婦產(chǎn)科學(xué) 卵巢腫瘤(英文)

OvarianTumor

Ovariantumor

Ovariancanceristhemostlethalgynecologicalcancer,rankingninthinincidence,butfifthinlethality,amongwomenintheUSAMainpresentationwithadvanced-stagediseaseduetolatesymptomsandthelackofeffectivescreeningforearlydisease,aswellasTreatedbycytoreductionandchemotherapywithcombinationtaxanesandplatinum,prolongssurvivaleveninthepresenceofstageIVdiseaseDuetochemoresistancealongwithtumorprogression;the5-yearsurvivalrateofpatientswithadvanced-stagehasremained30%-40%2ClassificationofOvariantumorHistologicalclassificationPercentageOriginEpithelialtumors50%-70%CoelomicormesotheliumGermcelltumors20~40%PrimordialcellsSexcord-Stromaltumors5%SexcordsorovarianstromaMetastatictumor5%-10%Femalegenitaltract,breast,gastrointestinaltract3EpithelialOvariantumorsHistologicaltypeCellulartypeSeroustumorEndosalpingealMucinoustumorEndocervicalEndometrioidtumorEndometrialClearcelltumorMullerianBrennerTransitionalMixedepithelialMixedcellulartypeUndifferentiatedAnaplastic4Germcelltumor

DysgerminomaYolksactumorEmbryonalcarcinomaPolyembryomaNon-gestationalChoriocarcinoma

Teratoma

●Mature:Solid,Cystic(dermoidcyst)

●Immature

●

Monodermal(e.g.struma

ovarii,carcinoid)Mixed5Sexcord-stromaltumorsGranulosa-stromalcelltumors:

Granulosacelltumors

Thecomas

FibromasSertoli-leydigcelltumors(androblastoma)Mixedorunclassifiedsexcord-stromaltumors6ClinicalmanifestationThemostcommonsymptomsinclude:bloatingpelvicorabdominalpaintroubleeatingorfeelingfullquicklyurinarysymptomssuchasurgencyorfrequencyThesesymptomsarealsocommonlycausedbybenigndiseasesandbycancersofotherorgans.Theyoccurmoreoftenoraremoresevere.7ClinicalmanifestationWomenwhohavethesesymptomsalmostdailyformorethanafewweeksshouldseethedoctor.preferablyagynecologist.Otherssymptomsofovariancancercaninclude:fatigueupsetstomachbackpainpainduringsexconstipationmenstrualchanges8ComplicationTorsionofpedicleRuptureInfectionCanceration9DiagnosisImagingstudies

Ultrasonography,AbdominalX-ray,CT,MRI,PETBloodtumormarker

CA-125,AFP,HCGBiopsyItcanbedoneduringthelaparoscopyprocedure.Usually,abiopsyisdoneatthetimeofsurgery.Ascitesaspirationforcytology10DifferentialDiagnosis

DifferentialContentsBenign

neoplasmsMalignant

neoplasmsHistorylongclinicalcourse,graduallyenlargeShortclinicalcourse,rapidlyenlargeFeaturesofneoplasmOftenunilateral,movable,cystic,smoothOftenbilateral,solidorsemisolid,irregularity,fixedAscitesnoneOften

asciteswithmalignantcells

GeneralconditiongenerallygoodconditioncachexiaB-Ultrasounddarkfluidechoarea,intracystic

diaphrragm,definedboundaryMixedstrongpointswithindarkfluidarea,poorboundaryCA125(>50y)<35U/ml

>35U/ml11DifferentialDiagnosis

DifferentialdiagnosisofbenignovarianneoplasmTumor-likedisease:follicularcyst,lutealcyst

Tubo-ovariancystuterinemyoma

pregnantuteruslargequantityascitesDifferentialdiagnosisofmalignantovarianneoplasmendometriosisTBperitonitisextra-reproductivetracttumorsMetastaticovariantumorpelvicconnectivetissuesinflammation12METASTASIS

