Epithelial Ovarian Cancer

Epithelial Ovarian Cancer



1. epithelial ovarian cancer

Ovarian cancer 90% coelomic epithelium or mesothelium Ѵ.̷ cells primitive mesoderm 깰μ metaplasia ĥ ִ. Neoplastic transformation ְų oncogenic agent Ǿ 쿡 .



2. Borderline epithelial ovarian tumor

ҿ ѵǸ ַ premenopausal women ߻ϸ İ ſ. Ҿ 50-70 ַ ߻ϴ Ϳ Ͽ borderline tumor ϰԴ 30-50̿ ߻Ѵ.

Metastasis ġ ߻ ִ. ̰ noninvasive or invasive forms , invasive form Ͽ ʷ ִ.

Borderline tumor ܱ

() Epithelial proliferation with papillary formation and psedostratification

() Nuclear atypia and increased mitotic activity

() Absence of true stromal invasion ( without tissue destruction)

Ǿ bordeline tumor 20-25% Ҹ  ٴ ̸, ̰ peritoneal implants well-differentiated carcinoma ִ. primary tumor ˻翡 ϴµ, invasive cancer stromal invasion δ. Borderline microinvasion 幰 ȹٴ ִ.



3. epithelial ovarian cancer pathology

Table 33.1

75% serous histologic type, mucinous(20%), endometrioid(2%), clear cell(<1%), Brenner(<1%), undifferentiated carcinomas(<1%)

serous tumors

() borderline serous tumors

l 10% ϸ 50% 40 ߻Ѵ. Serous boderline ȯ 40% extraovarian implants 40% ᱹ Ѵ.  ̴ ̸, ⿡ ִ.

l invasive and noninvasive , non invasive implantsȯ 50 3 Ϳ, invasive ȯ 6 4 ߴٴ ־.

() Malignant serous tumors

l Tumor grade ȮεǾѴ. Well-differentiated papillary and glandular structures predominantϸ HFP 0-2 mitosis δ. Poorly differentiated solid sheets of cells, nuclear pleomorphism ̸ HPF 밳 2-3 mitoses δ. Moderately differentiated 2 ߰ .

l 80% serous carcinomas calcified psammoma bodies ߰ߵȴ.

Mucinous tumors : primary epithelial ovarian tumor 8-10% ϸ mucin secreting epithelium liningǾְ, ſ ũⰡ Ŀ ־ ü ִ.

() Borderline mucinous tumors : ̴ tumorμ ַ endocervical mucus-secreting cells Ǹ, intestinal, serous, endometrioid epithelial foci ִ. Bordeline serous tumor section ̳ mucinous tumor ׷ ϴ. well-diffentiated section Ͽ poorly differentiated focus ִ. ǹִ anaplastic alteration Ȯϱ sections ˻ϴ ߿ϴ.

() Malignant mucinous carcinomas

l papillary proliferations serous tumors ŭ , ̷ atypical proliferation ⺻ ̸, mucinous carinoma mitotic activity Ȯ Ȯ ְ ش.

l 8-10% ߻ϸ, 95-98% intraovarian̴. 5-10% Benign mucinous cystsκ ߻Ѵ.

l κп intestinal type cells ϱ Ұ߸ G-I tractκ metastatic carcinoma ƴ. Primary ovarian neoplasms bowel serosa involveϴ ϳ bowel mucosa ̵Ǵ rareϴ. ݸ鿡 G-I tract origin vascular lymphatic spread direct extension ovary involve ϴ.

() Pseudomyxoma peritonei: psedomyxoma peritonei neoplastic epithelium 緮 gelatinous mucinous material кѴ. ̴ ϰԴ ovarian mucinous carcinoma, a mucocele of the appendix, well-differentiated colon carcinoma .

Endometrioid tumors

() Epithelial tumors 6-8% ϸ, endometriosis ̴ Ұ δ. Sampson ovarian adenocarcinoma  endometriosis ٰ Ͽµ, ؿ ϸ typical benigh ES adenocarcinoma Ͽ ߰ߵǾ ϸ, ѻ transition ȮεǾѴٰϿ. ̷ ؿ ´ adenocarcinoma exellent prognosis δ. Ovarian adenoca uterine adenoca ϰ 50% squamous component δ.endometriosis malignant potential ſ , ̰ 缺 Ư¡hemorrhagic foci ִ. 밳 serous or mucinous carcinomaŭ ũ ʴ.

