_tumor卵巢肿瘤课件

Ovarian tumor Ovarian tumor is one of the most common tumors of the female generative system. Little progress has been made in identifying precursory or in situ stages of these lesions. The 5-year survival rate for all stages is still 35 -38%little better than 35 years ago. Table 1 Histology of ovarian tumors (WHO, 1972) Epithelial ovarian tumorsEpithelial ovarian tumors (1) Serous(1) Serous (2)(2) Mucinous Mucinous (3)(3) Endometrioid Endometrioid (4) Clear cell(4) Clear cell (5) Brenner(5) Brenner (6) Mixed epithelial(6) Mixed epithelial (7) Undifferentiated(7) Undifferentiated GonadalGonadal sex cord sex cord stromal stromal tumor tumor (1)(1) Granulosa stromal Granulosa stromal cell tumor cell tumor GranulosaGranulosa cell tumor cell tumor ThecomaThecoma- -fibromafibroma tumor tumor (a) Theca cell tumor (b) (a) Theca cell tumor (b) Fibroma Fibroma (2)(2) Sertoli leydig Sertoli leydig cell tumor cell tumor ( (androblastomaandroblastoma) ) (3)(3) Gynandroblastoma Gynandroblastoma Lipid (lipoid) cell tumorLipid (lipoid) cell tumor Ovarian germ cell tumorsOvarian germ cell tumors (1)(1) Dysgerminoma Dysgerminoma (2)(2) Endodermal Endodermal sinus tumor (yolk-sac sinus tumor (yolk-sac tumor)tumor) (3) (3) EmbryonalEmbryonal carcinoma carcinoma (4)(4) Polyembryoma Polyembryoma (5)(5) Choriocarcinoma Choriocarcinoma (6)(6) Teratoma Teratoma ImmatureImmature Mature Mature (a) Solid (b) Cystic(a) Solid (b) Cystic MonodermalMonodermal and highly and highly specialized:specialized: (a) (a) Struma ovarii Struma ovarii (b) (b) Carcinoid Carcinoid (c) Others(c) Others (7) Mixed germ cell tumors(7) Mixed germ cell tumors GonadoblastomaGonadoblastoma Non-ovarian specific soft tissue Non-ovarian specific soft tissue tumor (sarcoma,tumor (sarcoma, fibrosarcoma fibrosarcoma, , lymphosarcomalymphosarcoma) ) Unclassified tumorUnclassified tumor MetastaticMetastatic tumor tumor Tumor like condition Follicle Tumor like condition Follicle cysts,cysts, lutein lutein cysts, and s cysts, and so ono on Epethelial tumors account for more than 5070% of all primary ovarian neoplasia and more than 85%-90% of ovarian malignant tumors. Ovarian germ cell tumors account for 20%- 40% of ovarian tumors. They include dysgerminoma, embryonal carcinoma, teratoma, endodermal sinus tumour, choriocarcinoma , and so on. Sex cord stromal tumors account for about 5% of all ovarian tumors. These tumors are potentially functional, that is, producing hormones, so we call them ovarian functional tumors. Metastatic tumors account for 5%-10% of ovarian tumors. The primary sites are commonly gastrointestinal tract, breast, genital organs. High risk factors 1. The factors of heredity and family 2. Environmental factors 3. Endocrine factors 【Pathophysiology】 1. Epithelial tumors Epithelial ovarian tumors present at an average age of 30-60 years. Cellular proliferation, atypia, and the presence of stromal invasion are the histologic criteria used to classify malignant potential. SEROUS CYSTADENOMA BENIGN TUMORs comprises approximately 25% of benign ovarian neoplasms. divided 2 categories, simple and papillary. Psammoma bodies (small irregular calcifications) are characteristic of serous tumors. BORDERLINE SEROUS CYSTADENOMA papillary formation good differentiation lack of stromal invasion SEROUS CYSTADENOCARCINOMA external papillary excrescences covered by stratified epithelium (usually over 4-5 layers) nuclear atypia occasional mitotic figures and stromal invision MUCINOUS CYSTADENOMA BENIGN TUMORs Account for approximately 20% of benign ovarian neoplasms Generally unilateral, rounded or ovoid, smooth, grayish-white Cut section reveals the multilocular cysts strikingly filled with a viscous and tremellose mucin. The rate of malignant alteration is 5%-10%. BORDERLINE MUCINOUS CYSTADENOMA The tumor generally is rather large. Microscopically, cellular stratification occurs. No stromal invasion Cellular atypia may be mild