1. Ovarian Carcinoma
Khalid Sait
Professor of Obstetrics and
Gynecology and Gynecological
oncology
Faculty of Medicine
King Abdulaziz University

2. QUESTIONS
• DIFFERNTIAL DIAGNOSIS OF ADNEXIAL MASS
• CLASSIFICATION OF OVARIAN MASS
• TUMOUR MARKER IN EACH CANCER
• PATHOGNOMIC FEATURE OF EACH TUMOUR
• INVESTIGATION AND MANAGEMENT OF OVARIAN
MASS
• OVARIAN CANCER ACCORDING TO AGE GROUP
• RISK FACTOR AND PREVENTION AND SCREENING
• STAGING
• TYPE OF CHEMOTHERAPY USE IN DIFF. OVARIAN
CANCER

3. Pelvic mass before puberty
• Newborn
Functional ovarian cyst
• Children
Ovarian germ cell tumour
Wilm’s tumor
neuroblastoma
lymphoma
other ( GI, musculoskeletal)

4. Pelvic mass in the young women
• Congenital anomalies such as imporferated
hymen and blind uterine horn to be considered
in adolescents
• Common causes of adnexial mass
functional cyst
PID(toa …)
choclet cyst
• Germ cell tumors

5. Pelvic mass in the peri/post
menopausal women
• Neoplasm ( benign and malignant )

6. Ovarian Mass
• Pathologic behavior :
Non neoplastic
Neoplastic
– (benign,malign, borderline).
• Morphology(cystic,solid).
• Histogenesis.

7. Ovarian Mass
Neoplastic
Epithelial T
Germ cell T.
Sex cord T.
Stromal T.
Others( Metastatic….)
Non neoplastic
Physiological:
Lutein cysts.
Follicular cysts.
Endometrial cysts:
endometriosis
Inflammatory

9. Evaluation of Ovarian Mass
• Preoperative assessment:
History
Physical Examination
Tumour markers
Ultrasound
• Intra-operative assessment

12. Lab evaluation
• Young patients with large complex or solid
masses: CA 125-LDH-AFP-HCG
• Peri/post menpousal women: CA 125 –
CEA
• Other marker : testosterone, estriol and
inhibin A

13. CA 125
• Correlates with stage of disease
Increase 90 % - Stage II,III,IV
Increase 50 % - Stage I

14. CA-125
Malignant conditions
• Cervical CA
• Fallopian tube CA
• Endometrial CA
• Pancreatic CA
• Colon CA
• Breast CA
• Lymphoma
• Mesothelioma
Benign conditions
• Endometriosis/
Menses
• Uterine fibroids
• PID
• Pregnancy
• Diverticulitis
• Pancreatitis
• Liver disease
• Renal failure
• Appendicitis

16. Sonographic parameters
Risk of
malignancy
Lower Higher
Tumour size <10cm >=10 cm
Septae Absent or thin
(1-2 mm)
Thick
Number of loculi unilocular Multilocular
Over all echo
density*
Hypo-echogenic
homogenous
Increased and /
or mixed and / or
solid component
Papillary
excrescences
absent present
* Excludes dermoid cyst/endometrioma

17. ROMA and RMI
Risk of Ovarian Malignancy Algorithm
CA 125 + HE4+Menopausal status
Risk of Malignancy Index
CA 125 + US+ Menopausal status

18. Evaluation of Ovarian Mass
• Preoperative assessment:
History
Physical Examination
Tumour markers
Ultrasound
• Intra-operative assessment

19. AIDA Storz

20. complications of benign ov Tumours
• torsion
• hemorrhage
• rupture
• infection
• incarceration
• malignant change
• complications during pregnancy

21. Clinical picture cancer ovary
Benign ovarian Tumours + The following suggest
malignancy
• age:mostly postmenopausal
• pain: chronic and persistent
• rapid course
• bilaterality
• Solidity ( variegated consistency )
• fixity
• metastases :nodules in DP, lymph nodes
• ascitis
• edema LL
• cachexia

29. Epidemiology
• 23,000 cases annually
• 15,900 deaths annually
• 4th common cause of cancer mortality
• Most (70%) diagnosed at advanced stage where
cure is uncommon.

