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1、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 epithel
2、ium,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.ge
3、rm 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).chorioca
4、rcinoma (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
5、ovarian tumor.sex cord stroma originates from mesenchymal tissues of primal coelom female and male differentiation epithelium differentiationgranulosa, Sertolic cell tumor functional tumor stromal differentiation theca cell, Leydig cell tumor sex cord stromal cells tumor includes (i).granulosa cell-
6、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.environ
7、mental 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
8、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
9、-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 : moder
10、ate size bilateral,more extracystic papilla microscopic examination :thin papillary branch,epithelium3 layers,slight cellular atypia,nuclear mitosis1/HP,no stroma invasion 5 year survival rate :over 90% serous cystadenocarcinoma morbidity :most common malignant ovarian tumor,40-50% macroexamination
11、: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,
12、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 exam
13、ination: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
14、section:thick walll,solid area,tiny soft papilla microscopic examination:epithelium3 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 t
15、umors macroexamination:unilateral,large size,papillary or solid area section:semicystic and semisolid,blurred or bloody fluid microscopic examination:dense gland,less stroma,glandular epithelium3 layers,obvious cellular atypia,stromal invasion 5 year survival rate:40-50%,prognosis is better than ser
16、ous 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 border
17、line: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 endometri
18、al 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 childhood and adolescence,morbidity before adolescence accounts for 60-90%,while after menopause it on
19、ly 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,s
20、mooth 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
21、 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
22、 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 l
23、ike 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 :
24、 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 whi
25、ch 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
26、,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-
27、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 exa
28、mination :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 s
29、ection: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 w
30、hite 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
31、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 as
32、cites 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:
33、(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
34、 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 t
35、he 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
36、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 undifferenationthe effects of histologic grade on the prognosis is more important than that of the histologic typ
37、es,VI.Clinical stage:the FIGO(1986) clinical stage is adoptedstage I tumor is localized in the ovaryIa tumor is localized in one ovary,the capsule is integrated, no tumor on ovary surface,no ascitesIb tumors are localized in bilateral ovarys,integrated capsule no tumor on surface,no ascitesIc based
38、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 metastasisIIa spread to uterus and (or)fallopian tubeIIb s
39、pread to other tissues in pelvisIIc 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
40、is extrapelvic peritoneal implantation and (or) the retroperitoneal or inguinal LN is positive,liver surface metastasis is stage IIIIIIa macroexamination shows that the tumor is loca- ted in the true pelvis,LN is negative but there is microscopic peritoneal implantationIIIb unilateral or bilateral o
41、varian tumor,there is peritoneal surface implantation and its diameter is2cm and (or) retroperitoneal or inguinal LN is positivestageIV unilateral or bilateral ovarian tumor with telemetastasis, hydrothorax contains cancer cells,and there is liver parenchyma metastasis,VII.Clinical Manifestation i.b
42、enign 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
43、 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 signsVIII.Diagnosis i.cytologic examination ii.B-Ultrasound iii.radiodiagnosis: (i).abdominal plain film (ii).intravenous pyelogr
44、aphy,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,ii.differential diagnosis of
45、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 connec
46、tive 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 prim
47、ary 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 sp
48、ontaneous 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 chang
49、e (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
50、.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,i