() Borderline endometrioid tumors : tumors endometial polyp or complex endometrial hyperplasia with crowding of glands ִ.  borderline tumor prominent fibromatous component µ adenofibroma Ѵ.

() Malignant endometrioid carcinomas

l Adenocarcinoma with benign-appearing squamous metaplasis excellent prognosisδ.

l ݸ鿡 mixed adenosquamous carcinomasȯڴ ſ δ.

() Multifocal disease :

l ovarian endometrioid tumors endometrium δ.̷ multifical disease Ȯϴ ߿ѵ uterus ovary ̵ 30-40% 5 ̴ Ϳ synchronous multifocal disease ȯڴ 75-80% 5 ̱ ̴.

l endometrium and ovarian tumor ̸ Ͻô ɼ ֱ ΰ ٸ primary lesions̴. Ұ ̸, well-differentiated̰, superficial invasion Ͻô endometrial tumors separated primary tumor ֵ ִ.

Clear cell(mesonephroid) tumors : 翡 ϴ 3%.

() ӻ hypercalcemia or hyperpyrexia õǴ ̸, 밳 ׷ metastatic disease ȴ. 밳 ̸ Ҹ  extentionʴ smooth surface δ. Cystic and solid components ȴ.

() Malignant clear cell carcinomas: ⺻ Ұ tubulocystic , papillary, solidϸ clear cells and hobnail cells̴. Focal areas of endometriosis and endimetrioid carcinoma ִ. δ DES Ǿ uterus or vagina ̴ clear cell ca ϴ.

Brenner Tumors

() Borderline Brenner tumor : epithelium stroma ħ ʴ´.

l  ڵ 汤 low-grade papillary transitional cell carcinoma 츦 proliferating tumorsϰ, higer grade of transitional cell carcinoma in situ borderline malignant Brenner tumors ٽ зϱ⵵ Ѵ.

() Malignant Brenner tumor: 幰, benign Brenner tumors invasive transitional cells ϰų Ȥ ٸ carcinoma ϴ 츦 Ѵ. Tissue infiltiltration destruction ְ ȴ.

() Transitional cell tumors

l recongnizable Brenner tumor 汤 transitional cell carcinoma 츦 ovarian transitional cell carcinoma Ѵ. ̷ tumor 50%̻ transitional cell carcinoma ϸ ׾ġῡ sensitiveϸ, ٸ poorly diffentiated ovarian carcinom İ .

l Transitional cell tumors malignant Brenner tumor ٸ ׵ advanced disease ߰ߵǰ, ڴٴ ̴.

Undifferentiated Carcinoma : large cell types small cell type Ѵ. Small cell type ַ ߻ϸ hypercalcemia ϼ ְ, immunohistochemical stains lymphoma, leukemia, sarcoma ִ.

Mesotheliomas

() peritoneal malignant mesotheliomas four categories зȴ.

l Fibrosarcomatous

l Tubopapillary(papillary-alveolar)

l Carcinomatous

l mixed

() ̷ multiple intraperitoneal masses Ÿ 缺ȯ Hysterectomy with BSO Ŀ ִ. Malignant mesotheliomas ovarian tumor implants and primary peritoneal mullerian neoplasms Ǿ Ѵ.

Peritoneal carcinomas : peritoneum malignant transformation primary peritoneal carcinomas or primary peritoneal papillary serous carcinoma Ѵ.

() ӻ ovarian carcinoma ϸ, ÿ ǥ鿡 microscopic or macroscopic cancer 鼭 󺹺 Ư omentum extensive disease ִ.

() Primary peritoneal tumor primary ovarian serous tumors ſ ִ. borderline serous peritoneal tumors and serous peritoneal carcinomas  쿡 Ҵ ̰ų minimally involvedǰ, ַ uterosacral ligments, pelvic peritoneum, omentum predominantly affect ִ.

() Borderline serous peritoneal tumors overall survival excellentϸ, ovarian borderline serous tumors ٸϴ. 38 borderline serous peritoneal tumorȯ 32 no persistent disease, 4 resection , Ѹ invasive serous carcinomaǾ, Ѹ 翡 ߴ.

