卵巢肿瘤-英文

1、1Obstetrics &Gynecology Hospital Fudan UniversityOvarian Neoplasm卵巢肿瘤What is ovarian neoplasm?2One 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 3What we are going to discussGene

2、ral 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4Key points in the sessionPathological classification of ovarian tumorSpread pattern and staging of ovarian cancer Differential diagnosis of benign and malignant ovarian neopl

3、asmThe use of tumor markers in diagnosis of ovarian neoplasm Principles of primary operation and chemotherapy for ovarian cancerWhat is ovarian neoplasm?5Female Reproductive Anatomy7What 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Metastati

4、c tumor5-10%转移性肿瘤Krukenberg tumor (库肯勃瘤）8Brief 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 treatmentChemothe

5、rapy greatly improved prognosis of ovarian cancerAll germ cell tumor can be treated with fertility preserving surgery9EpidemiologyAlmost 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 can

6、cer 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 cancer10Age 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Epit

7、helial ovarian cancerEpithelial ovarian neoplasm上皮性卵巢肿瘤11Etiology & Risk factors -Epithelial ovarian cancer12Most 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 ov

8、arian cancer13Sporadic 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 cancer14Risk factorsLate parity (35y) InfetilityOld age 50-6

9、0yOvulation for more than 40 Protective factorsEarly parity (1cm can be foundlow resistance and pulsatile indexes suggest the presence of a cancerous tumor.X-rayCT scanMRIbenignmalignantDiagnosis32Laboratory Tests Serum tumor markersCA125; HE4 epithelial ovarian cancerAFP Yolk sac tumor; other germ

10、cell tumorhCG ovarian choriocarcinomaSex hormones sex cord stromal tumor Tests for genetic mutations Microscopic examination of ovarian cancer cells from ascites or pleural effusionDiagnosis33CA125-epithelial cancer marker 85% of women with clinically apparent ovarian cancer have increased levels of

11、 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 DiagnosisDifferential diagnosis benignmalignanthistoryLong term, grow slowlyShort term, grow fastmassUnilate

12、ral, cystic, smooth and movableBilateral, solid or partially solid, irregular surface, unmovable and solid mass in cul-de-sacascitesnegativemalignant cells found in ascitesGeneral conditionwellLost of weight, cachexiaUltrasonographyUnilocular, thin-walled, no papillae, no solid areasMultilocular, th

13、ick walls, papillae present, mixed echogenicity due to solid areasCA125(50y)35U/ml3435Benign ovarian tumorPhysilogical ovarian cyst: follicular cyst; corpus luteum cyst Inflammatory cystUterine myomapregnancyAscitesDifferential diagnosisDifferential diagnosis36Malignant ovarian neoplasmsEndometriosi

14、sTuberculous peritonitis Chronic pelvic inflammatory diseaseMetastatic ovarian tumor (Krukenberg tumor)哑铃状Tumor from other pelvic organsWhat metastatic ovarian cancer might look like Staging 3738Stage ITumor limited to ovaryIa limited to one ovaryIb limited to both ovaryIc Ia or Ib +tumor on ovarian

15、 surface; tumor rupture; tumor cell (+） in peritoneal fluid or washing39Stage 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 washing40Stage IIIPeritoneal implants outside p

16、elvic; LN (+); superficial liver metastasisIIIa microscopic abdominal seeding IIIb abdominal implants2cmIIIc abdominal implants2cm; LN(+)41Stage IVWith distant metastasisTumor cell (+) in Pleural effusion parenchymal liver metastasis 肝实质转移4243Torsion 扭转Rupture 破裂Infection 感染Malignant transformation

17、恶性变Complications44Acute 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

18、at the pedicle siteEmergent operation is neededTumor should be moved with clapping the root of the pedicleTorsion should not be released before clapping the pedicle45Acute ComplicationsTumor rupture 肿瘤破裂Spontaneous or exogenesis mechanical reasonsMild or severe abdominal painSymptoms and signs of pe

