this lecture involves full simple description of ovarian neoplasm it include the following points: incidence and global spread of ovarian neoplasm risk factors for ovarian neoplasms protective factors for ovarian neoplasm normal ovarian histology WHO classification of ovarian neoplasms epithelial cell ovarian neoplasms germ cell ovarian neoplasms sex cord stromal neoplasm gonadoblastoma krukenberg tumor miscellaneous tumors of the ovary differential diagnosis of ovarian neoplasms Meigs syndrome complications of ovarian neoplasm clinical presentation of ovarian neoplasm Clinical features suggesting malignancy spread of ovarian cancer screening for ovarian cancer diagnosis for ovarian cancer management of ovarian neoplasms RMI (risk of malignancy index) IOTA (international ovarian tumor analysis) CA125

1. Ovarian
neoplasms
By
Dr. Ahmed Mohamed Nasef
Assistant lecturer in
Obstetrics & Gynecology
Benha University

2. Incidence
It is the 2nd most common
malignancy of female genital tract
(10-15/100000women)
It the most frequent cause of death
from gynecologic neoplasms
Its incidence increases with age (50-
70 years old)
The disease is more frequent among
whites than blacks

4. Risk factors
• Women who are related to frequent regular
ovulation at high risk (late menopause,
nulliparity or late childbearing)
• The number of years during which the
women has ovulated
• Talcum powder use over perineum
• Diet high in fat
• BRCA gene mutation
• Use of Ovulation induction drugs
(controversial)

5. Protective
factors
• Use of OCPs
• Breast feeding
• Pregnancy
• Tubal ligation & salpingectomy
• Hysterectomy with ovarian
preservation also decrease the
risk

6. Ovarian histology
The ovarian histology is composed of the
following:
Cortex (outer most part)
Covered by mesothelium (single layer of cuboidal
to columnar epithelium)
Composed of stroma and follicles (contain the
germ cells, oocyte)
Medulla (middle part)
Composed of stroma, blood vessels & nerves
Hilum
Where blood vessels enter parenchyma

7. Classification of ovarian neoplasm
WHO classified it according to site of origin into:
Surface epithelium (65%) most common
from surface epithelium
Germ cells (15%) 2nd most common
Main cause of ovarian malignancy in young women (20s)
From germ cells
Sex cord-stromal cells (10%) 3rd most common
From sex cord & stroma
Secretory ovarian tumors (secrete sex steroid hormones) or may be non secretory
Gonadoblastoma occur in dysgenetic gonads
Consist of germ cells & sex cord stromal elements
Metastases (5%)
From reproductive tract tumors or from distant sites (bowel or stomach)
Miscellaneous
Such as Hemangioma & lipoma

9. Epithelial tumors
• They resemble normal epithelium in the genitourinary tract
Serous tumors like fallopian tube epithelium
Mucinous tumors like endocervical mucosa
Endometrial tumors like endometrium
Brenner tumors like transitional epithelium of bladder
• many of them present a mixed histological appearance
• May be benign, borderline or malignant

11. Germ cell tumors
• Occur prior to puberty, in adolescence & early adult life
• They include
Teratoma (mature, immature, solid, cystic)
Monodermal tumors
Dysgerminoma
Yolk sac tumor
Mixed germ cell tumors
• All are malignant except the mature teratoma (dermoid cyst) has little tendency to malignant
transformation

13. Germ cell tumors
• Every type of them secrete substances in the blood which is used as a tumor marker
for diagnosis & follow up as:
Immature teratoma secrete CA19.9
Dysgerminoma secrete LDH
Endodermal sinus tumor secrete alpha fetoprotein

15. Sex-cord stromal tumors
• Functioning ovarian tumors as they secrete sex hormones like estrogens & androgens
• Composed of either male or female origin
• They include those containing (granulosa, theca, Sertoli or Leydig cells)
• Also, they include stromal elements (fibroma, fibro thecoma)

