WHO standards of histologic grading is chiefly• according to the histologic structure and cellular• differentiation.• Grade I:means the cell is well differentiated• Grade II:means moderate differenation• Grade III:means undifferenation• the effects of histologic grade on the prognosis is • more important than that of the histologic types

• VI.Clinical stage:the FIGO(1986) clinical stage is • adopted• stage I tumor is localized in the ovary• Ia tumor is localized in one ovary,the capsule is integrated,• no tumor on ovary surface,no ascites

• Ib tumors are localized in bilateral ovarys,integrated capsule• no tumor on surface,no ascites

• Ic based on Ia or Ib,there is tumor on the surface(unilateral• or bilateral);or capsule is ruptured;or there is malignant • cells in ascites ;or the abdominal cavity irrigating fluid• is positive

• Stage II unilateral or bilateral ovarian tumor with pelvic • metastasis• IIa spread to uterus and (or)fallopian tube

• IIb spread to other tissues in pelvis

• IIc based on the IIa or IIb, there is implantation on• unilateral or bilateral ovarian surface;or the capsule is• ruptured;or the ascites contains malignant cells;or the• abdominal cavity irrigating fluid is positive

• Stage III unilateral or bilateral ovarian tumor.there is• extrapelvic peritoneal implantation and (or) the• retroperitoneal or inguinal LN is positive,liver• surface metastasis is stage III• IIIa macroexamination shows that the tumor is loca-• ted in the true pelvis,LN is negative but there is • microscopic peritoneal implantation• IIIb unilateral or bilateral ovarian tumor,there is • peritoneal surface implantation and its diameter• is<2cm, LN is negative• IIIc the peritoneal surface implantation is>2cm and• (or) retroperitoneal or inguinal LN is positive• stageIV unilateral or bilateral ovarian tumor with telemetastasis,• hydrothorax contains cancer cells,and there is liver• parenchyma metastasis

VII.Clinical Manifestation i.benign ovarian tumor (i).at early stage (ii).when tumor is moderate size (iii).when tumor is large enough to occupy the full pelvis or abdominal cavity

ii.malignant ovarian tumor (i).at early stage (ii).once there are symptoms (iii).the severity of the symptoms depends ouon i).the tumor size,location and whether there is neighbour tissues or organs invasion ii).the histologic type of the tumor iii).whether there is complication

(iv).at late stage i).symptoms ii).body signs

VIII.Diagnosis i.cytologic examination ii.B-Ultrasound iii.radiodiagnosis: (i).abdominal plain film (ii).intravenous pyelography,barium meal,barium double contrast radiography or mammary soft tissue X-ray (iii).CT

(iv).laparoscopy (v).tumor marker i).CA-125 ii).AFP iii).HCG iv).sexual hormone

IX.Differential Diagnosis * *i.differential diagnosis between the benign and malignant ovarian tumor

Differential contents benign tumor malignant tumorHistory long clinical course short clinical course and and gradually enlarge rapidly enlargeBody sign often unilateral,movable, often bilateral,fixed solid cystic,smooth surface or semisolid,rough surface, no ascites bloody ascites with cancer cellsGeneral condition better cachexia is gradually developedB-Ultrasound dark fluid echo area,there echo group or points exist may be intracystic diaph- in the dark fluid area tumor ragm,tumor outline is outline is not clear clear

ii.differential diagnosis of benign ovarian tumor i.ovarian tumor like condition:may disappear within 2 month ii.tubo-ovarian cyst iii.uterine myoma iv.pregnant uterus v.large quantity ascites

iii. differential diagnosis of malignant ovarian tumor i.endometriosis:symptoms,body signs,B-Ultrasound and laparoscopy ii.pelvic connective tissues inflammation:history,symptoms,and body signs,B-Ultrasound iii.TB peritonitis:history,general symptoms,body signs, B-Ultrasound and gastrointestinal X-ray iv.extra-reproductive tract tumors: B-Ultrasound,Barium meal and intravenous pyelography v.metastatic ovarian tumor:generally no primary tumor history

X.Complications of ovarian tumor i.pediculotorsion:common gynecologic acute abdomen

(i).mechanism (ii).components of the pedicle (iii).pathologic change (iv).typical symptoms (v).body signs (vi).management

ii.tumor rupture:accounts for about 3% of ovarian tumor (i).traumatic and spontaneous rupture (ii).symptoms depends on the length of rupture,the

quantity and the quality of the cystic fluid flowing into abdominal

cavity (iii).body signs (iv).management

iii.infection:rarely encountered (i).cause of the infection (ii).clinical manifestation (iii).management

iv.malignant change (i).at early stage of malignant change (ii).suspicious manifestation (iii).management principle of ovarian tumor

XI.Prevention i.prevention of high risk factors : suggesting high protein and vitamin A diet and avoiding high cholesterol diet

ii.popularizing the regular examination and treatment

iii.early diagnosis and treatment

XII.Treatment of ovarian tumor i.benign ovarian tumor:once the diagnosis is confirmed operation should be performed

(i).young patient with unilateral tumor bilateral tumor (ii).perimenopausal patient with benign ovarian tumor (iii).manipualtion principle of operation

ii.malignant tumor:the treating principle is chiefly by operation and the chemotherapy and radiotherapy is as the accessory treatment (i).operation:operation play the key role for the treatment especially the first time of operation i).probe during operation ii).operating range:(a).for stage Ia or Ib (b).for stage Ic or over Ic (c).cytoreductive operation iii).the indications of reserving contralateral ovary (a).stage Ia,well differentiated (b).borderline or low malignant tumor (c).no tumor is found in the contralateral ovary (d).has the condition of closely postoperative follow up

(ii).chemotherapy chemotherapy is a chief accessory therapy.malignant ovarian tumor is relatively sensitive to the chemotherapy, the chemotherapy has certain effect even if the tumor has extensively metastasized the chemotherapy may be either for the prevention of recurrence or for the postoperative treatment in the patient whose tumor can not be thoroughly removed for late stage patient who does not fit for the operation,the chemotherapy can shrink the tumor and create the condition for afterwards operation

(iii).radiotherapy:the accessory treatment for the operation and chemotherapy dysgerminoma is very sensitive to the radiotherapy, granulosa cell tumor is moderate sensitive to the radiotherapy epithelial ovarian cancer also has certain sensitivity to the radiotherapy

XIII.Prognosis: prognosis is associated with the clinical stage, histologic type,age and treating methods among which the clinical stage is the most important

XIV.follow up i.time of follow up:once a time within 1 year after operation;once every 3 month in the second year after operation;once every 6 month in the third year and once a year over 3 years after operation ii.contents:symptoms body signs ,pelvic and general examination B-ultrasound,CT,MRI and tumor marker