Classification of ovarian tumors
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Just a presentation laying ground to the classification of ovarian tumors.
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Classification of ovarian tumors
- 1. OVARIAN TUMORS INTRODUCTION Dr Anusha Rao P PGY2 (OBG) CAIMS
- 2. NORMAL OVARIES • Normal size 5 x 3 x 3cm • Variation in dimensions can result from – Endogenous hormonal production(varies with age and menstrual cycle) – Exogenous substances, including OCs, GnRH agonists, or ovulation-inducing medication, may affect size
- 4. DIFFERENTIAL DIAGNOSIS OF ADNEXAL MASS ORGAN CYSTIC SOLID OVARY Functional cyst, Neoplastic cyst, Benign, Malignant, Endometriosis Neoplasm Benign Malignant FALLOPIAN TUBES Tubo-ovarian abscess Hydrosalpinx Paraovarian cyst Tubo-ovarian abscess Ectopic pregnancy Neoplasm UTERUS Intrauterine pregnancy in a bicornuate uterus Pedunculated or inteligamentous myoma BOWEL Sigmoid or caecum distended with gas or feces Diverticulitis, Ileitis, Appendicitis, Colonic cancer MISCELLANEOUS Distended bladder, Pelvic kidney, Urachal cyst Abdominal wall hematoma or abscess, retroperitoneal
- 5. Lifetime Risk of ovarian neoplasm • A woman has 5–10% lifetime risk of undergoing surgery for a suspected ovarian neoplasm and • 13–21% of these will be found to be have an ovarian malignancy
- 6. OVARIAN MASSES FUNCTIONAL INFLAMMATORY NEOPLASTIC OTHERS FOLLICULAR CYST CORPUS LUTEUM CYST THECA LUTEIN TUBO OVARIAN ABSCESS BENIGN BORDERLINE MALIGNANT ENDOMETRIOMA ENLARGED PCO PAROVARIAN CYST
- 7. COMMON OVARIAN TUMOURS Infancy Pre pubertal Adolescent Reproductive Peri menopausal Post Menopausal 1 Functional cyst Functional cyst Functional cyst Functional cyst Epithelial ovarian tumor Neoplastic ovarian tumor 2. Germ cell tumor Germ cell tumor Germ cell tumor Dermoid Functional cyst Functional cyst 3. Epithelial tumor Epithelial tumor Mets
- 8. Functional ovarian cysts • Follicular cysts • Corpus luteum cysts • Theca lutein cysts • Luteomas of pregnancy By far the most common clinically detectable enlargements of the ovary in the reproductive years. All are benign and usually asymptomatic.
- 11. I. Common Epithelial Tumors: • Serous tumors • Mucinous tumors • Endometrioid tumors • Clear cell tumors • Brenner tumors • Mixed epithelial tumors • Undifferentiated ca. • Unclassified epithelial tumors
- 12. II. Sex cord tumors: • Granulosa-stromal cell tumors, theca cell tumors • Androblastomas • Gynandroblastomas • Unclassified
- 13. III. Lipid cell tumors IV. Germ cell tumors: • Dysgerminoma • Endodermal sinus tumor • Embryonal ca. • Polyembryoma • Choriocarcinoma • Teratoma • Mixed
- 14. V. Gonadoblastomas: • Pure • Mixed VI. Soft tissue tumors (not specific to ovary) VII. Unclassified tumors VIII. Secondary tumors IX. Tumor-like conditions
- 15. Simple ultrasound-based rules for the diagnosis of ovarian cancer. Ultrasound Obstet Gynecol2008
- 17. CLINICAL PRESENTATION • Asymptomatic – accidentally discovered on USG • Chronic pattern of pain, increasing abdominal girth over months or weeks. • Associated with secondary symptoms of anorexia, nausea, vomiting, urinary frequency. • Could be associated with primary or secondary amenorrhea, menstrual irregularities, virilization, precocious puberty • Become acutely symptomatic if undergoes torsion, rupture or haemorrhage. Benign ovarian neoplasms are indistinguishable clinically from malignant counterparts
- 18. COMPLICATIONS • Torsion • Intracystic hemorrhage • Infection • Rupture • Pseudomyxoma peritonei • Malignancy
- 19. PHYSICAL EXAMINATION • Abdominal and vaginal examination and the presence or absence of local lymphadenopathy • Assess – Laterality – Cystic Vs solid – Mobile Vs fixed – Smooth Vs irregular – Ascites – Cul-de-sac nodules – Rapid growth rate
- 20. TVS • Pattern recognition is superior to all other scores. • Subjective evaluation of ovarian masses based on pattern recognition can achieve sensitivity of 88% to 100% and specificity of 62% to 96%. • Adding doppler does not seem to yield much improvement in the diagnostic precision, but increases the confidence with which a correct diagnosis of benignity or malignancy is made.