() peritoneal serous carcinomas moderately to poorly differentiated serous ovarian carcinoma ̸, primary peritoneal endometrioid carcinoma less commonϴ.



4. ovarian cancer ߻

Epithelial ovarian cancers 80%̻ postmenopausal women , peak age 62. 45 ġ ʴ.

Epithelial ovarian cancer 1%̸ 21 , 2/3 germ cell tumors.

Postmenopausal women ovarian neoplasm 30% malignancyӿ Ͽ premenopausal women 7% malignancy.



5. ovarian cancer screening

Transvaginal ultrasonography : early ovarian cancer detection 95% Ѵ sensitivity δ.

CA 125 : stage I disease 50%, stage II disease 60% detection ִ. CA125 specificity TV ultrasonography ǰų ݺϿ ð F/UǸ ִ.

CA125 Transvaginal ultrasonography false-positive results Ѵٸ, Ư premenopausal women ̷ ˻ cost-effectiveness , ovarian cancer screening ؼ routineϰԻǾ ȵȴ.



6. epithelial ovarian cancer genetic risk

Ovarian ca life time risk 1.4%̸ ִ . familial or hereditary pattern ܿ 5%̸ malignancy , κ sporadicϰԻ.

Site-Specific Familial Ovarian Cancer : ִ epithelial ovarian cancer risk . peak age 61 ΰͿ ô ׺ 10 , first-or sencond-degree relative 50 epithelial ov.ca ٸ affected gene ɼ ſ .

() First-degree relative(mother, sister or daughter) 2 epithelial ov.ca female first-degree relative affected gene 50% , autosomal dominant mode ġѴ.

() First-degree relativeѸ, ׸ second-degree relative(grandmother, aunt, first cousin, or granddaughter) Ѹ epithelial ov.caϽÿ affected gene risk . relative risk 쿡 ؼ 3-10 .

() First-degree relative Ѹ epithelial ov.ca affected gene risk ణ ϸ, relative risk 2-4 .

Breast/Ovarian Familial Cancer Syndrome : first-or second-degree relative combination of epithelial ovarian and breast cancer ҽô ı ִ. ̷ ı ô ̿ ̸, ִ.

() first-degree relative 2 affectedǸ ovarian cancer relative risk Ϲκ 2-4 . Primary history of breast cancer ̴ subsequent ovarian cancer incidence 2Ѵ.

() Breast/ovarian syndrome Ǵ gene locus 17q chromosome ġϸ BRCA 1 gene̴. BRCA 1 mutation 1/800-1000÷ ߻ϸ, ̷ mutation cumulative life time risk breast cancer 85-90%, ovarian cancer 50%.

Lynch II Syndrome (hereditary nonpolyposis colon cancer, or HNPCC): ̴ multiple adenocarcinomas ϴµ, familial colon cancer(known as the Lynch I syndrome) ovarian, endometrial, breast cancers high rate, ׸ G-I and G-U system malignancies combination δ.̷ epithelial ovarian cancer risk firsr-and secone-degree relatives affected frequency ϳ, 밳 Ϲκٴ  3 relative riskδ.

syndrome 쿡 BRCA1 gene mutation ִ ˻ϴ 輺 ִ ˾Ƴµ ߿ , risk Ȯ ϱ ؼ  3뿡 ó Ͽ Ѵ. Epithelial ovarian cancer Strong family historyִ care ׳ , İȹ, 輺 ؼ ȴ. ̷ 豺 TV ultarsonography CA125 screening õDZ⵵ Ѵ. ֱ õǾ recommendation .

() Ĵɺ ϴ 6 ĸ Ͽ ϸ, ̻ ָ ġ prophylactic oophorectomy ǾѴ. protective effect Ȯġ , ָ ڿԴ OC ִ.

() Familial ovarian or hereditary breast/ovarian cancer syndrome ִ ̻ ӽ ġ prophylactic BSO ؾѴ. ȯڿ Ŀ 輺 ƴϸ, peritoneal carcinomas BSOĿ ϿѴ.

() Lynch II syndrome ִ Ͱ ġǾ ϸ, ÷Ͽ ֱ screening mammography, colonoscopy, endometrial biopsy Ѵ.



7. epithelial ovarian cancer ¡



() 밳 ȯڵ Ⱓ . ִϴ ȣϸ Ư ϴ.