16. Border line
tumors
Criteria include:
Epithelial proliferation
Nuclear atypia
Increased mitotic activity
Absence of true stromal invasion
Diagnosed based on histologic features

17. Simple
clear cyst
by us

18. Dermoid cyst

19. Suspected malignant cyst by us

20. DD between
different classes
of ovarian
neoplasms
Surface epithelium
tumors
Germ cell tumors Sex cord-stromal
tumors
Cell of origin Coelomic epithelium Germ cells Sex cord & stroma
Incidence 65%
90% of malignant
15%
Most in young
10%
PF Ovulation age Dysgentic gonads
Age group B, BL (30-50)
M (50-80)
Young Any age
Bilaterality Bilateral Mainly unilateral Unilateral
Consistency Cystic, solid,
heterogenous
Most solid Solid white or
yellow
Behaviour B, BL, M All malignant except
dermoid
Granulosa M
Thecoma, fibroma B
Mixed LGM

21. Meigs syndrome
Criteria for diagnosis
Tumor must be (ovarian, solid, benign)
Both hydrothorax and ascites must be present
Removal of tumor must result in spontaneous and permanent cure

22. Complications of
ovarian
neoplasms
• Torsion
Dermoid cyst most prone to torsion
• rupture of a cyst
• Hemorrhage into a cyst
Most are self limited
• Incarceration
• Infection
• Intestinal obstruction
• Malignant transformation
• Pain
• Pressure
Constipation, distension, bloating, indigestion & dyspnea
• Pregnancy in presence of ovarian swellings

23. Clinical presentation
Symptoms
Asymptomatic
Bleeding
Complication
Dyspepsia leading symptom of ovarian tumor
Enlargement abdominal swelling
Pressure edema of legs & vulva
Pain
Discovered accidently in pregnancy
Signs
• General
Cachexia
Weight loss
• abdominal
Ascites
Consistency of the lesion (solid, cystic or
heterogenous)
Mobility, tenderness, bilaterality
• Local
vulval edema, vaginal bleeding

24. Clinical features suggesting malignancy
• Age
Incidence increase with age
Neoplasm in childhood (usually malignant)
• Bilaterality
• Edema & varicosities of lower limb or vulva
• Solid, nodular, irregular shaped edges
• Fixation
• Ascites
• Tenderness
• Enlargement rate
• Nodules in DP

25. Causes of
ascites
• Tumor perforated capsule (oozing)
• Peritoneal metastases (oozing)
• Subdiaphragmatic metastases (lymphatic
obstruction)
• Hepatic metastases (portal hypertension)
• Electrolyte imbalance
• Cachexia (hypoproteinemia)

26. Spread of
ovarian
cancer
• Direct
To pelvic & abdominal organs
• Lymphatic
To paraaortic, pelvic & inguinal lymph nodes
Left supraclavicular lymph node
• Blood
To brain, bone, liver & lung
• Implantation

27. Staging (FIGO surgical staging)
Stage 1
Limited to organ
A one ovary B both ovaries C (surgical spill, capsule ruptured, malignant cells in ascites or peritoneal washings
Stage 2
Limited to pelvis
A genital tract B (bladder, rectum & DP)
Stage 3
Spread to peritoneum outside pelvis and or metastasis to retroperitoneal lymph nodes
A microscopic involvement of retroperitoneal lymph nodes or extra pelvic peritoneum
B macroscopic peritoneal involvement outside pelvis > 2 cm
C macroscopic peritoneal involvement outside pelvis < 2 cm, or extension to only capsule of liver and spleen
Stage 4
Distant metastases
A pleural effusion B to extra abdominal organs and parenchymal involvement of liver and spleen

28. Screening

29. Screening
To whom
General population screening will be a financial
problem
In USA, the cost will exceed 10 billion dollar annually
So preferred to be done only for high-risk population
When to screen
Annually
How to screen
Physical examination (least sensitive)
Biomarkers (CA125)
Ultrasound

