卵巢癌-Ovarian-Cancer-狄文課件

OvarianCancer

DIWEN

M.D.,Ph.D.,Professor&ChairmanDepartmentOfObstetrics&GynecologyRenjiHospitalAffiliatedtoSJTUSchoolofMedicine2006-11-1七年制1OvarianCancerOvarianCancerGeneralIntroductionOvariantumorsarecommonestbetween30and60.Theyareparticularlyliabletobeortobecomemalignant.Intheirearlystages,theyareasymptomaticandpainless.Theymaygrowtoalargesize.1.4%lifetimeriskofovariancancer2006-11-1七年制2OvarianCancerGeneralIntroductionOvariantuRiskFactorsFamilyhistoryOvariancancerBreastcancerColoncancerGeneticfactorsOlderageCaucasianMoremenstrualcirclesduringlifetime(Ovulationinduction)2006-11-1七年制3OvarianCancerRiskFactorsFamilyhistory2006IncidenceNearly25%ofallovarianneoplasmaremalignant.Approximately80％ofthemareprimarygrowthsoftheovary.Theremainderbeingsecondary，usuallycarcinomata.2006-11-1七年制4OvarianCancerIncidenceNearly25%ofallovasymptomsLackofanyspecificsymptoms,ovariantumorsareoftenlargebythetimethedoctorisconsulted.Menstrualfunctionisseldomupset,andanyirregularityisattributedtothepatient’s‘timeoflife’.2006-11-1七年制5OvarianCancersymptomsLackofanyspecificssymptomsIncreasedabdominalsize2006-11-1七年制6OvarianCancersymptomsIncreasedabdominalsisymptomsPressuresymptomsGastro-intestinalsymptoms(Bloating)Urgetourinateplevicpain(adullpaininthelowerabdomen)Verylargetumorsmaycauserespiratoryembarrassmentandedemaorvaricositiesinthelegs,andacharacteristic‘ovariancachexia’develops.2006-11-1七年制7OvarianCancersymptomsPressuresymptoms2006-CLINICALFEATURESOFOVARIANTUMOURS2006-11-1七年制8OvarianCancerCLINICALFEATURESOFOVARIANTCLINICALFEATURESOFOVARIANTUMOURS2006-11-1七年制9OvarianCancerCLINICALFEATURESOFOVARIANTCLINICALFEATURESOFOVARIANTUMOURS2006-11-1七年制10OvarianCancerCLINICALFEATURESOFOVARIANTGeneralRule

Anexperiencedexaminerwillrecognizeanovariantumormainlybecauseovariantumoris,inthecircumstances,themostlikelydiagnosis.AllabdominalswellingsshouldbesubjectedtoultrasoundandX-rayexamination.DIFFERENTIALDIAGNOSIS2006-11-1七年制11OvarianCancerGeneralRule

AnexperiDIFFERENTIALDIAGNOSIS2006-11-1七年制12OvarianCancerDIFFERENTIALDIAGNOSIS2006-11-ASCITES

Afluidthrillmaybeelicitedfromanovariancyst,andascitesandtumormaycoexist;butasarulethedistinctionshouldbeeasilymade.DIFFERENTIALDIAGNOSIS2006-11-1七年制13OvarianCancerASCITESAfluidthrillmUterineFibroids

