Ovariancancer chandni
- 1. Chandni Thampi, Assistant professor Travancore college of nursing,Kollam Ovarian Cancer
- 3. Family History The strongest risk factor A women with a single first-degree relative with ov.Ca has a relative risk (RR) of approximately 3.6 for developing ov.ca compared with general population Her life time risk approx. 5% Families in which three or more first-degree relatives have ovarian or ovarian plus breast cancer are likley to have a cancer-susceptibility genetic mutation that is transmitted in an autosomal-dominant inheritance pattern
- 4. Ethnicity Higher in white women Higher in north America and northern Europe than Japan Incidence of ov.ca is higher in countries with higher in countries with higher per capita consumption of animal fat
- 5. Reproduction factors Nulliparous First childbirth after age 35 years Involuntary infertility Late menopause and early menarche Pts. With prolonged period or uninterrupted ovulation
- 6. Others Exogenous hormones :- HRT Dietary factors , Diets high in saturated animal fats seem to confer an increased risk by unknown mechanisms … Japanese women who move to the United States have an increased ovarian cancer risk. # Japanese women who move to the United States have an increased ovarian cancer risk. <<<<<<<<<<<<<<<<
- 7. Protective Factors Multiparity: First pregnancy before age 30 Oral contraceptives: 5 years of use cuts risk nearly in half Tubal ligation Hysterectomy Bilateral oopherectomy Lactation Epidemiologic and laboratory evidence suggest a potential role for retinoids , vitamin D, NSAIDs as preventive agents for ovarian cancer
- 8. Pathology Ovarian cancer can be divided into three major categories based on the cell type of origin . The ovary may also be the site of metastatic disease by primary cancer from another organ site. Unlike carcinomas of the cervix and endometrium, precursor lesions of ovarian carcinoma have not been defined.
- 9. Pathology Major Histopathologic Categories of Ovarian Cancer 1 Epithelial Serous, mucinous, endometrioid, clear cell, transitional cell (Brenner), undifferentiated 2 Germ Cell Dysgerminoma, endodermal sinus tumor, teratoma (immature, mature, specialized), embryonal carcinoma, choriocarcinoma, gonadoblastoma, mixed germ cell, polyembryona 3 Sex Cord and Stromal Granulosa cell tumor, bibroma, thecoma Sertoli-Leydig cell, gynandroblastoma
- 10. Pathology Major Histopathologic Categories of Ovarian Cancer 4- Neoplasms Metastatic to the Ovary Breast, colon, stomach, endometrium, lymphoma
- 11. Pathogenesis Ovarian carcinogenesis can be divided into two broad phases: 1- malignant transformation Benign borderline malignant ovarian tumors. 2- peritoneal dissemination
- 12. Ovarian cancer typically develops as an insidious disease, with few warning signs or symptoms. Most neoplastic ovarian tumors produce few symptoms until the disease is widely disseminated throughout the abdominal cavity. A history of nonspecific gastrointestinal complaints, including : nausea, dyspepsia, and altered bowel habits, is particularly common abdominal distention as a result of ascites are generally signs of advanced disease. A change in bowel habits, such as constipation and decreased stool caliber, is occasionally noted. Large tumors may cause a sensation of pelvic weight or pressure. Diagnosis and Clinical Evaluation
- 13. Rarely, an ovarian tumor may become incarcerated in the cul- de-sac and cause severe pain, urinary retention, rectal discomfort, and bowel obstruction. Menstrual abnormalities may be noted in as many as 15% of reproductive-age patients with an ovarian neoplasm vaginal bleeding may occur in patients with ovarian cancer in the presence of a synchronous endometrial carcinoma or as a consequence of metastatic disease to the lower genital tract. Ovarian stromal hyperplasia or hyperthecosis also may be associated with excess androgen production, which alters the normal menstrual cycle. Diagnosis and Clinical Evaluation
- 14. On Physical Examination ,, 1. General examination 2. Abdominal examination :- Abdominal distention is one of the more common findings. The presence of flank fullness and shifting dullness implies the presence of ascites or a large pelvic- abdominal mass , Recent eversion of the umbilicus 3. Lymph Node examination :- the supraclavicular and inguinal areas Diagnosis and Clinical Evaluation
- 15. On Physical Examination ,, 4. Pelvic examination :- A careful and thorough pelvic examination provides many helpful clues regarding the etiology of a pelvic mass. # Benign mass :- Mobile , smooth , cystic , unilateral #malignant mass :- fixed , irregular , sold or firm , bilateral. If I find a mass …. What could be else !!!! Endometrioma , Fibroid , Functional cyst , Ectopic pregnancy , Dermoid tumor (younger women) Diagnosis and Clinical Evaluation
- 16. Investigations ,, Tumor Markers :- an antigenic determinant on a high-molecular-weight glycoprotein recognized by the murine monoclonal antibody OC-125 upper limit of normal- 35 U/mL. In postmenopausal women :- lower cutoffs, 20 U/mL 85% of patients with epithelial ovarian cancer have >35 U/mL. Diagnosis and Clinical Evaluation
- 17. Investigations ,, Tumor Markers :- CA125 can be elevated :- 1. less frequently elevated in mucinous, clear cell, and borderline tumors compared to serous tumors. 2. in other malignancies (pancreas, breast, colon, and lung cancer) 3. in benign conditions and physiological states such as pregnancy, endometriosis, and menstruation. Many of these nonmalignant conditions are not found in postmenopausal women, improving the diagnostic accuracy of elevated CA125 in this population. Diagnosis and Clinical Evaluation
