Ovarian tumors Flashcards
What tumor markers should be ordered for ovarian tumors?
Order preoperatively:
B-hCG: choriocarcinoma
AFP : yolk sac
Ca-125 : epithelial
If suspected granulosa: inhibin A
What are the surgical principles of oncologic ovarian surgery
- assess peritoneal surfaces (including cul-de-sac), diaphragm, liver, omentum. biopsy if abnormal
- evaluate contralateral ovary, bx if abnormal.
- avoid spill (even if benign histology, increases recurrence)
- biopsy nodule if present
- send fresh
- send free fluid for cytology or peritoneal washing
- lymp node assessement. if abnormal on palpation or > 2cm, bx. dont biopsy normal nodes.
What is the f/u for patient with mature ovarian teratoma?
No need for serial marker measurement if they were normal at presentation.
F/u with US q 6 months x2 , then yearly until adulthood.
10% risk of contralateral teratoma
ipsilateral recurrence is rare.
describe a tumoral excision with ovarian sparing .
can do lap vs lap assisted (staging )with mini-lap (ovarian dissection)
2 techniques:
bivalve. seperate thinned ovarian parenchyma from underlying teratoma.
hilar: identify ovarian hilum and area where lesion meets normal parenchyma. score with bovie circumferentially and find cyst.
What are the main histological types of ovarian tumor
Epithelial (most adults, ex mucinous)
Sex-cord / stroma (ex granulosa)
germ cells (75%), ex teratoma
90% benign, 10% malignant
What histological tumor type predominates ?
Germ cell : 75%
Epithelial: 15%
Sex cord: 5%
Germ cells are separated into seminomatous and non seminomatous.
-seminomatous include: dysgermonoma(F)/seminoma (M)
Non seminomatous are:
- teratoma (vast majority)
- dysgerminoma
- yolk sac tumor(most common malignant)
- embryonal tumor,
- choriocarcinoma
- mixed tumors.
Epithelial tumors are present in 15%.
Sex cord: granulosa / sertoli-leydig
How is the surgical management affected by preoperatively elevated levels of AFP/BhCG?
a malignant tumor is suspected and the patient should undergo salpingoophorectomy.
in the case that malignant cells are not identified in the specimen, the tumor is still considered as malignant based on preop blood workl.
During exploration for a ruptured ovarian lesion, a nodule located in the cul-de-sac is identified and resected. Histopathological evaluation concludes in a benign glial immature lesion. is this considered as a metastasis?
no. rupture increases the risk of spill, with subsequent recurrence in the form of benign immature glial tumors.
What is the implication of immature element identification on histological exam?
debated. no clear impact on outcome. if R0 resection of local disease, no need for chemo.
Follow more closely for immature histology as increase malignant/recurrence potential
What is the implication of preoperative elevation in CA 125 during the workup for an ovarian mass?
Suspect epithelial tumor. Intraop: -salpingoophorectomy -peritoneal biopsy -omentectomy -fluid sampling of peritoneal cavity -LN sampling only if grossly + on ct or exam.
What ovarian lesion can result in isosexual precocious puberty, resulting in early vaginal bleeding.
Granulosa tumor (+inhibin a). most common functioning ovarian tumor.
granulosa tumors have an increase risk of recurrence are more agressive.
these tumors are sometime identified in the workup for mckune albright syndrome.
Describe COG’s staging for ovarian GCT
1: R0, N-, Markers - after resection
2: Markers remain elevated or R1,
3: peritoneal implant or R2 or N+, Cytology +, biopsy only
4: mets
What factor influences prognosis for GCT (male/female, gonadic and extragonadic included)
As per Malignant Germ Cell International Collaborative (MAGIC)
Age (<11 )
Location
COG stage
(histology not even there!!)
if malignant GCT dx , what is the metastatic workup?
complete with abdo-pelvis + chest ct.
If an ovarian sparing surgery is done, and specimen comes back as malignant. what is the management?
oophorectomy completion.
