Malignancy of the endometrium, ov, ft

24/03/2017 #DLSHSI_GYNEONCO2017 @doc_magno

MalignantNeoplasmoftheEndometrium,Ovary,FallopianTube

andPeritoneumAngelitoMagnoM.D.,FPOGS,FSGOP,FPSCPC

DeLaSalleHealthSciencesInsRtuteMarch24,2017


EndometrialCancer

•  13thMCcancerinbothsexes•  7thleadingsiteamongwomen•  3rdMCgynecologicmalignancy•  MostcommonmalignancyofthefemalegenitaltractintheUSandotherdevelopedcountries


EndometrialCancer

•  PerimenopausalandPostmenopausalage(50-65yearsold)

•  10-15%-youngerthan50years•  5%-womenlessthan40yearsold



EndometrialPathology:Progression

Normal Hyperplasia Cancer

UnopposedEstrogen


EarlyMenarcheHPNCC/Lynchsyndrome

Age


SYMPTOMSandSIGNS

•  Postmenopausalbleeding•  Abnormalpremenopausalandperimenopausalbleeding

•  Discharge•  Pelvicpain•  Uterineenlargement


Transvaginalultrasonography

•  Threshold:Endometrialthickness

•  ReproducRveage–  ProliferaRvephase:8mm–  Secretoryphase:upto1.4cm

•  Postmenopausalage:<5mm

•  NotausefultoolforasymptomaRcTamoxifenusers


DIAGNOSIS

•  HistologicexaminaRonoftheendometrium•  OfficeEndometrialBiopsy

– Novak’scuret–  Pipelle-usefuliftheendometrialthicknessof>6mm–  1stlineinthediagnosisofendometrialcancer–  Endometrialsampleisobtainedintheclinicwithnoanesthesia

– Advisableonlyforpostmenopausalwomenwiththickenedendometrium(notforpre-menopausalwomen)


OfficeEndometrialBiopsy


Diagnosis

•  IfinadequateoutpaRentevaluaRonorsample– FracRonal/Endometrialcurefage– Hysteroscopy


FracRonalcurefage

•  Underregionalanesthesia•  Completescrapingoftheendocervicalandendometriallinings


DIAGNOSIS HYSTEROSCOPY

•  Videoscopeisintroducedtranscervicallytovisualizeendometrialcavity

•  Togetherwithbiopsy,consideredthegoldstandardfortheinvesRgaRonofwomenwithsymptomsofendometrialpathology


Papsmear

•  Screeningtoolforcervicalcancer

•  NOTagoodscreeningtoolforendometrialcancer

•  Only50%orlessofcasesdetectedbypapsmear




Endometrioidadenocarcinoma

•  Mostcommontypeofendometrialcancer•  Glandsareinbacktobackpafernwithminimalornoinbetweenstroma



Backtobackpafern



DegreeofdifferenRaRon•  Grade1-well-differenRated,<5%solidcomponents

•  Grade2-moderatelydifferenRated,6-50%solidcomponent

•  Grade3-poorlydifferenRated,>50%solidcomponent



Adenocarcinomawithsquamouscomponent

•  Previouslytermedasadenoacanthomaoradenosquamouscarcinoma

•  Mixtureofglandular(adeno)andsquamousepithelium

•  PrognosisdependsonthedifferenRaRonoftheglandularcomponentandnotfromsquamouspart


UterinePapillarySerousCarcinoma

•  Highlyvirulent•  Uncommonhistologicsubtypeofendometrialcarcinomas(5%to10%)

•  Histologicallyresemblepapillaryserouscarcinomasoftheovary

•  Finger-like(papilla)projecRons




ClearCellCarcinoma

•  lesscommon(<5%)•  Resemblesclearcelladenocarcinomasoftheovary,cervix,andvagina

•  Hobnailcells•  Clearcytoplasmwithnucleusontheside



UPSCandClearcell

•  Prognosisisworsethanthetypicalendometrioidadenocarcinoma

•  Stage1endometrioidadenoarcinomahas5yearsurvivalof>90%butonly50%inbothUPSCandClearcellcarcinoma