- 21. DOPPLER EVALUATION • Hypoxic tissue in tumors recruit low-resistance, high-flow blood vessels • Role in evaluating ovarian mass is controversial – as the ranges of values of RI,PI,MSV between benign and malignant masses overlap. PI<1, RI<0.4 • To overcome this, vascular sampling of suspicious areas (papillary projections, solid areas, thick septations) using both 3D USG and power doppler both has been evaluated and found effective. • “Chaotic” vascular pattern in malignancy
- 22. OTHER IMAGING MODALITIES • CT, MRI, PET not recommended in the initial evaluation • CT scan: evaluating – LN involvement, – Omental mets, peritoneal deposits, hepatic mets, – obstructive uropathy – or a probable alternate primary site when cancer is suspected based upon TVS • MRI : differentiating non adnexal pelvic masses (like leiomyomata), expensive and inconvenient. • ACOG GUIDELINES 2007
- 23. TUMOR MARKERS
- 25. SENSITIVITY SPECIFICITY PPV NPV 61-90% 71-93% 35-91% 67-90% CA- 125 Most useful when non-mucinous epithelial cancers are present Elevated in 80% of patients with epithelial ovarian Ca but only in 50% of patients with stage I disease Increased sensitivity in post menopausal women esp. when associated with relevant clinical and USG findings Cut-off of 30 u/ml, sensitivity of 81% and specificity of 75%
- 26. HE4 • HE4 is a precursor to the epididymal secretory protein E4 and in normal ovarian tissue, there is minimal gene expression and production of HE4. • As a single tumor marker, HE4 had the highest sensitivity for detecting ovarian cancer, especially Stage I disease. • Combined CA125 and HE4 is a more accurate predictor of malignancy than either alone or to any other dual combination of markers • HE4 levels(>70 pM) were found to be elevated in over half of the patients with ovarian cancer with normal serum CA125 levels (>35 U/ml) • HE4 when studied in the premenopausal group of patients was able to discriminate benign tumors from malignancies Moore et al. / Gynecologic Oncology, 2008
- 27. NEW SCORES • ROMA: Risk of Ovarian Malignancy Algorithm The dual marker algorithm utilizing HE4 and CA125 to calculate a ROMA value In patients with stage I and II disease, ROMA achieved a sensitivity of 85.3% compared with 64.7% for RMI MOORE ET AL, AJOG 2010 • OVA 1: FDA approved. Combination of 5 immunoassays CA 125, transthyrettin, apo lipoprotein A1, transferrin, B2 microglobulin Sensitivity : 93%, specificity: 43% PPV 42% NPV 93% COMMUN ONCOL, 2010
- 28. Asymptomatic simple cysts <5cms Likely physiological (do not require follow up) 5-7 cms Yearly USG >7cm Require further imaging/surgical intervention. RCOG 2011
- 29. Ovarian mass in reproductive age group <5 cms. >/= 5 cms USG USG cystic observation Complex, solid, suspicious Persistence or progression surgery
- 30. Ovarian mass in childhood: History and physical examination Appr. Imaging studies Simple cyst - Observe and reassess Solid or solid cystic MRI and tumor markers High suspicion of malignancy Low suspicion of malignancy Laparotomy laparoscopy Frozen section Malignant – oophorectomy and staging Benign - cystectomy
- 31. Ovarian cysts in postmenopausal women: • Post menopausal gonad atrophies to a size of 1.5 X 1 X 0.5cm on average • Shouldn’t be palpable on pelvic examination. • Presence of palpable ovary must alert the possibility of an underlying malignancy.
- 32. • Incidence in asymptomatic post menopausal women – 1.5% by pelvic examination 3.3% to 14.5% by USG. obstet gynecol survey, 2002 • Causes -10% functional 90% neoplastic (either benign or malignant)
- 33. ASSESSMENT • It is recommended that ovarian cysts in postmenopausal women should be assessed using CA125 and transvaginal grey scale sonography. • There is no routine role yet for Doppler, MRI, CT or PET. RCOG 2010 SENSITIVITY SPECIFICITY TVS 89% 73% CA 125 81% 75%
- 36. RCOG • Simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a low risk of malignancy. It is recommended that, in the presence of a normal serum CA125 levels, they be managed conservatively. • Aspiration is not recommended for the management of ovarian cysts in postmenopausal women. • It is recommended that a ‘risk of malignancy index’ should be used to select women for laparoscopic surgery, to be undertaken by a suitably qualified surgeon. • It is recommended that laparoscopic management of ovarian cysts in postmenopausal women should involve oophorectomy (usually bilateral) rather than cystectomy.