to moderate and a moderate number of mitoses may be present. MYXOMA PERITONEI the progressive accumulation of mucin witnin the abdomen arise from either a mucinous ovarian tumor or from a mucocele of the appendix account for approximately 2%-5% of mucinous cystadenomas tumor cells secrete mucin rare cellular atypier and mitotic activity MUCINOUS CYSTADENOCARCINOMAS account for 10% of ovarian malignant neoplasms. Cut section reveals the multilocular cysts filled with a turbid or bloody mucin. Microscopically, glands are crowded and stroma are rather few. Stromal invasion and cellular atypia may occur strikingly. In contrast to serous cystadenocarcinoma, this tumor has a more favorable prognosis. OVARIAN ENDOMETRIOID TUMOR The malignant kinds of these neoplasms are endometrioid carcinomas, account for 10%-24% of primary ovarian malignant neoplasms. The histologic type are adenocarcinoma or adenoacanthoma, as in uterine carcinomas. Endometrial cancer found in the uterus and ovary commonly represents multifocal and not metastatic disease. OVARIAN GERM CELL TUMOR They are found in the gonad or at any site from which the germ cell arises or to which it migrates. This tumor occurs principally in young females60%-90% in prepuberal and only 4% in postmenopausal women. Germ cell tumors may contain germ cells as the predominant component. TERATOMA Teratoma is one of the most fascinating of all neoplasms. This tumor may contain tissues of ectoderm, endoderm, and mesoderm. MATURE TERATOMA Mature teratoma is the most common tumor of ovary. This tumor often occurs in patients 20-40 years old. Cut section reveals the unilocular cysts strikingly filled with adipose and hair, sometimes with bone and teeth. Special varieties of teratoma may produce unusual symptoms. Malignant change in a primarily benign cystic teratoma is uncommon. Any tissues may occur malignant change to form every kind of malignant tumors. The epithelium of scolex easily occur malignant change. IMMATURE TERATOMA The tumor commonly occurs during the early reproductive years. The degree of malignance is bases on the proportion of immature tissues, the cellular differentiation, and the neuroepithelium content. Maturation at a secondary site has even occurred in some instances. DYSGERMINOMA Occurs principally in young females. Comprises approxmately 5% of all malignant ovarian neoplasms. Radiation therapy is very effective in this tumor. The 5-year survival rate is 90%. ENDODERMAL SINUS TUMOR Occurs principally in young female. The biologic marker is alpha-fetoprotein (AFP). The survival time has been prolonged by combination chemotherapy and surgery. OVARIAN GONADAL SEX CORD STROMAL TUMOR GRANULOSA STROMAL CELL TUMOR GRANULOSA CELL TUMOR: Found in all age groups and associated with pseudoprecocious puberty. Early breast development , menstrual disorder, postmenopausal vaginal bleeding make up the characteristic symptom. Laboratory studies demonstrate an increase in the numbers of mature epithelial cells in the vaginal cytologic specimen, elevated urinary and serum estrogen levels, and variant degrees of endometrial proliferation. The characteristic cell is the round or slightly ovoid granulosa cell with its dark nucleus. Mitoses are common, and the “ovumlike” Call- Exner bodies are classic. THECA CELL TUMOR This tumor offen exists with granulosa cell tumor. The classic cell is short spindle, with abundant cytoplasm. The endometrium offen becomes proliferative, and postmenopausal vaginal bleeding may occur. The prognosis is better than that of other ovarian carcinomas. FIBROMA These tumors account for about 2%-5% of all ovarian tumors. These solid ovarian tumors may be associated with Meigs syndrome. SERTOLI LEYDIG CELL TUMORS also be called androblastoma often affect females beneath the ages of 40 years usually be luteinized, simulating the classic pattern of the testes and producing steroids generally benign, may produce the