24/03/2017 #DLSHSI_GYNEONCO2017 @doc_magno*ReporRngofposiRveperitonealcytology


StageI:confinedtotheCorpus

IA-Endometriumor<50%ofthemyometrium

IB->50%oftheendometrium


StageII:Cervicalstromabutnotbeyondtheuterus

II:tumorinvadesthecervicalstroma

*invasionofcervicalglandsisNOWstageIA


StageIII:Localorregionalspread

IIIA:Involvementofserosaofthecorpus

andAdnexa

*PosiRveperitonealcytologyisnolongerstageIIIA



IIIB:Vaginaland/orParametrialinvolvement

ParametrialRssue:paravaginalRssues,broadligament,cardinalligament,paracervicalRssues,otherpelvicRssues



IIIC:RegionalNodes

IIIC1:pelvicnodes

IIIC2:paraaorRc nodesw/orw/opelvicnodes


StageIVA:

IVA:bladdermucosaorrectal

mucosalinvolvement


StageIVBIVB:Distantmetastases

includingintra-abdominalorgansand

inguinalnodes

*intra-abdominalorgans=organsabovethepelvicbrim


PosiRvePeritonealcytology

•  Shouldbereportedseparatelywithoutchangingthestage

•  Example:– Endometrialadenocarcinoma,endometrioidtype,stageIB,(+)peritonealfluidcytology


PrognosRcFactors

ClinicalFactors PathologicFactorsAgeStageRace

TumorgradeHistologictypeTumorsizeDepthofmyometrialinvasion,VascularspacesinvolvementExtrauterineinvolvement(lymphnodes,peritoneumoradnexa)

FactorsthataffectprognosisofthepaRents


STAGE


MYOMETRIALINVASION



PafernofSpread•  A.Directextension

– Transtubalortranscervical/transvaginalspread•  B.LymphaRcs•  C.Hematogenous


PafernofSpread(LymphaRcs)(1)asmalllymphaRcbranchalongtheroundligamentthatrunstotheinguinalfemoralnodes


PafernofSpread(LymphaRcs)(2)branchesfromthetubal(3)ovarianpedicles(infundibulopelvicligaments),whicharelargelymphaRcsthatdrainintothepara-aorRcnodes;


PafernofSpread(LymphaRcs)(4)thebroadligamentlymphaRcsthatdraindirectlytothepelvicnodes


PafernofSpread(LymphaRcs)(1)asmalllymphaRcbranchalongtheroundligamentthatrunstotheinguinalfemoralnodes(2)branchesfromthetubal(3)ovarianpedicles(infundibulopelvicligaments),whicharelargelymphaRcsthatdrainintothepara-aorRcnodes;(4)thebroadligamentlymphaRcsthatdraindirectlytothepelvicnodes2,3,4-clinicallymostimportant


EvaluaRon

•  Imagingtechniques-CTScan,MRI,PET/CTScan

•  ColorDopplerUltrasound•  CA125


IMAGINGTECHNIQUES

-SGOP2015CPG


ColorDopplerUltrasound

•  adjunctultrasound•  DetectsneovascularizaRon(abnormalvesselformaRon)

•  Highresistanceindex-featureofmalignancy


CancerAnRgen(Ca)125

•  Generallyusedinepithelialovariancancer•  Usedinadvancedstageendometrialcancertodetectextrauterineinvolvementandaspost-operaRvemonitoring

•  Notusefulinearlystagedisease•  Non-specifictoendometrialcancer


SURGERY

•  primarytreatmentmodality•  Surgicopathologicstaging(usingthe2009FIGOStagingsystem)

•  ExcepRons:– PaRentswithpoorsurgicalriskduetounstablemedicalcondiRons

– YoungcancerpaRentsdesirousoffutureferRlity– Willusethe1971FIGOClinicalStagingSystemofEndometrialcancer


Surgery

Completestaging•  Peritonealfluidwashing•  Totalhysterectomywithsalpingo-oophorectomy

•  Bilateralpelviclymphadenectomy•  *Para-aorRclymphadectomy

– Notdoneforlowriskcancer


Surgery

•  Surgicalstaging(1) tumorspreadwithintheuterus(2) degreeofpenetraRonintothemyometrium(3) extrauterinespreadtoretroperitoneal

nodes,adnexa,and/ortheperitonealcavity


Surgery

•  Opensurgery/Laparotomy•  Minimallyinvasiveapproach

– ConvenRonalLaparoscopy– RoboRc


Minimallyinvasivetechniques

Advantages•  Samepathologicoutcome(adequacyofRssues,nodenumber)

•  Shorterhospitalstay•  Smallerwound•  BeferQOLpost-operaRvely•  Lessbloodloss,lesscomplicaRons


