Medical Archive

Introduction

• Evaluation of ovarian mass in premenopausal patients
  • Pelvic ultrasonography
  • CA-125: low specificity.
• Evaluation of ovarian mass in postmenopausal patients
  • Pelvic ultrasonography
  • CA-125
• Management
  • 6cm ??, ?? & ???
    • ??? ??? ?? ???? 2?? ? ?? ??.
    • ??? (??, ??, ??) ?? ?? ??
  • ?? ?? (??, ????, ?????, ???? ??, ????)
    • ?? ???.
    • ?? ??: 16???? ?? ?? -> 16?? ??
    • ?? ??: ??? ?? ??. C-sec?? ?? ??
    • ?? ? ??? ?? (torsion-m/c, ?? ? 3??? ??), 10cm ??, ?? ??? ?? ??.

Benign ovarian neoplasm

Initial evaluation is with pelvic ultrasound.
Low clinical suspicion for malignancy ? managed expectantly (eg, observation and repeat examination in 6 weeks)

Serous cystadenoma

M/c. Lined with fallopian tube-like epithelium. Often bilateral.

Mucinous cystadenoma

Multiloculated, large. Lined by mucus-secreting epithelium

Brenner tumor

Endometrioma

Epithelial ovarian cancer

Epithelium (90%), Germ cell, Gonadal stroma, Mesenchyme
Serous cystadenocarcinoma (80%)
Endometrioid(10%)
Mucinous cystadenocarcinoma (5%)
Clear cell(5%, worst – always grade III)

New 2 categories

Type 1	Low-grade Serous	Low-grade Endometrioid	Clear cell	Mucinous
Type 2	High-grade Serous ca.	High-grade Endometrioid adca.	Undifferenciated Ca.	Carcino-sarcoma

Pathogenesis

Type 1: Ovulation induced rupture ? cortical inclusion cyst ? neoplastic transformation
Type 2: STIC (serous tubal intraepithelial ca.) ? RRSO

Epidemiology

Risk factor
Unopposed E. High risk group: ??? FHx or ??? Hx

Prevention
???? ??? BSO, ??? ??? OCs, ?? ???? TVUSG/6month
Lynch II syndrome, BRCA 1/2 mutation ??? RRSO

? Lynch II SD (=HNPCC): “CEBO” colon, endometrial, breast, ovary cancer.
Screening
TVUSG + CA-125
Metastasis eval.
Barium enema, colonoscopy, IVP

Surgical staging

Cytology (ascites, cul-de-sac)
Explore
Biopsy (peritoneum, diaphragm, omentum)
Pelvic & para-aortic lymphadenectomy (~lt. renal vein level)

FIGO staging 2018

Stage	Sub-stage	Description	Surgery	Adjuvant
Stage 1 (Ovary only)	1A	한 쪽에만	TAH + BSO 임신 계획시 USO	CTx in G3
	1B	양 쪽에
	1C1	양 쪽 – Surgical spillage		CTx in All
	1C2	양 쪽 – Capsule rupture or tumor on surface
	1C3	양 쪽 – Malignant cell in ascites
Stage 2 (Pelvic organ )	2A	~ to uterus or fallopian tubes	Cytoreductive	CTx in All
	2B	~ to pelvic intraperitoneal tissues
Stage 3 (Peritoneal implants)	3A1	후복막 LN+
	3A2	미세한 골반 외 복막 전이
	3B	2cm 이하의 골반 외 복막 전이
	3C	2cm 이상의 골반 외 복막 전이
Stage 4 (Distant meta)	4A	Pleural effusion
	4B	To extra-abdominal organs

Chemotherapy

• Platinum? ???? ?? ??????
  • Carboplatin: ???? ??? ????
  • Paclitaxel: ?? ?? ????? ? ??? ??.
• ??? ????? ??? ??? ??.

‘Low risk’?? ??? uterus, ? ? ovary ? ???? (USO ? f/u)
Borderline: Unilateral oophorectomy or cystectomy , + RTx or CTx, Tx Assessment? CA125 level? (?? ??? ??, ??????)

Secondary cytoreduction

1? ?? ?? ??? ??? ????. Progressive?? ???? ???.

2nd line CTx: 1? ?? ????? progressive? ?.

Palliative management

Bowel obstruction – cause of death
??? 2-6?? ? ? ? ??? ??? ??.
Ascites ? pleural effusion

Germ cell tumor

For comparison, C40 Urology

20? ??? ??? ? 70%. ?? ??? ?? ?? ??. ??? ?? ???? karyotyping.
Germ cell tumor? CTx ??? ???. Node dissection ??? ??.

