卵巢肿瘤 英文ppt课件.ppt

1,Obstetrics &Gynecology Hospital Fudan University,Ovarian Neoplasm卵巢肿瘤,What is ovarian neoplasm?,2,One single disease or a group of diseases?A group of diseasesBenign or malignant disease?Benign, borderline and malignantCancer or sarcoma?Cancer, sarcoma, germ cell tumor ,3,What we are going to discussGeneral principles of ovarian neoplasmBenign 良性Malignant 恶性Epithelial ovarian neoplasm 上皮性卵巢肿瘤Nonepithelial ovarian neoplasm 非上皮性,4,Key points in the sessionPathological classification of ovarian tumorSpread pattern and staging of ovarian cancer Differential diagnosis of benign and malignant ovarian neoplasmThe use of tumor markers in diagnosis of ovarian neoplasm Principles of primary operation and chemotherapy for ovarian cancer,What is ovarian neoplasm?,5,Female Reproductive Anatomy,7,What is ovarian neoplasm?,Epithelial tumor50-70%上皮性肿瘤,Germ cell tumor20-40%生殖细胞肿瘤,Sex cord-stromal tumor5%性索间质肿瘤,Metastatic tumor5-10%转移性肿瘤Krukenberg tumor (库肯勃瘤）,8,Brief descriptionBenign-borderline-malignantEpithelial neoplasm is the most common typeMostly sporadic, 5-10% hereditary for malignanciesHard to be detected in early stage, often advanced when symptom appearedOperations is the most effective treatmentChemotherapy greatly improved prognosis of ovarian cancerAll germ cell tumor can be treated with fertility preserving surgery,9,EpidemiologyAlmost 1/3 of invasive malignancies of the female genital organsThe fifth most common cause of death from malignancy in women.A womans risk at birth of having ovarian cancer sometime in her life is 1% to 1.5%, and that of dying from ovarian cancer almost 0.5%5 year survival rate : 90% for malignant germ cell tumor; 30-40% for epithelial ovarian cancer,10,Age distribution of ovarian neoplasm,Epithelial ovarian neoplasm50-60 y绝经后妇女 Germ cell neoplasmUnder 30 y育龄年轻妇女,Epithelial ovarian cancer,Epithelial ovarian neoplasm上皮性卵巢肿瘤,11,Etiology & Risk factors -Epithelial ovarian cancer,12,Most benign and malignant ovarian neoplasms are sporadic, with familial or hereditary patterns accounting for 5% to 10% of all epithelial ovarian cancer.,Etiology & Risk factors -Epithelial ovarian cancer,13,Sporadic ovarian cancer 散发性卵巢癌Continuous ovulation 持续排卵Early menarche and late menopauseLow parity and infertilityDamage repair process leading to mutation EnvironmentPollution Diet,Etiology & Risk factors -Epithelial ovarian cancer,14,Risk factorsLate parity (35y) InfetilityOld age 50-60yOvulation for more than 40 Protective factorsEarly parity (25y)Oral contraceptive pills OCP,Etiology & Risk factors -Epithelial ovarian cancer,15,Hereditary ovarian cancer 遗传性卵巢癌Hereditary ovarian cancer 5-10% BRCA1, BRCA2 mutation (ovarian and breast cancer)Hereditary non-polyposis colorectal cancer遗传性非息肉性结直肠癌 (HNPCC) Syndrome (Lynch II syndrome) (multiple site adenocarcinoma),Etiology & Risk factors -Epithelial ovarian cancer,16,Hereditary ovarian cancerBRCA1 gene mutation + high-risk families= 28% to 44% lifetime risk of ovarian cancerBRCA2 gene mutation + high-risk families= 27% lifetime risk of ovarian cancer BRCA1 or BRCA2 mutation= 56% to 87% risk of breast cancerHereditary ovarian cancers occur 10 years younger than those with nonhereditary tumors,17,Epithelial ovarian neoplasm,Others,High Grade Serous HGSC 高级别浆液性,endosalpingeal,endocervical,endometrial,mullerian,Clear cellCCC 透明细胞,EndometriodEC 内膜样,MucinousMC黏液性,Low Grade SerousLGSC 低级别浆液性,Faloopian tube origin,Epithelial ovarian neoplams,18,Endometrioid tumor 内膜样肿瘤ovarian endometriosisEndometriod carcinoma 内膜样癌15-20%Complicated with endometrial cancer,Epithelial ovarian neoplasm,19,Serous cystadenoma浆液性囊腺瘤,Borderline serous cystademona,Serous cystadenocarcinoma浆液性囊腺癌,Epithelial ovarian neoplasm,20,Mucinous