Alargemidlineintramuralfibroidmaybeimpossibletodistinguishfromasolidovariantumoruntiltheabdomenisopenedandanentirelydifferentsurgicalproblemencountered.DIFFERENTIALDIAGNOSIS2006-11-1七年制14OvarianCancerUterineFibroidsAlargDIFFERENTIALDIAGNOSIS2006-11-1七年制15OvarianCancerDIFFERENTIALDIAGNOSIS2006-11-DIFFERENTIALDIAGNOSIS2006-11-1七年制16OvarianCancerDIFFERENTIALDIAGNOSIS2006-11-DIFFERENTIALDIAGNOSIS2006-11-1七年制17OvarianCancerDIFFERENTIALDIAGNOSIS2006-11-HistologicalClassificationMosttumorsarisefromtheovarianstromaandgerminalepithelium.TheembryoniccoelomfromwhichthatepitheliumdevelopsalsogivesrisetotheMullerianductfromwhichdevelopthestructuresofthegenitaltract,anditisthiscommonoriginwhichexplainsthegreatvarietyofepithelialpatternswhicharemetwith.2006-11-1七年制18OvarianCancerHistologicalClassificationPrimaryEpithelialTumorMucinouscystadenomaorcystadencarcinoma(of.Cervicalepithelium).Serouscystadenomaorcystadenocarcinoma(of.tubalepithelium).EndometriomaorEndometrioidcarcinoma(of.Endometrium).Clearcellcarcinoma.Brennertumour.2006-11-1七年制19OvarianCancerPrimaryEpithelialTumorMucinoOvarianGermCellTumorFibromaorsarcoma..Dysgerminoma..Teratoma..Gonadoblastoma..Yolksactumour..Carcinoid.ThyroidtumourChoriocarcinoma2006-11-1七年制20OvarianCancerOvarianGermCellTumorFibromaGonadalSexCordStromalTumorEstrogen-producing:Granulosacelltumour.Thecoma.Androgen-prodicing:Sertoli-Leydigcelltumor(Arrhenoblastoma).Hilarcelltumour.Lipoidcelltumour.2006-11-1七年制21OvarianCancerGonadalSexCordStromalTumorKrukenbergTumorThereisonewell-knownsecondarytumouroftheovary,thekrukenbergtumour,asecondaryofastomachcarcinoma.2006-11-1七年制22OvarianCancerKrukenbergTumorThereMucinouscystadenoma

Aunilocularormultilocularcystofovarylinedbytallcolumnarepitheliumresemblingthatofthecervixorlargeintestine.Itisusuallylargeandmayreachimmenseproportions,occupyingthewholeperitonealcavityandcompressingotherorgans.Itmayoccuratanyage.2006-11-1七年制23OvarianCancerMucinouscystadenomaAOVARIANTUMOURS--MUCINOUSCYSTADENOMA2006-11-1七年制24OvarianCancerOVARIANTUMOURS--MUCINOUSCYS

SEROUSCYSTADENOMA

Aunilocularormultilocularcystlinedbyepitheliumsimilartothefallopiantube.Theyarethemostcommonbenignepithelialtumorsandform20%ofallovarianneoplasm.In10%ofcasestheyarebilateral.Itisuncommontofindthemlargethanafetalhead.2006-11-1七年制25OvarianCancerSEROUSCYSTADENOMAAuOVARIANTUMORS--SEROUSCYSTADENOMA2006-11-1七年制26OvarianCancerOVARIANTUMORS--SEROUSCYSTADSerouscystadenocarcinoma

Thisisbyfarthecommonestprimarycarcinoma,accountingfor60%ofallcases,andinoverhalfthecasesitisbilateral.Thecystsarealwaysofpapillarytypeandtheepitheliumburrowingthroughthecapsuleproducespapillaryprocessesontheseroussurface.Extensionofthegrowthtothepelvisandadjacentorgansfixesthetumor.Ascitesisalwayspresent.2006-11-1七年制27OvarianCancerSerouscystadenocarcinomaEndometrioidCarcinomaoftheOvary

Itisnowrecognizedthatcarcinomaoftheovarymaybeofendometrialtype,sometimesarisinginendometrioma.Attacksofpain,unusualwithovariancancer,arecommon.Sometimesthereisuterinebleedinginpost-menopausalcases.2006-11-1七年制28OvarianCancerEndometrioidCarcinomaoftheEndometrioidCarcinomaoftheOvary

