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Benign Ovarian Tumors

Classification:
I. Functional cyst
• Follicular cyst
 most common cyst
 20 weeks aog – reproductive life
 multiple
 few mm – 15 cm
 at least 2.5 – 3 cm
 Gonadotrophin dependent for growth
 S/Sx same w/ other ovarian tumors
 Functional cyst may be solitary/multiple
 common in:
 young
 menstruating
 CA125 in Pregnancy:
 normal after 12 wks aog
 Grossly:
 translucent
 thin-walled
 filled with a watery, clear to straw-colored fluid
 Histology
 epitelial lining:
 closely packed granulosa cells
 with the spindle-shaped cells of the theca interna deeper in the
stroma
 S/Sx:
 asymptomatic
 Incidental finding on US
 When ruptured:
• tenesmus
• transient pelvic tenderness
• dyspareunia
 Management:
 Initial: observation 2 – 3 months
 if size is stable: OCP
 if size is unstable: evaluate for malignancy
 Indications for Cystectomy in perimenopausal/ menopause
• CA 125: >35
• Size: > 10 cm
• Corpus Luteum Cyst
 at least 3 cm
 associated w/:
 normal endocrine functions
 prolonged progesterone secretion
 develops from mature graffian follicles
 may develop into a corpus Luteum Hemorrhagicum
 S/Sx:
 asymptomatic to acute abdomen
 Halban’s Classic Triad
• delayed menses
• unilateral pelvic pain
• adnexal mass
 cannot differentiate w/ ectopic pregnancy
 Diagnostics:
 Pregnancy Test
 Culducentesis
 Transvaginal US
 Treatment: Cystectomy
• Theca Lutein Cyst
 Least common
 usually bilateral
 moderate to massive enlargement
 due to:
 prolonged/excessive stimulation by gonadotrophins
 increased sensitivity to gonadotrophins
 Hyperreactio Luteinalis:
 multiple luteinize follicular cyst
 Associated w/:
 50% molar pregnancies
 10% ChorioCA
 Pregnancies w/ Large Placentas
 Ovulation Induction Meds
 Grossly:
 20 – 30 cm diameter
 multiple cyst
 Bilateral
 honeycombed appearance
 S/Sx
 asymptomatic to vague pelvic symptoms
 Ascites
 Diagnostic:
 Palpation of ovarian mass
 Pelvic US
 Treatment: Conservative
• Luteoma of Pregnancy
 rare
 not a true neoplasm
 does not arise from corpus luteum of pregnancy
 hyperreaction of theca lutein cells
 regress after pregnancy
II. Benign Neoplasms of the Ovary
• Benign cystic Teratoma/Dermoid cyst/Mature Cystic Teratoma
 contains all 3 germ cell layers
 Teratoma = monstrous growth
 contains mature cells
 may be associated w/ a squamous cell CA in 1% of cases
 Most common benign ovarian tumor in reproductive age group
 slow growing
 Grossly:
 few mm – 25 cm diameter
 80% = < 10 cm
 single/ multiple
 bilateral 10 – 15%
 pedunculated
 unilocular
 thin walled
 shiny
 opaque white color
 thick sebaceous fluid
 with hair, cartilage & teeth
 sebaceous fluid solidifies in room temperature
 Histological:
 skin/appendages
 sebaceous glands
 sweat glands
 hair follicles
 muscle fibers
 cartilage
 bone
 teeth
 glial cells
 GIT & respiratory epithelium
 S/Sx:
 asymptomatic
 abdominal enlargement
 found in the cul de sac/ anterior to the broad ligament
 discovered during:
• routine PE
• Pelvic US
• Laparotomy
 presenting symptom:
• pelvic pain & pressure
 PathoPhysio
 arise from a totipotential cell stem cell
 46, XX chromosome
 Hypothesis:
• parthenogenesis from a 2o oocyte
• fusion of 2nd polar body w/ oocyte
 Treatment: Cystectomy
• Endometriomas
 endometriosis of the ovary that become cystic
 only 5% have ovarian enlargement detected by PE
 1-5 mm to 5 – 10 cm diameter
 larger cyst are usually bilateral
 most common symptom:
 pelvic pain
 dyspareunia
 infertility
 10% of laparotomy due to ruptured endometrioma
 PE:
 tender
 immobile
 Histology:
 Endometrial glands
 Endometrial stroma
 Hemosiderin laden-macropahges