() Early stage : Premenopause ȯڴ irregular menses , 汤 Ȥ йϸ 󴢳 ȣϱ⵵Ѵ. lower abdominal distention, pressure, dyspareunia pain ȣϱ⵵ Ѵ. Rupture or torsion ޼ ġʴ.

() Advanced stage : 밳 ascites, omental metastasis, bowel metastasis ̴µ, abdominal distention, bloating, constipation, nausea, anorexia, early satiety װ̴. Postmenopausal vaginal bleeding premenoapausal irregular or heavy menses ȣ ִ.

¡

() ߿ sign ü˻翡 ϴ ̴. Solid,irregular, fixed pelvic mass malignancy ϰ ûѴ. Դٰ 󺹺 ϸ Ȯ. ȯڰ ȣϱ pelvic exam , ĥ ִ.

()  1 Ҵ ǰ ʴ´. ̷ palpable pelvic mass ô Ǽ ؾϴµ ̸ postmenopausal palpable ovary syndrome̶ ҷԴ. Ŀ 5cm̸ palpable mass 3% malignancyٴ ִ.



8. epithelial ovarian cancer ˻

Serum CA 125 缺 Ǽ ش.

() Postmenopausal women 鼭 CA125>95U/ml 96% positive value for malignancyδ.

() Premenopuasal women ES, PID, myoma benign condition CA125 ֱ Specificity .

Premonopausal woman mobile, cystic, unilateral, regular contour ̴ 2 ʰ ֱ observationϴ reasonbleϸ, OC Hormone suppression Ǿ ִ. neoplastic ʴٸ regressؾϸ, regress ʰų ũⰡ Ŀ neoplastic ϸ ŵǾѴ.

ũ⵵ ߿Ͽ, 8cm ʰϴ cystic mass neoplastic ɼ . Ǽ ûϴ Ұ predominantly solid, relatively fixed, irregular shapedҽô laparotomy ؾѴ.

exploratory laparotomy ʿϸ ϻ ǰ˻ܿ chest x-ray, IVP ؾ Ѵ.abdominal and pelvic CT, or MRI definite pelvic mass ô ʿġʴ. 鼭 pelvic mass ô liver or pancreatic tumors ã CT or MRI ʿϴ. ̿ ʴ Liver-spleen scans, bone scans, brain scans ʿϴ.

45 ʰϴ ȯڿ primary colon cancer ̸ R/Oϱ barium enema colonoscopy ȴ. ̷ ˻ stool occult blood ְų Ű ִ ȯڿԼ ݵ ǾѴ. ô upper G-I series or gastroscopy ȴ. Breast mass ô bilateral mammography ̵Ǵµ ̴ primary breast cancer ҷ Ͽ primary ovarian cancerοε ֱ ̴.

ovarian cancer detection ġ ſ ̳ cervical cytology ݵ ǾѴ. Irregular menses or postmenopausal vaginal bleeding̴ ȯڴ ݵ endometrial biopsy and endocervical curettage Ͽ ̸ uterine or endometrial cancer 縦 R/OؾѴ.



9. Ovarian epithelial cancers spread pattern

ַδ exfoliation, lymphatic dissemination, hematogenous spreadδ.

Transcoelomic

() ʱ dissemination cancer cell exfoliation̸, peritoneal cavity surface implantѴ. ̰ ַ ȸθ µ ȣ pelvis, up the paracolic gutters(Ư ), along the intestinal mesenteries, to the right hemidiaphragm δ.

() ̴ posterior culdesac, paracolic gutters, right hemidiaphragm, liver capsule the peritoneal surface of the intestines and their mesenteries , omentum ַ .

() Intestinal lumen involve bowel loops functional intestinal obstruction߱Ѵ. ̸ carcinomatous ileus Ѵ.

Lymphatic

() Advanced disease lymphatic pelvis and para-aortic lymph node disseminationǴ ϴ. Diaphragm ĺ ؼ diaphragm ̵ Ư supraclavicular lymph nodesΰ.

() Stage III 78% Pelvic nodes ̸ , para-aortic nodes ̴ stage I 18%, II 20%, III 42%, IV 67%.

Hematogenous : ġ lung and liver vital organ ̴ 2-3% ߻Ѵ. ܴ diaphragm ȯڴ right pleural effusion.



