BENIGN AND MALIGNANT OVARIAN TUMOR Flashcards
INTRODUCTION
3rd most common site of cancer in female genital tract after Endometrium and Cervix
2nd most common gynecological cancer in Nigeria
Called a silent killer and symptoms only present in advanced stages in 75%
Classified into Benign(80%, 20-45ages), Borderline and Malignant(older ages)
Ovaries are almond shaped
With dimension of 3cm length, 1.5 wide and 1cm thick. Ovarian surface covered by simple cuboidal epithelium called germinal epithelium
Histologically Ovarian tumor arises from 3 components of the ovary
- The surface mullerian epithelium
- The Germ cell
- The sex cord stroma cell
AETIOLOGY
Nulliparity Family history (Brca1, Brca2 gene, P53gene) Endometriosis Complex Genetic Syndromes: A.Lynch syndrome B. Peutz Jaghers syndrome C. Gonadal dysgenesis in gonadoblastoma D. Nevoid basal cell carcinoma in ovarian fibroma
On Aetiopathogenesis
Recent molecular studies have classified ovarian carcinoma into 2 types based on pathogenesis
1. Those associated with Borderline tumors
E.g
Well differentiated serous, endometriod and mucinous carcinoma
- Those that arise as “De novo carcinoma”
E.g poorly differentiated serous carcinomas and MMMTs(Malignant Mixed Mullerian Tumors)
WHO CLASSIFICATION (TUMORS OF SURFACE EPITHELIUM)
60-70% of Ovarian Tumors
Arise Histologically from the 3 components of the ovaries, hence the first (surface mullerian epithelium)
—Classified into 5, Serous, Mucinous, Endometroid, Clear cell Mesonephroid and Brenner tumors
A. SEROUS
- serous cystadenoma
- Borderline serous tumor
- serous cystadenocarcinoma
B. MUCINOUS
- Mucinous cystadenoma
- Borderline mucinous tumors
- Mucinous cystadenocarcinoma
C. ENDOMETROID TUMORS
D. CLEAR CELL MESONEPHROID TUMORS
E. BRENNER TUMORS
WHO CLASSIFICATION (GERM CELL TUMORS)
Make up 15-20% of ovarian tumors
A. TERATOMAS
Benign (mature) teratoma
Malignant (immature) teratoma
Monodermal or specialized teratoma
B. DYSGERMINOMA
C. ENDODERMAL SINUS (YOLK SAC) TOKOR
D.CHORIOCARCINOMA
E. Others
WHO CLASSIFICATION (SEX CORD STROMAL TUMORS)
Account for 5-10 %
A. GRANULOSA-THECA CELL TUMORS
Granulosa cell tumor
Thecoma
Fibroma
B. SERTOLI-LEYDIG CELL TUMORS
Androblastoma and Arrhenoblastoma
C. GYNANDROBLASTOMA
CLINICAL FEATURES OF OVARIAN TUMOR
Abdominal pain and distension
Urinary and GIT symptoms due to Tumor compression or cancer invasion
Vaginal Bleeding
Ascites
*MEIG SYNDROME is ovarian fibroma with right sided hydrothorax(pleural effusion) and ascites
Menstrual irregularity
Weakness weight loss cachexia lymphadenopathy nightsweats
MORPHOLOGY(SURFACE MULLERIAN TUMORS)
A. SEROUS TUMOR
Most common malignant ovarian tumor
Serous carcinoma based on molecular and clincopathology has been classified into 2
1. Low grade (well differentiated) carcinoma
Exhibit mutation in KRAS and BRAF oncogene
2. High grade (poorly differentiated) serous carcinoma
Arising in Brca 1 and Brca 2 patients exhibit P53 mutation
THE GROSS:
Present with a (Cystic Lesion with Papillary epithelium) within the Fibrous wall or projecting from Ovarian Epithelium
THE HISTOLOGY:
Shows a Cystic lesion lined with Columnar epithelium with abundant cilia and microscopic papillae which accounts for each subtype of serous tumor
B. MUCINOUS TUMOR
THE GROSS:
Tumors have large cystic masses grossly
THE HISTOLOGY:
