卵巢癌ovariancancer狄文

1、Ovarian Cancer,DI WEN M.D., Ph.D., Professor & Chairman Department Of Obstetrics & Gynecology Renj

2、i Hospital Affiliated to SJTU School of Medicine,2,2006-11-1 七年制,Ovarian Cancer,,General Introduction,Ovarian tumors are commonest between 30 and 60. They are particularly liable to be or to become malignant.In their

3、early stages, they are asymptomatic and painless.They may grow to a large size.1.4% lifetime risk of ovarian cancer,,3,2006-11-1 七年制,Ovarian Cancer,Risk Factors,Family historyOvarian cancerBreast cancerColon cancer

4、Genetic factorsOlder ageCaucasianMore menstrual circles during lifetime (Ovulation induction),,4,2006-11-1 七年制,Ovarian Cancer,Incidence,Nearly 25% of all ovarian neoplasm are malignant.Approximately 80％ of them are p

5、rimary growths of the ovary.The remainder being secondary，usually carcinomata.,5,2006-11-1 七年制,Ovarian Cancer,symptoms,Lack of any specific symptoms, ovarian tumors are often large by the time the doctor is consulted.M

6、enstrual function is seldom upset, and any irregularity is attributed to the patient’s ‘time of life’.,6,2006-11-1 七年制,Ovarian Cancer,symptoms,Increased abdominal size,7,2006-11-1 七年制,Ovarian Cancer,symptoms,Pressure sym

7、ptomsGastro-intestinal symptoms (Bloating)Urge to urinateplevic pain (a dull pain in the lower abdomen)Very large tumors may cause respiratory embarrassment and edema or varicosities in the legs, and a characteristic

8、 ‘ ovarian cachexia’ develops.,8,2006-11-1 七年制,Ovarian Cancer,CLINICAL FEATURES OF OVARIAN TUMOURS,9,2006-11-1 七年制,Ovarian Cancer,CLINICAL FEATURES OF OVARIAN TUMOURS,10,2006-11-1 七年制,Ovarian Cancer,CLINICAL FEATURES OF

9、OVARIAN TUMOURS,11,2006-11-1 七年制,Ovarian Cancer,General Rule,An experienced examiner will recognize an ovarian tumor mainly because ovarian tumor is, in the circumstances, the most likely diagnosis. All abdominal swellin

10、gs should be subjected to ultrasound and X-ray examination.,DIFFERENTIAL DIAGNOSIS,12,2006-11-1 七年制,Ovarian Cancer,DIFFERENTIAL DIAGNOSIS,13,2006-11-1 七年制,Ovarian Cancer,ASCITES,A fluid thrill may be elicited from an ova

11、rian cyst, and ascites and tumor may coexist; but as a rule the distinction should be easily made.,DIFFERENTIAL DIAGNOSIS,14,2006-11-1 七年制,Ovarian Cancer,Uterine Fibroids,A large midline intramural fibroid may be impossi

12、ble to distinguish from a solid ovarian tumor until the abdomen is opened and an entirely different surgical problem encountered.,DIFFERENTIAL DIAGNOSIS,15,2006-11-1 七年制,Ovarian Cancer,DIFFERENTIAL DIAGNOSIS,16,2006-11-1

13、 七年制,Ovarian Cancer,DIFFERENTIAL DIAGNOSIS,17,2006-11-1 七年制,Ovarian Cancer,DIFFERENTIAL DIAGNOSIS,18,2006-11-1 七年制,Ovarian Cancer,Histological Classification,Most tumors arise from the ovarian stroma and germinal epithel

14、ium. The embryonic coelom from which that epithelium develops also gives rise to the Mullerian duct from which develop the structures of the genital tract, and it is this common origin which explains the great variety of

15、 epithelial patterns which are met with.,19,2006-11-1 七年制,Ovarian Cancer,Primary Epithelial Tumor,Mucinous cystadenoma or cystadencarcinoma (of. Cervical epithelium).Serous cystadenoma or cystadenocarcinoma (of

