malignancy of the endometrium, ov, ft
TRANSCRIPT
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MalignantNeoplasmoftheEndometrium,Ovary,FallopianTube
andPeritoneumAngelitoMagnoM.D.,FPOGS,FSGOP,FPSCPC
DeLaSalleHealthSciencesInsRtuteMarch24,2017
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EndometrialCancer
• 13thMCcancerinbothsexes• 7thleadingsiteamongwomen• 3rdMCgynecologicmalignancy• MostcommonmalignancyofthefemalegenitaltractintheUSandotherdevelopedcountries
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EndometrialCancer
• PerimenopausalandPostmenopausalage(50-65yearsold)
• 10-15%-youngerthan50years• 5%-womenlessthan40yearsold
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EndometrialPathology:Progression
Normal Hyperplasia Cancer
UnopposedEstrogen
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EarlyMenarcheHPNCC/Lynchsyndrome
Age
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SYMPTOMSandSIGNS
• Postmenopausalbleeding• Abnormalpremenopausalandperimenopausalbleeding
• Discharge• Pelvicpain• Uterineenlargement
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Transvaginalultrasonography
• Threshold:Endometrialthickness
• ReproducRveage– ProliferaRvephase:8mm– Secretoryphase:upto1.4cm
• Postmenopausalage:<5mm
• NotausefultoolforasymptomaRcTamoxifenusers
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DIAGNOSIS
• HistologicexaminaRonoftheendometrium• OfficeEndometrialBiopsy
– Novak’scuret– Pipelle-usefuliftheendometrialthicknessof>6mm– 1stlineinthediagnosisofendometrialcancer– Endometrialsampleisobtainedintheclinicwithnoanesthesia
– Advisableonlyforpostmenopausalwomenwiththickenedendometrium(notforpre-menopausalwomen)
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OfficeEndometrialBiopsy
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Diagnosis
• IfinadequateoutpaRentevaluaRonorsample– FracRonal/Endometrialcurefage– Hysteroscopy
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FracRonalcurefage
• Underregionalanesthesia• Completescrapingoftheendocervicalandendometriallinings
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DIAGNOSIS HYSTEROSCOPY
• Videoscopeisintroducedtranscervicallytovisualizeendometrialcavity
• Togetherwithbiopsy,consideredthegoldstandardfortheinvesRgaRonofwomenwithsymptomsofendometrialpathology
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Papsmear
• Screeningtoolforcervicalcancer
• NOTagoodscreeningtoolforendometrialcancer
• Only50%orlessofcasesdetectedbypapsmear
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Endometrioidadenocarcinoma
• Mostcommontypeofendometrialcancer• Glandsareinbacktobackpafernwithminimalornoinbetweenstroma
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Endometrioidadenocarcinoma
Backtobackpafern
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Endometrioidadenocarcinoma
DegreeofdifferenRaRon• Grade1-well-differenRated,<5%solidcomponents
• Grade2-moderatelydifferenRated,6-50%solidcomponent
• Grade3-poorlydifferenRated,>50%solidcomponent
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Adenocarcinomawithsquamouscomponent
• Previouslytermedasadenoacanthomaoradenosquamouscarcinoma
• Mixtureofglandular(adeno)andsquamousepithelium
• PrognosisdependsonthedifferenRaRonoftheglandularcomponentandnotfromsquamouspart
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UterinePapillarySerousCarcinoma
• Highlyvirulent• Uncommonhistologicsubtypeofendometrialcarcinomas(5%to10%)
• Histologicallyresemblepapillaryserouscarcinomasoftheovary
• Finger-like(papilla)projecRons
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ClearCellCarcinoma
• lesscommon(<5%)• Resemblesclearcelladenocarcinomasoftheovary,cervix,andvagina
• Hobnailcells• Clearcytoplasmwithnucleusontheside
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UPSCandClearcell
• Prognosisisworsethanthetypicalendometrioidadenocarcinoma
• Stage1endometrioidadenoarcinomahas5yearsurvivalof>90%butonly50%inbothUPSCandClearcellcarcinoma
24/03/2017 #DLSHSI_GYNEONCO2017 @doc_magno*ReporRngofposiRveperitonealcytology
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StageI:confinedtotheCorpus
IA-Endometriumor<50%ofthemyometrium
IB->50%oftheendometrium
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StageII:Cervicalstromabutnotbeyondtheuterus
II:tumorinvadesthecervicalstroma
*invasionofcervicalglandsisNOWstageIA
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StageIII:Localorregionalspread
