1. Malignant ovarian tumours
Lectures on Gynecology
Dr Magda Helmi

2. The process of malignant change is associated with reproduction and
ovulation, there are two main theories:
I -Incessant ovulation theory: his relates to
continuous ovulation causing repeated trauma to the
ovarian epithelium leading to genetic mutation and
development of a cancer. This is supported by an
increased incidence of “EOC in nulliparous women,
women with early menarche or late menopause and a
reduction in incidence of EOC in multiparous women
and in women who have used oral contraception.
2 -Excess gonadatrophin secretions: This
promotes higher levels of oestrogen which in turn leads
to epithelial proliferation and malignant transformation
of the ovarian epithelium.

3. Decreased risk of
ovarian cancer
Increased risk of
ovarian cancer
Multiparty Nulliparty
Oral contraceptive
Pill
Intrauterine device
(RR reduced by 20
% per 5 years use)
(RR 1 76)
Tubal Ligation Endometrioses
Hysterectomy Cigarette smoking
(mucinous tumours
only)
Obesity
Risk factors in ovarian cancer

4. Classification of malignant ovarian tumours
1 Epithelial ovarian tumours (80%) Serous
Mucinous
Endometroid
Clear cell
Undifferentiated
2 Sex cord stromal tumours (10%) Granulosa cell
Sertoli-Leydig
Gynandroblastoma
3 Germ cell tumours ( 10%) Dysgerminoma
Endodermal sinus (yolk sac)
Teratoma
Choriocarcinoma
Mixed
4 Metastatic (including Krukenberg tumours)

5. Epithelial tumours of the ovary can be
benign, malignant or borderline.
Approximately 10 per cent of epithelial
tumours are classified as borderline
tumours.
These tumours are well differentiated
with some features of malignancy but are
characterized by not invading the
basement membrane; borderline
tumours can spread to other structures
(peritoneum, omentum) and rarely recur
following initial surgery.

6. Staging of ovarian cancer
Stage Figo definition
I Growth limited to ovaries.
IA Limited to one ovary: no external tumour, capsule intact, no ascites
IB Limited to both ovaries: no external tumour, capsule intact, no ascites
IC Either IB or IB, but tumour on surface of ovary or with capsule ruptured or with ascites positive
for tumour cells
II Growth limited to pelvis
IIA Extension and or metastases to uterus or tubes
IIB Extension to other pelvic organs
IIIC As IIA or IIB, but tumour on surface of ovary or with capsule ruptured or with ascites positive
for tumour cells
III Growth limited to abdominal peritoneum or positive retroperitoneal or inguinallymph nodes
IIIA Tumour grossly limited to pelvis with negative nodes, but histologically confirmed microscopic
peritoneal implants
IIIB Abdominal implants <2 cm in diameter
IIIC Abdominal implants >2 cm diameter or positive retroperitoneal or inguinal lymph nodes
IV Growth involving one or both ovaries with distant metastases, Must have positive cytology on
pleural effusion, liver parenchyma.

7. Epidemiology
Internationally, the incidence is 3.1 cases per 100,000 women
in Japan and 21 cases per 100,000 women in Sweden. Around
the world, more than 200,000 women are estimated to
develop ovarian cancer every year and about 100,000 die
from the disease. Epithelial ovarian cancer occurs most
commonly in white women in the industrialized countries of
northern and western Europe and North America and least
commonly in India and Asia. Asian women have low risk
unless they relocate to North America or Europe.
Scandinavian and Norwegian women have the highest risk.

8. Prognosis
Five-year-survival rate for LMP tumors by FIGO stage (survival percentages
rounded to nearest
for epithelial ovarian carcinoma
by FIGO stage are as
follows:
Stage IA - 87%
Stage IB - 71%
Stage IC - 79%
Stage IIA - 67%
Stage IIB - 55%
Stage IIC - 57%
Stage IIIA - 41%
Stage IIIB - 25%
Stage IIIC - 23%
Stage IV - 11%
Overall survival rate – 46%
For tumors of low malignant
potential by FIGO are as
follows:
Stage IA - 93%
Stage IB - 90%
Stage IC - 91%
Stage IIA - 88%
Stage IIB - 86%
Stage IIC - 100%
Stage IIIA - 29%
Stage IIIB - 75%
Stage IIIC - 62%
Stage IV - 30%
Overall survival rate - 86%

9. Carriers of mutations may be detected through laboratory
analysis of the genetic structure of white blood cells.
Physical findings are uncommon in patients with early
disease. Patients with more advanced disease may
present with ovarian or pelvic mass, ascites, pleural
effusion, or abdominal mass or bowel obstruction.
Tumor marker used in ovarian carcinoma
Tumor
Tumor type Uses
marker
Ca 125 Epithelial ovarian cancer (serous), borderline ovarian
tumours
Pre operative, follow
up
Ca 19-9 Epithelial ovarian cancer (mucinous), borderline ovarian
tumours
Pre operative, follow
up
Inhibin Granulosa cell tumours follow up
B-hCG Dysgerminoma, choriocarcinoma Pre operative, follow
up
AFP Endo dermal yolk sack, teratoma Pre operative, follow
up

