Ovarian tumar

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      • Germ cell tumours
        • about 95% are benign cystic teratomas, also called dermoids. (MCQ)
        • Below the age of 20 years, 60% of the tumours are of germ cell origin
        • in girls under the age of 10 years almost 85% are of germ cell origin and are invariably malignant.
        • Teratoma
          • divided into three categories:
          • mature (benign), e.g. dermoid cyst
          • immature (essentially malignant), e.g. solid teratoma
          • monodermal or highly specialized, e.g. struma ovarii.
        • Dermoid cysts
          • usually unilocular with smooth surface
          • seldom attain more than 15 cm in diameter
          • contains sebaceous material and hair
          • wall is lined in part by squamous epithelium which contains hair follicles and sebaceous glands(MCQ)
          • Teeth, bone, cartilage, thyroid tissue and bronchial mucous membrane are often found in the wall
          • Sometimes the sebaceous material collects together in the form of small balls
          • Frequently (40% ) arise in association with mucinous cystadenomas (MCQ)
          • Multiple dermoid cysts in the same  ovary
          • Extraovarian dermoid cysts arise occasionally in the lumbar region, uterovesical area, parasacral region and rectovaginal septum. (MCQ)
          • epidermoid carcinoma occurs in 1.7%
        • Solid teratoma of the ovary
          • cut surface has a peculiar trabeculated appearance
          • Most are malignant tumours because of sarcomatous change
        • Struma ovarii
          • consists of thyroid tissue similar to that of a thyroid adenoma.
          • Some cases develop thyrotoxicosis.
      • Carcinoid tumours
        • argentaffmoma
        • sometimes primary and sometimes metastatic
        • histological property of reducing silver salts derived from the specialized Kulchitsky cells of the intestine
        • produces 5-hydroxytryptamine which causes attacks of flushing and cyanosis.
      • Dysgerminoma
        • corresponds to the seminoma of the testis
        • average incidence at the age of 20.
        • usually unilateral
        • occsionally undergoes torsion
        • associated with ascites.
        • The tumour consists of large cells arranged in bunches or alveoli
        • Diagnostic histologic finding : (MCQ)
          • Lymphocytes and giant cells are always found amongst the tumour cells.
          • appearance of large dark-staining nuclei with clear, almost translucent, cytoplasm and lymphocytic infiltration of the fibrous septa is diagnostic (MCQ)
      • The tumour is neutral and does not secrete either male or female sex hormones
      • secretes (MCQ)
        • placental alkaline phosphatase (PLAP)
        • lactate dehydrogenase (LDH)
        • Beta-hCG.
      • Association of dysgerminoma of the ovary and genital abnormality(MCQ)
        • hypoplasia or absence of some part of the genital tract
        • pseudohermaphrodites.
      • malignancy rate is 30-50%
      • suggestive findings at laparotomy
        • A unilateral tumour confined to one ovary is relatively benign.
        • The presence of active invasion of the pelvic viscera is of poor prognosis.
        • The presence of extra pelvic metastases in the general peritoneal cavity, lymph glands, omentum or liver renders the outlook hopeless.
      • Conservative surgery is recommended in young girls.
      • highly radiosensitive(MCQ)
      • ovarian destruction contraindicates radiotherapy in young girls(MCQ)
      • Postoperative chemotheapy yields 90% success.
      • Chemotherapy comprises: (MCQ)
        • bleomycin
        • etoposide   
        • cisplatin
      • Alternate chemotherapy
        • VAC (vincristine, adriamycin and cyclophosphamides) (MCQ)
        • VBP  (vincristine,  bleomycin  and  cisplatin) (MCQ)
        • Carboplatin and ifosfamide
      • Radiotherapy   is   employed   only  for   residual   and recurrent tumour. (MCQ)
      • Sex cord stromal tumours
        • originate either from the
          • sex cords of the embryonic gonad
          • stroma of the ovary
      • Since theca cells are the source of ovarian steroids, many of these are functional and exert feminizing effects.
      • Feminizing functioning mesenchymoma
        • Granulosa ceil tumour
          • observed in 80% of women over 40 years and in 5% of prepubertal girls. (MCQ)
          • main clinical features depend upon the oestrogenic activity of the tumour (MCQ)
          • When occurring before puberty, they cause precocious puberty(MCQ)
          • When occurring in adult life the hyperoestrogenic  effects(MCQ)
            • exaggerated proliferative pattern with cystic glandular hyperplasia
            • amenorrhoea, followed    by   prolonged    bleeding.   