IIIA:Involvementofserosaofthecorpus
andAdnexa
*PosiRveperitonealcytologyisnolongerstageIIIA
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StageIII:Localorregionalspread
IIIB:Vaginaland/orParametrialinvolvement
ParametrialRssue:paravaginalRssues,broadligament,cardinalligament,paracervicalRssues,otherpelvicRssues
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StageIII:Localorregionalspread
IIIC:RegionalNodes
IIIC1:pelvicnodes
IIIC2:paraaorRc nodesw/orw/opelvicnodes
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StageIVA:
IVA:bladdermucosaorrectal
mucosalinvolvement
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StageIVBIVB:Distantmetastases
includingintra-abdominalorgansand
inguinalnodes
*intra-abdominalorgans=organsabovethepelvicbrim
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PosiRvePeritonealcytology
• Shouldbereportedseparatelywithoutchangingthestage
• Example:– Endometrialadenocarcinoma,endometrioidtype,stageIB,(+)peritonealfluidcytology
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PrognosRcFactors
ClinicalFactors PathologicFactorsAgeStageRace
TumorgradeHistologictypeTumorsizeDepthofmyometrialinvasion,VascularspacesinvolvementExtrauterineinvolvement(lymphnodes,peritoneumoradnexa)
FactorsthataffectprognosisofthepaRents
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STAGE
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MYOMETRIALINVASION
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PafernofSpread• A.Directextension
– Transtubalortranscervical/transvaginalspread• B.LymphaRcs• C.Hematogenous
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PafernofSpread(LymphaRcs)(1)asmalllymphaRcbranchalongtheroundligamentthatrunstotheinguinalfemoralnodes
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PafernofSpread(LymphaRcs)(2)branchesfromthetubal(3)ovarianpedicles(infundibulopelvicligaments),whicharelargelymphaRcsthatdrainintothepara-aorRcnodes;
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PafernofSpread(LymphaRcs)(4)thebroadligamentlymphaRcsthatdraindirectlytothepelvicnodes
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PafernofSpread(LymphaRcs)(1)asmalllymphaRcbranchalongtheroundligamentthatrunstotheinguinalfemoralnodes(2)branchesfromthetubal(3)ovarianpedicles(infundibulopelvicligaments),whicharelargelymphaRcsthatdrainintothepara-aorRcnodes;(4)thebroadligamentlymphaRcsthatdraindirectlytothepelvicnodes2,3,4-clinicallymostimportant
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EvaluaRon
• Imagingtechniques-CTScan,MRI,PET/CTScan
• ColorDopplerUltrasound• CA125
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IMAGINGTECHNIQUES
-SGOP2015CPG
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ColorDopplerUltrasound
• adjunctultrasound• DetectsneovascularizaRon(abnormalvesselformaRon)
• Highresistanceindex-featureofmalignancy
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CancerAnRgen(Ca)125
• Generallyusedinepithelialovariancancer• Usedinadvancedstageendometrialcancertodetectextrauterineinvolvementandaspost-operaRvemonitoring
• Notusefulinearlystagedisease• Non-specifictoendometrialcancer
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SURGERY
• primarytreatmentmodality• Surgicopathologicstaging(usingthe2009FIGOStagingsystem)
• ExcepRons:– PaRentswithpoorsurgicalriskduetounstablemedicalcondiRons
– YoungcancerpaRentsdesirousoffutureferRlity– Willusethe1971FIGOClinicalStagingSystemofEndometrialcancer
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Surgery
Completestaging• Peritonealfluidwashing• Totalhysterectomywithsalpingo-oophorectomy
• Bilateralpelviclymphadenectomy• *Para-aorRclymphadectomy
– Notdoneforlowriskcancer
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Surgery
• Surgicalstaging(1) tumorspreadwithintheuterus(2) degreeofpenetraRonintothemyometrium(3) extrauterinespreadtoretroperitoneal
nodes,adnexa,and/ortheperitonealcavity
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Surgery
• Opensurgery/Laparotomy• Minimallyinvasiveapproach
– ConvenRonalLaparoscopy– RoboRc
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Minimallyinvasivetechniques
Advantages• Samepathologicoutcome(adequacyofRssues,nodenumber)
• Shorterhospitalstay• Smallerwound• BeferQOLpost-operaRvely• Lessbloodloss,lesscomplicaRons
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OthertreatmentmodaliRes
• UnstablemedicalcondiRons• YoungpaRentsdesirousofpregnancy
• RadiaRonalone• Medicaltherapy