19、ritoneal irritationIntraperitoneal bleedingPreexisted Pelvic mass cloud not be felt or became smaller on pelvic examinationEmergent operation is neededComplicationsManagement46Benign ovarian neoplasmCystectomy or salphingo-oophorectomyMalignant ovarian neoplasmComplete staging surgeryFertility prese

20、rvation surgery for selected young womenCytoreductive surgery for advanced stageChemotherapyRadiotherapyManagement47Complete staging surgeryLaporotormy-A midline or paramedian abdominal incision is recommended to allow adequate access to the upper abdomen Laparoscopic operation- only for early stage

21、 ovarian cancerManagement48complete 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

22、biopsy including diaphragmManagement49complete 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 l

23、ymph node dissectionAppendectomy when mucinous cancer50Management51Indication 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

24、52Cytoreductive surgery 肿瘤细胞减灭术Staging surgery Maximal efforts should be made to remove all gross diseasesOptimal cytoreduction: residual disease 5cmHigh alert if enlarged ovary before menarche, after menopause or oral contraceptive pills is taken regularlyConsider laparoscope or laparotomy if pelvi

25、c mass can not be diagnosed clearly or no effect after treatmentPrevention and Screening60Hereditary 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 contrac

26、eptives 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 Screening61Hereditary ovarian cancerAnnual mammographic screening beginning at age 30 years for women having str

27、ong family history of breast or ovarian cancerHNPCC syndrome: be treated as above and undergo periodic screening mammography, colonoscopy,and endometrial biopsyNonepithelial ovarian neoplasm非上皮性卵巢肿瘤62Nonepithelial ovarian neoplasm63Ovarian germ cell tumor 卵巢生殖细胞肿瘤Derived from the primordial germ cel

28、ls of the ovaryAffect mostly in young women and girls 60-90% before menarche4% after menopauseHighly sensitive to chemotherapyFertility can be preserved for most patientsOvarian germ cell tumor64Teratoma 畸胎瘤Mature teratoma 成熟性畸胎瘤Very common10-20% of ovarian neoplasm85-97% of ovarian germ cell tumor9

29、5% 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 malignantOvarian germ cell tumor65TeratomaImmature teratoma 不成熟畸胎瘤malignantAverage age of incidence 11-19yH

30、igh recurrence and metastatic rateMature transformation after recurrenceOvarian germ cell tumor66Dysgerminoma 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 si

31、nus tumor 内胚窦瘤Highly malignantAffect young women and girlsTumor marker: AFPOvarian germ cell tumor67Embryonal 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

32、germ cell tumor68TreatmentOperationBenignTumor 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,

33、cisplatin顺铂) 3-6 courses (3weeks per course)RadiotherapyDysgerminoma 无性细胞瘤most sensitive to radiotherapyOvarian 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 n

34、eoplasmstromamesenchymenormalfemaleGranulosa cellTheca cellmaleSertoli cellLeydig celltumorfemaleGranulosa cell tumorThecoma FibromamaleSertoli-Leydig cell tumor69Ovarian sex cord stromal tumor70Solid tumorSome can secrete sex hormones （Functional tumor 功能性肿瘤)Manifested by symptoms of disturbed repr

35、oductive endocrinologySex hormone level be helpful for diagnosisOvarian sex cord stromal tumor71Granulosa 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 malignan

36、tteenageOvarian sex cord stromal tumor72Thecoma 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 syndromeOvarian sex cord stromal tumor73Sertoli-Leydig cell tumorAlso named Androblastoma 卵巢

37、男性细胞瘤 Affect women 40y70% are benignSecret androgenSeldom secret estrogenOvarian sex cord stromal tumor74TreatmentOperationBenignTumor resection/ unilateral salpingo-oophorectmy/ hysterectomy + bilateral salpingo-oophorectomyMalignantComplete staging surgeryFertility preserving surgery should be done for Stage Ia young patientsChemotherapyPlatinum based chemotherapyBEP (bleomycin, etoposide, cisplatin) 3-6 courses (3weeks per course)75Key points in the sessionPathological classification of ovarian tumor: epithelial, germ cell, stromal cellSpread pattern