Ovarian Cancer

المساهمات : 19 تاريخ التسجيل : 11/02/2008

Ovarian Cancer

FEATURES:

Third most common site of malignancy in the reproductive tract but most common cause of death than all gyne Ca combined.
Fourth leading cause of cancer death in the female after Breast, Colorectal, and Lung

Incidence:

• 19/100,000 women diagnosed annually

• ETIOLOGY: Cause unknown.

• Predisposing factors:

• 3-5 times more common in the industrialised nations---Japan excluded.

• Whites and black similar

• Mostly postmenopausal---Peak age 61 yrs

• 60%----45 – 65 years

• 20%---Below 45 years

• 20%---Above 65 years

Etiology:

• Higher in Nulliparas

• Lower in patients with repeated pregnancies, chr. Anovulation and breastfeeding.

• O.C. pill users ---- Protected in later years.

• Repeated ovulation – causally related to the dev of this disease.

• Rep ov may provide ample opportunity for somatic gene deletions and mutations to occur which in turn can contribute to tumor initiation and progression.

• Ovulation induction --- slight increase of the disease

• Familial: 1-3%

• Colon, breast, endometrial Ca maybe in the same patient. 90% inheritance due to a mutation in the BRAC 1 gene.

• Foreign body involved? – Females in asbestos and Talc industries.

CLASSIFICATION:

• FIGO System is HISTOLOGIC

• 90% ---- Epithelial in origin.

• 1. Serous cystadenocarcinoma --- (Commonest)

• 2. Mucinous cystadenocarcinoma

• 3.Endometriod Cancer.

• 4. Mesonephric or Clear cell cancer

• 5. Undifferentiated

• 6. Secondaries to the ovaries.

المساهمات : 19 تاريخ التسجيل : 11/02/2008

Borderline Tumors (or Low Malignant Potential):

• Tumors which are intermediate in both BEHAVIOUR and HISTOLOGIC features between benign and malignant tumors:-mitotic figures and nuclear abnorm

-no evidence of stromal invasion.

• Extraovarian spread can occur – slow

• Staging same as Ov Ca

• Prognosis:

-Degree of differentiation of tumor

-Extent of spread

Serous Cystadenocarcinoma:

• Commonest of the malignant primary ov tumors

• May be predominantly cystic or solid uni or multilocul with coarse, irregular papillae

• Bilateral in 40 -60% cases.

• Worst prognosis

Mucinous Cystadenocarcinoma:

• Second most common type of epithelial Ov. Ca

• Bilateral in 10% cases.

• Attain very large size, multiloculated cysts

• May have benign, borderline and malignant HP in the same tumor

• Pseudomyxoma peritonei may result

Endometrioid Cancer:

• HP resembles endometrial adenoCa.

• Bilateral in 30 – 50% cases

• Rarely (<10% cases) arises in foci of endometriosis.

• 10-20 cm diameter, more solid tumor with cystic spaces containing dark hemorr fluid.

• Associated with endometrial CA---30% pts

• Best prognosis

Clear Cell Carcinoma:

• Smaller in size than serous and mucinous tumors

• Biologically aggressive –hypercal, hyperpyrexia

• Cystic to solid

• Commonly unilateral

• Prognosis worse than endometriod Ov.Ca.

Undifferentiated Carcinoma:

• Absence of any distinguishing microscopic features.

• Solid tumors

• Bilateral – 50%

• Prognosis: Poor

METASTATIC Ca to the ovary:

· 25% of all Ov malignancies, bilateral usually, 25% unilateral

• breast, stomach, colon, endometrium

موضوع: رد: Ovarian Cancer الجمعة فبراير 15, 2008 4:31 pm

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المساهمات : 19 تاريخ التسجيل : 11/02/2008

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المساهمات : 19 تاريخ التسجيل : 11/02/2008

STAGING of Ovarian Carcinoma:

• Stage 1: Growth limited to the Ovaries

• 1a ---- one ovary involved

• 1b ---- both ovaries involved

• 1c ---- 1a or 1b with ov surface tumor, ruptured capsule, peritoneal washings positive for malignant cells.