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RadiaRon
• RadiaRonalone:Inferiorthansurgery– Stage1surgeryalone:87%5yrsurvivalversus67%forradiaRonalone
– NotrecommendedforpaRentsdesirousofpregnancy(radiaRonwillkilltheovaries)
• Asadjuvanttherapy:givenpost-operaRvetreatmentifwithpoorprognosRcfactors– IncreasessurvivalofpaRentswithadvancedendometrialcancer
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Stage1
SGOP2015CPG
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StageII
SGOP2015CPG
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StageIII
SGOP2015CPG
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StageIV
SGOP2015CPG
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UPSCandClearCellHistology
SGOP2015CPGSimilarsurgicaltreatmentwithovariancancerbecauseUPSCandclearcellcancerbehavelikeovariancancer
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Medical/ConservaRvetreatmentConservaRvetreatmentisonlyofferedtopaRentswhohave:• WelldifferenRatedtumor(endometrioidtype)• Nomyometrialinvasion(asevaluatedbyMRI)• Nocervicalinvolvement• Noextrauterineinvolvement:
– Noadnexalinvolvement– Noparametrialinvolvement– Novaginalinvolvement– Nosuspiciousretroperitonealnodesornoevidenceoflymphnodemetastasis
– NegaRvePFC• NoLVSI(lymphovasularspaceinvasion)• NocontraindicaRonsformedicalmanagement
SGOP2015CPG
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Medical/ConservaRvetreatmentThefollowingarealsoessenRal:• ProgesRnreceptorposiRvity• PaRentunderstandsandacceptsthatthisisnotstandardtreatment– (Informedconsent)–InformpaRentsthattheprocedureofpreservaRonofferRlityissRllexperimentalandthereislowpregnancyrate
• PaRentwithstrongdesiretopreserveherchildbearingpotenRal
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Medical/ConservaRvetreatment• Agentsused:DuraRonoftreatmentisvariable
•Megestrolacetate40-60mg/day•Medroxyprogesteroneacetate(MPA)100-800mg/day•Levonorgestrel-containingintrauterinesystem(LNG-IUS)•Tamoxifen+ProgesRns•Anastrozole+ProgesRns
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Medical/ConservaRvetreatmentMonitoring:• repeatdilataRonandcurefageauer3monthsoftherapy
• Noresponseauer3monthsoftherapy=treatmentfailure
• maintenancetreatmentwithoralcontracepRvepills(OCPs),cyclicprogesRns,depotmedroxyprogesteroneacetate(DMPA),orLNG-IUSunRlpregnancyisdesired
• Ifpregnancyisdesired,afemptsshouldbemadeauer3monthsfromreversionofthecancer.
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OVARIANCANCER
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OvarianCancer
• 2ndmostcommongynecologiccancerandmostcommoncauseofcancerdeathintheU.S
• Incidenceincreaseswithage(beyond50years)-epithelialtumor
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2010PhilippineCancerFactsandEsRmates
0 2000 4000 6000 8000 10000 12000 14000
StomachThyroid
LeukemiaCorpusLiverOvary
Colon/rectumLung
CervixBreast
Es#matedleadingnewcancercases,females
5th
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2010PhilippineCancerFactsandEsRmatesEsRmatedLeadingNewCancerDeaths,females
0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000
Brain/NS
Corpus
Stomach
Ovary
Leukemia
Colon/rectum
Liver
Cervix
Lung
Breast
7th
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Pathogenesis
A.AccumulaRonofgeneRcaberraRon-Rasfamilyofoncogenes-p53
B.InheritedgenemutaRon-BRCAmutaRon&LynchSyndrome
C.DeNovoproliferaRon-incessantovulaRon-PIDandEndometriosisassociatedtumors
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Pa0ernofSpread:
• TranscoelomicdisseminaRonordirectextension
• LymphaRc• Hematogenous
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PresentaRons
• Non-specific(earlysaRety,epigastricpain,bloatedness,weightloss)
• Abdominalenlargement• Pelvicmass• Vaginalbleeding
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DIAGNOSIS• Ultrasoundremainstobethemosthelpfulimaging
examinaRonforovariancancerdiagnosiswiththehighestsensiRvity
• CA125andHE4(morespecifictumormarkerforovarian
cancer)
*However,ROUTINEscreeningforaverage-riskwomenusingTVUTS,CA125andpelvicexamisnotrecommended
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SuggesRveofOvarianmalignancy
• complexmasswithbothsolidandcysRccomponents
• papillaryexcrescencesandprojecRons• internalechoesandseptaRons• Ascites• peritonealmetastasis
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RiskFactors• Nodefinitecause
Factorsthatincreaserisk:• Nulliparity• MenstrualirregulariRes• Hxofbreastorendometrialcancer