masculinization The 5-year survival rate is 70%-90%. OVARIAN METASTATIC TUMORS Krukenbergs tumor PATTERNS OF SPREAD At the time of diagnosis, over 70% of patients with epithelial carcinomas have metastased outside the pelvis. The most common location of metastases Peritoneum85% Omentum70% Contralateral ovary70% Liver35% Pleura33% Lung25% Uterus20% Vagina15% Bone15% STAGING The extent of the disease determines the stage and the appropriate form of management. Growth limited to the ovaries A Growth limited to one ovary; no ascites present containing malignant cells; no tumor on the external surface; capsule intact B Growth limited to both ovaries; no ascites present containing malignant cells; no tumor on the external surface; capsule intact C Tumor either stage A orB, but with tumor on the surface of one or both ovaries; or with ruptured capsule; or with ascites containing malignant cells or with positive peritoneal washings Growth involving one or both ovaries, with pelvic extension A Extention and/or metastases to the uterus and/or tubes B Extention to other pelvic tissues C Tumor either stage A or B, but with tumor on the surface of one or both ovaries; or with capsule(s) ruptured; or with ascites present containing malignant cells or with positive peritoneal washings Tumor involving one or both ovaries, with peritoneal implants outside the pelvic and/or positive retroperitoneal or inguinal nodes; superficial liver metastasis equals stage . Tumor is limited to the true pelvis, but with histologically proven malignant extention to small bowel or omentum A Tumor grossly limited to the true pelvis, with negative nodes but with histologcally confirmed microscopic seeding of abdominal peritoneal surfaces B Tumor involving one or both ovaries, with histologically confirmed inplants of abdominal peritoneal surfaces, none exceeding 2 cm in diameter; nodes are negtive C Abdominal inplants greater than 2 cm in diameter and/or positive retroperitoneal or inguinal nodes Growth invoving one or both ovaries with distant metastases. If pleural effusion is present, there must be positive cytologic findings to allot a case to stage ; parenchymal liver metastasis equals stage Table 2. FIGO stages for primary carcinoma of the ovary (1985) CLINICAL FIDINGS 1. BENIGN OVARIAN TUMORS These tumors are generally asymptomatic and are found on routine pelvic examination. On physical examination the most common signs of an ovarian tumor include an adnexal mass (or masses), an abdominal mass. If the tumors are large enough, they may produce pelvic pain, urinary retention or frequency micturition, rectal discomfort, and bowel obstruction, no ascites. 2. MALIGNANT OVARIAN TUMORS The evaluation includes a carful history and complete physical examination in addition to a pelvic examination. Most neoplastic ovarian tumors produce few symptoms. On physical examination the most common signs include an adnexal mass (or masses), an abdominal mass ascites, or evidence of metastasis. When interpreting an adnexal mass,it must be remembered that any palpable ovarian mass in a premenarcheal or postmenopausal woman is abnomal. DIAGNOSIS Although most ovarian tumors have not special symptoms, they may be diagnosed by patitnts age, careful histories and complete physical examination in addition to a pelvic examination. 1. CELLULAR ANALASIS Ascites or peritoneal washing is of greatest value when the process appears to be early or to be unilateral. If there is clear extension of malignancy to peritoneal surfaces, if there is omental tumor extension, or if the entire tumor cannot be removed, the peritoneal washing are less value. 2. FINE-NEEDLE PARACENTESIS Routine paracentesis to obtain samples for cellular analysis is not recommended but may be useful in the diagnosis of advanced or inoperable diseases. 