13SurgicalStaging(FIGO2000)StageIGrowthlimitedtotheovariesIaGrowthlimitedtooneovary;noascitescontainingmalignantcells.Notumorontheexternalsurface;capsuleintact.IbGrowthlimitedtobothovaries;noascitescontainingmalignantcells.Notumorontheexternalsurfaces;capsulesintact.IcaTumoreitherstageIaorIbbutwithtumoronthesurfaceofoneorbothovaries;orwithcapsuleruptured;orwithascitespresentcontainingmalignantcellsorwithpositiveperitonealwashings.StageIIGrowthinvolvingoneorbothovarieswithpelvicextensionIIaExtensionand/ormetastasestotheuterusand/orfallopiantubes.IIbExtensiontootherpelvictissues.IIcTumoreitherstageIIaorIIbbutwithtumoronthesurfaceofoneorbothovaries;orwithcapsule(s)ruptured;orwithascitespresentcontainingmalignantcellsorwithpositiveperitonealwashings.1415SurgicalStaging(FIGO2000)StageIIITumorinvolvingoneorbothovarieswithperitonealimplantsoutsidethepelvisand/orpositiveretroperitonealoringuinalnodes.SuperficiallivermetastasisequalsstageIII.Tumorislimitedtothetruepelvis,butwithhistologicallyprovenmalignantextensiontosmallboweloromentumIIIaTumorgrosslylimitedtothetruepelviswithnegativenodesbutwithhistologicallyconfirmedmicroscopicseedingofabdominalperitonealsurfaces.IIIbTumorofoneorbothovarieswithhistologicallyconfirmedimplantsofabdominal

peritonealsurfaces,noneexceeding2cmindiameter.Nodesnegative.IIIcAbdominalimplants>2cmindiameterorpositiveretroperitonealoringuinalnodesorboth.StageIVGrowthinvolvingoneorbothovarieswithdistantmetastasis.Ifpleuraleffusion

ispresent,theremustbepositivecytologictestresultstoallotacasetostage

IV.ParenchymallivermetastasisequalsstageIV.1617EpithelialOvariantumorINTRODUCTIONEpithelialovariantumor(EOC)isthemostcommonovariantumor.MalignantEOCaccountforabout90%ofmalignantovariantumorsItincludesbenign,borderlineandmalignanttumorMajorityoccursbetween30~60yearsold19RiskFactors

InheritedGeneticFactors:5%-10%

HBOC:Hereditarybreast-ovariancarcinomaHSSOC:Hereditarysite-specificovariancancersyndromeHNPCC:hereditarynonpolyposiscolorectalcancerBreast/ovarianfamilialcancersyndrome(BRCA1,BRCA2)PersistantovulationPredisposingfactors:Nulliparity,PrimaryinfertilityProtectivefactors:Multiplepregnancy,Lactation,OCTEnvironmentalfactorsandothersoringredientIndustrialchemicalproducts,diethabit20EpithelialOvarianTumors-BenignBenignepithelialovariantumorsMostepithelialovariantumorsarebenign,donotspread,andusuallydonotleadtoseriousillness.Thereareseveraltypesofbenignepithelialtumors:SerousAdenomasMucinousAdenomasBrennerTumors21Serous&Mucinous

cystadenoma

SerouscystadenomaMucinous

cystadenoma22EpithelialOvarianTumors-BorderlineBorderlinepithelialovariantumorsBorderlineepithelialovariancancerdonotclearlyappeartobecancerous(lowmalignantpotential)Thesedifferfromtypicalovariancancersinthattheydonotgrowintotheovarianstroma.Likewise,iftheyspreadoutsidetheovary(e.g.intotheabdominalcavity),theydonotusuallygrowintotheliningoftheabdomen.23EpithelialOvarianTumors-CarcinomaAbout85%to90%ofovariancancersareEOC.EpithelialovariancarcinomacellshaveseveralfeatureswhichareusedtoclassifyepithelialovariancarcinomasintoSerousMucinousEndometrioidClearcelltypesUndifferentiatedepithelialovariancarcinomas24TREATMENTBenignOncethediagnosisisconfirmed,operationshouldbeperformedYoungpatientwithunilateraltumororbilateraltumorpostmenopausalpatientwithbenignovariantumormanipualtionprincipleofoperationBorderlineSurgeryisthemajortreatmentStageI

DependingontheexpectationonFertilityStageII-IVSurgicalstaging,cytoreductionifnecessaryChemotherapyControversial,preferredforcellcellcarcinoma25Surgicalstaging