OthertreatmentmodaliRes

•  UnstablemedicalcondiRons•  YoungpaRentsdesirousofpregnancy

•  RadiaRonalone•  Medicaltherapy


RadiaRon

•  RadiaRonalone:Inferiorthansurgery– Stage1surgeryalone:87%5yrsurvivalversus67%forradiaRonalone

– NotrecommendedforpaRentsdesirousofpregnancy(radiaRonwillkilltheovaries)

•  Asadjuvanttherapy:givenpost-operaRvetreatmentifwithpoorprognosRcfactors–  IncreasessurvivalofpaRentswithadvancedendometrialcancer


Stage1

SGOP2015CPG


StageII

SGOP2015CPG


StageIII

SGOP2015CPG


StageIV

SGOP2015CPG


UPSCandClearCellHistology

SGOP2015CPGSimilarsurgicaltreatmentwithovariancancerbecauseUPSCandclearcellcancerbehavelikeovariancancer


Medical/ConservaRvetreatmentConservaRvetreatmentisonlyofferedtopaRentswhohave:•  WelldifferenRatedtumor(endometrioidtype)•  Nomyometrialinvasion(asevaluatedbyMRI)•  Nocervicalinvolvement•  Noextrauterineinvolvement:

–  Noadnexalinvolvement–  Noparametrialinvolvement–  Novaginalinvolvement–  Nosuspiciousretroperitonealnodesornoevidenceoflymphnodemetastasis

–  NegaRvePFC•  NoLVSI(lymphovasularspaceinvasion)•  NocontraindicaRonsformedicalmanagement

SGOP2015CPG


Medical/ConservaRvetreatmentThefollowingarealsoessenRal:•  ProgesRnreceptorposiRvity•  PaRentunderstandsandacceptsthatthisisnotstandardtreatment–  (Informedconsent)–InformpaRentsthattheprocedureofpreservaRonofferRlityissRllexperimentalandthereislowpregnancyrate

•  PaRentwithstrongdesiretopreserveherchildbearingpotenRal


Medical/ConservaRvetreatment•  Agentsused:DuraRonoftreatmentisvariable

•Megestrolacetate40-60mg/day•Medroxyprogesteroneacetate(MPA)100-800mg/day•Levonorgestrel-containingintrauterinesystem(LNG-IUS)•Tamoxifen+ProgesRns•Anastrozole+ProgesRns


Medical/ConservaRvetreatmentMonitoring:•  repeatdilataRonandcurefageauer3monthsoftherapy

•  Noresponseauer3monthsoftherapy=treatmentfailure

•  maintenancetreatmentwithoralcontracepRvepills(OCPs),cyclicprogesRns,depotmedroxyprogesteroneacetate(DMPA),orLNG-IUSunRlpregnancyisdesired

•  Ifpregnancyisdesired,afemptsshouldbemadeauer3monthsfromreversionofthecancer.


OVARIANCANCER


OvarianCancer

•  2ndmostcommongynecologiccancerandmostcommoncauseofcancerdeathintheU.S

•  Incidenceincreaseswithage(beyond50years)-epithelialtumor


2010PhilippineCancerFactsandEsRmates

0 2000 4000 6000 8000 10000 12000 14000

StomachThyroid

LeukemiaCorpusLiverOvary

Colon/rectumLung

CervixBreast

Es#matedleadingnewcancercases,females

5th


2010PhilippineCancerFactsandEsRmatesEsRmatedLeadingNewCancerDeaths,females

0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000

Brain/NS

Corpus

Stomach

Ovary

Leukemia

Colon/rectum

Liver

Cervix

Lung

Breast

7th


Pathogenesis

A.AccumulaRonofgeneRcaberraRon-Rasfamilyofoncogenes-p53

B.InheritedgenemutaRon-BRCAmutaRon&LynchSyndrome

C.DeNovoproliferaRon-incessantovulaRon-PIDandEndometriosisassociatedtumors


Pa0ernofSpread:

•  TranscoelomicdisseminaRonordirectextension

•  LymphaRc•  Hematogenous


PresentaRons

•  Non-specific(earlysaRety,epigastricpain,bloatedness,weightloss)

•  Abdominalenlargement•  Pelvicmass•  Vaginalbleeding


DIAGNOSIS•  Ultrasoundremainstobethemosthelpfulimaging

examinaRonforovariancancerdiagnosiswiththehighestsensiRvity

•  CA125andHE4(morespecifictumormarkerforovarian

cancer)

