OVARIAN CANCER – EPITHELIAL

DRA. BAUTISTA (AJB) GYNECOLOGY 2018

Outline  Extremely rare

 Classification of ovarian neoplasm  Categorized according to the criteria for soft tissue
 Epithelial ovarian neoplasms tumors arising elsewhere in the body
o Serous tumors 7. Unclassified Tumors
o Mucinous tumors  Be placed in any of the preceding categories
o Clear-clear (mesonephroid) tumors  Small cell CA, which is highly virulent cancer affecting
o Brenner tumors primarily young women.
 Benign epithelial ovarian tumors: the adnexal mass 8. Metastatic Tumors to the Ovary
o Adnexal mass and ovarian cancer  May arise elsewhere in the reproductive tract or from
 Use of ultrasound screening and cancer antigen 125 in distant sites such as bowel or stomach (Krukenberg’s
the evaluation of adnexal mass tumor) -usually arise from the GIT, not primarily from
 Ovarian cancer screening the ovary
 Diagnosis, staging, spread, and preoperative 9. Tumor-like conditions
evaluation  Refer to enlargement of the ovary, such as extensive
 Management edema, pregnancy luteoma, endometriomas, and
follicular or luteal cysts, none of which are true
Frequency of ovarian neoplasms (WHO) neoplasms.

Epithelial ovarian tumor cell types:

Epithelial Ovarian Neoplasms

 Benign=adenoma
 Malignant=adenocarcinoma -with gland component
 Intermediate form=borderline malignant
Classification: adenocarcinoma or tumors of low malignant potential
 Papillary=papillae
1. Epithelial stromal tumors: most frequent  Prefix cyst=cystic structures
2. Germ cell tumors:  Suffix fibroma=adenofibroma, when the ovarian
 2nd most frequent and are the most common among stroma predominates
young women (teens and early 20s) – pwedeng benign
or malignant Serous Tumors
 Composed of extraembryonic elements or may have
deatures that resembles any or all of the three  Most frequent ovarian epithelial tumors
embryonic layers (ectoderm, mesoderm, or endoderm) o Benign forms: occur primarily during the
3. Sex cord-stromal tumors: reproductive years
 3rd most frequent o Malignant forms: 40% or more of ovarian
 Contain elements that recapitulate the constituents of cancers and occur in women older than 40 years
the ovary or testis of age
 May secrete sex steroid hormones or may be o Borderline tumors: occur in women 30-50 years
hormonally inactive or active of age
4. Lipid (lipoid) cell tumors: -pwedeng well or poorly differentiated
 Extremely rare
 Histologically resemble the adrenal gland  Well-differentiated serous tumors:
5. Gonadoblastomas - rare o Consists of ciliated epithelial cells that resemble
 Consist of germ cells and sex cord-stromal elements those of fallopian tube
 Occur in individuals with dysgenetic gonds, particularly o Classifying serous ovarian cancers into low or high
when a Y chromosome is present grade cancer
6. Soft tissue tumors not specific to the ovary  Histological variants
 Hemangioma or lipoma o Serous surface papillary carcinoma of the ovary

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DRA. BAUTISTA (AJB) GYNECOLOGY 2018

 Aggressive tumor with small ovaries that are Brenner Tumors

usually less than 4-5cm in diameter
 With extensive disease on the ovarian  Consist of cells that resemble the transitional
surface and metastatic disease in the epithelium of the bladder and Walthard nests of the
abdomen ovary
o Primary peritoneal serous adenocarcinoma  Abundant stroma
 Often difficult histologically to distinguish  Mayroong benign brenner at malignant brenner
 Far advanced reading, because they arise
from the peritoneum Bilaterality of ovarian tumors