FactorsthatcouldbeprotecRve:• Pregnancy• OralcontracepRves
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PoorSurvivalRatedueto:
• Latediagnosis• Noreliablescreeningmethods• Nodefiniteriskfactors• NoknowneRology• Noprecursorlesions• Non-specificsymptomsandsigns
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ContrastofSurgicalFindingsBenign Malignant
Surface papillae Rare Very common Intracytic papillae Uncommon Very common
Solid areas Rare Very common Bilaterality Rare Common Adhesions Uncommon Common
Ascites (>100 ml) Rare Common Necrosis Rare Common
Peritoneal implants
Rare Common
Capsule intact Common Infrequent Totally cystic Common Rare
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FIGO1988 FIGO2014
FIGOGuidelinesCommifee:
RevisethestagingsystemtoimproveuRlityandreproducibility
Ovarian,Fallopiantubeandprimary
peritonealcancer:samestagingsystembecauseofcommonhistology:Seroustype
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FIGO STAGE 1 NEW STAGING OLD STAGING
I Tumor confined to ovaries or fallopian tube(s)
Tumor limited to the ovaries (one or both)
IA Tumor limited to one ovary (capsule intact) or fallopian tube No tumor on ovarian or fallopian tube surface No malignant cells in the ascites or peritoneal washings
Tumor limited to one ovary; capsule intact No tumor on ovarian surface No malignant cells in ascites or peritoneal washings
IB Tumor limited to both ovaries (capsules intact) or fallopian tubes No tumor on ovarian or fallopian tube surface No malignant cells in the ascites or peritoneal washings
Tumor limited to both ovaries; capsule intact No tumor on ovarian surface No malignant cells in ascites or peritoneal washings
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FIGO STAGE 1 NEW STAGING OLD STAGING
I Tumor confined to ovaries or fallopian tube(s)
Tumor limited to the ovaries (one or both)
IC
IC1
IC2
IC3
Tumor limited to one or both ovaries or fallopian tubes with any of the following: Surgical spill intraoperatively Capsule ruptured before surgery or tumor on ovarian or fallopian tube surface Malignant cells in the ascites or peritoneal washings
Tumor limited to one or both ovaries with any of the following:
Capsule ruptured, tumor on ovarian surface, malignant cells in ascites or peritoneal washings
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FIGO STAGE 2 NEW STAGING OLD STAGING
II Tumor involves one or both ovaries or fallopian tubes with pelvic extension (below pelvic brim) or primary peritoneal cancer
Tumor involves one or both ovaries with pelvic extension
IIA Extension and/or implants on the uterus and/or fallopian tubes and/or ovaries
Extension and/or implants on uterus and/or tube(s); no malignant cells in ascites or peritoneal washings
IIB Extension to other pelvic intraperitoneal tissues
Extension to other pelvic tissues No malignant cells in ascites or peritoneal washings
IIC Pelvic extension (IIa or IIb) with malignant cells In ascites or peritoneal washings
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FIGO STAGE 3
NEW STAGING OLD STAGING
III Tumorinvolvesoneorbothovaries,fallopiantubes,orprimaryperitonealcancer,withcytologicallyorhistologicallyconfirmedspreadtotheperitoneumoutsidethepelvisand/ormetastasistotheretroperitoneallymphnodes
Tumorinvolvesoneorbothovarieswithmicroscopicallyconfirmedperitonealmetastasisoutsidethepelvisand/orregionallymphnodemetastasis
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FIGO STAGE 3
NEW STAGING OLD STAGING
IIIA
IIIA1PosiRveretroperitoneallymphnodesonly(cytologicallyorhistologicallyproven)(i)Metastasis<10mmingreatestdimension(ii)Metastasis>10mmingreatestdimensionIIIA2Microscopicextrapelvic(abovethepelvicbrim)peritonealinvolvementwithorwithoutposiRveretroperitoneallymphnodes
Microscopicperitonealmetastasisbeyondpelvis
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FIGO STAGE 3
NEW STAGING OLD STAGING
IIIB Macroscopicperitonealmetastasisbeyondthepelvisupto2cmingreatestdimension,withorwithoutmetastasistotheretroperitoneallymphnodes
Macroscopicperitonealmetastasisbeyondthepelvis,2cmorlessingreatestdimension
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FIGO STAGE 3
NEW STAGING OLD STAGING IIIC
Macroscopicperitonealmetastasisbeyondthepelvismorethan2cmingreatestdimension,withorwithoutmetastasistotheretro-peritoneallymphnodes(includesextensionoftumortocapsuleofliverandspleenwithoutparenchymalinvolvementofeitherorgan)