*However,ROUTINEscreeningforaverage-riskwomenusingTVUTS,CA125andpelvicexamisnotrecommended


SuggesRveofOvarianmalignancy

•  complexmasswithbothsolidandcysRccomponents

•  papillaryexcrescencesandprojecRons•  internalechoesandseptaRons•  Ascites•  peritonealmetastasis


RiskFactors•  Nodefinitecause

Factorsthatincreaserisk:•  Nulliparity•  MenstrualirregulariRes•  Hxofbreastorendometrialcancer

FactorsthatcouldbeprotecRve:•  Pregnancy•  OralcontracepRves


PoorSurvivalRatedueto:

•  Latediagnosis•  Noreliablescreeningmethods•  Nodefiniteriskfactors•  NoknowneRology•  Noprecursorlesions•  Non-specificsymptomsandsigns


ContrastofSurgicalFindingsBenign Malignant

Surface papillae Rare Very common Intracytic papillae Uncommon Very common

Solid areas Rare Very common Bilaterality Rare Common Adhesions Uncommon Common

Ascites (>100 ml) Rare Common Necrosis Rare Common

Peritoneal implants

Rare Common

Capsule intact Common Infrequent Totally cystic Common Rare


FIGO1988 FIGO2014

FIGOGuidelinesCommifee:

RevisethestagingsystemtoimproveuRlityandreproducibility

Ovarian,Fallopiantubeandprimary

peritonealcancer:samestagingsystembecauseofcommonhistology:Seroustype


FIGO STAGE 1 NEW STAGING OLD STAGING

I Tumor confined to ovaries or fallopian tube(s)

Tumor limited to the ovaries (one or both)

IA Tumor limited to one ovary (capsule intact) or fallopian tube No tumor on ovarian or fallopian tube surface No malignant cells in the ascites or peritoneal washings

Tumor limited to one ovary; capsule intact No tumor on ovarian surface No malignant cells in ascites or peritoneal washings

IB Tumor limited to both ovaries (capsules intact) or fallopian tubes No tumor on ovarian or fallopian tube surface No malignant cells in the ascites or peritoneal washings

Tumor limited to both ovaries; capsule intact No tumor on ovarian surface No malignant cells in ascites or peritoneal washings



I Tumor confined to ovaries or fallopian tube(s)

Tumor limited to the ovaries (one or both)

IC

IC1

IC2

IC3

Tumor limited to one or both ovaries or fallopian tubes with any of the following: Surgical spill intraoperatively Capsule ruptured before surgery or tumor on ovarian or fallopian tube surface Malignant cells in the ascites or peritoneal washings

Tumor limited to one or both ovaries with any of the following:

Capsule ruptured, tumor on ovarian surface, malignant cells in ascites or peritoneal washings



II Tumor involves one or both ovaries or fallopian tubes with pelvic extension (below pelvic brim) or primary peritoneal cancer

Tumor involves one or both ovaries with pelvic extension

IIA Extension and/or implants on the uterus and/or fallopian tubes and/or ovaries

Extension and/or implants on uterus and/or tube(s); no malignant cells in ascites or peritoneal washings

IIB Extension to other pelvic intraperitoneal tissues

Extension to other pelvic tissues No malignant cells in ascites or peritoneal washings

IIC Pelvic extension (IIa or IIb) with malignant cells In ascites or peritoneal washings


FIGO STAGE 3

NEW STAGING OLD STAGING

III Tumorinvolvesoneorbothovaries,fallopiantubes,orprimaryperitonealcancer,withcytologicallyorhistologicallyconfirmedspreadtotheperitoneumoutsidethepelvisand/ormetastasistotheretroperitoneallymphnodes

Tumorinvolvesoneorbothovarieswithmicroscopicallyconfirmedperitonealmetastasisoutsidethepelvisand/orregionallymphnodemetastasis


FIGO STAGE 3


IIIA

IIIA1PosiRveretroperitoneallymphnodesonly(cytologicallyorhistologicallyproven)(i)Metastasis<10mmingreatestdimension(ii)Metastasis>10mmingreatestdimensionIIIA2Microscopicextrapelvic(abovethepelvicbrim)peritonealinvolvementwithorwithoutposiRveretroperitoneallymphnodes

