1、Ovarian Cancer DI WEN M.D.,Ph.D.,Professor&Chairman Department Of Obstetrics&Gynecology Renji Hospital Affiliated to SJTU School of Medicine22006-11-1 七年制Ovarian CancerGeneral IntroductionvOvarian tumors are commonest between 30 and 60.vThey are particularly liable to be or to become malignant.vIn t
2、heir early stages,they are asymptomatic and painless.vThey may grow to a large size.v1.4%lifetime risk of ovarian cancer32006-11-1 七年制Ovarian CancerRisk FactorsvFamily historyOvarian cancerBreast cancerColon cancervGenetic factorsvOlder agevCaucasianvMore menstrual circles during lifetime(Ovulation
3、induction)42006-11-1 七年制Ovarian CancerIncidencevNearly 25%of all ovarian neoplasm are malignant.vApproximately 80 of them are primary growths of the ovary.vThe remainder being secondary，usually carcinomata.52006-11-1 七年制Ovarian CancersymptomsvLack of any specific symptoms,ovarian tumors are often la
4、rge by the time the doctor is consulted.vMenstrual function is seldom upset,and any irregularity is attributed to the patients time of life.62006-11-1 七年制Ovarian CancersymptomsvIncreased abdominal size72006-11-1 七年制Ovarian CancersymptomsPressure symptomsGastro-intestinal symptoms(Bloating)Urge to ur
5、inateplevic pain(a dull pain in the lower abdomen)Very large tumors may cause respiratory embarrassment and edema or varicosities in the legs,and a characteristic ovarian cachexia develops.82006-11-1 七年制Ovarian CancerCLINICAL FEATURES OF OVARIAN TUMOURS92006-11-1 七年制Ovarian CancerCLINICAL FEATURES O
6、F OVARIAN TUMOURS102006-11-1 七年制Ovarian CancerCLINICAL FEATURES OF OVARIAN TUMOURS112006-11-1 七年制Ovarian CancerGeneral Rule An experienced examiner will recognize an ovarian tumor mainly because ovarian tumor is,in the circumstances,the most likely diagnosis.All abdominal swellings should be subject
7、ed to ultrasound and X-ray examination.DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS122006-11-1 七年制Ovarian CancerDIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS132006-11-1 七年制Ovarian CancerASCITES A fluid thrill may be elicited from an ovarian cyst,and ascites and tumor may coexist;but as a rule the dis
8、tinction should be easily made.DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS142006-11-1 七年制Ovarian CancerUterine Fibroids A large midline intramural fibroid may b e i m p o s s i b l e t o distinguish from a solid ovarian tumor until the abdomen is opened and an entirely different s u r g i c a l p r
9、 o b l e m encountered.DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS152006-11-1 七年制Ovarian CancerDIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS162006-11-1 七年制Ovarian CancerDIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS172006-11-1 七年制Ovarian CancerDIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS182006-11-1 七年
10、制Ovarian CancerHistological Classification Most tumors arise from the ovarian stroma and germinal epithelium.The embryonic coelom from which that epithelium develops also gives rise to the Mullerian duct from which develop the structures of the genital tract,and it is this common origin which explai
11、ns the great variety of epithelial patterns which are met with.192006-11-1 七年制Ovarian CancerPrimary Epithelial TumorvMucinous cystadenoma or cystadencarcinoma (of.Cervical epithelium).vSerous cystadenoma or cystadenocarcinoma (of.tubal epithelium).vEndometrioma or Endometrioid carcinoma (of.Endometr
12、ium).vClear cell carcinoma.vBrenner tumour.202006-11-1 七年制Ovarian CancerOvarian Germ Cell TumorFibroma or sarcoma.Dysgerminoma.Teratoma.Gonadoblastoma.Yolk sac tumour.Carcinoid.Thyroid tumour Choriocarcinoma212006-11-1 七年制Ovarian CancerGonadal Sex Cord Stromal TumorGranulosa cell tumour.Thecoma.Sert
13、oli-Leydig cell tumor(Arrhenoblastoma).Hilar cell tumour.Lipoid cell tumour.222006-11-1 七年制Ovarian CancerKrukenberg Tumor There is one well-known secondary tumour of the ovary,the krukenberg t u m o u r,a s e c o n d a r y o f a stomach carcinoma.232006-11-1 七年制Ovarian CancerMucinous cystadenoma A u
14、 n i l o c u l a r o r multilocular cyst of ovary lined by tall columnar epithelium resembling that of the cervix or large intestine.It is usually large and may reach immense proportions,occupying the whole peritoneal cavity and compressing other organs.It may occur at any age.242006-11-1 七年制Ovarian