16、. tubal epithelium).Endometrioma or Endometrioid carcinoma (of. Endometrium).Clear cell carcinoma.Brenner tumour.,20,2006-11-1 七年制,Ovarian Cancer,Ovarian Germ Cell Tumor,Fibroma or sarcoma..Dysgerminoma..Teratom

17、a..Gonadoblastoma..Yolk sac tumour..Carcinoid.Thyroid tumour Choriocarcinoma,21,2006-11-1 七年制,Ovarian Cancer,Gonadal Sex Cord Stromal Tumor,Estrogen-producing:Granulosa cell tumour.Thecoma.Androgen-prodicing:Sert

18、oli-Leydig cell tumor (Arrhenoblastoma).Hilar cell tumour.Lipoid cell tumour.,22,2006-11-1 七年制,Ovarian Cancer,Krukenberg Tumor,There is one well-known secondary tumour of the ovary, the krukenberg tumour, a secondary o

19、f a stomach carcinoma.,23,2006-11-1 七年制,Ovarian Cancer,Mucinous cystadenoma,A unilocular or multilocular cyst of ovary lined by tall columnar epithelium resembling that of the cervix or large intestine. It is usually lar

20、ge and may reach immense proportions, occupying the whole peritoneal cavity and compressing other organs. It may occur at any age.,24,2006-11-1 七年制,Ovarian Cancer,OVARIAN TUMOURS --MUCINOUS CYSTADENOMA,25,2006-11-1 七年制,O

21、varian Cancer,SEROUS CYSTADENOMA,A unilocular or multilocular cyst lined by epithelium similar to the fallopian tube. They are the most common benign epithelial tumors and form 20% of all ovarian neoplasm. In 10% of case

22、s they are bilateral. It is uncommon to find them large than a fetal head.,26,2006-11-1 七年制,Ovarian Cancer,OVARIAN TUMORS --SEROUS CYSTADENOMA,27,2006-11-1 七年制,Ovarian Cancer,Serous cystadenocarcinoma,This is by far the

23、commonest primary carcinoma, accounting for 60% of all cases, and in over half the cases it is bilateral. The cysts are always of papillary type and the epithelium burrowing through the capsule produces papillary process

24、es on the serous surface. Extension of the growth to the pelvis and adjacent organs fixes the tumor. Ascites is always present.,28,2006-11-1 七年制,Ovarian Cancer,Endometrioid Carcinoma of the Ovary,It is now recognized th

25、at carcinoma of the ovary may be of endometrial type, sometimes arising in endometrioma. Attacks of pain, unusual with ovarian cancer, are common. Sometimes there is uterine bleeding in post-menopausal cases.,29,2006-11-

26、1 七年制,Ovarian Cancer,Endometrioid Carcinoma of the Ovary,Usually the lesion is cystic and chocolate brown in color. If such a cyst ruptures spontaneously, malignancy should be suspected. The histology varies as in uteri

27、ne carcinoma. It may be a well-differentiated adenocarcinoma, an adeno-acanthoma, mucinous adenocarcinoma or clear-celled carcinoma.,30,2006-11-1 七年制,Ovarian Cancer,Fibroma,This is composed of fibrous tissue and resemble

28、s fibromata found elsewhere. It is most common in the elderly and accounts for 4-5% of all ovarian neoplasm.The fibroma is believed by many to be a thecoma which has undergone fibrous transformation. It is sometimes ass

29、ociated with Meig’s syndrome.,31,2006-11-1 七年制,Ovarian Cancer,Dysgerminoma,This is the only solid ovarian tumor of characteristic appearance. Usually ovoid with a smooth capsule, it is of rubbery consistency and greyish

30、colour. It is commonest in younger age groups, under 30 years as a rule, and is often bilateral. Sometimes it is found in cases of intersex.,32,2006-11-1 七年制,Ovarian Cancer,Teratoma,Cystic teratoma or dermoidSolid terat

31、oma,33,2006-11-1 七年制,Ovarian Cancer,Yolk Sac Tumor,rare Children and young adultshighly malignantalphafetoprotein,34,2006-11-1 七年制,Ovarian Cancer,Estrogen-producing Tumors,These belong to the granulosa-theca cell grou

32、p and are found at all ages. They account for 3% of all solid tumors of the ovary.,35,2006-11-1 七年制,Ovarian Cancer,Estrogen-producing Tumors,In childhood there is accelerated skeletal growth and appearance of sex hair.