cystadenoma黏液性囊腺瘤,Borderline mucinous cystadenoma,Mucinous cystadenocarcinoma黏液性囊腺癌,Epithelial ovarian neoplasm,21,Benign ovarian tumorUnilateralBall-like with smooth wallSingle or multiple fociBorderline ovarian tumorlow malignant potentialaverage age is 46 years for borderline tumorslesions tend to remain confined to the ovary for long periodsoccur predominantly in premenopausal womengood prognosisMalignant ovarian tumorPeak incidence 56 to 60 years 30% of ovarian neoplasms in postmenopausal women are malignant,22,Transcelomic 腹腔内扩散The most common and earliest mode of dissemination is by exfoliation of cells then implant along the surfaces of the peritoneal cavity.Lymphatic 经淋巴转移retroperitoneal ( pelvic and paraaortic ) LN spreading is common in advanced- stage disease. Hematogenous 血行转移uncommon, lungs and liver is the most common sites,Pattern of spread,23,24,Omental Cake,Symptoms-nonspecific 非特异症状,25,Benign and early stage malignancyAlways found during physical examination when the mass is smallBenign and Early stage-vague and nonspecific symptomsOvary dysfunction - irregular menses Mass occupation- Lower abdominal distention, pressure, or painMass compression - urinary frequency or constipation, dyspareuniaAcute symptoms - pain secondary to rupture or torsion,Symptoms,26,Advanced-stage malignancyAscites or mass occupation, omental /bowel metastases abdominal distention, bloatingGI symptoms: constipation, nausea, anorexia 厌食, or early satiety 早饱Cachexia 恶病质irregular or heavy menses,Signs,27,BenignPelvic mass with smooth wallMalignantsolid, irregular, fixed pelvic mass Pelvic floor nodules upper abdominal mass or ascites,Diagnosis,28,HistoryPhysical examinationImaging studyLaboratory examinationCytological examinationLaparoscopic examination and biopsyOther auxiliary examination needed,Diagnosis,29,Use of oral contraceptivesPregnancy and breast-feeding historyPrevious gynecologic surgery : tubal ligation or hysterectomy History of ovarian tumor in the familyPrevious cancer history smoking habits exposures to harmful occupational or environmental substances,History,30,Pelvic examination,If the mass is larger than 5cm, is solid rather than cystic, or is bilateral , ovarian cancer may be present.Nodules on the floor of the pelvis indicate ovarian cancer.,benign,Malignant,Diagnosis,31,Image studies,Ultrasonography-most ovarian mass1cm can be foundlow resistance and pulsatile indexes suggest the presence of a cancerous tumor.X-rayCT scanMRI,benign,malignant,Diagnosis,32,Laboratory Tests Serum tumor markersCA125; HE4 epithelial ovarian cancerAFP Yolk sac tumor; other germ cell tumorhCG ovarian choriocarcinomaSex hormones sex cord stromal tumor Tests for genetic mutations Microscopic examination of ovarian cancer cells from ascites or pleural effusion,Diagnosis,33,CA125-epithelial cancer marker 85% of women with clinically apparent ovarian cancer have increased levels of CA125 ( 35 U/ml).CA125 is not a specific tumor markeras the protein also is increased during other conditionsSome ovarian cancers may not produce enough CA125 to cause a positive test result,Diagnosis,Differential diagnosis,34,35,Benign ovarian tumorPhysilogical ovarian cyst: follicular cyst; corpus luteum cyst Inflammatory cystUterine myomapregnancyAscites,Differential diagnosis,Differential diagnosis,36,Malignant ovarian neoplasmsEndometriosisTuberculous peritonitis Chronic pelvic inflammatory diseaseMetastatic ovarian tumor (Krukenberg tumor)哑铃状Tumor from other pelvic organs,What metastatic ovarian cancer might look like,Staging,37,38,Stage ITumor limited to ovaryIa limited to one ovaryIb limited to both ovaryIc Ia or Ib +tumor on ovarian surface; tumor rupture; tumor cell (+） in peritoneal fluid or washing,39,Stage IIWith pelvic