10. Risk factors in ovarian cancer
Decreased risk of ovarian
cancer
Increased risk of ovarian cancer
Multiparty Nulliparty
Oral contraceptive Pill Intrauterine device
(RR reduced by 20 % per 5
(RR 1 76)
years use)
Tubal Ligation Endometrioses
Hysterectomy Cigarette smoking (mucinous
tumours only)
Obesity

11. Biopsy
Fine-needle aspiration
(FNA) or
percutaneous biopsy
of an adnexal mass is
not routinely
recommended
Mucinous ovarian carcinoma
Micrograph of serous carcinoma

12. Imaging
Routine imaging is
not required in all
patients in whom
ovarian cancer is
highly suggested.
If diagnostic
uncertainty is
present, a pelvic
ultrasound or CT
scan of the
abdomen and
pelvis is
warranted.
Chest radiographs
are common and
considered routine
MRI can increase
the specificity of
imaging evaluation
in cases where the
ultrasound
appearance of the
lesion is
indeterminate.

13. Surgery
Is the initial treatment of choice,
provided patients are medically fit.
Patients who are not fit for surgery may
be given chemotherapy and considered
for surgery later. The aim of surgery is to
confirm the diagnosis, define the extent
of disease, and resect all visible tumors.

14. Surgical Staging
The staging procedure should
include the following:
•Peritoneal cytology
•Multiple peritoneal biopsies
•Omentectomy
•Pelvic and para-aortic lymph node
sampling.

15. Cytoreductive Surgery
This should be performed by a gynecologic oncologist
at the time of initial laparotomy, Patients with
advanced ovarian cancer are classified in 3 groups as
follows, based on the postoperative residual tumor:
•Good risk - Microscopic disease outside the pelvis
(stage IIIa) or macroscopic disease less than 2 cm
outside the pelvis (stage IIIb)
•Intermediate risk - Macroscopic disease less than 2
cm outside the pelvis only after surgery
•Poor risk - Macroscopic disease more than 2 cm after
surgery or disease outside the peritoneal cavity

16. Interval Debulking
Interval debulking can be
performed in patients who were
not adequately debulked at the
time of initial surgery. It should also
be considered in those patients in
whom an initial debulking surgery
was not attempted.

17. Choosing Appropriate Surgery
Appropriate surgery depends on whether or
not disease is visible outside the ovaries.
Surgery for patients with stage IV disease
should be individualized, particularly when
disease is in the liver and above the
diaphragm. Patients who are in stage IV
because of small-volume disease in the
liver, abdominal wall, or lung should undergo
cytoreductive surgery if medically fit.

18. Laparoscopic Surgery
According to guidelines developed
by the American College of
Obstetricians and Gynecologists,
laparoscopy may be used for
diagnostic purposes in a patient
with low risk for ovarian cancer and
to remove cystic masses. The mass
must be 10 cm or smaller as viewed
by a sonogram

19. Secondary Surgery
Secondary cytoreductive surgery is safe
and effective in patients with platinum-sensitive
recurrent ovarian cancer. The
surgery is most beneficial in patients
who had remained disease free for more
than 24 months after primary treatment
and in those who achieved optimal
cytoreduction.

20. Chemotherapy Regimens
Only a small percentage of women with epithelial ovarian cancer can be
treated with surgery alone. These include patients with stage IA grade 1 and
stage IB grade 1.
Patients not treated with chemotherapy should be monitored closely at
regular intervals, Standard therapy for all patients with advanced disease
following surgery is a taxane/platinum combination, usually carboplatin and
either paclitaxel or docetaxel for a minimum of 6 courses; however, this may
be changing soon. Adding pazopanib, a kinase inhibitor, to the standard
postsurgical chemotherapy regimen has shown promise for progression-free
survival in advanced ovarian cancer.
Patients receiving adjuvant intraperitoneal chemotherapy are more likely to
have recurrences outside the abdominal cavity,
Postoperative chemotherapy is indicated in all patients with ovarian cancer
except those who have surgical-pathologic stage I disease

21. Intraperitoneal chemotherapy
Neoadjuvant chemotherapy
Maintenance chemotherapy
Second-line chemotherapy
Hyperthermic intraperitoneal
chemotherapy
Radiation Therapy.
Estrogen Replacement Therapy
Experimental Medications

22. Epithelial tumors are found
as partially cystic lesions
with solid components. The
surface may be smooth or
covered in papillary
projections (see the image
below), and the cysts
contain fluid ranging from
straw-colored to opaque
brown or hemorrhagic.
Ovarian adenocarcinoma deposit in the mesentery of the small
bowel
and the omentum
An enlarged ovary with a papillary serous carcinoma on the
surface
.