Usuallythelesioniscysticandchocolatebrownincolor.Ifsuchacystrupturesspontaneously,malignancyshouldbesuspected.Thehistologyvariesasinuterinecarcinoma.Itmaybeawell-differentiatedadenocarcinoma,anadeno-acanthoma,mucinousadenocarcinomaorclear-celledcarcinoma.2006-11-1七年制29OvarianCancerEndometrioidCarcinomaoftheFibromaThisiscomposedoffibroustissueandresemblesfibromatafoundelsewhere.Itismostcommonintheelderlyandaccountsfor4-5%ofallovarianneoplasm.Thefibromaisbelievedbymanytobeathecomawhichhasundergonefibroustransformation.ItissometimesassociatedwithMeig’ssyndrome.2006-11-1七年制30OvarianCancerFibromaThisiscomposedoffiDysgerminomaThisistheonlysolidovariantumorofcharacteristicappearance.Usuallyovoidwithasmoothcapsule,itisofrubberyconsistencyandgreyishcolour.Itiscommonestinyoungeragegroups,under30yearsasarule,andisoftenbilateral.Sometimesitisfoundincasesofintersex.2006-11-1七年制31OvarianCancerDysgerminomaThisistheTeratomaCysticteratomaordermoidSolidteratoma2006-11-1七年制32OvarianCancerTeratomaCysticteratomaorderYolkSacTumorrareChildrenandyoungadultshighlymalignantalphafetoprotein2006-11-1七年制33OvarianCancerYolkSacTumorrare2006-11-1Estrogen-producingTumorsThesebelongtothegranulosa-thecacellgroupandarefoundatallages.Theyaccountfor3%ofallsolidtumorsoftheovary.2006-11-1七年制34OvarianCancerEstrogen-producingTumorsEstrogen-producingTumorsInchildhoodthereisacceleratedskeletalgrowthandappearanceofsexhair.

5%occurinchildrenprecociouspuberty.

60%occurinchild-bearingyearsirregularmenstruation.

30%occurinpost-menopausalwomenpost-menopausalbleeding.2006-11-1七年制35OvarianCancerEstrogen-producingTumorsAndorogen-producingTumoursThreedistincttypesofmasculinisingovariantumorarerecognised:a)Sertoli-Leydigcelltumor(Arrhenoblastoma),b)Hilarcelltumor,c)Lipoidcelltumor.Allthreecauseamenorrhoea.2006-11-1七年制36OvarianCancerAndorogen-producingTumoursSpread-DirectThefirstspreadisdirectlyintoneighbouringstructures–peritoneum,uterus,bladder,bowelandomentum.2006-11-1七年制37OvarianCancerSpread-DirectThefirsSpread-Lymphatics

Ovariandrainageistothepara-aorticglands,butsometimestothepelvicandeveninguinalgroups.Cellsseededontotheperitoneumaredrainedviathelymphaticchannelsontheundersideofthediaphragmintothesubpleuralglandsandthencetothepleura.2006-11-1七年制38OvarianCancerSpread-LymphaticsOvariaSpread-BloodStream

Bloodspreadisusuallylate,totheliverandlungs.2006-11-1七年制39OvarianCancerSpread-BloodStreamBlooStagingofovariancancerSTAGEIGrowthlimitedtoovariesIaLimitedtooneovary.Noascites.IbLimitedtobothovaries.Noascites.IcAscitesorpositiveperitonealwashingsalsopresentortumouronsurfaceofoneorbothovariesorcapsuleruptured.2006-11-1七年制40OvarianCancerStagingofovariancancerSTAGEStagingofovariancancerSTAGEIIPelvicextensionIIaSpreadtouterus/tubesIIbSpreadtootherpelvictissuesIIcIIbwithascitesorpositiveperitonealwashingsortumouronsurfaceofoneorbothovariesorcapsuleruptured.2006-11-1七年制41OvarianCancerStagingofovariancancerSTAGEStagingofovariancancerStageIIIExtrapelvicintraperitonealspreadand/orretroperitonealoringuinalpositivenodes,orsuperficiallovermetastases.IIIaApparentlimitationtotruepelvisIIIbHistologicallyprovenabdominalperitonealsuperficialimplants<2cmdiameter.IIIcAbdominalimplants>2cmdiameterorpositiveretroperitonealoringuinalnodes.2006-11-1七年制42OvarianCancerStagingofovariancancerStageStagingofovariancancerStageIVDistantmetastasesorpleuraleffusionwithpositivecyotlogyorparenchymallivermetastases.2006-11-1七年制43OvarianCancerStagingofovariancancerStageDiagnosisPelvicexamUltrasoundCTscanCA125bloodtestSURGERY2006-11-1七年制44OvarianCancerDiagnosisPelvicexam2006-11-1TORSIONofthePEDICLE