Microscopicperitonealmetastasisbeyondpelvis


FIGO STAGE 3


IIIB Macroscopicperitonealmetastasisbeyondthepelvisupto2cmingreatestdimension,withorwithoutmetastasistotheretroperitoneallymphnodes

Macroscopicperitonealmetastasisbeyondthepelvis,2cmorlessingreatestdimension


FIGO STAGE 3

NEW STAGING OLD STAGING IIIC

Macroscopicperitonealmetastasisbeyondthepelvismorethan2cmingreatestdimension,withorwithoutmetastasistotheretro-peritoneallymphnodes(includesextensionoftumortocapsuleofliverandspleenwithoutparenchymalinvolvementofeitherorgan)

Peritonealmetastasisbeyondpelvis,morethan2cmingreatestdimensionand/orregionallymphnodemetastasis


FIGO STAGE 4


IV Distantmetastasisexcluding

peritonealmetastasesIVA:PleuraleffusionwithposiRvecytology

IVB:Parenchymalmetastasesandmetastasestoextra-abdominalorgans(includinginguinallymphnodesandlymphnodesoutsidetheabdominalcavity)

Growthinvolvingoneorbothovarieswithdistantmetastases.Ifpleuraleffusionispresent,theremustbeposiRvecytologytoallotacasetoStageIV.ParenchymallivermetastasisequalsStageIV



Borderlinetumor/LowMalignantPotenRal

•  10to15%ofepithelialovariancancers•  Mostcommon:earlystage•  Rarelymetastasizeinlymphnodes•  Nuclearatypia,straRficaRonoftheepithelium,formaRonofmicroscopicpapillaryprojecRons,cellularpleomorphism,andmitoRcacRvity

•  ABSENCEofstromalinvasion•  Recurrenceispossible(usuallylate)


Pathology:SerousCA

•  >50%ofovariancancerareseroushistology•  PredominantlycysRcwiththinfluidwithinwithpapillaryexcresences/muralnodule

•  Resemblesthefallopiantubeepithelium•  Pathognomonic:PSAMMOMABODIES•  CA-125:mostusefultumormarker


Pathology:SerousCA


Pathology:SerousCA


Pathology:SerousCA


Pathology:Endometrioid

•  About15to20percentofepithelialovariancancers

•  Histology:similartotheendometrialglands•  MixtureofcysRcandsolidmass.•  AssociatedwithEndometriosisandPID•  CA-125alsouseful






This can be cystic with smooth surface and variable amounts of intracystic soft or solid masses or papillae. This can sometimes have necrosis and hemorrhage.

There is irregular, infiltrative proliferation of glandular type epithelium resembling proliferative type endometrium with cytologically malignant nuclear features.



Pathology:Mucinous

•  5to10percentoftrueepithelialovariancancers•  MulRloculated,mulRcysRcmasswiththickmaterialwithin

•  Resemblesmucin-secreRngadenocarcinomasofintesRnalorendocervicalorigin

•  Associatedwithappendicealtumorandpseudomyxomaperitonei

•  CA-19-9(tumormarkerformucin-producingcellslikeappendix,pancreas,intesRne)


Pathology:Mucinous


Pathology:Mucinous


Pathology:Mucinous


ClearcellcarcinomaoftheOvary

•  5to10percentofepithelialovariancancers•  CysRcmasswithsolidcomponent•  mostfrequentlyassociatedwithpelvicendometriosisandPID

•  PresenceofclearcellandHOBNAILcells


ClearcellcarcinomaoftheOvary


Management:Ovariancancer

Surgery– ExploratoryLaparotomy(midlineverRcal)– Peritonealwashing(diaphragm,rightandleuhemi-abdomen,pelvis)

– CarefulinspecRonandpalpaRonofallperitonealsurfaces

– BiopsyandresecRonofanysuspiciouslesions,masses,andadhesions

– Totalabdominalhysterectomy+bilateralsalpingo-oophorectomy(THBSO)


•  Surgery– (USO)withfrozensecRon(FS)ispermifedforyoungpaRentswithstageI

– Infracolicomentectomyorinfragastricomentectomy

– Randomperitonealbiopsies(undersurfaceoftherighthemidiaphragm,bladderreflecRon,cul-de-sac,rightandleuparacolicrecessesandpelvicsidewalls)