            • metropathia haemorrhagica. (MCQ)
            • In the postmenopausal patient, the most remarkable feature is postmenopausal bleeding
        • The cells are arranged either in cords or in trabeculae, and are often surrounded by structureless hyaline tissue, which resembles the glass membrane of an atretic follicle.
        • Call-Exner Bodies(MCQ)
          • small cyst-like spaces are characteristic features of the granulosa cells of the graafian follicle. (MCQ)
          • Most granulosa cell tumours are encapsulated
          • clinically benign.
        • metastases are interesting
          • opposite ovary first becomes involved
          • then metastases develop in the lumbar region
          • secondary deposits become scattered in the mesentery, the liver and mediastinum.
        • Association of carcinoma of the endometrium with granulosa cell tumours(MCQ)
          • theca cell tumour is four times more commonly associated with endometrial cancer than the granulosa cell tumour
      • Theca cell tumour
        • usually arises after the menopause
        • nearly always unilateral and forms a solid mass.
        • cut surface is yellow in colour and, if stained selectively, lipoid material is characteristically present. (MCQ)
        • tumour consists of spindle-shaped cells reminiscent of an ovarian fibroma (MCQ)
        • tumour is intensely oestrogenic and causes postmenopausal haemorrhage
        • both granulosa cell tumours and theca cell tumours may show luteinization of their cells, (MCQ)
          • progesterone is secreted
          • secretory hypertrophy can be demonstrated in the endometrium.
      • Arrhenoblastoma
        • secrete androgens
        • cause defeminization followed by masculinization.
        • incidence of malignant transformation is rated to be higher than with feminizing tumours. (MCQ)
      • Complications of ovarian tumours
      • Axial rotation: Torsion
      • Chocolate cysts and malignant ovarian tumours (MCQ)
        • usually fixed by adhesions
        • very rare for these ovarian tumours to undergo torsion
      • paraovarian cysts and the broad ligament cysts (MCQ)
        • most likely pelvic tumours to undergo torsion
        • they develop in the outer part of the broad ligament
        • come to lie above the infundibulopelvic fold and above the pelvic brim
      • In most cases, the cyst is about 10 cm or over in diameter when it undergoes torsion. (MCQ)
      • Because of the high incidence of mucinous cystadenomas, torsion is most frequently seen with this tumour. (MCQ)
      • Rupture
      • may be traumatic or spontaneous.
      • most interesting cases of spontaneous rupture are those arising with actively growing mucinous cystadenomas. (MCQ)
      • Pseudomyxoma of the peritoneum
      • findings at laparotomy almost exactly resemble boiled sago pudding.
      • material cannot be removed completely at operation because of its attachment to bowel,
      • condition tends to recur after operation
      • usually occurs with a mucinous cystadenoma of the ovary
      • also been reported with a
        • mucocele of the appendix
        • carcinoma of the large intestine in men.
      • prognosis is bad, even after the ovaries and the appendix are removed(MCQ)
      • Infection
      • Extraperitoneal development
      • Some ovarian tumours burrow extraperitoneally during their development and may spread upwards into the perinephric region
      • Secondary malignancy
        • occur in 50% serous cystadenomas, 5% in mucinous cystadenomas, but only in 1.7% of dermoid cysts. (MCQ)

 

          • Clinical examination
            • Ovarian tumour  versus ascites (MCQ)
              • on percussion it is dull over the centre of the tumour but resonant in the flanks which are occupied by the displaced large and small bowel.
              • This sign is reversed in ascites.
            • An ovarian cyst may simulate very closely a cystic degenerated myoma
              • cardinal sign that distinguishes a mobile ovarian tumour from a uterine tumour is when the ovarian tumour is raised up by the abdominal hand the cervix remains stationary to the vaginal fingers.
          • Differential diagnosis
            • abdominal physical signs of an ovarian cyst may be simulated by a
              • full bladder
              • a pregnant uterus
              • a myoma,
              • ascites
            • Full bladder
              • Full bladder is (MCQ)
                • tense and tender, fixed in position
                • anterior to the uterus
                • project anteriorly more than an ovarian cyst
                • a catheter should be passed to establish the diagnosis.
            • Myoma
              • A myoma is usually hard or firm, without the tense cystic consistency of a typical ovarian cyst.
            • encysted tuberculous peritonitis with ascites
              • history of oligomenorrhoea or amenorrhoea can be elicited.
              • tympanic note over the tumour suggests intestinal adhesions over the cyst.
              • patient loses weight, is pyrexial with  other signs of tuberculosis in the body.
            • A benign cyst is characteristically (MCQ)
              • unilateral, unilocular or multilocular with a thin wall and thin septa of less
              • than 5 mm in a multilocular cyst
              • cavity is non-echogenic.