Systematicexplorationofintra-abdominalsurfacesandvisceraCytologicevaluation:hemidiaphargm,pelviccul-de-sac,peritonealwashings,Infracolic

omentectomy:omentum

resectedfromthetransversecolonSelectivelymphadenectomy:pelvic¶-aorticBiopsy:anysuspiciousareasoradhesions;randomizedbiospyoftissuesfromtheperitoneumofthepelviccul-de-sac,paracolicgutters,overthebladder,intestinalmesentaryHysterectomy&bilateralsalpingo-oophorectomyAppendectomyshouldbeperformedformucinouscarcinoma26TREATMENT-MalignantEOCPrincipleSurgerycombinedwithchemo,radiationandothersFIGOI-II

Comprehensivesurgicalstaging

Indicationforfertilitypreservation(a)StageIa,welldifferentiated,(b)negativeevidenceofthecontralateralovarywithnormalappearance(c)Closepostoperativefollow-upFIGOIII-IVCytoreductiveSurgeryGoal:RemovalofalltheprimarycancerandassociatedmetastaticdiseaseAllmetastaticnodulesshouldbereducedtolessthan1cm；OptimalinitialcytoreductionissignificantlycorrelatedwithsurvivalRecurrentControversial,lifequalityshouldbethepriorityoffocusRelieveintestinalobstructionCytoreductiononpatientswhoissensitiveforsecond-linechemotherapyRemovethesingleisolatedlesion27TREATMENT-MalignantEOCAdjuvanttreatmentChemotherapyIntraperitonealchemo:cisplatinIntravenouschemo:TC,TP,PCNeoadjuvant

chemo:FIGOIII-IV,largevolumeascites,pleuraleffusionsEarlystage,highrisk(morepoorlydifferentiated,ormalignantcellseitherinascitesfluidorinperitonealwashings(b)Advanced–stageEOC(FIGOIII-IV)RadiationtherapyWhole-abdominalradiationforrecurrentorpersistentdiseaseisassociatedwithahighmorbidityandisnotrecommendedImmunetherapy（a)Cytokines:IL-2,IFN-α,thymosin（b)CSF,G-CSF,GM-CSFforchemo-inducedbonemarrowsuppression(c)Trialstage:cellularimmunetherapyTIL,DCTargetedtherapyMolecularsignalpathways:VEGF,EGFRResearchfocus&promisingpotential28TREATMENT-SURGERYTheresectionofthepelvictumormayincluderemovaloftheuterus,tubes,andovaries,aswellasportionsofthelowerintestinaltractSeparationoftheomentumfromstomachandtransversecolon29SurvivalbyStageStageRelative5-YearsSurvivalRateIa92.7%Ib85.4%Ic84.7%IIa78.6%IIb72.4%IIc64.4%IIIa50.8%IIIb42.4%IIIc31.5%IV17.5%30GermCellTumorINTRODUCTIONDerivedfromtheprimordialgermcelloftheovary.IncidencesecondarytoEOC,arethemostcommonovariancancersinwomenyoungerthan20years.Mostgermcelltumorsarebenign,althoughsomearecancerousandmaybelifethreatening.ThemostcommongermcelltumorsareTeratomaDysgerminomaYolksactumor(Endodermalsinustumor)Choriocarcinoma

32TERATOMAAtumorpossessingcomponentsresemblingnormalderivativesofmorethanonegermlayersThemalignancyisdeterminedbythetissuedifferentiationratherthantextureMatureTeratoma-dermoidcystGeneral95%ofteratoma,Occursatanyage,mostlybetween20-40yAppearanceUsually,unilateral,moderatesize,roundorelliptic,smoothandthinwallComponentsEndoderm+Etcoderm+Mesoderm;Occasionallymonoderm:struma

ovariiPrognosisBenign,but2-4%malignanttransformation,mostlyseeninpostmenopauseImmatureTeratomaGeneral1-3%ofteratoma,averageageofoccurrenceis11-19yAppearanceUsually,solidtextureaccompaniedwithcysticareasComponents2-3germlayers;Immatureembryonictissue,mainlyprimitiveneurontissuePrognosisMalignancedependsontheratioanddifferentiationofimmaturetissueandthequantityofnervousepithelium.Recurrentandmetastaticrateishigh33TERATOMAMatureTeratomaImmatureTeratoma34DYSGERMINOMAMildmalignant,themostcommonmalignantgermcelltumor,accountingfor30%-40%ofallovariancancersofgermcellorigin;75%occurbetween10-30ylargeround,ovoid,solid,oftenunilateral(right-ovaryinvolvement),moderatesize,eraser-liketexture,smoothsurfaceorlobularappearanceHighlysensitivetoradiationtherapywith90%of5yearsurvivalrate;Poorprognosisifpresentedwithmixedtype35YOLKSACTUMOREndodermalsinustumors(EST),derivedfromtheprimitiveyolksac.Malignant,thethirdmostfrequentmalignantgermcellsoftheovary.Medianageofoccurrenceis16-18yunilateral,relativelylarge,roundorelliptic;Section:partialcystic,brittle,bleeding,necrosisMostsecreteAFP-usefultumormarkerRapiddevelopmentandearlymetastasis,poorprognosis36RareGermcelltumorsoftheovaryEMBRYONALCARCINOMAExtremelyraretumor,multipledifferentiationpotential