extensionIIa to uterus or fallopian tubeIIb to other pelvic tissueIIc IIa or IIb +tumor on ovarian surface; tumor rupture; tumor cell (+） in peritoneal fluid or washing,40,Stage IIIPeritoneal implants outside pelvic; LN (+); superficial liver metastasisIIIa microscopic abdominal seeding IIIb abdominal implants2cmIIIc abdominal implants2cm; LN(+),41,Stage IVWith distant metastasisTumor cell (+) in Pleural effusion parenchymal liver metastasis 肝实质转移,42,43,Torsion 扭转Rupture 破裂Infection 感染Malignant transformation 恶性变,Complications,44,Acute ComplicationsTorsion 扭转Tumor with long pedicelMiddle sizedWithout adhesionContent not evenly distributed Sudden occurrence of pain after changing of position, defecation or urination Complicated with nausea or vomiting, even shockTenderness of the pelvic mass, most prominent at the pedicle siteEmergent operation is neededTumor should be moved with clapping the root of the pedicleTorsion should not be released before clapping the pedicle,45,Acute ComplicationsTumor rupture 肿瘤破裂Spontaneous or exogenesis mechanical reasonsMild or severe abdominal painSymptoms and signs of peritoneal irritationIntraperitoneal bleedingPreexisted Pelvic mass cloud not be felt or became smaller on pelvic examinationEmergent operation is needed,Complications,Management,46,Benign ovarian neoplasmCystectomy or salphingo-oophorectomyMalignant ovarian neoplasmComplete staging surgeryFertility preservation surgery for selected young womenCytoreductive surgery for advanced stageChemotherapyRadiotherapy,Management,47,Complete staging surgeryLaporotormy-A midline or paramedian abdominal incision is recommended to allow adequate access to the upper abdomen Laparoscopic operation- only for early stage ovarian cancer,Management,48,complete staging surgery 完全分期手术ExplorationFree fluid or peritoneal washings for cytological evaluationSystematic exploration of all the intra-abdominal surfaces and visceraclock wiseBiopsy any suspicious areas or adhesions on the peritoneal surfaces; and Random peritoneal biopsy including diaphragm,Management,49,complete staging surgeryOperationTotal hysterectomy+ bilateral salpingectomy & oophorectomy (Keep and encapsulated mass intact during removal)Unilateral salpingo oophorectomy when fertility preservation is desired in selected patientsOmentectomyAortic & pelvic lymph node dissectionAppendectomy when mucinous cancer,50,Management,51,Indication for fertility preserving operation 保留生育功能手术The uterus and the contralateral ovary can be preserved whenYoung and desires fertilityStage IaLow grade No evidence of spread beyond the ovary after a thorough staging laparotomy,52,Cytoreductive surgery 肿瘤细胞减灭术Staging surgery Maximal efforts should be made to remove all gross diseasesOptimal cytoreduction: residual disease 1cm,Management,Epithelial ovarian neoplasm,53,ChemotherapyAll epithelial ovarian cancer except for stage Ia-Ib low grade TP regimen Taxane紫杉烷 / carboplatin 卡铂 IV or IP for 6-9 courses (3 weeks per course),Epithelial ovarian neoplams,54,prognosis,55,Treatment for borderline ovarian tumor 交界性卵巢肿瘤Stage I Hysterectomy + bilateral salpingo-oophorectomy Unilateral salpingo oophorectomy when fertility preservation is desiredStage II-IV complete staging surgery,Management,56,Mostly benignTeratomaCystic adenomaDiagnosed byPelvic examination during early pregnancy Ultrasonography after mid-term pregnancy,Pregnancy complicated with ovarian neoplasm妊娠合并卵巢肿瘤,57,ComplicationAbortionTorsionRuptureAbnormal fetal growthBirth tract obstructionFast progression of malignant tumorManagementOperation after 3 months of pregnancySurgery when C-S if found during late term pregnancy,Pregnancy complicated with ovarian neoplasm,Prevention and Screening预防与筛查,58,Sporadic ovarian cancer