30. TEN LEADING CANCER SITES IN
WOMEN

31. Patterns of spread
• Direct extension
• Exfoliation of clonogenic cells
• Lymphatic spread

32. Risk Factors
• Any age ( common >40ys) .
• Nulliparous.
• Late age 1st preg
• History of breast or colon cancer.
• Gonadal Dysgenesis
• Talcum powder
– Increased risk in women who use talc powder on
genital area

33. Risk Factors
• M.H:
– Early menarche.
– Late menopause
– prolonged use of fertility drugs without achieving
pregnancy
– Uninterrupted ovulation.
• F.H
– Mother, sister or daughter with ovarian
cancer.
– BRCA

34. Protective factors
• Multiparity: First pregnancy before age 30
• Oral contraceptives.
• Hysterectomy
• Lactation
• Bilateral oopherectomy

35. • Screening
( Early diagnosis)
• GENETIC TESTING

36. Treatment
• Depends on
– Staging
– Tumor type
– Age
– Desire for future fertility
• Include surgery, chemotherapy

37. Approach
When approaching an adnexal mass, there
are 2 important questions:
• Does this mass need to be
removed or can it be observed?
• What are the chances of cancer?

38. Principle of surgical management
• Prepare the patient for the appropriate
surgery ( GI preparation …..)
• Avoid intraoperative rupture of the cyst
• Obtain frozen section if suspecious
• Try to do the necessary procedure in one
setting
• Try to preserve fertility and ovarian
function in young patient

39. Guideline
EORTIC, NCCN, NIH, SGO
• The more localized the disease appear ,
the more extensive the assessment should
be( STAGING)
Level II-3 A
• Optimal debulking for advance stage
provide a median survival benefit
Level II-b

44. Ovarian Ca - advanced disease
Optimal Residual Disease
better prognosis
no
residual
tumor
<0.5 cm
0.5 - 1.5 cm
CORRELATES

45. Ovarian Cancer Staging
• Stage 1
– 1A: One ovary
– 1B: Both ovaries
– 1C: with malignant
ascites, rupture surface
tumor

46. Ovarian Cancer Staging
• Stage 2
– 2A: Reproductive organs
– 2B: Other pelvic organs
– 2C: with malignant ascites or washings

47. Ovarian Cancer Staging
• Stage 3
– 3A: microscopic upper abdominal disease
– 3B: upper abdominal metastasis less than 2
centimeters
– 3C: upper abdominal metastasis greater than
2 centimeters

48. Ovarian Cancer Staging
• Stage 4 is disease outside the peritoneal
cavity
– Liver parenchymal metastasis.
– Pleural effusion
– Supraclavicular nodes

49. Rationale of debulking
• Goldie-Coldman hypothesis

50. Adjuvant chemotherapy
• Carboplatin (Calvert AUC =
6-7)
• Taxol (175 mg/m2)
• x6 courses q3 weeks

51. Serous Tumors
• Bilateral (30-66%).

52. § The commenst
cystic benign
ovarian tumor is
cystadenoma.
§ The commenst
ovarian carcinoma
is papillary serous
cystoadenocarcino
ma.

53. Mucinous Tumors:
• very large.
• Pseudomyxoma
peritonei.

57. Germ cell tumour

58. Germ cell tumors
classification:
– benign: Teratoma ( mature),
– malignant: Dysgerminoma, endodermal sinus t. immature
teratoma, embryomal, choricarcinoma ? gonadoblastoma

59. ( Tumor marker)
• LDH: dysgerminoma
• AFP : endodermal sinus tumor
• HCG : choriocarcinoma, embryonal
carcinoma

60. Cystic Teratoma

62. Dysgerminoma
• The most-common
malignant germ cell tumor
• 5% dysgenetic gonad
• Significant rate of
bilaterality
• Radiation therapy; very
sensitive

63. Immature Teratoma
• The second most common GCT
• Contains elements that resemble tissues
derived from the embryo.

64. Endodermal sinus tumor
• Secrete AFP
• Hobnail bodies

65. Chemotherapy. BEP
• Cisplatin : 100mg/m i.v d1
• Bleomycin : 10-15mg d1-3(24h inf)
• Etoposide : 100mg/m i.v d1-3

67. SEX CORD-STROMAL
TUMORS( SCTS)

68. Granulosa Cell Tumor:

69. Sertoli lydig cell tumour
• Testestrone secreted

71. Metastatic Tumors of Ovary

72. Krukenberg
Tumor:

73. Thanks
• www.jcsp.sa.com
• www.cabwt.kau.edu.sa