3. OTHER ACCESSORY EXAMINATIONS Ultrasonography (endovaginal ultrasound) and computed tomography are accurate techniques. A laparotomy at least for histological purposes is mandatory. CA125 is the best known marker for ovarian cancer. In young patients, serum human chorionic gonadotrophin (-hCG) , -fetoprotein (AFP) titres should be determined. 【DIFFERENTIAL GIAGNOSIS】 1. Benign ovarian tumors and malignant ovarian tumors See table 3 Table 3. Benign ovarian tumors and malignant ovarian tumors Content BenignMalignant HistoryLong, growth slowly Short, growth rapidly SignGenerally unilateral, active, cystic, smooth, no ascites Generally bilateral, fixed, solid or semisolid, nodular or lobulated, often with bloody ascites containing malignant cells General physical condition GoodCachexia present UltrasoundOpaque dark area of fluid, with interval band, edge clearly Opaque dark area of fluid with light beam or sport, edge not clearly 2. DIFFERENTIAL DIAGNOSIS OF BENIGN OVARIAN TUMORS (1) OVARIAN TUMOR LIKE CONDITION Follicle cysts and lutein cysts are the most common. Indeed, in a normally menstruating woman any adnexal mass larger than 5cm should be concidered suspect if it persists for more than 6 weeks. (2) SALPINGO-OOPHORY CYSTS These are inflammation cysts and often produce infertility. (3) LEIOMYOMA Leiomyomas are generally multiple, linked with uterine, often associated with a menstrual abnormality. On physical examination, the tumor moves when corpus uteri and cervix move. (4) UTERINE PREGNANCY The careful menstrual history, the HCH study, and untrasonography scane may be useful to differentiate the two conditions. (5) ASCITES The patient often has history of hepatic disease, or cardiac disease. When the patient lies down, the shape of her abdomen likes as frog-belly. Percussion note is tympany in the middle abdomen, dullness in the lateral abdomen. The shifting dullness is positive. 3. DIFFERENTIAL DIAGNOSIS OF MALIGNANT OVARIAN TUMORS (1) ENDOMETRIOSIS The lesion generally produces progressive dysmenorrhea, hypermenorrhea, premenstrual irregular vaginal bleeding, and so on. Ultrasound, laparoscopy are the promising adjuvant examination. Laparotomy should be performed if ovarian neoplasms cannot be ruled out. (2) PELVIC INFLAMMATION OF CONNECTIV TISSUE The patient may have history of abortion or puerperal inflammation. Use of antibiotic may remit symptoms, and make the mass or masses small or disappear. (3) TUBERCULOUS PERITONITIS The lesions often occur in young or infertility women, generally have history of lung tuberculosis, often produce leanness, asthenia, low fever, night sweat, anorexia, infrequent menstruation or amenorrhea. Ultimately the dignosis of this lesion depends on surgical exploration. (4) EXTRA-GENERATIVE TRACT TUMORS Ovarian malignant neoplasms must be differentiated from retroperitoneal masses, rectal cancer or sigmoid cancer. Untrasound, barium enema, intravenous pyelography may assist in establishing the diagnosis. (5) METASTATIC OVARIAN TUMORS The metastatic ovarian neoplasms should be suspect if the adnexal mass or masses were bilateral, median large, kedney shape, active and solid. The patient has gastrointestinal symptoms, history of gastrointestinal cncer, and breast cancer. 【COMPLICATION】 Complications include pediculotorsion, capsule ruptured, inflammation, and malignant transformation. They may produce pelvic pain or abdominal pain, fever, ascities, abdominal mass or masses, and so on. 【TREATMENT】 1. BENIGN TUMORS Operation should be performed while the diagnosis is established. The extent of surgery depends on the patients age, the patients desire of childbearing, and contralateral ovary. Frozen section should be used at the time of surgery. 2. MALIGNANT TUMORS (1) SURGERY Surgery is usually performed to establish the type, histologic grading, and stage of the tumor. In certain early or borderline cases, surgery may also be curative, and in nearly all cases it is a major part of therapy. At the time of surgery, peritoneal fluid or peritoneal washing should be aspirated f