Medianageofoccurrenceis14yearsold

Maysecreteestrogen:precociouspseudopubertyorirregularbleeding

Generallylarge,withamediandiameterof17centimetres;

Unilateral,2/3areconfinedtooneovaryatthetimeofdiagnosis

ClinicalpicturessimilartoEST,

Highly

aggressive,extensivemetastasis;LongtermsurvivalhasimprovedfollowingtheadventofchemotherapyChoriocarcinoma

Extremelyraretumor

Histologically,sameappearanceasgestationalchoriocarcinomametastatictotheovaries,

Diagnosis

requiresthepresenceofsyncytiontrophoblasticandcytotrophoblasticcellMostpatientsareyoungerthan20yearsThepresenceofhCG

canbeusefulinmonitoringthepatient’sresponsetotreatmentHighlyaggressive,worseprognosiscomparedtothegestationalchoriocarcinoma37DIAGNOSISClinicalcharacteristicsyoungpatientslargetumorsizehighriskofascitesdevelopmentrapidprogressionPositivetumormarker:AFP，hHCGDynamicleveliscorrelatedwiththeprogressionofdiseaseMonitoringtherecurrenceorresponsetothetreatmentDefinitivediagnosisismadethroughthepathologicalexamination38TREATMENTBenigngermcelltumorUnilateralCystectomyorsalpingo-oophorectomyBilateralCystecomyispreferredifapplicablePerimenopauseHysterectomy&bilateralsalpingo-oophorectomycouldbeconsideredMalignantgermcelltumorSurgeryFortheyoungpatientswithexpectationonfertility,fertilitypreservationshouldbeperformedaslongasthecontralateral

adnexaisintactChemotherapyChemo-sensitive:BEP,BVP,VACRadiationAdjuvanttherapyforsurgeryandchemotherapyDysgerminomaisthemostsensitivetypeSeldomusecurrentlyduetothesideeffectsofradiationonfertility39SexcordstromalTumorINTRODUCTIONDerivedfromthesexcordsandtheovarianstromaormesenchymeAccountforabout5%-8%ofallovarianmalignanciesFunctioningtumorsanunusualgroupoftumorscharacterizedbyhormoneproductionComposedofvariouscombinationsofelements,including：“female”cells(i.e.,granulosaandthecacells)“male”cells(i.e.,SertoliandLeygidcells)41CLASSIFICATIONGranulosa

celltumorAdulttype:Mildmalignant,olderwomen(45-55y),Estrogenproduction,

ClassicCall-Exnerbody,80%of5yearsurvivalrateJuveniletype:Highmalignant,unilateralof98%,occurinchildrenandyoungwomen,rarelyseenCall-ExnerbodyThecacelltumorBenign(rarelydemonstratemalignant)Unilateral,encapsulatedwithfibrouscapsuleEstrogenproduction(Feminization)FibromaBenign,occuratallagesbutaremostfrequentlyseeninmiddle-agedwomenMeigsSyndrome:onoccasion,ascitesorpleuraleffusionsisaccompaniedSertoli-leydigcelltumorAndroblastoma,occurmostfrequentlyinthethirdandfourthdecadesoflige;Typicallyproduceandrogens,andclinicalvirilization

isnotedin70%-85%ofpatients;Mostfrequentlylow-grademalignancy.42TREATMENTBenign:Fibroma,thecacelltumor,sclerosing

stromaltumorUnilateralCystectomyorsalpingo-oophorectomy(youngpatients)BilateralCystecomyispreferredifapplicable(youngpatients)PerimenopauseHysterectomy&bilateralsalpingo-oophorectomycouldbeconsideredMalignant:Granulosacelltumor，