15、 CancerOVARIAN TUMOURSOVARIAN TUMOURS-MUCINOUS CYSTADENOMAMUCINOUS CYSTADENOMA252006-11-1 七年制Ovarian Cancer SEROUS CYSTADENOMA A unilocular or multilocular cyst lined by epithelium similar to the fallopian tube.They are the most common benign epithelial tumors and form 20%of all ovarian neoplasm.In
16、10%of cases they are bilateral.It is uncommon to find them large than a fetal head.262006-11-1 七年制Ovarian CancerOVARIAN TUMORSOVARIAN TUMORS-SEROUS CYSTADENOMA-SEROUS CYSTADENOMA272006-11-1 七年制Ovarian CancerSerous cystadenocarcinoma This is by far the commonest primary carcinoma,accounting for 60%of
17、 all cases,and in over half the cases it is bilateral.The cysts are always of papillary type and the epithelium burrowing through the capsule produces papillary processes on the serous surface.Extension of the growth to the pelvis and adjacent organs fixes the tumor.Ascites is always present.282006-
18、11-1 七年制Ovarian CancerEndometrioid Carcinoma of the Ovary It is now recognized that carcinoma of the ovary may be of endometrial type,sometimes arising in endometrioma.Attacks of pain,unusual with ovarian cancer,are common.Sometimes there is uterine bleeding in post-menopausal cases.292006-11-1 七年制O
19、varian CancerEndometrioid Carcinoma of the Ovary Usually the lesion is cystic and chocolate brown in color.If such a cyst ruptures spontaneously,malignancy should be suspected.The histology varies as in uterine carcinoma.It may be a well-differentiated adenocarcinoma,an adeno-acanthoma,mucinous aden
20、ocarcinoma or clear-celled carcinoma.302006-11-1 七年制Ovarian CancerFibromav This is composed of fibrous tissue and resembles fibromata found elsewhere.It is most common in the elderly and accounts for 4-5%of all ovarian neoplasm.vThe fibroma is believed by many to be a thecoma which has undergone fib
21、rous transformation.It is sometimes associated with Meigs syndrome.312006-11-1 七年制Ovarian CancerDysgerminoma This is the only solid o v a r i a n t u m o r o f characteristic appearance.Usually ovoid with a smooth capsule,it is of rubbery consistency and greyish colour.It is commonest in younger age
22、 groups,under 30 years as a rule,and is often bilateral.Sometimes it is found in cases of intersex.322006-11-1 七年制Ovarian CancerTeratomavCystic teratoma or dermoidvSolid teratoma332006-11-1 七年制Ovarian CancerYolk Sac Tumorv rare vChildren and young adultsvhighly malignantvalphafetoprotein342006-11-1
23、七年制Ovarian CancerEstrogen-producing Tumors These belong to the granulosa-theca cell group and are found at all ages.They account for 3%of all solid tumors of the ovary.352006-11-1 七年制Ovarian CancerEstrogen-producing Tumors In childhood there is accelerated skeletal growth and appearance of sex hair.
24、v 5%occur in children precocious puberty.v 60%occur in child-bearing years irregular menstruation.v 30%occur in post-menopausal women post-menopausal bleeding.362006-11-1 七年制Ovarian CancerAndorogen-producing Tumours Three distinct types of masculinising ovarian tumor are recognised:a)Sertoli-Leydig
25、cell tumor(Arrhenoblastoma),b)Hilar cell tumor,c)Lipoid cell tumor.All three cause amenorrhoea.372006-11-1 七年制Ovarian CancerSpread-Direct The first spread is directly into neighbouring structures peritoneum,uterus,bladder,bowel and omentum.382006-11-1 七年制Ovarian CancerSpread-Lymphatics Ovarian drain
26、age is to the para-aortic glands,but sometimes to the pelvic and even inguinal groups.Cells seeded on to the peritoneum are drained via the lymphatic channels on the underside of the diaphragm into the subpleural glands and thence to the pleura.392006-11-1 七年制Ovarian CancerSpread-Blood Stream Blood
27、spread is usually late,to the liver and lungs.402006-11-1 七年制Ovarian CancerStaging of ovarian cancervSTAGE I Growth limited to ovariesIa Limited to one ovary.No ascites.Ib Limited to both ovaries.No ascites.Ic Ascites or positive peritoneal washings also present or tumour on surface of one or both o
28、varies or capsule ruptured.412006-11-1 七年制Ovarian CancerStaging of ovarian cancervSTAGE II Pelvic extensionIIa Spread to uterus/tubesIIb Spread to other pelvic tissuesIIc IIb with ascites or positive peritoneal washings or tumour on surface of one or both ovaries or capsule ruptured.422006-11-1 七年制O
29、varian CancerStaging of ovarian cancervStage III Extrapelvic intraperitoneal spread and/or retroperitoneal or inguinal positive nodes,or superficial lover metastases.IIIa Apparent limitation to true pelvisIIIb Histologically proven abdominal peritoneal superficial implants2cm diameter or positive re