Peritonealmetastasisbeyondpelvis,morethan2cmingreatestdimensionand/orregionallymphnodemetastasis
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FIGO STAGE 4
NEW STAGING OLD STAGING
IV Distantmetastasisexcluding
peritonealmetastasesIVA:PleuraleffusionwithposiRvecytology
IVB:Parenchymalmetastasesandmetastasestoextra-abdominalorgans(includinginguinallymphnodesandlymphnodesoutsidetheabdominalcavity)
Growthinvolvingoneorbothovarieswithdistantmetastases.Ifpleuraleffusionispresent,theremustbeposiRvecytologytoallotacasetoStageIV.ParenchymallivermetastasisequalsStageIV
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Borderlinetumor/LowMalignantPotenRal
• 10to15%ofepithelialovariancancers• Mostcommon:earlystage• Rarelymetastasizeinlymphnodes• Nuclearatypia,straRficaRonoftheepithelium,formaRonofmicroscopicpapillaryprojecRons,cellularpleomorphism,andmitoRcacRvity
• ABSENCEofstromalinvasion• Recurrenceispossible(usuallylate)
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Pathology:SerousCA
• >50%ofovariancancerareseroushistology• PredominantlycysRcwiththinfluidwithinwithpapillaryexcresences/muralnodule
• Resemblesthefallopiantubeepithelium• Pathognomonic:PSAMMOMABODIES• CA-125:mostusefultumormarker
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Pathology:SerousCA
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Pathology:SerousCA
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Pathology:SerousCA
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Pathology:Endometrioid
• About15to20percentofepithelialovariancancers
• Histology:similartotheendometrialglands• MixtureofcysRcandsolidmass.• AssociatedwithEndometriosisandPID• CA-125alsouseful
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Pathology:Endometrioid
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Pathology:Endometrioid
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This can be cystic with smooth surface and variable amounts of intracystic soft or solid masses or papillae. This can sometimes have necrosis and hemorrhage.
There is irregular, infiltrative proliferation of glandular type epithelium resembling proliferative type endometrium with cytologically malignant nuclear features.
Pathology:Endometrioid
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Pathology:Mucinous
• 5to10percentoftrueepithelialovariancancers• MulRloculated,mulRcysRcmasswiththickmaterialwithin
• Resemblesmucin-secreRngadenocarcinomasofintesRnalorendocervicalorigin
• Associatedwithappendicealtumorandpseudomyxomaperitonei
• CA-19-9(tumormarkerformucin-producingcellslikeappendix,pancreas,intesRne)
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Pathology:Mucinous
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Pathology:Mucinous
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Pathology:Mucinous
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ClearcellcarcinomaoftheOvary
• 5to10percentofepithelialovariancancers• CysRcmasswithsolidcomponent• mostfrequentlyassociatedwithpelvicendometriosisandPID
• PresenceofclearcellandHOBNAILcells
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ClearcellcarcinomaoftheOvary
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Management:Ovariancancer
Surgery– ExploratoryLaparotomy(midlineverRcal)– Peritonealwashing(diaphragm,rightandleuhemi-abdomen,pelvis)
– CarefulinspecRonandpalpaRonofallperitonealsurfaces
– BiopsyandresecRonofanysuspiciouslesions,masses,andadhesions
– Totalabdominalhysterectomy+bilateralsalpingo-oophorectomy(THBSO)
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• Surgery– (USO)withfrozensecRon(FS)ispermifedforyoungpaRentswithstageI
– Infracolicomentectomyorinfragastricomentectomy
– Randomperitonealbiopsies(undersurfaceoftherighthemidiaphragm,bladderreflecRon,cul-de-sac,rightandleuparacolicrecessesandpelvicsidewalls)
– PelvicandparaaorRclymphnodesampling– Appendectomyformucinoustumors
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– ParacentesisininiRalmanagementofovarianmassisnotrecommended
– Pfannensteilincisionalsonotadvised
– **Tumordebulkingforadvancedstage
– Chemotherapyasadjuvanttherapy
• CarboplaRn-Paclitaxel
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IndicaRonsfor“E”operaRon:
• Anyadnexalmassauermenopauseorbeforepuberty
• solidadnexalmassatanyage• cysRcmass>8cm• cysRcmassbet5-8cm,
– persistent>8wks• (+)complicaRons
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GermCelltumors
