1. Dr M.C.Bansal
Ovarian Malignancy
MBBS.,MS.FICOG.MICOG.

2. Epidemology
2nd most common of all genital cancers , accounts for 10-15 %
incidence.
In last 2 decades its incidence as well as survival rate has increased.
The risk of woman developing ovarian cancer in her life time is 1:70
to 1: 100.
Women with low parity, infertility and delayed child bearing
predisposes higher chances.
5-10% ovarian tumors are genaticaly affected ---BRACE_1&@
mutations on chromosome 17 & 13 respectively . if one family
member is affected, the life long risk is 2.7% but it goer up to 13%
with2 or more sibblings. They develop at earlier age < 40 years.
. Inheritance pattern is autosomal dominant. The risk increases with
advancing age up to 70 years.
Induction of ovulation, industrial pollution, talc use at perineum, High
dietary fat , western world have increased incidences
streak ovaries, mums infection at puberty leading to premature
ovarian failure.

3. Epidemology----
Protective factors Multiparity , ocs ,Breast feeding
,anovulation ,Prophylactic oopherectomy.
Late diagnosis and early metastasis are responsible for
poor prognosis.
80% malignancies are of epithelial origion,.almost 80%
report in late stage iii or iv .
80% are primary carcinoma.
20% are secondary form.
Before menarche 10% are malignant.
During reproductive period15% are malignant., but rises
to > 50% after menopause.

4. Pathology
• Epitehelial ovarian carcinoma---80-90%
Papillary cystadenocarcinoma
Mucinous cystadenocarcnoma
• Nonepethelial carcinoma---10-20% these
include malignancy of (A) Germcells (2)Sex
cord stromal(3)Metastatic (4) Rare malignancy
like Sarcoma, lipoid cell carcinoma.

5. Coincidence of uterine and ovarian
cancer
• In some cases primary lies in uterus and direct spread to
ovaries
• Primary in ovary and secondaries in uterus.
• Estrogen / and progesteron producing tumor of ovary and
primary cancer endometrium.
• Cancer present in uterus and cancer in ovary are histologicaly
different.
• Theerfore extended hysterectomy along with bilateral
oopherectomy should always be done in either case’

6. Spread
• Lymphatic--- Para -aortic Lymph Nodes and
superior gastric , mediastinal---pleural effusion
, supra-clavicular.
• Blood spread---uncommon---lungs
• Direct spread through peritoneum----Rupture
capsule—exfoliation of malignant
cells, peritoneal irritation---ascites, omental
cake., intestine, parietal, visceral peritoneum--
-- liver spleen, dome of
diaphragm, uterus, tubes.

7. STAGING CARCINOMA OVAARY FIGO

8. STAGING CARCINOMA OVAARY FIGO

9. FIGO STAGING OVARIAN CANCERS

10. FIGO STAGING OVARIAN CANCERS

11. OMENTAL CAKING AT STAGING LAPROTOMY

16. Management
• Laparotomy and maximal removal of cancer tissue----intra
operative staging, cytology of ascitic fluid, pan
hysterectomy, partial or complete omantectomy, enucleation
of cancer growth on parietal and visceral peritoneum with out
perforating the viscera.
• If non operable---intra peritoneal instillation of radioisotopes
(p34)or chemotherapeutic agent.
• Chemotherapy---followed by second look laparotomy to
remove uterus ,ovaries ,omantum and any residual cancer
tissue.
• Radiotherapy for nodal metastasis.
• Stem cell Therapy.
• Immunotherapy.
• Palliative therapy –to relieve pain(opiates/NSAIDs, nutritional
supplimentaton(callories, proteins to keep Hb > 10 gm% and
wt loss < 10 %), psychological support , symptomatic

21. Role of Laparoscopy in the Clinical Management of Ovarian
Cancer
At present, the role of laparoscopy in the management of
ovarian cancer is evolving. There are several clinical settings
in which the potential for this surgical modality has been
investigated
(a) primary surgery for early-stage ovarian cancer
(b) restaging of unstaged ovarian cancer
(c) primary cytoreductive surgery for advanced-stage ovarian
cancer
(d) assessment of resectability
(e) intra-peritoneal catheter placement
(f) second-look surgery
(g) secondary cytoreductive surgery.

22. STRATEGIES TO REDUCE THE INCIDENCE OF GENITAL TRACT
MALIGNANCIES
• First injection at elected time.
• Second injection 2 months later.
• Third injection 6 months after the first injection.
• The cost of each injection is $200, and immunity is expected to last 5 years.
The only benefit as seen today is a longer interval of screening in HPV-
negative women. page 429 page 430 There have been advances in strategies
evolved to reduce the incidence of genital cancers. The following are
notable amongst these: 1. The role and value of periodic 'Pap smear' tests is
well-established in reducing the incidence of invasive carcinoma of the
cervix.
• 2. Evaluation of abnormal Pap tests with colposcopy-directed biopsies has
enabled the diagnosis of intraepithelial cancers and diagnosis of early
invasive cancer of the cervix.