 Management:
 Medical
 Cystectomy
• Fibroma
 most common solid, benign ovarian tumor
 Low malignant potential
 5% of ovarian neoplasms
 20% of all solid tumors of the ovary
 size:
 small nodule to 50lbs
 extremely slow growing
 associated w/ ascites
 ascites is directly proportional to the size of the tumor
 90% unilateral
 solitary-multiple fibromas
 Ave age: 48 y.o
 tumor arises from undifferentiated fibrous stroma
 S/Sx:
 pressure symptoms
 abdominal enlargement
 no change in menstrual flow
 PE:
 palpable pelvic mass
 firm
 Meig’s syndrome
 Fibroma
 ascites
 hydrothorax
 Grossly:
 heavy
 solid
 encapsulated
 grayish white
 Cut-section:
• homogenous white/yellowish tissue
• trabeculated/ whorl like pattern
 Histology
 spindle shaped connective tissue
 stromal cells
 collagen fibers
 Management: Excision
• Transitional Cell Tumors/ Brenner Tumors
 rare
 small
 smooth
 solid fibroepithelial tumors
 benign
 low malignant potential
 40 – 60 y/o
 30% associated w/ serous cystic neoplasia
 mostly unilateral
 Grossly:
 smooth
 firm
 gray-white
 solid tumors
 Histology
 Brenner tumor cyst is lined by an inner layer of endocervical-
type mucinous cells and an outer layer of stratified transitional
cells
 Treatment: Excision

Non-Epithelial Ovarian Tumors

• 10% of all ovarian CA


• includes:
o Germ Cell origin
o Sex-cord Stromal origin
o Metastatic Ca to the ovary
o Rare ovarian tumors

GERM CELL TUMORS


• Derived from primordial germ cells of the ovary
• Second most frequent among ovarian neoplasms
• 20 – 25% of all ovarian tumors
• 1/10th the incidence of malignant germ-cell tumors of the testis
• Can arise from:
o gonad from undifferentiated germ cells
o extragonadal sites: mediastinum and retroperitoneum
• HISTOLOGIC TYPING OF GERM CELL TUMORS:
o DYSGERMINOMA
o TERATOma
 Immature
 Mature
 Solid
 Cystic
 Monodermal & Highly Specialized
 Struma ovarii
 Carcinoid
 Mixed
 Others
o Endodermal Sinus tumor
o Embryonal CA
o Polyembryoma
o Choriocarcinoma
o Mixed forms
• Most frequent malignant tumor:
o Dysgerminoma
o Immature teratoma
o Endodermal sinus tumor
• Tumor Markers
o Embryonal CA
 hCG
 AFP
o Endodermal sinus CA
 AFP
o ChorioCA
 hCG
o Dysgerminoma
 Placental Alkaline Phosphatase
 LDH
• Clinical Features:
o Rapidly growing mass
o Subacute pain  distention, hemorrhage, necrosis
o Pressure symptoms
o Menstrual irregularities
o Abdominal distention ascites
o Palpable adnexal mass
o Signs of ascites, pleural effusion, organomegaly
• Diagnosis:
o Adnexal Mass
 >/= 2 cm in premenarcheal girls
 >/= 8 cm in premenopausal women
o hCG, AFP titers, CBC, liver function tests
o Chest X-Ray, karyotype
o Preoperative CT Scan, MRI

A. Dysgerminoma
• Most common malignant germ cell tumor
• Accounts for 30-40%
• 5 – 10% in patients younger than 20 years of age
• 75% occur between the ages of 10 and 30 years
• 20 - 30% cases associated with pregnancy
• Represent abnormal proliferations of the basic germ cell
• Gross
o 5 to 15 cm
o slightly bosselated
o capsule
o Spongy and gray
o brown on cut
o surface
• Histology:
o large, round, ovoid
o or polygonal cells
o w/ abundant, clear,
o very pale staining
o cytoplasm
o large and irregular
o nuclei w/ prominent
o nucleoli
o mitotic figure seen
• May co-exist with immature teratoma, chorioCA, EST and other extraembryonal
lesions
• 5% cases in phenotypic females with abnormal gonad
o Pure gonadal dysgenesis: 46XY, streak gonads
o Mixed gonadal dysgenesis: 45X/46XY, unilateral streak gonad, contralateral
testis
o Androgen insensitivity syndrome: 46XY
• 75% cases are at stage I
• 85 - 90% cases are confined to one ovary
• 10 - 15% cases are bilateral
• Rapidly growing
• 25% cases are metastatic
• Management:
o Surgery
 Unilateral Oophorectomy
 TAHBSO
 If there is a Y chromosome on karyotype: remove both ovaries
 Inspect and palpate peritoneal surfaces
 Lymphadenectomy
o Radiation
 Dysgerminoma is extremely sensitive
o Chemotherapy
 Allows preservation of fertility
 Tumor markers for ff-up monitoring  AFP, βhCG
o For recurrent Disease:
 Chemotherapy or radiotherapy
 In pregnancy
 Stage 1a  remove ovary
 Advanced stages  continuation of pregnancy depends on
the AOG
 Chemotherapy may be given in the 2nd and 3rd trimester
• Prognosis:
o Stage 1a: 95% 5 year disease – free survival
o Greater possibility of recurrence is seen when:
 Lesion is 10 – 15 cm
 Patient is less than 20 years old
 Microscopic pattern shows numerous mitosis, anaplasia, medullary
pattern

