19.ppt十九、卵巢肿瘤

nullOvarian CancerOvarian CancernullcancernullnullnullnullnullIntroduction Introduction Ovarian cancer is the most common cause of death from gynecological malignancy The fifth most common cause of cancer death after breast, lung, colon, and stomach cancer. IntroductionIntroductionApproximately 1 woman in 70 will develop ovarian cancer 1 woman in 100 will die from it. The overall 5-year survival rate is poor, about 30%, primarily due to the late presenting nature of the disease. Incidence is age-relatedIncidence is age-related In woman less than 30 years age, the incidence is 3/100,000; in ages 30-50, 21/100.000; > 50 years, 37/100,000; greater than 60 years, 46/100,000; 75-79,54/100,000. Etiology Etiology Hereditary factors Site-Specific Familial Ovarian Cancer First-degree: mother, sister, daughter 7% lifetime risk Second-degree: grandmother, aunt 5% lifetime risk Breast-Ovarian Cancer Syndrome EtiologyEtiologyMolecular factors P53 gene mutations; X-chromosome inactivation EtiologyEtiologyTalc The use of talc (hydrous magnesium silicates) on the perineum is reported to increase the risk of developing ovarian cancer. EtiologyEtiologyDiet High fat food is associated with an increased risk of ovarian cancer. Japanese woman eats more fish and drink less milk have low risk of ovarian cancer. Do not drink whole milk. Fat free milk EtiologyEtiologyInfertility It is reported that married infertile woman had increased risk for the development of ovarian cancer EtiologyEtiologyPregnancy It is reported that a decreased risk for the development of ovarian cancer is associated with pregnancy EtiologyEtiologyOral contraceptives The data from the Centers for Disease Control showed that 40% reduction in the risk for developing ovarian cancer in woman ages 20-54 that had used oral contraceptives. EtiologyEtiologyTuble ligation In a prospective study of 121,700 female nurses, tubal ligation was found to significantly decrease the risk of developing ovarian cancer. A strong inverse relationship between tubal ligation and ovarian cancer. EtiologyEtiologyFertility drug Clomiphone menotropines There is a very strong association between fertility drug and developing ovarian cancer. Oncogene /cancer suppressor gene Oncogene /cancer suppressor gene OncogeneCancernormalApoptosisSuppressor geneVariety of oncogene and suppressor geneVariety of oncogene and suppressor geneOncogene Suppressor gene ras基因 (细胞的信号传导) p53基因 C-erB-2(细胞增生、分化和凋亡 ) BRCA1基因 bcl-2 (细胞增生、分化和凋亡 ) nm23基因 C-myc Pathological VarietiesPathological Varieties The neoplasms can be grouped under four main types Epithelial Germ Stromal metastaticnullTumors originating in the epitheliumTumors originating in the epitheliumSerous tumor Mucinous tumor Endometrioid tumor Clear cell carcinoma Brenner tumor Serous tumorSerous tumorBenign: Unilocular (single cyst with a smooth lining ); multilocular (several cyst with smooth lining) Have an excellent prognosis, lack of cellular atypia, abnormal nucleocytoplasmic ratio, few mitoses and no evidence of either serous microinvasion or frank invasion into underlying stroma.The most common type of ovarian new growth nullBenign serous tumornullBenign serous tumornullBenign serous tumornullSerous tumorSerous tumorBorderline( Tumor of low malignant potential): Have a good prognosis generally. Characterized by the presence of pseudostratification. Nuclear and cellular atypia, increased mitotic activity and detachment. However, the pathological diagnosis also requires the absence of neoplastic cell invasion of the underlying stroma.nullBorderline Serous tumornullBorderline Serous tumornullBorderline Serous tumorSerous tumorSerous tumorMalignant: Have an extremely poor prognosis if disseminated from the primary site. The primary tumor frequently contain the solid regions of malignant tissue which grow rapidly and often exhibit hemorrhagic and necrotic regions. Nuclear and cellular atypia, a high nucleocytoplasmic ratio, a frequent mitoses. There is, however, destructive invasion of the underlying stroma by the malignant adenocarcinoma cells. One third of all serous tumors are malignant, and serous adenocarconoma account for just under half of all epithelial ovarian cancer. nullMalignant serous tumornullMalignant serous tumornullMalignant serous tumor   Mucinous tumor   Mucinous tumorThe common type of ovarian tumor Benign: most are multilocular, being composed of several cysts. Sometime the huge mucinous tumor can be found, if left untreated. nullBenign Mucinous tumornullBenign Mucinous tumornullBenign Mucinous tumornull   Mucinous tumor   Mucinous tumorBorderline: Same as serous tumor. Mucinous LMP tumors are less common than serous LMPs and may be difficult to distinguish from malignant tumor. nullBorderline mucinous tumornullMucinous tumorMucinous tumorMalignant: Both serous and mucinous are called epithelial ovarian cancer. About 5% of ovarian cancer are classified as mucinous. One fifth of all mucinous tumor are malignant. nullnullEndometrioid tumor Endometrioid tumor A few cases of tumor arising in endomeriosis of ovarian, but this are very rare . A much more common tumor arises from the surface epithelium of the ovary, quite like the tumor of uterine endometrium. Endometrioid tumors are malignant and account for about 15% of all EOCs. nullEndometrioid tumornullEndometrioid tumornullClear cell carcinomaClear cell carcinoma Clear cell carcinoma are uncommon (6% of EOCs) and so-called because of the appearance of the cytoplasm after removal of the abundant cytoplasmic glycogen during the specimem preparation process. nullClear cell carcinoma Brenner tumor Brenner tumor Brenner tumors have the gross apprearance of white, fibrous tumor similar to a fibroma nullBrenner tumorSex cord stromal tumor Sex cord stromal tumor Represent 8% of all ovarian tumors and the third most common type of ovarian tumor after epithelial and germ cell tumors. Arise from the specialized gonadal stroma (sex cords) or from the nonspecific measenchyme of the genital ridge itself. 