Mucinous Tumors

 Consist of epithelial cells filled with mucin

 Most are benign (reproductive year)
 They reach a size which is very thick, sometimes
parang buntis ng 9 months kahit benign lang pala
 Cells resemble cells of the endocervix or may mimic
intestinal cells, which can pose a problem in the
differential diagnosis of tumors that appear to
originate from the ovary or intestine
 Back to back cysts lined by single layer of mucinous
epithelium: uniform tall columnar cells
 Mucinous carcinoma: seen in 30-60 years of age range
 Prominent vacuoles: mucin
-may patient daw sya 24years old lang Stage 1 pero
nagamot agad Benign Endothelial tumors: the adnexal mass
 >5cm
Endometrioid Tumors o Considered abnormal;
o Age and menstrual status must also be
 Consist of epithelial cells resembling those of the considered.
endometrium  5 to 8 cm (unilocular) – could be benign or malignant
 Usually occur in women in their 40s and 50s o Regular menses and in her 40s  functioning
 May be seen in conjunction with endometriosis and ovarian cyst
ovarian endometriomas o Women in her 20s and early 30s  observe
 NOT A COMPLETELY BENIGN ENTITY ANYMORE -it for two menstrual cycles and then repeat
can convert into a CA later on. ultrasound after 2-3 menstrual cycle and
 Arise directly from the surface epithelium of the ovary usually request UTZ on day 5 to 7 – because
 Confluent villoglandular epithelial proliferation >5mm in ovarian menstrual cycle, follicle starts to
enlarge after menstruation even day 1. So
Clear cell (mesonephroid) Tumors kung day 5 ka magrequest you shouldn’t find
any cyst there, baka maliit pa ang mga
 Large vacuoles presence of glycogen follicles dyan. If you find a large cyst already
 Cells: abundant clear cytoplasm, polyhedral on day 5, that is an abnormal finding.
 Contain cells with abdundant glycogen and so called o Women taking OCPs
hobnail cells in which the nuclei of the cells protrude  5 to 8 cm
into the glandular lumen o (Multilocular) more likely to be neoplastic
 Very aggressive, walang benign na clear cell, almost all  Risk of malignancy rises:
are malignant o After the age of 40
 Identical histologic features are found in the o Pre-and post-menopausal women taking
endometrium, cervix and vagina. That is considered as tamoxifen for breast cancer
grade 3 already which is poorly differentiated  Transvaginal ultrasound scan
 Not related to diethylstilbestrol exposure o Reliably detect an ovary greater than 1.0cm in
 Occur primarily in women 40 to 70 years of age diameter
 Highly aggressive, they recur o Preferably with a vaginal probe
o Occasionally, it is discovered that the adnexal
mass is paraovarian (the ovary is normal but
there is a cyst beside the ovary)

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OVARIAN CANCER – EPITHELIAL
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Adnexal mass and ovarian cancer  Kung meron maraming colorful blood vessels and
large, probably malignant, so call the gyne onco.
 Request for CA 125 (cancer antigen 125) o Resistance index: measures resistance to flow in
o Expressed by approximately 80% of ovarian the vessels
epithelial carcinomas but less frequently by  Presumable is low in the presence of
mucinous tumors neovascularization that is seen with malignant
o Also increased in endometrial and tubal tumors
carcinoma  Three-dimensional (3-D) ultrasonography
o >35 U/ml: considered increased o May allow more accurate volume assessments
o Lack of specificity  Color doppler 3-D UTS
o Specificity appears to be better for increased o May permit better detection of vessel
values in the postmenopausal patient. irregularity, coiling, and branching
Because there are a lot of conditions that can  Future possiblility: use of contrast media to quantify
affect CA-125 in premenopausal women. and permit earlier detection of abnormal
angiogenesis
Benign conditions in which CA-125 has been found to be
elevated: Ovarian Cancer Screening
 Endometriosis
 Peritoneal inflammation, including pelvic inflammatory  Ovarian cancer is characterized by advanced stage
disease disease at diagnosis and high mortality
 Leiomyoma  Early-stage disease is often curable
 Pregnancy  May patients na early stage palang may complain na
 Hemorrhagic ovarian cysts minsan bloated sila so punta sila sa GI specialist,
 Liver disease bibigyan lang sila ng Maalox or Omep,kaya pag
pupunta sa amin usually late stage na or kalat kalat
Used of ultrasound screening and cancer antigen 125 in the na.
evaluation of the adnexal mass -we don’t really screen for
Ovarian CA because it is very expensive kung mag UTZ at  Prevention—screening to identify early-stage
CA125 ka lagi, unlike Cervical CA there is Pap’s smear. disease
o Amenable to screening
 Ultrasound has helped to define criteria to allow  Sufficiently severre (high mortality)
conservative follow-up and the risk of malignancy of  Have a natural history from latency to overt
some adnexal masses. disease that is well characterized
 In UTZ you can already see if there is a cyst, so kung  There should be successful outcome if early
wala naman bat ka pa magrequest ng CA125. disease is treated
 Scoring system:  3 modialites
o Is the finding a simple (unilocular) or complex? o Physical examination
(multicystic/multilocular with solid components) o Biomarkers (such as CA 125),
cysts? proteomics/genomics (experimental)
o Are there papillary projections? o Sonography
o Are the cystic walls and/or septa regular and  History
smooth? Kasi kung makapal ang septa probably  PE
malignant yan. o Least sensitive and specific
o What is the echogenicity (tissue characterization)? o Easiest to implement
Marami bang puti puti (echogenic)? o Poor sensitivity limits this intervention as an
effective strategy
 Combined transvaginal ultrasonography and normal  Biomarkers such as CA 125
CA 125 values o Easy to obtain and serial evaluation can be
o You have an increased accuracy rate of tracked
preoperative evaluation. o A reliable biomarkers of epithelial nonmucinous
o Example there is a patient with ovarian cyst, but ovarian cancer
the generalist don’t know if malignant or benign. o Limitation of this as a sole strategy for ovarian
Because it is malignant dapat kumpleto operation cancer screening
mo, so call the gyne oncologist pag hindi ka sure. o Used also for recurrence monitoring
 You can request for Transvaginal pulsed Doppler  UTS
color-enhanced flow studies to differentiate benign o More expensive and less amenable to
from malignant masses. population screening