B. Immature Teratoma
• The second most common germ cell malignancy
• Resembles tissues derived from the embryo
• Consist of immature embryonic structures admixed with mature elements
• 10 – 20% of all ovarian tumors in women < 20
• 50% occur in women between the ages of 10 and 20 years
• Rarely bilateral
• Grow rapidly, cause pain early
• 2/3 confined to ovary
• Pure teratomas don’t produce hCG or AFP
• Pathogenesis: proliferation of a meiotic germ cell
• Diagnosis
o X-ray, UTZ  calcifications
o No tumor markers
• Gross:
o smooth external surface
o Predominantly solid maybe cystic
o Necrosis and hemorrhage
o Hair, bone, keratinaceous debris, cartilage
• Histology:
o Immature tissues from all 3 germ cell layers
o Immature neural elements are common and may correlate with outcome
• Classification:
o based on the degree of differentiation and quantity of immature tissue
o The amount of undifferentiated NEURAL tissue is of prognostic importance
 Grade 1 - <1 LPF with immature neural elements
 Grade 2 – 1 to 2 LPF with immature neural elements
 Grade 3 - >3 LPF with immature neural elements
• Management:
o Surgery: unilateral oophorectomy, USO, TAHBSO
o Inspect and palpate peritoneal surfaces
o Hematogenous spread: lungs, liver, brain
o Chemotherapy
o Radiation: not used in primary treatment
• Prognosis:
o Grade of Lesion
o Stage of Disease
o Extent of tumor
C. Endodermal Sinus Tumor
• 10% of malignant germ cell tumors
• The third most frequent malignant germ cell tumor of the ovary
• Also known as:
o Yolk sac tumor
o Mesonephroma
o Mesoblastoma of Vitellium
o Teilum tumor
• Recapitulates extraembryonic tissue: yolk sac
• Presents with abdominal or pelvic pain in 75% of cases
• Peak incidence 19 years
• Range of 16 months to 46 years
• AFP elevated in these tumor
• Metastasis by lymphatic system to: liver, lungs, peritoneum, lymph nodes, bowel
• 15% associated with mature cystic teratomas
• 100% unilateral
• Secretes AFP and rarely -1-antitrypsin (AAT)
• US:
o large predominantly cystic mass measuring 20 to 30 cms in greatest
diameter
o Large, solid, soft tissue components with low level echoes intermixed with
numerous septations
• Gross:
o Soft
o Grayish brown with cystic areas that result from degeneration
o Capsule usually intact
• Histology:
o Presence of endodermal sinus or SCHILLER DUVAL BODIES
o Cystic spaces lined w/ a layer of flattened or irregular endothelium into
w/c projects glomerulus tuft with central vascular core
o Contains clear, glassy cytoplasm
• Management:
o Surgical exploration, USO with frozen section
o TAH and contralateral SO  does not appear to alter the outcome
o Second look laparotomy is not done
D. Embryonal CA
• Least differentiated germ cell tumor
• Differentiated from choriocarcinoma by its lack of syncitiotrophoblast and
cytotrophoblast
• Occurs in patients between 4 and 28 years old
• Secretes estrogen
• Tumor markers  AFP, hCG
• Treatment: same as EST; radiation is of no use
E. ChorioCA
• Pure ovarian choriocarcinoma of germ cell origin is a very uncommon neoplasm
• May originate as:
o Primary gestational CA asstd with ovarian pregnancy
o Metastatic focus from primary gestational carcinoma elsewhere in genital
tract
o Germ cell tumor differentiating in the direction of trophobalstic structures
• Same appearance as gestational choriocarcinoma metastatic to the ovaries
• Mostly affects those , 20 years old
• Tumor markers  hCG
• Isosexual precocity occur in about 50% of patients
• Chemotherapy: MAC, BEP
• Prognosis: poor
• Microscopic:
o Sheets of anaplastic syncitiotrophoblast and cytotrophoblast without
chorionic villi
F. Polyembryoma
• Extremely rare
• Composed of “embryoid bodies”
• Very young, premenarcheal girls with pseudopuberty
• Tumor markers  AFP and hCG
• Chemotherapy  VAC
