Ovarian Neoplasms

Ovarian Neoplasms Ovarian cancer is most common gynae malignancy Peak age 75 yrs, 5 yr survival approx 25% Risk Factors Nulliparous – higher parity = decreased risk HRT - risk not proven Repeated ovulation – supported by child bearing & COCP being protective Genetic – if early onset or more than 1 affected 1st degree relative (linked to BRCA genes) Protective factors Oral contraceptive – reduce risk as reduce ovulation Pelvic surgery – hysterectomy, unilateral oophorectomy & sterilisation reduce risk Epithelial = 70% Serous – 50% of ovarian cancers, mainly reproductive age. Serous cystadenoma = usually unilocular cysts filled with straw coloured fluid & variable size, may have solid components Mucinous – 20% of ovarian cancers (< 10% are malignant). Largest of epithelial tumours. Usually multiloculated & contain mucinous fluid of variable viscosity – gelatinous tumour Endometroid – uncommon, usually malignant, closely mimic endometrial cancer (histologically) Clear cell tumours – uncommon, virtually all malignant, often found in association with endometriosis Urothelial like tumours – uncommon, rarely malignant, have urothelial like stroma Germ cell = 20-25% - mainly children & young women Dysgerminoma – most common malignant germ cell tumour but only 3% of ovarian cancers. 75% in 10-30yrs. May be elevated hCG Endodermal sinus / yolk sac – 2nd most common malignant germ cell, <1% of ovarian cancer. Median age = 19, rare > 40yrs. Sudden onset pelvic symptoms & pelvic mass. Elevated AFP with normal HCG. Can coexist with teratoma Choricarcinoma – secrete hCG. Can present with precocious pseudopuberty. Poor progonosis & don’t respond well to chemotherapy Teratoma – 20% of ovarian neoplasms (50% in under 20s). Components from all 3 germ layers. Contain epithelium, hair, teeth & greasy sebum. Malignant change is rare Sex cord/stromal = 5% Granulosa cell – low grade, approx 5% ovarian malignancy. ¾ secrete sex hormones may à precocious pseudopubery, irregular menstrual bleeding or post menopausal bleeding. Can be monitored by serum oestrodiol Thecoma/fibroma – rare, usually unilateral and rarely malignant. Some are oestrogenic, may cause non malignant ascites Sertoli/leydig cell – rarest of ovarian tumours, occur in young women (mid 20s), commonly androgenic Metastatic = common Endometrial & Breast spread is common. Cervical is rare. Can get spread from GI tract à krukenberg tumour (adenocarcinoma). Spread Mainly via peritoneal cavity à intestinal obstruction à cachexia Can get intrahepatic mets & malignant pleural effusions Presentation Incidental - Can be during pregnancy USS or abdo papation Often present late due to features of mets – pain, abdo swelling, anorexa, N&V, weight loss, abnormal bleeding, change in bladder/bowel habit Investigation & Staging Usually laparotomy & biopsy (check serum markers (80% have increased CA125) & IVU before) Staging by FIGO. 1A – confined to one ovary 1B – confined to both ovaries 1C – confined to ovaries but expressed on sersosal surface or malignant cells in ascities/washings 2 – extension to pelvic organs 3 – confined to peritoneal cavity / lymph nodes 4 – outside peritoneal cavity or LN Usually don’t present until stage 3 or worse 30% 5 yr survival Treatment Benign – excision / drainage by laparoscopy. Epithelial – radical surgical debulking fb platinum based chemo (+ taxanes) Non epithelial – limited surgery & chemo are very effective Recurrent disease – chemo, repeated surgery etc are possible