              • normal CA-125 level below 35 U/ml indicate benign nature
            • A raised CA-125 level is also reported in (MCQ)
              • Abdominal tuberculosis
              • pelvic endometriosis.
            • only 50% Stage I epithelial ovarian malignant tumours present raised CA-125 level levels. (MCQ)
            • A  solid  tumour  suggests  malignancy  except  in  a fibroma   and   Brenner   tumour.   (MCQ)
            • A   menopausal   ovary   measures   not   more   than 2 x 1.5 x lcm in size (volume 8 ml). (MCQ)
              • A size more than this is suspicious of an ovarian growth.
            • A malignant ovarian tumour is suspected if ultrasound reveals (MCQ)
              • bilateral (may be unilateral) or a solid tumour with ascites.
              • tumour wall is thick with echogenic areas within the tumour.
              • The septum is more than 5 mm thick with papillary projections from its wall. (MCQ)
              • Except in Meig’s syndrome, the presence of ascites as shown on ultrasound strongly points to malignant nature of the tumour.
              • Colour flow Doppler technology,
                • indicates increased blood flow to the tumour and probability of the tumour being malignant.
                • Low pulsatile index also suggests increased blood flow in a malignant tumour
            • CEA (carcinoembryonic antigen)  more than 5 mg/1 is seen in mucinous ovarian tumour(MCQ)
          • Treatment
              • Laparotomy is required in every case
              • Even a benign ovarian tumour requires removal;
              • Open laparotomy is preferred to laparoscopic excision
              • Prophylactic oophorectomy(MCQ)
              • Bilateral removal of ovaries at hysterectomy is also desirable in a woman with family history of(MCQ)
                • ovarian cancer
                • colonic and breast cancer
                • previous hyperstimulation of ovaries in infertility
                • in a woman carrying BRCA-1 and BRCA-2 genes.
              • Benign ovarian tumours
              • The treatment comprises:
                • Abdominal   hysterectomy   and   bilateral   salpingo-oophorectomy
                • Unilateral ovariotomy
                • Ovarian cystectomy
                • Laparoscopic cystectomy-ovariotomy
                • Laparoscopy/ultrasound-guided aspiration of the cyst.
              • Abdominal    hysterectomy    and    bilateral    salpingooophorectomy (MCQ)
                • recommended in a perimenopausal women,
                • Done even if the tumour is benign and unilateral.
              • Ovariotomy/cystectomy(MCQ)
                • In a young woman, irrespective of parity, conservation of healthy ovary is highly desirable.
                • ovarian tumour should be enucleated (cystectomy)
            • Ovarian tumours associated with pregnancy
              • The ovarian tumour discovered during pregnancy is an
                • enlarged corpus luteal cyst
                • a benign  tumour.
                • malignant tumour.
              • Corpus luteal cyst
                • regresses after twelfth week (MCQ)
                • can therefore be observed.
              • Benign tumour
                • should be removed in the second trimester
                • removed between fourteenth and sixteenth week. (MCQ)
              • The tumour discovered late in pregnancy
                • emoved in early puerperium to avoid torsion and infection(MCQ)
              • Malignant ovarian tumours
                • malignant ovarian tumour requires laparotomy at the earliest, irrespective of the duration of pregnancy.
            • Ovarian cyst in a menopausal woman
              • A simple unilocular cyst measuring less than 5 cm (MCQ)
                • can be observed with repeat ultrasound and CA-125 every 3 months
                • Many resolve in 6 months
              • A persistent cyst
                • removal laparoscopically or by laparotomy.
              • Aspiration of the cyst is contraindicated because of
                •  low yield of malignant cells (false-negative)
                • possibility of spread of malignancy if the cyst proves malignant histo-logically;
              • Many perform bilateral oophorectomy and hysterectomy.
              • Does the preserved ovary continue to function after hysterectomy?
                • It is observed    that    following hysterectomy, ovarian blood supply is compromised and at best it may retain its function for about 4 years.
              • Following oophorectomy, is HRT effective?
                • Though effective, it is advisable not to continue HRT for more than 5 years because of the risk of breast cancer.
            • Ovarian remnant syndrome
              • follows hysterectomy in 1.4% cases
              • caused by ovarian adhesions to the vaginal vault
              • causes cyclical abdominal pain and deep dyspareunia.
              • It requires oophorectomy.
            • Ovarian tumours in adolescents
              • Before the age of 20 years(MCQ)
                • 60% are germ cell tumours
                • 65% of these are malignant.