G. Mixed Germ Cell Tumors
• The most frequent combination  Dysgerminoma + Endodermal Sinus Tumor
• Combination chemotherapy: BEP
• Second look laparotomy: indicated
• The most important prognostic feature:
o Size of primary tumor and relative amount of its most malignant
component
• Stage Ia > 10 cm: 100% survival rate
H. Sex Cord – Stromal Tumors
• 5 - 8% of all ovarian malignancies
• Consist of germ cell and sex cord-stromal elements
• Germ cell resemble dysgerminoma
• “female cells”  granulosa and theca cells
• “male cells”  sertoli and leydig cells
• Classification:
1. Granulosa-stromal-cell tumors
• Low grade malignancy
• Rarely, thecomas & fibromas  fibrosarcoma
• These tumors are most commonly observed in post-menopausal women
• Secretes estrogen
• Are usually unilateral (2% cases are bilateral)
• Gross:
o Smooth, lobulated surface
o Granular and frequently trabeculated
o Yellow or gray-yellow
• Histology:
o round or ovoid cells with scant cytoplasm and may assume small
clusters or rosette formation around a central cavity: CALL EXNER
BODIES
o the nucleus is compact, finely granular or hyperchromatic with a
groove thus resembling “coffee bean”
o other variant patterns include folliculoid, diffuse, cylindroid,
Pseudoadenomatous, mixed
• Features/Clinical Manifestations/Diagnosis:
o Prepubertal: 75% associated with sexual pseudoprecocity
o Reproductive age: menstrual irregularity due to amenorrhea and
cystic hyperplasia
o Postmenopausal: AUB
 5%  endometrial Ca
 25 - 50%  endometrial hyperplasia
o Other signs and symptoms: non-specific
o Tends to be hemorrhagic → rupture → hemoperitoneum
o Usually stage Ia at diagnosis
o Spreads hematogenously → lungs, liver, brain
o Tumor marker: inhibin
• Management:
o Surgery
o Radiation
o Chemotherapy
• Prognosis:
o Prolonged natural history
o Tendency for late relapse
 10 year survival rates 90%
 20 year survival rates 75%
o Presence of residual disease: most important
o DNA Ploidy: an independent prognostic factor
 Residual negative, DNA diploid  96% 10 yr survival rates
• Classifications
a. Granulosa cell tumor
b. Tumors in the thecoma – fibroma group
i. Thecoma
ii. Fibroma
iii. Unclassified
2. Androblastomas; Sertoli leydig cell tumors
• Well-differentiated
o Sertoli cell tumor
o Sertoli-Leydig cell tumor
o Leydig cell tumor; hilus cell tumor
• Moderately differentiated
• Poorly differentiated
• With heterologous elements
• 3rd to 4th decades of life
• < 0.2% of ovarian cancers
• Produces androgens and clinical virilization in 70 to 85%
• ↑ testosterone, androstenedione, DHEAS
• Low grade malignancies; occasionally poorly differentiated
• <1% cases are bilateral
• Gross:
o Average size 13. 5 cm ranging from 5 to 15 cm
o Variable in appearance but usually do not have much blood
filled cysts & are almost unilocular
• Histology:
o Tubules were solid or hollow
o Delicate septa were occasionally seen
o The cells usually had pale to occasionally densely eosinophilic
cytoplasms
• Treatment:
o Unilateral Salpingo-oophorectomy (USO)
o Total Abdominal hysterectomy w/ BSO (TAHBSO)
o Radiation or chemotherapy: of ? value
• Prognosis
o 70 – 90% 5 year survival rate
3. Gynandroblastomas
4. Unclassified
I. Metastatic Tumors
• 5-6% cases
• Source: genital tract, breast, GIT
• Ovaries and vagina: most common site of metastasis to female genital tract
• Four pathways of spread:
o direct extension (tubal Ca, Cervical Ca, adenoCA)
o Lymphatic metastasis: most common
o Hematogenous: nongynecologic, breast Cancer
o Peritoneal implantation
• Krukenberg Tumor
o Makes up 30-40% of metastatic cancer to ovaries
o Arises in the ovarian stroma
o Composed of mucin filled, SIGNET-RING cells
o Primary tumor:
 most common: stomach
 less frequent: colon, breast, biliary tract
 rare: cervix and bladder
o Usually bilateral