– PelvicandparaaorRclymphnodesampling– Appendectomyformucinoustumors


– ParacentesisininiRalmanagementofovarianmassisnotrecommended

– Pfannensteilincisionalsonotadvised

– **Tumordebulkingforadvancedstage

– Chemotherapyasadjuvanttherapy

• CarboplaRn-Paclitaxel


IndicaRonsfor“E”operaRon:

•  Anyadnexalmassauermenopauseorbeforepuberty

•  solidadnexalmassatanyage•  cysRcmass>8cm•  cysRcmassbet5-8cm,

–  persistent>8wks•  (+)complicaRons


GermCelltumors

•  mostcommonovarianmalignanciesdiagnosedduringchildhoodandadolescence

•  Symptomsaresimilartotheepithelialcounterpart

•  Massdoesnotgrowasbigastheepithelialtumors



Dysgerminoma•  Mostcommonmalignantovariangermcelltumor•  Mostcommonovarianmalignancydetectedduringpregnancy

•  theonlygermcellmalignancywithasignificantrateofbilateralovarianinvolvement(15-20%)

•  Ingeneral:Solid,cream-coloredtumor•  large,rounded,polyhedralclearcellsthatarerichincytoplasmicglycogenwithlymphocyteinfiltraRon

•  LactateDehydrogenase(LDH)-animpt.tumormarker•  5%-(+)HCG




YolkSactumor

•  PreviouslycalledEndodermalsinustumor•  Solid,yellowishtumor•  Schiller-Duvalbodiesarepathognomonicwhenpresent

•  Alpha-Fetoprotein(AFP)astumormarker



IMMATURETERATOMA

•  3rdmostcommonmalignantgermcelltumor•  Gross:solidw/cysRcspaces•  Micro:immatureRssuederivedfrom3germlayers

•  usuallyfromendodermal,e.g.neuroepithelium

•  Tumormarker:AFP


This typically has a smooth surface and is cystic. Cut section demonstrates greasy yellow sebaceous material and hair. Often there is a thickening of the cyst wall (Rokitansky's protuberance) from which hair and sometimes teeth and bone arise.

This cystic structure is lined predominantly by skin and cutaneous adnexal structures, usually with abundant sebaceous and sweat glands. Hair is almost always present. Other components include cartilage, bone, bronchial or gastrointestinal epithelium and mature glial tissue. If only skin and adnexal structures are present it can be termed dermoid cyst.

Sebaceous land

skin



Immature Glands Immature Neural Tissue

Immature Cartilage

The diagnosis of this tumor requires the presence of immature elements derived from any of the three germ layers: skin elements, mature neural tissue, connective tissue, cartilage, bone, gastrointestinal or bronchial epithelium.

IMMATURETERATOMA


Choriocarcinoma

•  HighB-HCG•  SyncyRotrophoblastandcytotrophoblastwithnodilatedvilli

•  Lesscommongermcelltumors:– Polyembryona– Embryonalcarcinoma–  Immatureteratoma


GermCellTumors

Germ Cell Tumor Tumor Marker Histology

1. Dysgerminoma – MC

LDH Lymphocytic stromal infiltration

2. Endodermal sinus tumor – 2MC

AFP Schiller – Duvall Bodies

3. Teratoma, immature – 3MC

Carcinoid Struma ovarii

AFP

Neuroectodermal

4. Embryonal Carcinoma

HCG, AFP Syncytio

5. Polyembryoma HCG

6. Choriocarcinoma HCG Syncytio / cyto


ManagementofGermcelltumor

ConservaRvesurgicalmanagement(USO)maybeanopRonformalignantgermcelltumorifthepaRentisyoungordesirousofpregnancyduetohighresponsetochemotherapy


Sex-Cordtumor:Granulosa-celltumor

•  Mostcommon•  Feminizing•  Symptomsareage-determined•  Pre-puberty-isosexualprecociouspuberty•  ReproducRve-Abnormalmenstrualcycles•  Postmenopause-postmenopausalbleeding


Sex-Cordtumor:Granulosa-celltumor

•  Gross:maybesolidorcysRc•  Micro:Call-ExnerBodies-rosefelikearrangementofgranulosacells

•  ComplicaRons:endometrialhyperplasiaoradenocarcinoma

•  RadiosensiRve•  Bilaterality:5%


Granulosa-celltumor

•  AdultGranulosacelltumor– diagnosedauerage30,withtheaverageagebeing52years

– menometrorrhagiaandpostmenopausalbleedingarecommon

–  inhibinA,inhibinB,andserumestradiol






Granulosa-celltumor

•  JuvenileGranulosacelltumor– childrenandyoungadults,andhalfarediagnosedbeforepuberty.Themeanageatdiagnosisis13years

