74. Malignant ovarian tumors. Flashcards
what increases the risk of malignant ovarian cancer ?
hereditary ovarian occurs in two forms -
1) hereditary breast ovarian cancer syndrome
BRCA1 and BRCA2 gene mutations
- the cancer presents at an early age
serous not mucinous epithelial ovarian cancer
2) hereditary nonpolyposis colorectal cancer -
autosomal dominant tramsinssion
also called lynch 2 syndrome
has a 50 percent chance for endometrial cancer and 12 percent ovarian cancer
majority of epithelial cancer are not familial and hereditary and they constitute for 90 percent of primary ovarian carcinoma with malignant changes of benign cystic tumors
peutz jegherz syndrome - sex cord tumor with annular tubules
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increasing the risk for ovarian cancer is :
40-60
absolute infertility
anything causing longer period of ovulation such as
not being pregnant , early menarche , not breastfeeding
PCOS
primary ovarian cancer is pathologically classified into ?
1) Epithelial 90 percent (although most of benign)
cystic : (more common than solid)
> serous -cystadenocarcinoma - most common
> mucinous cyst adenocarcinoma
solid
>endometroid adenocarcinoma - characterised by the resemblance to endometrium
solid
> brenner
> undifferentiated
> clear cell (associated with endometriosis)
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2) non epithelial
solid
A ) germ cell :
>immature teratoma >dysgerminoma
>endodermal sinus tumor
>choriocarcinoma
B) sex cord (ovarian follicle ) gonadal stromal cell tumor (connective tissue in the ovary):
> granulose cell tumor - sex cord
> thecaoma - gonadal stroma
> fibroma - gonadal stroma
malignant epithelial ovarian tumors charachtersitically are ?
bilateral in 50 percent of the cases
what are the early stage symptoms ?
early-stage disease. These symptoms are nonspecific
Changes in urination (e.g., frequency or urgency)
abdominal distension
adnexal mass
Early satiety
non specific pelvic pain
abnormal bleeding esp post menopausal!!!
what are the signs and symtoms of ovarian cancer in late stages ?
FIRST TRUE SYMPTOM OF OVARIAN CANCER = abdominal swelling which may be rapid and clothes no longer fit
Sudden loss of weight.
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metastatic :
ASCITIS - obstruction of peritoneal fluid outflow principally through the diaphragm
nausea and vomitting - bowel obstruction
right sided pleural effusion - dyspnea
pain during sexual intercourse
liver - jaundice
omentum - omental caking - abdominal pain
inguinal lymphadenopathy
how do we diagnose ovarian cancer
pelvic examination -
not mobile
and ultrasound - giving heterogenous echogencity
1) US TAS + TVG - suspecting
malignant
>internal - irregular thickened spate
( thin )
> indistinct borders / papillary proj
> echo - hypo / anch/ hyperecho
(anech)
> content - cystic and solid
(cystic)
pouch of douglas - possible free fluid
(no)
central neovascularity
(no)
3D contrast enhanced more diagnostic
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staging
CT scan (metastasis and lymph node involvement) and PET scan for staging
ca also do MRI
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tumor markers
CA-125
premenopausal - elevation benign
but postmenapausl arise - malignancy
only used in monitoring disease progression
germ cell tumors :
bhcg levels - dygerminoma , choriocarcinoma
AFP - yolk sac tumor
immature teratoma
LDH - immature teratoma
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sex chord tumor
granulosa cell - inhibit
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non invasive biopsy - not recommenced due to risk of tumor seeding
laparoscopic biopsy taken
how is the ovarian cancer staged and graded ?
FIGO ovarian cancer staging
stage 1 limited to ovaries
1a-one ovary no ascitis
B - both ovaries not ascitis
c - tumor on surface of one or both ovaries / capsule rupture / ascites consisting of malignant cells
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stage 2 - limited to lesser pelvis
one or two ovaries with pelvic
a - extension or uterus or tubes or ovaries
b - pelvic tissue
c - a or b with ascitis
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stage 3 -
metastasis outside the pelvis or in the retroperitoneal / inguinal lymph nodes or
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stage 4 -
a - distant metastasis eg
pleural effusion with positive cytology or liver or spleen
carcinoma of the ovary spread in which ways ?
spread along the peritoneal surface - ovaries , parietal ad intestinal peritoneal surfaces - the undersurface of right side of the diaphragm
- transcoelmic (across the peritoneal cavity)
through penetration of tumor capsule or rupture of it , or direct exfoliation of cells
lymphatic
paraaortic, superior gastric nodes and pelvic lymph nodes
direct
hematogenous
what are prevention methods of ovarian cancer?
high risk
Genetic screening for BRCA 1 and BRCA 2
Lynch type II families
family predelicton
= elective salpingooopherectomy
if not 6 month pelvic US and CA-125
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combined oral contraceptives
hysterectomy
parity
breastfeeding
what is the treatment for ovarian cancer ?
surgery
hysterectomy with bilateral saplingo-oopherectomy
Pelvic and paraaortic lymph node dissection
Omentectomy
surgical debulking : whenever possible maximum cytoreduction which is removal of visible tumor
<1cm of residual tumor is optimal debulking
for stage 1-3
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chemotherapy
paclitaxel and carboplatin ( / cisplatin) are commonly used
ADJUVANT THERAPY AFTER initial debunking
= maintenance
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targeted molecular therapy - PARP inhibitor
in BRCA1 and BRCA2 positive
and
maintenance therapy after surgical debunking and chemotherapy
why is CA 125 done in post menapsual more?
too many false positives in premenopausal women due to endometriosis , adenomyosis , fibroids
when is CA 125 indicating cancer ?
more than 200
the prognosis of ovarian cancer is 30-35 percent why ?
because it presents late
what would determine that an ovarian teratoma is malignant ?
immature fetal-like cells /embryonic-like tissues
contralateral ovary is involved in primary malignancy why is that ?
due to retrograde spread through the paraortic glands
BODY of the uterus also mostly affected due to lymphatic spread