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OVARIAN CANCER – EPITHELIAL
DRA. BAUTISTA (AJB) GYNECOLOGY 2018

o Has become increasely accurate in identifying Diagnosis

early changes within the ovary  Usually diagnosed by detection of an adnexal mass
o As with single-modality testing, sonography is on pelvic or abdominal examination
too insensitive to be widely used from  Unfortunately, the diagnosis is frequently made only
screening after the disease has spread beyond the ovary
 More than 90% of women diagnosed with ovarian
NON-MALIGNANT NEOPLASMS cancer report symptoms before diagnosis
o Symptoms are vague and not specific for early-
 Most are asx, unilateral adnexal masses that can be stage disease or even ovarian cancer -walang
treated by oophorectomy or occasionally cystectomy pain
kung benign.  Increased abdominal size, bloating, urinary urgency,
 Women beyond her reproductive years hysterectomy and and pelvic pain
bilateral salpingo-oophorectomy are usually performed  Diagnosis is established by histologic examination of
tumor tissue removed at operation
Endometriod Tumors  Occasionally, the initial diagnosis is suggested by
malignant cells found in ascitic fluid obtained at
 Large and reach sized of 30cm or more paracentesis
 Possible complications: perforation and rupture
deposit and growth of mucin-secreting epithelium in
the peritoneal cavity (pseudomyxoma peritonei) –
check din if may complication sa appendix

Adenofibromas
 Consist of fibrous and epithelial elements
 Epithelial components maybe serous, mucinous, clear-
cell, or endometrioid
 Appearance will depend on the predominant
histologic features: epithelial or fibrous
 Managed by simple excision, oophorectomy can also
be done

Brenner Tumors
 Brenner tumors:
o Rare and often incidental findings
o In women in their 40s and 50s
o Almost always benign but there is also a
malignant Brenner
o Can usually be managed by oophorectomy
 Lower abdominal transverse (pfannenstiel) incision or
by laparoscope I don’t prefer this for ovarian cyst.
 Vertical incision
o Tumor should be removed intact.
Kasi kung Lap baka kumalat pa.
 Frozen section should be obtained if gross
examination of the ovarian tumor is at all suspicious
for malignancy
o For women of reproductive age desiring fertility
– you can still do conservative procedure, just
remove the part that is affected – USO (unilateral
salphingoophorectomy and do the LN dissection
and appendectomy for proper staging)
o If the diagnosis of malignancy is suspected but Preoperatively
uncertain even after a frozen section is obtained,
the operation should be terminated after  Preoperative workup usual for a major abdominal
removal of the ovarian tumor operation, cardiac clearance especially if the patient
is at 50s
 CA 125