–  isosexualperipheralprecociouspuberty– Moreaggressive


ManagementofGranulosacelltumor

Chemotherapyasadjuvanttherapy(Bleomycin,EtoposideCisplaRn)


MetastaRccanceroftheovary

•  Krukenbergtumor•  Primarycanceroriginatedfromcolon,stomach,smallintesRne,appendix

•  Solidmass•  Commonlybilateral•  Signet-ringcells




This tumor typically has rounded, firm, white masses that may be bosselated, yellow or white on cut section. Fleshy, gelatinous or spongy areas are common.

Presence of mucin-laden, signet-ring cells strewn individually and in small clusters within a hypercellular ovarian stroma (occasionally with storiform pattern). The cytoplasm occasionally is granular and eosinophilic rather than pale and vacuolated (sometimes has bull's-eye appearance, containing large vacuole with central eosinophilic body).

Krukenbergtumor


PrimaryFallopianTubeCancer

•  Incidence(US):0.41per100,000women(‘0.14-1.8%’)

•  Age:60-79y/ohighestincidencerates•  Incidence(Phil):0.1%-0.5%ofallgynecologiccancers

•  Age:40-65years,mean=52years


Criteriatodiagnoseprimarytubalcancer:

1.Gross :maintumorinthefallopiantube2.Micro :mucosashouldbemainlyinvolved :TransiRonbetweenbenign& malignantdemonstrated


The oviducts, or fallopian tubes, vary from 8 - 14 cm in length and are covered by peritoneum. It is divided into the following potions: interstitium (a), isthmus (b), ampulla (c), and infundibulum (d).

d

c

b b a a

b

c

d

NomalFallopianTube



This is composed of fine branching papillae (Arrow) covered by one or more layers of epithelium with enlarged pleomorphic hyperchromatic nuclei (inset). There is increased and abnormal mitoses. In poorly differentiated areas, the tumor may grow in solid sheets of cells with small or large foci of necrosis.

InvasiveAdenocarcinomaOfFallopianTube


Pathology•  Themajority(88%)ofPFTCswereadenocarcinomas;

–  Serous 44%–  Endometrioid19%.–  Mixed 3.9–16.7%–  UndifferenRated 7.8–11.3%–  Mucinous3–7.6%

•  TumorGrade–  GradeI 15–20%–  GradeII 20–30%–  GradeIII 50–65%

•  Laterality–  Unilateral 89%–  Bilateral 11%

•  Stageatdiagnosiswasfairlyevenlydistributed–  localized(36%)–  regional(30%)–  distant(32%) Stewart et al,

2007


ClinicalFeaturesClinical Features Percentage Vaginal bleeding or spotting 50%–60%

Abdominal pain, colicky or dull 30%–49%

Abdominal or pelvic mass 60% (range, 12%–84%)

Ascites 15%

Rare presentations (acute abdomen, palpable inguinal node, umbilical-bone cerebral metastases, cerebellar degeneration, asymptomatic)

[38–41]

Postmenopausal bleeding or spotting with negative Pap smear

Pectasides et al, 2009


LATZKO’STRIADAsyndromewhichconsistsof:1)  profusewateryorhoney-coloredvaginal

discharge,2)  apelvicmass,and3)  colickypelvicpainthatessenRallygoes

awayuponsuddendisappearanceofthemass

AlthoughthistriadisrarelyfoundinpracRce,

it’saclassicdiagnosRcsyndromeforfallopiantubedisease.

Sotto & Manalo, 1994


Diagnosis

•  Imagingstudies– Ultrasound– CTScan– MRI

•  CA-125level•  Cytology•  Pathology


STAGING:SameasovariancancerTREATMENT:1.Surgery

ConservaRve:StIA&desirousofpregnancyComplete:>StIB

2.Chemotherapy-adjuvant

Agents:sameasinovarianca3.Radiotherapy-rolecontroversial


PROGNOSIS:Poor5-yearSurvivvalRateStageI 60%II 40%III10%IV0%


PrimaryPeritonealCarcinoma•  Upto15percentoftypicalepithelialovariancancersare

actuallyprimaryperitonealcarcinomas•  Serousisthemostcommonhistology



ThankYou

Health & Medicine

Malignancy of the endometrium, ov, ft