• Stage II: Extension of the neoplasm from the ovary to the pelvis

• IIa --- extension to the uterus or fallopian tubes -- serosa

• IIb --- extension to other pelvic tissues

• IIc --- IIa or IIb and tumor on surface capsule, ruptured capsule,

+ peritoneal cytology

• Stage III: Disease extension to the abdominal cavity

• IIIa ----- Abdominal peritoneal surfaces with microscopic metastases.

• IIIb ---- tumor metastases < 2 cm in size

• IIIc ---- tumor metastases > 2 cm in size or pelvic, para-aortic or inguinal lymph nodes involved

• Stage IV: Distant metastatic disease.

-malignant pleural effusion

-pulmonary parenchymal metastases

-liver or splenic parenchymal metastases

-metastases to the supraclavicular lymph nodes or skin, bone etc

Metastases:

• 70% pts have metst outside the true pelvis at the time of daignosis.

• Peritoneum—85%

• Omentum and other ovary---70%

• Liver—35%, pleura---33%, lung---25%

• Uterus--- 20%, Vagina—15%, Bone—15%

• Spleen, kidney, adrenal, skin: 5-10%

• Vulva, Brain: 1%

• 80% ---- Para-aortic lymph nodes

• 50% ---- Mediastinal or supraclavicular L. nodes

CLINICAL PRESENTATION:

• 15% pts asyptomatic at the time of diagnosis.

• EARLY: Few sympts, vague nonspecific digestive sympts.

• LATE: Abd pain/distention, pressure sympts, pelvic discomfort, weight or pressure

• Menstrual irregularity in 15% pts only.

• ADVANCED disease: abd distention, pain, wt loss, cachexia, LL edema, varicosities, hemorrhoids.

• TERMINAL: Pleural effusion, DVT, Intestinal obstruction

• Bladder symptoms: frequency, urgency, or retention

• Change in bowel habits

• Signs: Solid, fixed, rapidly growing pelvi-abd mass, ascites, irregular masses in POD

Investigations:

• CBC, Full Chemistry, Urine, Cx smear, Ca 125

• Chest and Abd x-ray, IVP, Ba meal and series.

• USG: pelvi-abdominal

• CT scans and MRI

• Liver, spleen, bone scans.

• PARACENTESIS: not advocated routinely

• Diagnostic thoracocentesis may be useful

• Screening mammogram study

TREATMENT:

• SURGICAL: Cornerstone of therapy

• LAPAROTOMY----- vertical incisssion

• Staging: determines prognosis and TT decisions

• Explore: peritoneum, ovary, para-aortic and pelvic LN, omentum, liver mesentry, bowel

• Peritoneal washings to be taken

• Biopsy of para-aortic lymph nodes

• Document findings thoroughly

• HP type of tumor and Histology grade

• Monitoring the course of the disease and Pt response:

• Second look laparotomy: second cyto reductive surgery

• Follow up: Examinations of the pt, tumor markers, scans etc

Surgery:

• Stage I and II: TAH and BSO and infracolic omentectomy

• Later Stages: Debulking of the tumor mass

Chemotherapy:

• Stage I: grade 1a & b and 2 tumors---no need for chemotherapy----low risk of recurrence, does not improve 5-yr survival rate of 90%

INDICATIONS:

• ALL OTHER STAGES: postop chemo given

• If tumor is Stage I adherent/ ruptured/ grade III or clear cell cancer post operative chemo to be started after wound has healed—6 cycles at 3-week intervals.

• Stages 2,3 : Debulk and 6 courses of systemic combination chemo.

• Stage 4: Chemotherapy and later debulk

• Alkylating agents + cis platinum or carboplatin, vincristin, hexamethylmelamine, adriamycin, paclitaxel ----------- multiagents used.

Radiation therapy:

• Currently very limited role in this disease.

• Radioisotopes e.g. Intraperitoneal P32 may benefit in Stg Ic and those with microscopic positive second look ops

ALTERNATIVE THERAPIES:

• -Immunotherapeutic approaches: (still experimental)

• systemic or intraperitoneal administration of recombinant cytokines-----30% response rates in otherwise chemo-resistant pts.

• -Several gene therapeutic approaches developed.

Prognosis:

• Overall 5-yr survival rate: 35-38%

• Low malignant potential: 95%

• Stg I: 90% -- lesion was intracystic

56% -- cyst ruptured

51% -- if cyst was adherent

• Stg II: 60 – 74%

• Stg III: 25 - 41%

• Stg: IV: 4.2 - 11%