33、 5% occur in children precocious puberty. 60% occur in child-bearing years irregular menstruation. 30% occur in post-menopausal women post-menopausal bleeding.,,,,36,2006-11-1 七年制,Ovarian Cancer,Andorogen-prod

34、ucing Tumours,Three distinct types of masculinising ovarian tumor are recognised: a) Sertoli-Leydig cell tumor (Arrhenoblastoma), b) Hilar cell tumor, c) Lipoid cell tumor. All three cause amenorrhoea.,37,2006-11-1 七年制,O

35、varian Cancer,Spread -Direct,The first spread is directly into neighbouring structures – peritoneum, uterus, bladder, bowel and omentum.,38,2006-11-1 七年制,Ovarian Cancer,Spread -Lymphatics,Ovarian drainage is to the para-

36、aortic glands, but sometimes to the pelvic and even inguinal groups. Cells seeded on to the peritoneum are drained via the lymphatic channels on the underside of the diaphragm into the subpleural glands and thence to the

37、 pleura.,39,2006-11-1 七年制,Ovarian Cancer,Spread -Blood Stream,Blood spread is usually late, to the liver and lungs.,40,2006-11-1 七年制,Ovarian Cancer,Staging of ovarian cancer,STAGE I Growth limited to ovariesIa Limited

38、to one ovary. No ascites.Ib Limited to both ovaries. No ascites.Ic Ascites or positive peritoneal washings also present or tumour on surface of one or both ovaries or capsule ruptured.,41,2006-11-1 七年制,Ovarian Cancer,S

39、taging of ovarian cancer,STAGE II Pelvic extensionIIa Spread to uterus/tubesIIb Spread to other pelvic tissuesIIc IIb with ascites or positive peritoneal washings or tumour on surface of one or both ovaries or capsule

40、 ruptured.,42,2006-11-1 七年制,Ovarian Cancer,Staging of ovarian cancer,Stage III Extrapelvic intraperitoneal spread and/or retroperitoneal or inguinal positive nodes, or superficial lover metastases.IIIa Apparent limitati

41、on to true pelvisIIIb Histologically proven abdominal peritoneal superficial implants2cm diameter or positive retroperitoneal or inguinal nodes.,43,2006-11-1 七年制,Ovarian Cancer,Staging of ovarian cancer,Stage IV Dis

42、tant metastases or pleural effusion with positive cyotlogy or parenchymal liver metastases.,44,2006-11-1 七年制,Ovarian Cancer,Diagnosis,Pelvic examUltrasoundCT scanCA125 blood testSURGERY,45,2006-11-1 七年制,Ovarian Cance

43、r,TORSION of the PEDICLE,The commonest complication Occur with any tumor Except those with adhesions,,,46,2006-11-1 七年制,Ovarian Cancer,Clinical Features-Subacute,The patient complains of recurrent abdominal pain whic

44、h passes off as the pedicle untwists. There is a rise in pulse and temperature during the bleeding; And over a period anemia develops.,TORSION of the PEDICLE,47,2006-11-1 七年制,Ovarian Cancer,Clinical Features-acute,The si

45、gns and symptoms are those of an acute abdominal condition. The problem becomes one of differential diagnosis to exclude those conditions in which laparotomy is not needed and laparoscopy may be useful. Pain tends t

46、o be intense and continuous.,TORSION of the PEDICLE,48,2006-11-1 七年制,Ovarian Cancer,Ruptured Cyst,This may occur alone or in conjunction with torsion. Rupture is not particularly upsetting to the patient unless the conte