30. Screening by
ultrasound
• If positive screening
Cyst > 7cm, unilocular, thin wall, clear fluid,
premenopausal
Follow up after 2 months
Cyst < 7cm, multilocular, thick wall, turbid
fluid, postmenopausal
IOTA description
B surgical treatment
Uncertain further evaluation
M oncology work up
• If negative screening
Rescreen annually

32. Diagnosis
Diagnosis is done in 2 steps:
• Preoperative
Physical examination
Ultrasound (IOTA)
Biochemical (tumor markers)
RMI
Advanced imaging (CT, MRI)
• Operative
only diagnosis and staging is surgical
Diagnosis is established by histologic examination of tumor tissue
removed at operation

33. IOTA (international ovarian
tumor analysis) USA

34. IOTA (international ovarian
tumor analysis) USA
Ultrasound suggestion of benign or
malignant
Likely benign Likely malignant
B1 Unilocular cyst M1 Solid
B2 No solid
component or
> 7 mm
M2 Ascites
B3 Acoustic
shadows
M3 < 4 papilla
B4 Smooth
Diameter >
10cm
M4 Irregular
Diameter <
10cm
B5 No color flow M5 Strong color
flow

35. IOTA interpretation
M features B features
Very low risk No 3 or more
Low risk No 2
No 1 B (B1)
Intermediate risk No 1B (but not B1)
Elevated risk M features > B features
Very high risk M features < B features

36. RMI (Risk of Malignancy
Index) UK

37. RMI (Risk
of
Malignancy
Index) UK
Product of ultrasound score, menopausal
status & serum CA125 level
RMI= U × M × CA125
RMI final score
• >25 low malignancy risk
• 25 – 200 intermediate malignancy risk
• < 200 high malignancy risk

38. RMI (U)
Ultrasound result Ultrasound score to be
used in RMI calculation
Multilocular cysts 0 or 1 U 0 For ultrasound score of
0
Solid areas 0 or 1 U 1 For ultrasound score of
1
Metastases 0 or 1 U 3 For ultrasound score < 1
Ascites 0 or 1
Bilateral lesions 0 or 1

39. RMI (M)
Premenopausal 1
Postmenopausal 3

40. RMI (CA125 level)
Measured in IU/ml

42. Management
of ovarian
neoplasm
According to tumor behavior whether benign,
border line or malignant
And according to surgical stage
Also, preoperative preparation is very
important to decide whether to be treated
surgically or need oncology management
Management of malignant lesions may
include surgery and chemotherapy

43. Surgical rules
Cystectomy
Only remove cyst
Ovariectomy (oophorectomy)
Remove ovary
Salpingoophrectomy
Remove tube and ovary
Cytoreductive surgery
TAH, BSO, complete omentectomy, resection of all
visible tumor, retroperitoneal lymphadenectomy
Additional procedures (diaphragmatic resection,
splenectomy, hepatic resection, bowel and bladder
resection)

44. Surgical rules
Exploratory staging
Involve
Sampling of any free fluid
All intraabdominal viscera are explored
systematically
Biopsies are taken from suspicious areas
Biopsies from diaphragmatic surface
Retroperitoneal spaces are explored
Omentectomy are performed

45. Benign ovarian
neoplasm
• Young & need fertility
Cystectomy
• Elderly
TAH & BSO

46. Malignant
border line and
stage 1 low
grades
No cystectomy
Young need fertility
USO then after complete
childbearing TAH & BSO
All others TAH & BSO
Follow up after treatment
Periodic pelvic examinations &
CA125 level till childbearing end

47. Stage 1A high
grade
TAH & BSO
Chemotherapy and follow up
Further management according to
result if there is remission may
need maintenance therapy

48. Stage 2
TAH & BSO
Pelvic & paraaortic lymph nodes
are samples
Omentectomy, appendectomy
Then chemotherapy, follow up
Further management according to
result may need secondary
cytoreduction

49. Stage 3 & 4
Cytoreductive surgery
Chemotherapy and follow up
Further management according to
result may need trial of mew
modalities of chemotherapy