- 18. Investigations ,, Tumor Markers :- One of the limitations of CA125 is that 15% to 20% of ovarian cancers do not express the antigen. LDH (lactate dehydrogenase)— dysgerminoma HCG (human chorionic gonadotropin)– choriocarcinoma. AFP (alpha fetal protein)-- endodermal sinus tumors Other routine tests ( CBC , LFT , RFT , CXR ) Diagnosis and Clinical Evaluation
- 19. Investigations ,, Initial imaging modality of choice # for benign vs malignant that US detects more stage I ovarian carcinomas than CA125 levels and physical examination Diagnosis and Clinical Evaluation
- 20. Investigations ,, benign :- smooth, thin walls; few, thin septations; absence of solid components or mural nodularity. Diagnosis and Clinical Evaluation
- 21. Investigations ,, mural nodules, mural thickening or irregularity, solid components, thick septations (3 mm) and associated findings such as ascites, peritoneal implants, and/or hydronephrosis suggest malignancy Diagnosis and Clinical Evaluation
- 22. Investigations ,, TVS is significantly more accurate Diagnosis and Clinical Evaluation
- 23. Investigations ,, Computed Tomography Diagnosis and Clinical Evaluation
- 24. Investigations ,, Magnetic Resonance Imaging As with CT, disease metastatic to the ovary is often indistinguishable from primary ovarian cancer on MRI scans both the colon and the stomach should be examined as potential primary tumor sites if an ovarian mass is detected. Diagnosis and Clinical Evaluation
- 25. Investigations ,, Positron Emission Tomography Diagnosis and Clinical Evaluation
- 26. According to International Federation of Gynecology and Obstetrics (FIGO) Staging of Ovarian Neoplasms :- Stage I. Growth limited to the ovaries Ia —one ovary involved Ib —both ovaries involved Ic —Ia or Ib and ovarian surface tumor, ruptured capsule, malignant ascites, or peritoneal cytology positive for malignant cells Staging …
- 27. Staging …
- 28. Stage II. Extension of the neoplasm from the ovary to the pelvis IIa—extension to the uterus or fallopian tube IIb—extension to other pelvic tissues IIc—IIa or b and ovarian surface tumor, ruptured capsule, malignant ascites, or peritoneal cytology positive for malignant cells Staging …
- 29. Staging …
- 30. Stage III. Disease extension to the abdominal cavity IIIa—abdominal peritoneal surfaces with microscopic metastases IIIb—tumor metastases < 2 cm in size IIIc—tumor metastases > 2 cm in size or metastatic disease in the pelvic, paraaortic, or inguinal lymph nodes Staging …
- 31. Staging …
- 32. Stage IV. Distant metastatic disease Maligna Pulmon Liver or s Metasta nt pleural effusion ary parenchymal metastases plenic parenchymal metastases (not surfa ses to the supraclavicular lymph nodes or s ce implants) kin Staging …
- 33. Typical spread– omentum, peritoneal surfaces such as undersurface of diaphragm, paracolic gutters and bowel serosa Lymphatics– follows bld supply thru infundibulopelvic lig to nodes in para aortic region Drainage thru broad lig and parametrium– involves ext iliac, obturator and hypogastric regions Along round lig– involves inguinal nodes Extra abd mets– pleura, liver , spleen, lung, bone and CNS Metastasis …
- 34. Unfortunately, there are no good screening methods for ovarian cancer at present; most use a combination of physical exam, CA125 levels, and TVS. Screening …
- 35. The treatment of ovarian cancer is based on the stage of the disease which is a reflection of the extent or spread of the cancer to other parts of the body. There are basically three forms of treatment of ovarian cancer:- 1. The primary one is surgery at which time the cancer is removed from the ovary and from as many other sites as is possible 2. Chemotherapy is the second important modality. 3. radiation treatment, which is used in only certain instances. It utilizes high energy x-rays to kill cancer cells. Management …
- 36. Surgery A vertical incision is required for an adequate exploration of the upper abdomen. The pelvis and upper abdomen are explored carefully to identify metastatic disease. This is usually possible in the majority of stage I and stage II, but impossible in advanced cases. Management …
- 37. Surgery I. Complete hysterectomy & removal of tubes and ovaries II. •Lymph node evaluation III. •Omentectomy IV. •Intestinal resection V. •Peritoneal stripping/Tumor debulking VI. •Conservative management for those desiring to preserve fertility with early stage disease Management …
- 38. Surgery 1. in a young , nulliparous woman with unilateral tumour and no ascites ( stage Ia ), unilateral salpingo-oophorectomy may be done after careful exploration to exclude metastatic disease , and curettage of the uterine cavity to exclude a synchronous endometrial tumour. If the is subsequently found to be poorly differentiated or if the washings are positive, a second operation to clear the pelvis will be necessary. - For older women who complete her family a total hysterectomy and bilateral salpingo-oophorectomy is usually done. Management …
- 39. Chemotherapy Women with stage Ia or Ib and well or moderately differentiated tumours will not require further treatment. All other patient with invasive ovarian carcinoma require chemotherapy (stage II-IV –possibly stage Ic ). Drugs used are Carboplatin, cisplatin and taxol. Management …
- 40. Radiation Therapy Currently, radiation therapy plays a limited role in the treatment of patients with epithelial ovarian cancer mainly because of radiation damage to the small bowel, liver, and kidneys. radiation therapy has been used successfully in the treatment of patients with dysgerminoma . Management …
- 41. Alternative Therapies A number of alternative therapies have been applied for the treatment of epithelial ovarian cancer. Cytokines like interleukin-2 and interferon either alone or in combination with chemotherapy have shown some promising effects. Monoclonal antibodies directed against ovarian cancer- associated antigens, including CA-125, HMFG (human milk-fat globulin) Management …