10. ovarian epithelial cancer

Pathologic factors

() morphology and histologic pattern(architecture and grade) ߿ ڴ. Histologic type ߿ ڷ ʾ ֱ clear cell ca ٸ types İ ڴٰ Ǿ.

() Histologic grade ߿ ڷ ڸ ̸ ̱ ġ ʾҴ.

Biologic factors

() flow cytometry ovarian cancer aneuploid, ư FIGO stage Ploid̿ ־. low-stage cancers diploid, high-stage cancer aneuploid ־. Diploid tumors ȯڰ aneuploidȯں ǹְ median survival .(5: 1) multivariate analysis ϸ ploidy independent prognostis variable̸ one of the most significant predictors of survival̴.

() 60 ̻ proto-oncogenes ȮεǾ. ѿ ϸ HER-2/neu oncogene epithelial ova ca 30% expressedǸ İ ڴٰ ϸ, Ǵٸ ϸ HER-2/neu expression overall incidence 11% ڷμ ġ ġ ʴٰ Ͽ.

Clinical factors

() stage Ͽ, the extent of residual disease after primary surgery, the volume of ascites, patient age, performance scale ΰ independent prognostic variables̴.

() Stage I ȯڿ Tumor grade and dense adherence to the pelvic peritoneum Ŀ ǹְ , ݸ鿡 intraoperative tumor spillage or rupture ׷ ʾҴ.

() Ovarian cancer ߿ rupture or spillageǴ ĸ ȭŰ ʴ ݸ ̹ rupture ĸ δ.



11. ovarian epithelial cancers Staging

Table 33.2

FIGO stage surgicall exploration ʸ ΰ , ̷ surgical staging ġḦ ſ ߿ϴ.



12. surgical staging technique

malignancy ǽɵǾ 󺹺η midline or paramedian abdominal incision õȴ. Transverse incision ġ ϰ malignancy ߰ߵ rectus muscle ڸų ġ񿡼 ν 󺹺η ϰ ϴµ ̰ ġ ô Ǻ Ͽ J ش.

intact · Ͽ Ѵ. Ǽ̸ surgical staging ܰ迡 Ѵ.

()  free fluid(Ư cul-de-sac) cytologic evaluationؾѴ.

() Free fluid ô 50-100ml saline pelvic cul-de-sac, each paracolic gutter, beneath each diaphragm instilling and recoveringϿ cytology .

() All intra-abdominal surfaces and viscera ö Ѵ. ̶ ð cecum Ͽ paracolic gutter-> ascending colon to the right kidney->liver and GB->right hemidiaphragm->the entrance to the lesser sac at the paraaortic area->across the transverse colon to the left hemidiaphragm-> down the left gutterand descending colon to the rectosignmoid colon ϰԵȴ. Small intestine and its mesentery Treitz ligament cecum Ѵ.

() ִ  ǽɽ biopsyǾ Ѵ. disease evidence ô biopsies ϴµ, cul-de-sac, both paracolic gutters, peritoneum over the bladder, intestinal mesenteries biopsyѴ.

() Diaphragm biopsyȤ scraping with a tongue depressor samplingϿϸ, cytology sample ȮϿѴ.

() Omentum transverse colon ϴµ ̸ infracolic omentectomy Ѵ.켱 greater omentum underside ϴµ transverse colonκ a few millimeters peritoneum Ѵ. Gastroepiploic vessels branches ϰ ߶ش. Infracolic omentum feedingϴ 鵵 Ͱ ش. Gastrocolic ligament ̶ ܵ ʿ.

() Pelvic and para-aortic nodes evalutationϱ retroperitoneal spaces Ѵ. Enlarged nodes ŵǾ Ѵ.  ̵ ٸ formal pelvic lymphadenectomy ǾѴ.



13. surgical staging ߿伺

Pelvis Ǿִٰ stage I,IIȯڵ鿡 occult metastasis diaphragm biopsy 7.3%, omentum 8.6%, pelvic lymph nodes 5.9%, aortic lymph nodes 18.1%, peritoneal washing 26.4% ߰ߵȴ.

Histologic grade occult metastasis significant predictor. primary surgical staging grade I̾ 16%, grade II 34%, grade III additional surgical staging upstagedȴ.