• mostcommonovarianmalignanciesdiagnosedduringchildhoodandadolescence
• Symptomsaresimilartotheepithelialcounterpart
• Massdoesnotgrowasbigastheepithelialtumors
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Dysgerminoma• Mostcommonmalignantovariangermcelltumor• Mostcommonovarianmalignancydetectedduringpregnancy
• theonlygermcellmalignancywithasignificantrateofbilateralovarianinvolvement(15-20%)
• Ingeneral:Solid,cream-coloredtumor• large,rounded,polyhedralclearcellsthatarerichincytoplasmicglycogenwithlymphocyteinfiltraRon
• LactateDehydrogenase(LDH)-animpt.tumormarker• 5%-(+)HCG
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YolkSactumor
• PreviouslycalledEndodermalsinustumor• Solid,yellowishtumor• Schiller-Duvalbodiesarepathognomonicwhenpresent
• Alpha-Fetoprotein(AFP)astumormarker
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IMMATURETERATOMA
• 3rdmostcommonmalignantgermcelltumor• Gross:solidw/cysRcspaces• Micro:immatureRssuederivedfrom3germlayers
• usuallyfromendodermal,e.g.neuroepithelium
• Tumormarker:AFP
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This typically has a smooth surface and is cystic. Cut section demonstrates greasy yellow sebaceous material and hair. Often there is a thickening of the cyst wall (Rokitansky's protuberance) from which hair and sometimes teeth and bone arise.
This cystic structure is lined predominantly by skin and cutaneous adnexal structures, usually with abundant sebaceous and sweat glands. Hair is almost always present. Other components include cartilage, bone, bronchial or gastrointestinal epithelium and mature glial tissue. If only skin and adnexal structures are present it can be termed dermoid cyst.
Sebaceous land
skin
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Immature Glands Immature Neural Tissue
Immature Cartilage
The diagnosis of this tumor requires the presence of immature elements derived from any of the three germ layers: skin elements, mature neural tissue, connective tissue, cartilage, bone, gastrointestinal or bronchial epithelium.
IMMATURETERATOMA
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Choriocarcinoma
• HighB-HCG• SyncyRotrophoblastandcytotrophoblastwithnodilatedvilli
• Lesscommongermcelltumors:– Polyembryona– Embryonalcarcinoma– Immatureteratoma
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GermCellTumors
Germ Cell Tumor Tumor Marker Histology
1. Dysgerminoma – MC
LDH Lymphocytic stromal infiltration
2. Endodermal sinus tumor – 2MC
AFP Schiller – Duvall Bodies
3. Teratoma, immature – 3MC
Carcinoid Struma ovarii
AFP
Neuroectodermal
4. Embryonal Carcinoma
HCG, AFP Syncytio
5. Polyembryoma HCG
6. Choriocarcinoma HCG Syncytio / cyto
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ManagementofGermcelltumor
ConservaRvesurgicalmanagement(USO)maybeanopRonformalignantgermcelltumorifthepaRentisyoungordesirousofpregnancyduetohighresponsetochemotherapy
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Sex-Cordtumor:Granulosa-celltumor
• Mostcommon• Feminizing• Symptomsareage-determined• Pre-puberty-isosexualprecociouspuberty• ReproducRve-Abnormalmenstrualcycles• Postmenopause-postmenopausalbleeding
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Sex-Cordtumor:Granulosa-celltumor
• Gross:maybesolidorcysRc• Micro:Call-ExnerBodies-rosefelikearrangementofgranulosacells
• ComplicaRons:endometrialhyperplasiaoradenocarcinoma
• RadiosensiRve• Bilaterality:5%
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Granulosa-celltumor
• AdultGranulosacelltumor– diagnosedauerage30,withtheaverageagebeing52years
– menometrorrhagiaandpostmenopausalbleedingarecommon
– inhibinA,inhibinB,andserumestradiol
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Granulosa-celltumor
• JuvenileGranulosacelltumor– childrenandyoungadults,andhalfarediagnosedbeforepuberty.Themeanageatdiagnosisis13years
– isosexualperipheralprecociouspuberty– Moreaggressive
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ManagementofGranulosacelltumor
Chemotherapyasadjuvanttherapy(Bleomycin,EtoposideCisplaRn)
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MetastaRccanceroftheovary
• Krukenbergtumor• Primarycanceroriginatedfromcolon,stomach,smallintesRne,appendix
• Solidmass• Commonlybilateral• Signet-ringcells
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This tumor typically has rounded, firm, white masses that may be bosselated, yellow or white on cut section. Fleshy, gelatinous or spongy areas are common.