              • Why epithelial tumours are extremely rare  during adolescent period(MCQ)
                • epithelial tumours are related to ovulation
                • ovulation occurs only after puberty,
              • Dysgerminoma (MCQ)
                • commonest tumour in  adolescents
                • causes amenorrhoea.
              • Conservative surgery followed by chemotherapy is effective in young girls. (MCQ)
            • Ovarian tumour
              • The most common are the epithelial tumours (80% ) (MCQ)
              • 80% are benign tumours and 20% malignant.  (MCQ)
              • Of all the malig­nant tumours,
                • 90% are epithelial in origin (MCQ)
                • 80% are primary in the ovary
                • 20% secondary from breasts, gastrointestinal tract and colon
              • Benign tumours can become secondarily malignant.
                • Mucinous cyst becomes malignant in 5%
                • papillary cystadenoma becomes malignant in 50% if left untreated. (MCQ)
              • Unfortunately patients with ovarian tumours are often symptom-free for a long time
              • By the time ovarian malignancy is estab­lished, about two-thirds of these are already far advanced and the prognosis in such cases is unfavourable.
              • An ovarian tumour in adolescent and postmenopausal women is more often malignant than benign.
              • Most of the germ cell tumours occur in young girls  (MCQ)
              • Benign ovarian tumours     
                • Not related to age or parity, (MCQ)
                • most common during childbearing period
                • Slow-growing tumour, no pain.
                • No menstrual disorder unless it is a feminizing tumour
                • Usually unilateral, cystic, well-defined and mobile.
                • No ascites (except in Meig syndrome.)
                • No nodules in abdomen or pouch of Douglas(MCQ)
                • Doppler ultrasound–  No increased vascularity
                • CA-135 – normal(MCQ)
                • Well-defined ovarian cystic or solid tumour. (MCQ)
              • Malignant ovarian tumour
                • Seen most commonly in adolescents and elderly women
                • mostly after 50 years of age.
                • Low parity or infertile woman(MCQ)
                • Rapidly growing tumour, pain in advanced stage.
                • Postmenopausal bleeding(MCQ)
                • Family history of breast, ovarian or colonic cancer
                • May be bilateral and solid, fixed.
                • Ascites may be present.
                • Metastatic nodules may be felt per abdomen.
                • Nodules in the pouch of Douglas(MCQ)
                • Often solid and bilateral fixed with internal echoes, ascites may be present
                • Metastatic noduies may be seen
                • Doppler ultrasound(MCQ)
                  • increased vascularity
                  • Pulsatile index <1. 1
                  • Resistance index <4
                • Metastatic and enlarged lymph nodes may be detected
                • CA-125 raised more than 35IU/ml(MCQ)
                • Fixed solid tumour, often bilateral – with blood-stained ascites
                • Metastatic growth over the omentum and peritoneal cavity(MCQ)
                • Lymph nodes may be enlarged

 

 

 

              • Pathology
                • WHO classification of ovarian tumours (major groups)
                • Common epithelial tumours:
                  • Serous tumours
                  • Mucinous tumours
                  • Endometrioid tumours
                  • Clear cell (mesonephroid tumours)
                  • Brenner tumours
                  • Mixed epithelial tumours
                  • Undifferentiated carcinoma
                  • Unclassified epithelial tumours
                • Sex cord (gonsdal stromal) tumours:
                  • Granulosa-stromal cell tumours
                  • theca celltumours
                  • Androblastomas
                  • Sertoli-Leydig cell tumours
                  • Gynandroblastomas
                  • Unclassified
                • Lipid (lipoid) cell tumours
                • Germ cell tumours:
                  • Dysgerminoma
                  • Endodermal sinus tumour
                  • Embryonal carcinoma
                  • Polyembryoma
                  • Choriocarcinoma
                  • Teratoma
                  • Mixed forms
                • Gonadoblastoma:
                  • Pure
                  • Mixed with dysgerminoma or other germ cell tumours
                • Soft tissue tumours not specific to ovary
                • Unclassified tumours
                • Secondary (metastatic) tumours
                • Tumour-like conditions
              • Epithelial ovarian neoplasms
                • arise from the mesoepithelial cells on the ovarian surface.
                • constitute about 80% of all ovarian cancers. (MCQ)
                • most common histologic type is the papillary serous cystadenomas and carcinomas
                • degree of cellular differentiation of the epithelial ovarian neoplasm expressed as histologic  grade has an important prognostic significance as well as in identifying malignancy. (MCQ)
                • Stage I Grade ‘0’ tumours is more than 90%
              • Borderline ovarian tumours or ovarian epithelial tumours of low malignant potential (LMP)
                • Patients have a high survival rate.