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OVARIAN CANCER – EPITHELIAL
DRA. BAUTISTA (AJB) GYNECOLOGY 2018

 CT scan of the abdomen to search for  BRACA1 and BRACA2 mutations

retroperitoneal node enlargement for parenchymal
liver masses o Serous surface papillary carcinoma of the ovary:
 Barium enema or colonoscopy is performed to survival improved if the patients were treated
evaluate pelvic and/or gastrointestinal symptoms postoperatively with combination chemotherapy
 Endoscopic or gastrointestinal radiographic o Primary peritoneal carcinoma
examination is perfomed if there is evidence of o Role of this gene that resides on chromosome
gastrointestinal bleeding or the suggestion of any 12q11: not clear
gastrointestinal pathology o Increase risk of breast and ovarian cancer
 Programmed to cleanse the bowel pre-op o Hereditary ovarian caner group have a better
 Prophylactic board-spectrum antibiotics prognosis
 Venous thromboembolism prophylaxis o Very expensive, ipapadala pa sa ibang bansa. So we
o Variable compression leg support stockings get a very good family history nalang, ask them
o Heparin (fractionated and unfractionated) kung ang lola ba nila may ovarian, endometrial,
colonic, or breast CA, sisters and mother. (direct
Operatively relative) –kung meron, bantayan nyo na para mas
ok ang prognosis. They undergo testing pwedeng
 May infiltrate the peritoneal surfaces of both the twice a year or once a year.
parietal and intestinal areas, undersurface of the
diaphragm, particularly on the right side  Tumor grade
 Important note the paraaortic nodes. o Major determinant of patient prognosis
 Grade 0 (borderline) tumors: best
Grade 1: well differentiated prognosis
Grade 2 : moderately differentiated  Grade 3 (poorly differentiated tumors):
Grade 3: poorly differentiated markedly worse prognosis
Clear cell, papillary, serous – poorly differentiated o Low grade tumors generally clusted with LMP
neoplasms
o High-grade tumors differentially expressed
genes linked to cell proliferation, chromosomal
instability, and epigenetic silencing

 Ploidy of the tumor:

o Aneploidy: negative prgnositc factor

o Independent prognostic association with the
DNA index and S-phase (S-phase cells: better
prognosis)

 Size of residual nodules

o 5 year survival rate
Prognosis  Stage 3 tumors that were completely
 Cell type: resected: >30%
 Stage 3 tumors when resection was
o Epithelial cancers: most common, worst incomplete: 10%
prognosis ( more poorly differentialed and o Frequently used categories are microscopic (
discovered at the higher stage) present on biopsy, but not grossly), less than
o Mucinous and endometrioid tumors: better 1.0 cm, or greater than 1.0cm
prognosis Before we used to be content with 1.0 cm diameter of
o Transitional cell carcinoma (variant of papillary residual tumor, but now hindi na kami contented, dapat 0
serous): rare, more chemo sensitive tumor residual tumor, but technically it is not possible, what if it is in
o Clear-cell cancers: worse prognosis, mitotic activity the bowels,tapos studded na lahat. You cannot remove
and tumore stage everything. Chemotherapy ka after but you know that the
o Tubulocystic pattern: no effect on prognosis prognosis is not good when you leave a residual tumor behind.
o Aggressive tumorsL propensity for reccurence even
I stage 1

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OVARIAN CANCER – EPITHELIAL
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o Paraaortic and pelvic lymph node sampling – for