Presence of mucin-laden, signet-ring cells strewn individually and in small clusters within a hypercellular ovarian stroma (occasionally with storiform pattern). The cytoplasm occasionally is granular and eosinophilic rather than pale and vacuolated (sometimes has bull's-eye appearance, containing large vacuole with central eosinophilic body).
Krukenbergtumor
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PrimaryFallopianTubeCancer
• Incidence(US):0.41per100,000women(‘0.14-1.8%’)
• Age:60-79y/ohighestincidencerates• Incidence(Phil):0.1%-0.5%ofallgynecologiccancers
• Age:40-65years,mean=52years
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Criteriatodiagnoseprimarytubalcancer:
1.Gross :maintumorinthefallopiantube2.Micro :mucosashouldbemainlyinvolved :TransiRonbetweenbenign& malignantdemonstrated
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The oviducts, or fallopian tubes, vary from 8 - 14 cm in length and are covered by peritoneum. It is divided into the following potions: interstitium (a), isthmus (b), ampulla (c), and infundibulum (d).
d
c
b b a a
b
c
d
NomalFallopianTube
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This is composed of fine branching papillae (Arrow) covered by one or more layers of epithelium with enlarged pleomorphic hyperchromatic nuclei (inset). There is increased and abnormal mitoses. In poorly differentiated areas, the tumor may grow in solid sheets of cells with small or large foci of necrosis.
InvasiveAdenocarcinomaOfFallopianTube
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Pathology• Themajority(88%)ofPFTCswereadenocarcinomas;
– Serous 44%– Endometrioid19%.– Mixed 3.9–16.7%– UndifferenRated 7.8–11.3%– Mucinous3–7.6%
• TumorGrade– GradeI 15–20%– GradeII 20–30%– GradeIII 50–65%
• Laterality– Unilateral 89%– Bilateral 11%
• Stageatdiagnosiswasfairlyevenlydistributed– localized(36%)– regional(30%)– distant(32%) Stewart et al,
2007
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ClinicalFeaturesClinical Features Percentage Vaginal bleeding or spotting 50%–60%
Abdominal pain, colicky or dull 30%–49%
Abdominal or pelvic mass 60% (range, 12%–84%)
Ascites 15%
Rare presentations (acute abdomen, palpable inguinal node, umbilical-bone cerebral metastases, cerebellar degeneration, asymptomatic)
[38–41]
Postmenopausal bleeding or spotting with negative Pap smear
Pectasides et al, 2009
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LATZKO’STRIADAsyndromewhichconsistsof:1) profusewateryorhoney-coloredvaginal
discharge,2) apelvicmass,and3) colickypelvicpainthatessenRallygoes
awayuponsuddendisappearanceofthemass
AlthoughthistriadisrarelyfoundinpracRce,
it’saclassicdiagnosRcsyndromeforfallopiantubedisease.
Sotto & Manalo, 1994
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Diagnosis
• Imagingstudies– Ultrasound– CTScan– MRI
• CA-125level• Cytology• Pathology
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STAGING:SameasovariancancerTREATMENT:1.Surgery
ConservaRve:StIA&desirousofpregnancyComplete:>StIB
2.Chemotherapy-adjuvant
Agents:sameasinovarianca3.Radiotherapy-rolecontroversial
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PROGNOSIS:Poor5-yearSurvivvalRateStageI 60%II 40%III10%IV0%
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PrimaryPeritonealCarcinoma• Upto15percentoftypicalepithelialovariancancersare
actuallyprimaryperitonealcarcinomas• Serousisthemostcommonhistology
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ThankYou