                • Tumours run a typical indolent course.
                • Spontaneous   regression   of peritoneal   implants   is known to occur.
                • Multiple   sections   must   be   examined   to   exclude invasion.
                • occur in younger women (35-55 years), 10 years younger than their malignant counterparts.
                • Risk factors (MCQ)
                  • Low parity and failure to lactate
                  • Unopposed oestrogen and obesity
                  • Smokers
                  • Induction of ovulation
              • borderline ovarian tumours are mainly serous (intest­inal and endocervical type)
              • Management
                • Conservative sur­gery
                  • ovarian cystectomy, ovariotomy or salpingo-oophorectomy (MCQ)
                • In mucinous bor­derline tumour, it is prudent to perform appendicectomy
                  • because many believe this ovarian tumour is sec­ondary to appendix.
                  • Appendicectomy avoids occurrence of pseudomyxoma peritonei(MCQ)
                • No adjuvant chemotherapy or radiotherapy is necessary
                • but follow-up is mandatory, as recurrence of 10-30% is reported.
              • Serous cystadenoma and cystadenocarcinoma
                • most common of cystic ovarian neoplasm(MCQ)
                • account about 50% of all ovarian tumours
                • 60-70% are benign
                • Serous cystadenomas occur in the third, fourth and fifth decades of life
                • In about half of the cases they are bilateral.
                • Delicate papillary excrescences may be seen on the sur¬face and within the loculi in a benign cyst. (MCQ)
                • Histologically the benign variety shows cystic spaces, and the lining of the tumour consists of tall columnar ciliated epithelium resembling the endosalpinx. (MCQ)
                •  The loculi contain a serous straw-coloured fluid, which may be blood stained when malignant transformation occurs. (MCQ)
              • Mucinous tumours
                • multiloculated cysts lined by epithelium resembling the endocervix
                • cut surface shows multiloculi and honey-combed appearance.
                • can grow to a large size and often weigh as much as 5-10 kg
                • often pedunculated. (MCQ)
                • may be combined with a dermoid cyst or a Brenner tumour (MCQ)
                • usually unilateral
                • essentially benign
                • Mucinous ovarian cyst is often uni­lateral.
                • Bilateral tumours are often metastatic from the gastrointestinal tract, mainly mucocele of appendix or primary adenocarcinoma of appendix. (MCQ)
                • occur in women between 30 and 60 years
                • If the tumour ruptures, it may lead to formation of pseu-domyxoma peritonei
                • Appendicectomy at the time of primary sur­gery prevents pseudomyxoma peritonei(MCQ)
              • Endometrioid tumours
                • mostly malignant
                • lined by a glandular epithelium resembling the endometrium.
                • In 15% of cases ovarian endometriosis may coexist(MCQ)
                • associated with endometrial cancer in 20%.(MCQ)
              • Mesonephroid tumour
                • also called clear cell carcinoma
                • composed of large cuboidal epithelial cells with abundant clear cyto­plasm
                • characteristically form tubules, glands, small cystic spaces lined by clear cells showing large dark nuclei protruding into.the lumen (hobnail cells). (MCQ)
                • The tumour is highly malignant.
              • Brenner tumour
                • it resembles a fibroma of the ovary
                • cut surface appears gritty and yel­lowish grey
                • generally unilateral, small to moderate in size,
                • essentially benign
                • have no endocrine function.
                • generally seen in women around meno­pause, and causes postmenopausal bleeding. (MCQ)
                • pseudo-Meig syndrome(MCQ)
                  • Brenner tumor  associated with ascites and hydrothorax
                • Walthard cell rests  (MCQ)
                    • Histologically, the tumour shows a background of fibrous tissue: interspersed within it are nests of transi­tional epithelium (MCQ)
                    • These cells demonstrate a longitudinal groove resembling puffed wheat. (MCQ)
                    • this tumour may be com­bined with a mucinous adenoma of the ovary. (MCQ)


Surgery for ovarian tumor.
Ovarian Cancer
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Surgical removal of the ovarian tumors
The surgery started at 24 Agust 2012, at 7:00 pm
with dr. Nasdaldy, SpBOnk
The surgery success and thankyou so much with dr.Nasdaldy and team.
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TeamCirisano Teaching Series: Ovarian Cancer Radical Surgery
The management of ovarian cancer has been previously premised upon advanced stages of disease at diagnosis. Typically, ovarian cancer is diagnosed at stages III and IV, when the tumor has already demonstrated spread beyond the primary site of origin within the ovarian capsule or skin ( epithelium ).
Borderline ovarian tumor associated with Endometrioma.
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