Medical Archive

No37 Ovarian, Fallopian Tube, and Peritoneal Cancer

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

Indications for screening

  • Routine screening with CA-125 or transvaginal ultrasound is not recommended in individuals with an average risk of ovarian cancer.
  • In individuals at high risk, familial risk assessment should be performed, after which genetic counseling and subsequent genetic testing for hereditary cancer syndromes (e.g., BRCA1, BRCA2, or Lynch syndrome) may be indicated.
    • Some of the tools used for familiar risk stratification include the Ontario Family History Assessment Tool, the Manchester Scoring System, the Referral Screening Tool, and the Pedigree Assessment Tool.
    • In patients with high-risk mutations:
      • Risk-reducing bilateral salpingo-oophorectomy (rrBSO) is a preventive treatment option for patients who do not wish to conceive in the future.
      • Periodic screening for ovarian cancer (e.g., annual transvaginal ultrasound, pelvic exam, and CA-125 levels) is an alternative to rrBSO

Surgical staging

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

FIGO staging 2018

StageSub-stageDescriptionSurgeryAdjuvant
Stage 1
(Ovary only)		1A한 쪽에만TAH + BSO

임신 계획시 USO		CTx in G3
1B양 쪽에
1C1양 쪽 – Surgical spillageCTx in All
1C2양 쪽 – Capsule rupture or tumor on surface
1C3양 쪽 – Malignant cell in ascites
Stage 2
(Pelvic organ )		2A~ to uterus or fallopian tubesCytoreductiveCTx in All
2B~ to pelvic intraperitoneal tissues
Stage 3
(Peritoneal implants)		3A1후복막 LN+
3A2미세한 골반 외 복막 전이
3B2cm 이하의 골반 외 복막 전이
3C2cm 이상의 골반 외 복막 전이
Stage 4
(Distant meta)		4APleural effusion
4BTo 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.