卵巢癌OvarianCancer狄文.ppt

Ovarian Cancer,DI WEN M.D., Ph.D., Professor & Chairman Department Of Obstetrics & Gynecology Renji 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 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 history Ovarian cancer Breast cancer Colon cancer Genetic factors Older age Caucasian More 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 primary 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. Menstrual function is seldom upset, and any irregularity is attributed to the patients 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 symptoms Gastro-intestinal symptoms (Bloating) Urge to urinate plevic 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 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 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 swellings 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 ovarian 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 impossible 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 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 epithelium. 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 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 . 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. .Teratoma. .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: Sertoli-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 of 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 large 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,Ovarian 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 cases 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 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 processes 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 that 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.,29,2006-11-1 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 uterine 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 resembles 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 associated with Meigs 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 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 dermoid Solid teratoma,33,2006-11-1 七年制,Ovarian Cancer,Yolk Sac Tumor,rare Children and young adults highly malignant alphafetoprotein,34,2006-11-1 七年制,Ovarian Cancer,Estrogen-producing Tumors,These belong to the granulosa-theca cell group 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. 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-producing 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,Ovarian 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-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 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 ovaries Ia Limited 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,Staging of ovarian cancer,STAGE II Pelvic extension IIa Spread to uterus/tubes IIb Spread to other pelvic tissues IIc IIb with ascites or positive peritoneal washings or tumour on surface of one or both ovaries or capsule 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 limitation to true pelvis IIIb 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 Distant metastases or pleural effusion with positive cyotlogy or parenchymal liver metastases.,44,2006-11-1 七年制,Ovarian Cancer,Diagnosis,Pelvic exam Ultrasound CT scan CA125 blood test SURGERY,45,2006-11-1 七年制,Ovarian Cancer,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 which 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 signs 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 to 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 contents 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. Tumors 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 cysts 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 exclude 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 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 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 follicular 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,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 compounds, 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 it should be stopped does not affect prognosis, so should only be performed with informed consent in c