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Ovarian Tumours Normal Histology Approach History Gynaecology history LMP Menstrual cycle Previous pregnancies Contraception Drug,

family history Systemic review metastatic tumour Physical Examination Lymph node palpation Abdominal examination Bimanual palpation (nodules in pouch of Douglas) (tenderness)

Classification Surface Epithelial Cell 70% frequency > 20 y/o Serous tumor Mucinous tumor Endometriod tm. Clear cell tumor Brenner tumor Cystadenofibroma Etiology

Germ Cell 20% frequency 0-25 y/o Teratoma Dysgerminoma Endodermal sinus (yolk sac tumor) Choriocarcinoma

Sex Cord-Stroma 10% frequency All ages Fibroma Granulosa-Theca cell tumor Sertoli-Leydig cell tumor

Metastasis to ovary 5% frequency Varies

Investigations Ultrasound X-ray y Chest (metastasis) y Abdomen (calcification benign teratoma) CT-PET scan (assist staging) Blood test y Infection (WBC) y Platelet (haemorrhage) Hormonal level estrogen y Physiological follicular cyst y Sex cord stromal tumour CA-125 (serous, endometroid carcinoma) -fetoprotein (endodermal sinus (yolk sac) tumour) Inhibin (granulose cell tumour) -HCG (dysgerminoma) FIGO Staging (Laparotomy) 1. Growth limited to ovaries 2. Growth involving 1 ovaries with pelvic extension 3. Growth involving 1 ovaries with peritoneal implants outside pelvis +ve retroperitoneal/ inguinal lymph node Superficial liver metastasis = stage 3 4. Growth involving 1 ovaries with distance metastasis If pleural effusion, +ve cytology = stage 4 Parenchymal liver metastasis = stage 4 Management Surgery Primary therapy (Diagnose, treat) y Total abdominal hysterectomy & bilateral salpingo-oophorectomy y Omentectomy y Conservative primary surgery (unilateral salpingooophorectomy) Young, nulliparous women with stage Ia disease No synchronous endometrial tumour Chemotherapy Adjuvant therapy Indication Stage Ic and above Type y Clear cell carcinoma y Serous papillary cystadenocarcinoma Type of drug Epithelial Non-Epithelial Carboplatin BEP Bleomycin Cisplatin Etoposide Paclitaxel Cisplatin

Risk Nulliparity Early menarche Late menopause Estimated no. of years of ovulation Unmarried, married with low parity Family history BRCA 1, BRCA 2 Genetic mutations sporadic (HER2/ NEU, K-RAS, p53)

Risk Oral contraceptive st Age at 1 birth

Incessant Ovulation Theory Ovulation rupture surface epithelium Repair by proliferation (DNA synthesis) Successive bouts of trauma (rupture) Repair induce genetic instability Mutation risk Epithelial tumours Clinical Features Asymptomatic y Until well advanced y Found accidentally during investigation of unrelated problems, check up Abdominal swelling (when tumour is large) Pain (from torsion, rupture, haemorrhage, infection) Pressure effect (constipation, urinary incontinence, frequency) Menstrual disturbances Hormonal effects (sex cord tumour estrogen effect) Abnormal cervical smear Constitutional symptoms for cancer y Appetite y Weight y Cachexia

Benign Ovarian Tumour Epidemiology Young women Germ cell tumour Pathology Physiological cyst Follicular cyst Luteal cyst Benign surface epithelial tumour Serous cystadenoma Mucinous cystadenoma Endometroid cystadenoma Brenner tumour Clear cell tumour Benign germ cell tumour Dermoid cyst (mature cystic teratoma) Mature solid teratoma Benign sex cord stromal tumour Sex cord stromal tumour Granulosa cell tumour Theca cell tumour Fibroma Sertoli-Leydig cell tumour Mature Teratoma (Dermoid Cyst) Unilateral (80%) Enlarged (< 10cm in diameter) Other Benign Surface Epithelial Tumours Clear cell/ Brenner/ Endometroid Mesonephroid Transitional Tumor Tumor Epithelial Tumor Tubular glands Cystic neoplasm Solid nests of formation Polypod masses transitional Protrude in cyst (urothelium) like Chocolate cells (fill linings of Clear cytoplasm Resemble lining cystic spaces) of urinary tract Encased in dense fibrous stroma Other Benign Tumours

Older women Surface epithelial cell tumour

Cystadenofibroma Proliferation of fibrous stroma Multinodular tumor Small Multilocular Simple papillary processes

No stratification No stromal invasion Serous Cystadenoma, Mucinous Cystadenoma Serous Cystadenoma

Mucinous Cystadenoma

Malignant Ovarian Tumour Serous Carcinoma (Serous Cystadenocarcinoma), Mucinous Carcinoma (Mucinous Cystadenocarcinoma) Serous Carcinoma (Serous Cystadenocarcinoma) Mucinous Carcinoma (Mucinous Cystadenocarcinoma) Most common (40% of all malignant ovarian tumours) 10% of all malignant ovarian tumours 45 65 y/o Middle adult life (rare - before puberty, after menopause) Secrete serous fluid Secrete mucinous fluid

Serous Cystadenocarcinoma Bilateral (usually) Solid (haemorrhage, necrosis), cystic (large cysts divided by septa multilocular) Nodular irregularities (papillary projections)

Mucinous Cystadenocarcinoma Unilateral (usually) Larger, Multilocular Thin-walled cysts with a smooth external surface Mucinous fluid (sticky, gelatinous fluid, rich in glycoproteins) Papillation Serosal penetration (invasion) Solidified areas

Other Malignant Tumours Endometroid Carcinoma Resemble endometrial carcinoma Cystic Unilocular Turbid brown fluid Resemble endometrial epithelial lining (tubular glands)

Clear Cell Carcinoma (mesonephroid) Least common Clear cell pattern (abundant clear cytoplasm) Tubulo-cystic pattern Hob-nail appearance

Brenner Tumour Uncommon (only some is malignant) Solid Unilateral Transitional-like epithelium (resemble urinary tract)

Immature Teratoma Rare Coexist with other germ cell (eg. Choriocarcinoma) Prepubertal adolescent, young women 18 y/o (mean age) Resemble fetus/ embryo tissue (rather than adult) Gross Solid Smooth external surface Areas of haemorrhage, necrosis Hair Cartilage Grumous material Histology Immature tissues (cartilage, bone, glands) Immature neuroepithelium

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