70% of patients present with stage I disease.Sex cord stromal tumorSex cord stromal tumor1)    Granulosa –stromal cell tumor a. Granulosa cell tumor b. Thecoma/fibroma Thecoma Fibroma 2)    Sertoli-stromal tumor 3)    Gynandroblastoma nullnullnullnullnullnullnullnullGerm cell tumor Germ cell tumor Account for approximately 20% of all ovarian neoplasms. 1)  Dysgerminoma 2)  Endodermal sinus tumor (Yolk sac tumor) 3)  Teratoma 4)  Embryonal tumor 5)  Polyembryoma 6)  Choriocarcinoma 7)  Mixed germ cell tumornullDysgerminomanullnullEndodermal sinus tumornullMatrue teratomanullnullMatrue teratomanullMatrue teratomanullnullnullMatrue teratomanullTeratocarcinomanullnullnullnullMixed germ cell tumorMetastatic tumorsMetastatic tumors Breast tumor Endometrial cancer Krukenberg tumor: Usually arising from in the stomach or colon, both ovaries are always involved. nullnullnullnullThe metastatic ways of ovarian cancer The metastatic ways of ovarian cancer 1. Invasion directly: via direct continuity to pelvic and abdominal peritoneal structures by seeding from primary tumor 2. Metastasis by lymphotube: via lymphatic dissemination from the lymphatics to the pelvic lymph nodes The metastatic ways of ovarian cancer The metastatic ways of ovarian cancer 3. Metastasis by blood vessel: via dissemination from the lymphatic along the ovarian vessels to the para-aortic lymph nodes in the region of the renal vessels . Hematogenous spread is rare and thus distant metastasis to the lung, kidney, bone, and liver is rare. nullnullnullMetastasisnullnullnullnullHistological gradeHistological grade Grade I : Well differentiation Grade II: middle differentiation Grade III: Badly differentiation Symptoms and Physical Findings Symptoms and Physical Findings Symptoms: Because ovarian cancer is often asymtomatic in its earliest stages over 70% of woman present with widespread (stage III and IV) disease at the time of Diagnosis. Symptom do not occur until the ovarian mass begin to encroach on other viscera or there is intra-abdominal spread discomfort, abdominal swelling, most often secondary to ascites and spread to the omentum. Pelvic discomfort, low back pain, and vaginal bleeding may also be noted and usually occur after these initial symptoms.Physical Findings:Physical Findings:pay attention when ovarian is measured more over 5 cm by examination, especially in woman over 40 years of age, further evaluation is necessary. Sometime a functional ovarian cyst (follicular or corpus luteum cyst) unless it has benign characteristics: smooth, cystic , mobile, unilateral, no larger than 5-7 cm in diameter, persists for less than 4-6 weeks, occurs during reproductive years, and is primarily cystic on ultrasonic examination . Physical Findings:Physical Findings: Since only 5% of benign tumors are bilateral at initial presentation, compared with 25% of malignant tumor, the presence of bilateral ovarian masses, even in the young age group, requires immediate evaluation to rule out ovarian cancer. Ascites and nodularit of the rectovaginal septun may be present with malignant tumors. Diagnosis and ScreeningDiagnosis and Screening1. Cytological examination: Vaginal- cervical cells collection: ascite cytological examination 2. Ultrasonographic finding: solid/ cyst ; limited/ extension. ascit/no ascit Non specific sign Age; History; local sign.nullDiagnosis and ScreeningDiagnosis and Screening 3. Computed tomography (CT) 4. Laparoscopy: are able to see directly ; pelvis washing; biopsy 5. Tumor marker: CA125 (EOCs); AFP (endodermal sinus tumor) ; -HCG (choriocarcinoma) nullDifferential diagnosisDifferential diagnosis Benign Malignant History Long term; short term Growth slowly growth fast Physical sign unilateral ; bilateral; non-movable; movable Cyst; solid; smooth surface nodal surface; Non ascit Ascit positive General condition all right weakly; cachexia Ultrasonography cyst; limited solid; extension invasion Treatment Treatment Surgery Benign: surgical remove with short term monitor   Borderline: IA without child – one side appendix remove. Pelvic washing. Multiple biopsies if necessary IA with child or old woman and IB and IC-complete hystereatomy+ both side appendix remove + omentumsection II, III, IV Cytoreductive surgeryTreatmentTreatmentMalignant: Unilateral appendix section: Young without child IA Grade I Opposite ovary looks normal biopsy negative Pelvic washing negative   Other stage: complete hystereatomy+ both side appendix remove + omentumsection + pelvic lymph nodes and remove or cytoreductive surgeryChemotherapyChemotherapyResults before the discovery of Cisplatin   Five-and Ten-year survival using cisplatin-based chemotherapy   Taxol as first-line chemotherapy   Second –look laparotomy/laparoscopeRadiation nullhealthyhappiness