Shows cystic lesion lined with columnar epithelium with apical mucin and absence of cilia
C. ENDOMETROID CARCINOMA
Arises in the setting of endometriosis
THE GROSS:
Tumors have a combination of solid and cystic component
THE HISTOLOGY:
Shows tubular glands resemblance of endometrial origin
Low grade tumor with 5 year survival 75-% for stage 1
D. BRENNER TUMOR
90% are unilateral in presentation
Grossly may also be cystic or solid
Histology: shows ovarian stroma with sharply demarcated nest of epithelium of urinary tract origin often with Mucinous gland at the center
MORPHOLOGY(GERM CELL TUMOR)
1. TERATOMA (3 types) A. Mature (benign) B. Immature (malignant) C. Monodermal or specialized teratoma A.MATURE TERATOMA 1% undergo transformation to malignant
Grossly Unilocular cysts containing hair and chessy materials
Histologically: shows a cyst wall composed of stratified squamous epithelium with underlying sebacious gland, hair shaft, cartilage, bone etc
B. IMMATURE TERATOMA
- DYSGERMINOMA
All tumors are malignant but unresponsive to chemotherapy with over 80% survival rate
Histologically: shows sheets or cords of large vesicular cell with central nucleus and clear cytoplasm and scanty fibrous stroma infiltrated by mature lymphocytes
- ENDORDERMAL SINUS TUMOUR (yolk sac)
Rare tumor but more common than DYSGERMINOMA
Seen in children and young women
Characterized by glomerulus like structure composed of central blood vessels enveloped by germ cells
SEX CORD STROMAL CELL TUMOR
Most common sites from which malignancy spreads to the ovaries includes Breast GIT Genital tract Hematogenous malignancy
Bilaterality is a clue in metastatic ovarian tumor
Metastasis occurs by lymphatics, hematogenous or direct to adjacent structures
Sertoli-leydig cell tumors can produce masculinization in females
CLINICAL INVESTIGATIONS
- Clinical history.
•2.Tumour biomarker studies: Plasma CA-125 proven markers for ovarian cancer also to monitor disease progression.
•Others include ostepontin,alpha-fetoprotein(AFP),alpha1-antitrypsin(AAT),tyrosine kinase c-kit assay,organic cation transporter3/4(Oct3/4) transcription factor assay,Nanog transcription factor assay
•3.Hormonal assay: estrogen, androgen, inhibin and gonadotrophic hormones - Genetic studies :KRAS mutation(endometrioid tumour)
•5.Immunochistochemistry:CK7+/CK20- typical of serous tumour,CEA(mucinous tumour),keratin,EMA,vimetin and PAX8 (endometrioid tumour),p53,
•4.Ancillary investigations:imaging techniques such as 1.Abdominal ultrasound scan.
•2.CT SCAN. - MRI
TREATMENT AND PREVENTION
Relative risk reduction by half:
Fallopian tube ligation
Oral contraceptive pill usage
Prophylactic saloingo oophorectomy
SURGERY: Multidisciplinary team (gynecology oncology surgeon and pathologist,clinical and medical oncologist,etc).
•Procedures include: A.Conservative surgery for children,stage and grade 1 etc.
•B. surgery ;TAH+BSO,pelvic ¶ortic lymphadenectomy,bowel surgery,appendicectomy.
•Current standard prophylactic measure is salpingo-oophoretomy.
CHEMOTHERAPY:
•A.Standard post-operative chemotherapy(cisplastin,carboplatin or paclitaxel).
•B.Intraperitoneal chemotherapy.
•C. 2ND line chemotherapy drugs such as 5FU+ leucovorin,ifosfamide,docetaxel,orap etoposide,doxorubicin.
•The use of combination chemotherapy is curative in york sac tumour.
- Radiation therapy for DYSGERMINOMA