47、nts are irritant.,TORSION of the PEDICLE,49,2006-11-1 七年制,Ovarian Cancer,Suggestive of Malignancy,Age. If the patient is over 50 the chance of malignancy is over 50% as opposed to less than 15% in premenopausal women. Tu

48、mors in childhood are usually malignant.Rapid growth.Ascites.,50,2006-11-1 七年制,Ovarian Cancer,Suggestive of Malignancy,Solid tumours, especially when bilateral.Multilocular cysts with solid areas. (At least 10% of cys

49、ts are malignant).Pain. Pressure pain can occur with any tumor; But referred pain suggests malignant involvement of nerve roots.Tumor markers, such as CA125, may be measured in the blood, but a normal level does not ex

50、clude malignancy.,51,2006-11-1 七年制,Ovarian Cancer,Treatment,Surgery Chemotherapy Radiation Therapy ? Hormonal Therapy,52,2006-11-1 七年制,Ovarian Cancer,Surgical Procedures,To classify the growth according to its extent

51、of spread (staging) as accurately as possible.To remove as much cancerous tissue as possible (‘surgical debulking’;’cyto-reductive treatment’).,53,2006-11-1 七年制,Ovarian Cancer,Surgical Procedures,Benign ovarian over 10

52、 cm in diameter must be removed, but clinical and ultrasonically diagnosed cysts under 10 cm (the size of a lemon) in women under 35 years may be reviewed in a few months if there is no suspicion of malignancy. A follicu

53、lar or luteral cyst may resolve spontaneously.,54,2006-11-1 七年制,Ovarian Cancer,SURGICAL TREATMENT OF OVARIAN TUMMOURS,55,2006-11-1 七年制,Ovarian Cancer,SURGICAL TREATMENT OF OVARIAN TUMMOURS,56,2006-11-1 七年制,Ovarian Cancer

54、,SURGICAL TREATMENT OF OVARIAN TUMMOURS,57,2006-11-1 七年制,Ovarian Cancer,Follow-up,Follow-up with intensive chemotherapy, using various combinations of antineoplastic drugs. Taxanes, probably combined with platinum compou

55、nds, are an appropriate first choice.,58,2006-11-1 七年制,Ovarian Cancer,Second Look,A ‘second look’ laparotomy or laparoscopy operation (SLO), to determine the actual effectiveness of the chemotherapy and to decide whether

56、 it should be stopped does not affect prognosis, so should only be performed with informed consent in clinical trials.,59,2006-11-1 七年制,Ovarian Cancer,Surgical Procedures -Incision,A vertical incision which can be extend

57、ed is essential to allow a full inspection. Reduction of a cyst by tapping and extraction through a suprapubic incision is not acceptable practice.,60,2006-11-1 七年制,Ovarian Cancer,Surgical Procedures - Cytology,Before ha

58、ndling the tumour, take specimens of ascitic fluid or peritoneal saline washings for cytological examination, and a cytology smear from the underside of the diaphragm.,61,2006-11-1 七年制,Ovarian Cancer,SURGICAL PROCEDURES

59、IN OVARIAN CANCER,62,2006-11-1 七年制,Ovarian Cancer,DI WEN M.D., Ph.D. Professor & Chairman Department of Obstetrics & Gynecology

60、 Renji Hospital Affiliated to SJTU School of Medicine,Thanks for Your Attention,64,2006-11-1 七年制,Ovarian Cancer,65,2006-11-1 七年制,Ovarian Cancer,Hereditary Breast and Ovarian Cancer: BRCA1,,Auto

61、somal Dominant Transmission Precise Risk for Male Breast Cancer Unclear Increased Risk for Prostate Cancer?,Breast cancer 50%-85%,Second primary breast cancer 40%-60%,Ovarian cancer 20%-60%,,,,Adapted from ASCO,66,20

62、06-11-1 七年制,Ovarian Cancer,Hereditary Breast and Ovarian Cancer: BRCA2,Autosomal Dominant Transmission Increased risk of prostate, laryngeal, melanoma and pancreas cancers,breast cancer (50%-85%),ovarian cancer (10%-