- 38. They were not separately classified by the FIGO and the WHO until the early 1970s. • Borderline tumors make up approximately 15% of all epithelial ovarian tumors. • The mean age of occurrence is approximately 10 years younger than that of women with frankly malignant ovarian cancer.
- 39. Tumour subtypes • 2 major histological tumor subtypes – Serous(50%) • (bilateral in 30%) • Could be associated with extraovarian lesion : implants(35%) – Mucinous (46%) • Mucinous tumors do not have a clearly defined origin. – Substantial information indicates that many tumors may actually originate from the appendix; thus, this organ should be removed at the time of surgery.
- 41. Histology and Cytology • According to Dietel and Hauptmann, the histology of borderline tumors is characterized by the following features: – Epithelial multi-layering of more than 4 cell layers – Not more than 4 mitoses per 10 high-power field (HPF) – Mild nuclear atypia – Increase in nuclear/cytoplasmic ratio – Slight to complex branching of epithelial papillae and pseudopapillae – Epithelial budding and cell detachment into the lumen – No destructive stromal invasion - A major component in differentiating malignant from borderline tumors
- 42. TUMOR STAGING • Comprehensive staging : of significant prognostic value and is performed surgically • Borderline ovarian tumors are staged according to the FIGO classification of ovarian cancer.
- 43. International Federation Of Obstetrics And Gynecology (FIGO) staging FIGO stage Definition I Tumor confined to the ovary II Peritoneal implants within the pelvis III Peritoneal implants beyond the pelvis, Positive lymph nodes, or both IV Liver parenchyma involvement, or tumor beyond the peritoneal cavity
- 44. TREATMENT
- 45. * No further chemotherapy (in all stages.)
Hinweis der Redaktion
- Using these rules the reported sensitivity was 95%, specificity 91%, positive likelihood ratio of 10.37 and negative likelihood ratio of 0.06.
- The morphology index (MI) presently used in the University of Kentucky Ovarian Cancer Screening Trial was published initially by Ueland and colleagues and is illustrated in Figure 49.3. Both morphologic complexity and tumor volume, as calculated by the prolate ellipsoid formula, were related directly to the risk of malignancy Morphologic abnormalities were easy to categorize, and interobserver variation was minimal. Risk of malignancy varied from 0.3% in ovarian tumors with a MI of <5 to 84% in tumors with a MI >=8. Using a MI >=5 as indicative of malignancy, the following statistical parameters were observed: sensitivity 0.981, specificity 0.808, PPV 0.409, and NPV 0.997. Therefore, morphologic indexing is a relatively accurate and cost-effective method to predict risk of malignancy in an ovarian tumor.
- Wenever possible conservative or minimally invasive surgery is preferred to preserve endocrine and reproductive function.
- BOTs form a separate entity within the group of ovarian tumours
- BOTs can be divided according to their epithelial characteristics as serous (50%),mucinous (46%), and mixed, endometrioid, clear cell, or Brenner tumors (3.9%). Serous BOTs are bilateral in 30% of patients and can be associated with extraovarian lesions (so-called implants) in 35%. These implants can be invasive or noninvasive depending on their microscopic appearance, which will in turn influence therapeutic options. Mucinous BOTs are classified as intestinal (85%) or endocervical/Mullerian type (15%) depending on the nature of the epithelial lining. They can be associated with pseudomyxoma peritonei (10%), necessitating a thorough investigation of the GI tract with special attention to the appendix because this can be the primary tumor origin. Presenting symptoms of borderline ovarian tumors Borderline tumors, as with other ovarian tumors, are difficult to detect clinically until they are advanced in size or stage. In one study, the most common presenting symptoms were abdominal pain, increasing girth or abdominal distention, and abdominal mass. Approximately 23% of patients were asymptomatic.
- Without comprehensive surgical staging, the prognosis for an individual patient is difficult to predict. Many clinicians group stages II-IV together for prognostic consideration. Important component is description of the type of implants, as these have significant prognostic value. Preoperatively, borderline tumors are often presumed to be either benign or malignant ovarian masses; however, as with other ovarian masses, staging is performed surgically. Many sources recommend complete staging if a borderline tumor is found. Current guidelines include biopsy specimens of the pelvic peritoneum (cul-de-sac, pelvic wall, and bladder peritoneum), abdominal peritoneum (paracolic gutters and diaphragmatic surfaces), omentum, intestinal serosa and mesentery, and retroperitoneal lymph nodes (pelvic and para-aortic).
- Surgical removal of BOTs is the cornerstone in the management of BOTs, but a lot of debate exists on the extent of the staging procedure and the surgical approach. Lately, the use of laparoscopy and conservative surgery, which is defined as surgery with complete staging but with preservation of the uterus and at least part of one ovary (Fig 1), is gaining popularity. However, the question arises about whether this management is appropriate or whether we should be more cautious.