23. • 3. The practice of preferring total over subtotal
hysterectomy for benign diseases
(fibroids, adenomyosis, dysfunctional uterine bleeding-
DUB) protects against risk of future cervical stump
carcinoma estimated to occur in 2% of cases.
• 4. Early diagnosis of sexually transmitted diseases (STDs)
and their eradication. Herpes and HPV infections render
an individual prone to cancer of vulva and the cervix.
Barrier contraceptives protect against STD as well as
cervical cancer.
• 5. HPV vaccine is now available which may eradicate
lower genital tract malignancies in young women. The
available vaccine is type specific and therefore protective
in only 60-70%.
• 6. The treatment of cervical dysplasia by CO2
laser/conization for CIN lesions.

24. • 7. Addition of progestogens to oestrogens in
hormone replacement therapy (HRT) reduces the
risks of uterine endometrial cancer.
• 8. Thorough investigation of a woman with
postmenopausal bleeding often brings to light
early unsuspected endometrial/ovarian/tubal
cancers.
• 9. The practice of routine removal of both ovaries
when performing hysterectomy for benign
conditions after the age of 50 years is a
prophylaxis against risk of future ovarian cancer.
Prophylactic oophorectomy in a genetically
predisposed woman is recommended, though
premature menopause remains a risk. This also
reduces breast cancer by 50%.

25. • 10. Early diagnosis of ovarian cancer is the
primary objective for long-term survival, though
this is not obtained as of today. Seventy-five per
cent tumours are advanced when diagnosed.
• 11. Oral combined pills reduce the incidence of
uterine and ovarian cancer by 40-50%. Barrier
contraceptives prevent cervical cancer.
• 12. Gene study can select women at high risk
for cancer.

26. • 13. Evaluation of adnexal masses with
scans, Doppler velocimetric studies, and CA-125
tumour marker to diagnose ovarian cancer.
• 14. Hysteroscopy/laparoscopy/selective biopsies of
suspicious lesions.
• 15. Routine mammography for all women over the
age of 40 years, earlier whenever clinical
examination reveals a doubtful lump, or in women
with strong family history of breast cancer.
• For many women the obstetrician-gynaecologist is
likely to be the only physician to provide them
healthcare. Hence the importance of developing
skills for evaluation and counselling for genital
cancers and adopting clinical practices which
reduce the future risks of genital cancers lies with
the gynaecologists.

27. KEY POINTS
• Vulval intraepithelial neoplasia (VIN) is a well-recognized
entity which can be effectively treated by conservative
surgery.
• Vulval cancer, mostly squamous cell carcinoma, is
encountered in 2-4% of all genital tract malignancies. An
elderly woman of low parity and associated with previous STD
is the high-risk case.
• The treatment of vulval cancer is based on the age of the
woman, type and extent of the lesion and involvement of the
regional lymph nodes. Local wide excision, skinning
vulvectomy with split skin graft, laser therapy and simple or
radical vulvectomy have improved the survival rate without
increasing the surgical morbidity.

28. • Endometrial cancer is the disease of the perimenopausal and
postmenopausal women with low parity.
• Endometrial cancer is fast becoming the more common
cancer in women. Early menarche, late menopause, small
family size, obesity, carbohydrate intolerance, PCOD-related
infertility and unsupervised HRT in menopausal women
contribute to its occurrence.
• Oestrogen therapy, tamoxifen cause hyperplasia and
endometrial cancer over a period of time. Oral combined pills
have a protective effect and reduce the incidence by 40-50%.

29. • CT and MRI help in preoperative staging and determine the
extent of spread of malignancy. Hysteroscopic evaluation and
biopsy improve the diagnostic accuracy.
• Abdominal hysterectomy with bilateral salpingo-
oophorectomy, peritoneal washing and omental biopsy form
the primary surgical therapy in early stages.
• Radiotherapy and chemotherapy are recommended in the
advanced stage of the disease and are also adjuvants to
surgery.

30. • Progestogens are beneficial in advanced stages of endometrial
cancer and pulmonary metastasis.
• Carcinoma of the cervix is the most common genital tract
cancer in women and ranks second to the breast cancer. It
occurs in younger women.
• Late marriage, contraception, small family size, improved
personal hygiene, avoidance of extramarital relationships and
regular gynaecological check-ups inclusive of a Pap test and
colposcopy have contributed to the lowering of its incidence.
• Endometrial cancer developing in a woman following
unopposed oestrogen uptake is well-differentiated and less
invasive with better prognosis. It also responds well to
progestogens.

31. • Endocervical cancer has different aetiology and requires
chemotherapy with radiotherapy, followed by radical
surgery.
• Fallopian tube cancer is rare, and is often mistaken for
ovarian cancer. It is treated the same way as ovarian cancer.
• Ovarian cancer is the second most common genital cancer.
It remains asymptomatic for a long time. Many cases are
already far advanced at the time of diagnosis. Germ cell
tumours and mesenchymomas are known to occur in
younger women. Epithelial tumours occur in older women.
Surgical removal is adequate treatment for cases of
borderline malignancy. Surgery followed by chemotherapy
is indicated in advanced cases.
• The gold standard is abdominal hysterectomy and bilateral
salpingo-oophorectomy with omentectomy in the early and
operative cases of ovarian cancer. Debulking, radiotherapy
and chemotherapy prolong life and duration of remission.