ThecommonestcomplicationOccurwithanytumorExceptthosewithadhesions2006-11-1七年制45OvarianCancerTORSIONofthePEDICLEThecomClinicalFeatures-SubacuteThepatientcomplainsofrecurrentabdominalpainwhichpassesoffasthepedicleuntwists.Thereisariseinpulseandtemperatureduringthebleeding;Andoveraperiodanemiadevelops.TORSIONofthePEDICLE2006-11-1七年制46OvarianCancerClinicalFeatures-SubacuteClinicalFeatures-acuteThesignsandsymptomsarethoseofanacuteabdominalcondition.Theproblembecomesoneofdifferentialdiagnosistoexcludethoseconditionsinwhichlaparotomyisnotneededandlaparoscopymaybeuseful.

Paintendstobeintenseandcontinuous.TORSIONofthePEDICLE2006-11-1七年制47OvarianCancerClinicalFeatures-acuteTRupturedCyst

Thismayoccuraloneorinconjunctionwithtorsion.Ruptureisnotparticularlyupsettingtothepatientunlessthecontentsareirritant.TORSIONofthe

PEDICLE2006-11-1七年制48OvarianCancerRupturedCystThismayoSuggestiveofMalignancyAge.Ifthepatientisover50thechanceofmalignancyisover50%asopposedtolessthan15%inpremenopausalwomen.Tumorsinchildhoodareusuallymalignant.Rapidgrowth.Ascites.2006-11-1七年制49OvarianCancerSuggestiveofMalignancyAge.ISuggestiveofMalignancySolidtumours,especiallywhenbilateral.Multilocularcystswithsolidareas.(Atleast10%ofcystsaremalignant).Pain.Pressurepaincanoccurwithanytumor;Butreferredpainsuggestsmalignantinvolvementofnerveroots.Tumormarkers,suchasCA125,maybemeasuredintheblood,butanormalleveldoesnotexcludemalignancy.2006-11-1七年制50OvarianCancerSuggestiveofMalignancySolidTreatment

SurgeryChemotherapyRadiationTherapy?HormonalTherapy2006-11-1七年制51OvarianCancerTreatmentSurgery2006-11-1七年SurgicalProceduresToclassifythegrowthaccordingtoitsextentofspread(staging)asaccuratelyaspossible.Toremoveasmuchcanceroustissueaspossible(‘surgicaldebulking’;’cyto-reductivetreatment’).2006-11-1七年制52OvarianCancerSurgicalProceduresToclassifySurgicalProceduresBenignovarianover

10cmindiametermustberemoved,butclinicalandultrasonicallydiagnosedcystsunder10cm(thesizeofalemon)inwomenunder35yearsmaybereviewedinafewmonthsifthereisnosuspicionofmalignancy.Afollicularorluteralcystmayresolvespontaneously.2006-11-1七年制53OvarianCancerSurgicalProceduresBenigSURGICALTREATMENTOFOVARIANTUMMOURS2006-11-1七年制54OvarianCancerSURGICALTREATMENTOFOVARIANSURGICALTREATMENTOFOVARIANTUMMOURS2006-11-1七年制55OvarianCancerSURGICALTREATMENTOFOVARIANSURGICALTREATMENTOFOVARIANTUMMOURS2006-11-1七年制56OvarianCancerSURGICALTREATMENTOFOVARIANFollow-up

Follow-upwithintensivechemotherapy,usingvariouscombinationsofantineoplasticdrugs.Taxanes,probablycombinedwithplatinumcompounds,areanappropriatefirstchoice.2006-11-1七年制57OvarianCancerFollow-upFollow-upwSecondLookA‘secondlook’laparotomyorlaparoscopyoperation(SLO),todeterminetheactualeffectivenessofthechemotherapyandtodecidewhetheritshouldbestoppeddoesnotaffectprognosis,soshouldonlybeperformedwithinformedconsentinclinicaltrials.2006-11-1七年制58OvarianCancerSecondLookA‘secondloSurgicalProcedures-IncisionAverticalincisionwhichcanbeextendedisessentialtoallowafullinspection.Reductionofacystbytappingandextractionthroughasuprapubicincisi