Primitive germ cell tumors

Dysgerminoma (m/c malignancy)

10-30? ??, ???? ???? 20-30%. ???? ???? ???? ?.
From scrotum. Seminoma? ???? ?? ???. Adolescents, ??-hCG, ?LDH
??? ??? Y? ??? scrotum? ?? ?? ??? ?. 2? ?? ? cancerous change? ? ? ?? ??? ????.
Histology- sheets of uniform �fried egg� cells (like seminoma)

Management

• Surgery
  • USO
    • ????? ???, localized disease (stage Ia, ?? ??, well encapsulated)
    • 10-15% bilateral ? Frozen ??? malig? ???? ???? ? (Lymphatic spreads ?)
  • TAH & BSO: ????? ???
  • BSO: Y chromosome (+)? ?, IVF-ET? ?? uterus ???
• Chemotherapy
  • BEP (Bleomycin, etoposide, cisplatin)
  • Metastasis ?? ?.
• Radiotherapy
  • Most radiosensitive.
  • But ?? ??? 1st line Tx? ??.
• f/u: LDH, PLAP (placental ALP)

Yolk sac tumor

16-18? ??, 100% unilateral.
Aggressive. Patients typically present with abdominal pain.
m/c tumor in male infants.
Yellow, friable (hemorrhagic), solid mass.
50% have Schiller-Duval bodies (resemble glomeruli)

Management

• USO
• Chemotherapy
  • ?? ????? ???.

Embryonal carcinoma

Elevated hCG.
Rapid-onset pelvic pain.

Choriocarcinoma

? Composed of trophoblasts and syncytiotrophoblasts; mimics placental tissue, but villi are absent
? Small, hemorrhagic tumor with early hematogenous spread.
? Poor response to chemotherapy

Biphasic or triphasic teratoma

Immature teratoma (2nd)

• ????? Dysgerminoma? ?? ??.
• Grade? ?? ??? Px factor ? Stage Ia G1??? ?? +adj. CTx

Mature teratoma (=Dermoid cyst)

• ??? ?? ?? ????. 15%? torsion??.
• ?? ??? tissue? ????. ? ovarian cystectomy
• Struma ovarii: teratoma composed primarily of thyroid tissue.
• Endodermal sinus tumor (EST) (3rd, 1st in children)
  • Schiller-Duval bodies (glomerulus-like structures) are classically seen on histology
  • 100% unilateral. USO + ??? CTx ??

Stromal tumors

Granulosa cell tumor

Epidemiology and pathology

Predominantly women in their 50s.

Histology – Call-Exner bodies; granulosa cells arranged haphazardly around collections of eosinophilic fluid, resembling primordial follicles

Clinical presentation

• Estrogen ??
  • ???, ?? ??
  • Breast tenderness
  • Endometrial hyperplasia

Management

• Endometrial biopsy
  • d/t the possibility of concomitant endometrial hyperplasia/cancer from excessive estrogen
• Surgery
  • ???? 2% ? ? USO; ?? ????? ??.
• CTx? ?? ??. Malignancy??? meta? ??? ??. Meta? recur ??? ? palliative RTx
• Rupture? ??? emergency ?

Thecoma

? Like granulosa cell tumors, may produce estrogen.
? Usually presents as abnormal uterine bleeding in a postmenopausal women.

Fibroma

? Benign tumor of fibroblasts
? Associated with pleural effusions and ascites (Meigs syndrome); syndrome resolves with removal of tumor.

Sertoli-Leydig cell tumor

? Testosterone ??; Associated with hirsutism and virilization

Gynandroblastoma

? Both hormone ??

Fallopian tube cancer

???? ??, ??, staging, treatment ?? ???? ??
BRRCA1, 2 mutation? ??? ??.

TRIAD
Watery vaginal discharge
Pelvic pain
Pelvic mass

Metastatic tumors

? ovarian ca.? ??? ????? ??

Krukenberg tumor (30~40%)

? ?? Bilateral, m/c from gastric carcinoma
? ??? ??? kidney shape
? Mucin-filled signet-ring cells (mucin???? cell? ???)

Pseudomyxoma peritonei

? Massive amounts of mucus in the peritoneum.
? Due to a mucinous tumor of the appendix, usually with metastasis to the ovary

?? ????: “G-BEL” – GI(?? ?),
Breast, Endometrium, Lymphoma

#Brenner tumor

Resembles bladder epithelium (transitional cell tumor). Solid tumor that is pale yellow-tan and appears encapsulated.
�Coffee bean� nuclei on H&E stain. Usually benign.