Management accurate sampling

 Borderline ovarian tumors (ovarian carcinomas of Summary: Remove all the resectable gross tissues, scrape the
low malignant potential) underside of the right diaphragm, check the liver, remove the
o 20% of ovarian epithelial cancers omentum, do washings, remove the paraaortic and pelvic LN
o Excellent prognosis regardless of stage samples, inspect other organs for tumor involvement.
o Serous and mucinous tumors: most common
histologies  Well-differentiated (grade 1) ovarian tumors confined
o Do not invade the stroma of the ovary to one ovary (stage 1A)
o Slower growth rate than do invasive ovarian o Tumor confine to one ovary
carcinomas, manifested by prolonged survival o Tumor well differentiated (grade1) with no invasion
o Occur in young women during the of capsule, lymphatics, or mesovarium
reproductive years desirable to ascertain the o Peritoneal washings negative
safety of the conservative therapy for patients o Omental biopsy specimen negative
with borderline stage 1A tumors (confined to o Young women of childbearing years with strong
one ovary) desired preserve reproductive function
o Stage 1 and 2: rare recurrences  Follow the patient closely for any evidence of
o Stage 3: 40% 20-year survival rate future ovarian enlargement with vaginal
o Stage 1: unilateral ultrasonography
 Normal opposite ovary: no biopsy or -after you remove, after a few months dapat maging
wedge resection pregnant na sya, kasi after her reproductive years you have
o Mucinous borderline tumors: excellent to complete the procedure, tanggalin mo na lahat because
prognosis the high chance of recurrence is there. So after nya
 Associated with widespread growth of magkaanak kapag ok na sya, remove mo na. and then
mucin-producing cells in the peritoneum follow-up the patient closely for future ovarian enlargement
(pseudomyxoma peritonei) - do not do by TransV UTS. Ganito ang gagawin kung may young
bikini cut woman na gusto ipreserve yung reproductive career nya.
 Assocatied with recurrent bouts of bowel
obstruction Postoperative management: (Adjuvant)
 Appendectomy is indicated  Chemotherapy
 Tends to recur and to require repeated  Radiation therapy-hindi binibigay sa ovarian
laparotomy to relive bowel obstruction  IP radiocolloids
o Conservative therapy unilateral  Immunotherapy
oophorectomy (preservation of childbearing
function) Neoadjuvant chemotherapy:
 Tumor is confirmed to be at stage 1A If the tumor is very very extensive, fixed, studded, pag open
 Extensive histologic sampling of the tumor mo frozen pelvis--give chemotherapy first, shrink the tumor and
confirms it to be borderline tumor then after 3 or 4 sessions of chemotherapy at lumiit na sya,
 The contralateral ovary appears normal pwede mo na operahan.
 Biopsy specimens of areas of omental or  Alternative for patients thaough to have substantial
peritoneal nodularity are negative operative risk or preoperative disease distribution that
 Results of peritoneal cytologic test are could preclude optimal cytoreduction
negative for tumor cells  To allow for an improvement in performing status,
decreasing operative morbidity through less extensive,
Invasive epithelial carcinoma surgery, and increasing the opportunity to achieve an
optimal result
 Primary treatment of ovarian epithelial carcinoma
removal of all resectable gorss diease Interval cytoreduction:
o Ascitic fluid: sent for cytologic evaluation  Refers to a secondary attempt at maximal surgery after
o Peritoneal washing (pelvis, upper abdomen, and surgery and adjuvant chemotherapy
right and left paracolic gutters and diaphragm)  Such therapy improved the likelihood or subsequent
o Biopsy or, preferably, excision of any suspicious successful resection and subsequent effectiveness of
nodules is performed chemotherapy
o TAHBSO, appendectomy and infracolic Sometimes di matanggal, fixed or frozen pelvis, what we do,
omentectomy we just get a biopsy and then submit to histopath and then give
 Not just omentum biopsy

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OVARIAN CANCER – EPITHELIAL
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neoadjuvant, then repeat the operation later on kapag lumiit na

yung lesion.

Second-look procedures:
We usually do not do this anymore kasi ooperahan mo na
naman sya to look kung nagwork ang chemotherapy mo.
Meron naman CT scan or MRI, we do not operate the patient
anymore just to look.
 Second-look laparotomy is perfumed, it is important to
extensively sample the peritoneal surfaces and lymph
nodes
 Recommend that the operation not be done for those
with low-stage tumors
 Favorable factors for a negative second-look operation:
o Low tumor grade
o No residual disease after primary operation
o Young age (younger than 55 years)
o Rapid regression to normal of increased CA 125
values
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SOURCE: Powerpoint, Quid Refert Trans, and Recording

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