PreventionChild bearingOral contraceptive pills,Prevention and Screening,59,Sporadic ovarian cancer ScreeningUltrasonography + CA125 every 6 months for high risk womenSurgery if tumor 5cmHigh alert if enlarged ovary before menarche, after menopause or oral contraceptive pills is taken regularlyConsider laparoscope or laparotomy if pelvic mass can not be diagnosed clearly or no effect after treatment,Prevention and Screening,60,Hereditary ovarian cancerGenetic counseling and genetic testing for BRCA1and BRCA2.Screening by transvaginal ultrasonography every 6 months for women wishing to preserve their reproductive capacity Oral contraceptives for young women before they embark on an attempt to have a family.Prophylactic bilateral salpingo-oophorectomy for women who do not wish to maintain their fertility,Prevention and Screening,61,Hereditary ovarian cancerAnnual mammographic screening beginning at age 30 years for women having strong family history of breast or ovarian cancerHNPCC syndrome: be treated as above and undergo periodic screening mammography, colonoscopy,and endometrial biopsy,Nonepithelial ovarian neoplasm非上皮性卵巢肿瘤,62,Nonepithelial ovarian neoplasm,63,Ovarian germ cell tumor 卵巢生殖细胞肿瘤Derived from the primordial germ cells of the ovaryAffect mostly in young women and girls 60-90% before menarche4% after menopauseHighly sensitive to chemotherapyFertility can be preserved for most patients,Ovarian germ cell tumor,64,Teratoma 畸胎瘤Mature teratoma 成熟性畸胎瘤Very common10-20% of ovarian neoplasm85-97% of ovarian germ cell tumor95% of teratomaContent: fat, hair, bone, teethX-raymature teratoma with bones and teethEasily diagnosed by ultrasonography and X-raySeldom highly differentiated: struma ovarii 卵巢甲状腺肿2-4% become malignant,Ovarian germ cell tumor,65,TeratomaImmature teratoma 不成熟畸胎瘤malignantAverage age of incidence 11-19yHigh recurrence and metastatic rateMature transformation after recurrence,Ovarian germ cell tumor,66,Dysgerminoma 无性细胞瘤Malignant solid tumorAffect young women of teenage and reproductive ageSensitive to radiotherapy5 year survival rate 90% for pure dysgerminomaYolk sac tumor 卵黄囊瘤Also named Endodermal sinus tumor 内胚窦瘤Highly malignantAffect young women and girlsTumor marker: AFP,Ovarian germ cell tumor,67,Embryonal Carcinoma 胚胎癌Multiple potential malignant tumorChoriocarcinoma of the ovary 卵巢绒毛膜细胞癌Nongestational Highly malignantPoorer prognosis than gestational choriocarcinomaTumor marker: hCG,Ovarian germ cell tumor,68,TreatmentOperationBenignTumor resection/ unilateral salpingo-oophorectmy/ hysterectomy + bilateral salpingo-oophorectomyMalignantComplete staging surgeryFertility preserving surgery could be done for all stage ChemotherapySensitive to chemotherapyBEP (bleomycin 博来霉素, etoposide依托泊甙, cisplatin顺铂) 3-6 courses (3weeks per course)RadiotherapyDysgerminoma 无性细胞瘤most sensitive to radiotherapy,Ovarian sex cord stromal tumor卵巢性索间质肿瘤,account for about 4.3% to 6% of all ovarian tumors malignancies derived from the primordial sex cords and mesenchyme: stroma or mesenchymeFunctional ovarian neoplasm,69,Ovarian sex cord stromal tumor,70,Solid tumorSome can secrete sex hormones （Functional tumor 功能性肿瘤)Manifested by symptoms of disturbed reproductive endocrinologySex hormone level be helpful for diagnosis,Ovarian sex cord stromal tumor,71,Granulosa cell tumor 颗粒细胞瘤Adult granulosa cell tumor account for 95%low malignant45-55 ySecret estrogenMight complicated with endometrial cancerJuvenile granulosa cell tumor account for 5% highly malignantteenage,Ovarian sex cord stromal tumor,72,Thecoma 卵泡膜细胞瘤Benign ovarian tumorCan secret estrogenMight complicated with endometrial cancerFibroma 纤维瘤Benign tumorMight complicated with ascites or hydrothoraxMeigs syndrome,Ovarian sex cord s