30、troperitoneal or inguinal nodes.432006-11-1 七年制Ovarian CancerStaging of ovarian cancervStage IV Distant metastases or pleural effusion w i t h p o s i t i v e c y o t l o g y o r parenchymal liver metastases.442006-11-1 七年制Ovarian CancerDiagnosisvPelvic examvUltrasoundvCT scanvCA125 blood testvSURGE
31、RY452006-11-1 七年制Ovarian CancerTORSION of the PEDICLEv The commonest complication v Occur with any tumor v Except those with adhesions462006-11-1 七年制Ovarian CancerClinical Features-Subacute The patient complains of recurrent abdominal pain which passes off as the pedicle untwists.There is a rise in
32、pulse and temperature during the bleeding;And over a period anemia develops.TORSION of the PEDICLETORSION of the PEDICLE472006-11-1 七年制Ovarian CancerClinical Features-acute The signs and symptoms are those of an acute abdominal condition.The problem becomes one of differential diagnosis to exclude t
33、hose conditions in which laparotomy is not needed and laparoscopy may be useful.Pain tends to be intense and continuous.TORSION of the PEDICLETORSION of the PEDICLE482006-11-1 七年制Ovarian CancerRuptured Cyst This may occur alone or in conjunction with torsion.Rupture is not particularly upsetting to
34、the patient unless the contents are irritant.TORSION of theTORSION of the PEDICLEPEDICLE492006-11-1 七年制Ovarian CancerSuggestive of MalignancyvAge.If the patient is over 50 the chance of malignancy is over 50%as opposed to less than 15%in premenopausal women.Tumors in childhood are usually malignant.
35、vRapid growth.vAscites.502006-11-1 七年制Ovarian CancerSuggestive of MalignancyvSolid tumours,especially when bilateral.vMultilocular cysts with solid areas.(At least 10%of cysts are malignant).vPain.Pressure pain can occur with any tumor;But referred pain suggests malignant involvement of nerve roots.
36、vTumor markers,such as CA125,may be measured in the blood,but a normal level does not exclude malignancy.512006-11-1 七年制Ovarian CancerTreatmentv Surgeryv Chemotherapyv Radiation Therapyv?Hormonal Therapy522006-11-1 七年制Ovarian CancerSurgical ProceduresvTo classify the growth according to its extent o
37、f spread(staging)as accurately as possible.vTo remove as much cancerous tissue as possible(surgical debulking;cyto-reductive treatment).532006-11-1 七年制Ovarian CancerSurgical Procedures Benign ovarian over 10 cm in diameter must be removed,but clinical and ultrasonically diagnosed cysts under 10 cm(t
38、he size of a lemon)in women under 35 years may be reviewed in a few months if there is no suspicion of malignancy.A follicular or luteral cyst may resolve spontaneously.542006-11-1 七年制Ovarian CancerSURGICAL TREATMENT OF OVARIAN TUMMOURSSURGICAL TREATMENT OF OVARIAN TUMMOURS552006-11-1 七年制Ovarian Can
39、cerSURGICAL TREATMENT OF OVARIAN TUMMOURSSURGICAL TREATMENT OF OVARIAN TUMMOURS562006-11-1 七年制Ovarian CancerSURGICAL TREATMENT OF OVARIAN TUMMOURSSURGICAL TREATMENT OF OVARIAN TUMMOURS572006-11-1 七年制Ovarian CancerFollow-up Follow-up with intensive chemotherapy,using various combinations of antineopl
40、astic drugs.Taxanes,probably combined with platinum compounds,are an appropriate first choice.582006-11-1 七年制Ovarian CancerSecond Look A second look laparotomy or laparoscopy operation(SLO),to determine the actual effectiveness of the chemotherapy and to decide whether it should be stopped does not
41、affect prognosis,so should only be performed with informed consent in clinical trials.592006-11-1 七年制Ovarian CancerSurgical Procedures-Incision A vertical incision which can be extended is essential to allow a full inspection.Reduction of a cyst by tapping and extraction through a suprapubic incisio
42、n is not acceptable practice.602006-11-1 七年制Ovarian CancerSurgical Procedures-Cytology Before handling the tumour,take specimens of ascitic fluid or peritoneal saline washings for cytological examination,and a cytology smear from the underside of the diaphragm.612006-11-1 七年制Ovarian CancerSURGICAL P
43、ROCEDURES IN OVARIAN CANCERSURGICAL PROCEDURES IN OVARIAN CANCER622006-11-1 七年制Ovarian Cancer DI WEN M.D.,Ph.D.Professor&Chairman Department of Obstetrics&Gynecology Renji Hospital Affiliated to SJTU School of Medicine Thanks for Your Attention642006-11-1 七年制Ovarian Cancer652006-11-1 七年制Ovarian CancerHereditary Breast and Ovarian Cancer:BRCA1Adapted from ASCO662006-11-1 七年制Ovarian CancerHereditary Breast and Ovarian Cancer:BRCA2