EPITHELIAL OVARIAN TUMORS


• Leading cause of death from gynecologic malignancies
• Second most common gynecologic cancer
• The mortality rate is higher than cervical and endometrial cancers combined
• Incidence:
o Most marked beyond 50 years old with gradual, increase continuing to age 70
years followed by a decrease for those over age 80.
• Survival & Mortality Rates
o Lowest survival rate
o Over-all 5 year survival rate of 30 – 35% has changed little for the past two
decades
o Due largely to a late diagnosis
o Hence more than half of patients have advance disease at the time of diagnosis
o Reasons for Late Diagnosis:
 Currently available screening procedures are too costly
 Risk factors has not been fully defined
 Unknown etiology for the development of ovarian cancers
 Absence of identifiable precursor lesions
• Clinical Features
o 80% of cases found in postmenopausal women
o peak incidence = 62 y/o
o <45 y/o relatively rare
o <1% occur before 21 y/o
o 30% in post menopausal women are malignant
o only 7% in premenopausal women are frankly malignant
• Screening:
o Ultrasonography
 screening with transabdominal US is encouraging but specificity is
limited
o Tumor Marker
 CA 125 may contribute to the early diagnosis of epithelial ovarian
cancer
 Can detect 50% of patients with stage I and 60% of patients with stage II
 Specificity can increase if the result is combined with transvaginal
ultrasound
• S/Sx:
o Usually asymptotic
o symptoms are vague and non-specific
o irregular menses = early stages
o urinary frequency or constipation
o Acute pain due to rupture or torsion is unusual
o Advanced Stages symptoms:
 Abdominal distension
 Pelvic and/ or abdominal mass
 Abdominal or pelvic pain
 Abnormal uterine bleeding
 Pressure symptoms
 GI symptoms
 Leg edema
 Systemic symptoms
• Diagnosis:
o No typical clinical history
o No identifiable risk factors
o Suspect if w/ presenting symptom of abdominal enlargement with a pelvic
mass
o Not infrequently the diagnosis is made on the operating table
o Tumor markers that can be found in ovarian malignancy includes:
 serum CA 125
 carcino embryonic antigen
 alpha - feto protein
o ultrasonography and CT scan are of limited use
o final diagnosis is made by histopathologic examination of the mass
• Labs prior to OR
o Hematologic and biochemical assessment
o Chest x-ray
o IVP
o Abdominal and pelvic CT scan or MRI
o Barium enema and colonoscopy
o Bilateral mammography
• Current Diagnostic tools for early detection:
o transvaginal ultrasound
o color Doppler velocimetry
o serum CA 125 determination
o these diagnostic tools can result in the early detection of ovarian cancer but is
not cost effective
• Patterns of spread
o Exfoliation
 most common and earliest mode
 follows the circulatory path of the peritoneal fluid
 the fluid moves with respiration from: the pelvis, paracolic gutters
specially on the right, intestinal mesenteries, to the right
hemidiaphragm
o Lymphatic dissemination
 usually to the para-aortic and pelvic lymph nodes
o Hematogenous spread
 uncommon
 occurs in about 2 – 3% of patients
 seen more frequently in patients who survive the initial disease

PATHOLOGY:
TUMORS OF LOW MALIGNANT POTENTIAL
• Remains in the ovary for long periods
• > Premenopausal women
• Associated with a good prognosis
• Criteria for the Diagnosis of Borderline Tumors
o Epithelial Proliferation with papillary formation & pseudo stratification
o Nuclear Atypia & Increased Mitotic Activity
o Absence of True Stromal Invasion
• BORDERLINE TUMORS
o 20 – 25% may spread beyond the ovary
o Cannot be differentiated w/ a well-differentiated carcinoma
o Diagnosis must be based on the histology of the PRIMARY tumor

1. SEROUS TUMORS
• 40% of primary tumors of the ovary
• Grossly characterized by:
o Presence of multiple papillary, cauliflower-line excrescences on the outside
and inside of the lining of the tumor
o Has friable projections which may be numerous as to fill up the cavities giving
it a solid appearance
o Fluid content is thin and watery but can be viscid and mucoid
• Histology:
o Epithelium is made up of ciliated and non – ciliated low columnar or cuboidal
cells similar to the fallopian tube lining
o There are laminated calcific granules (psamoma bodies) – (+)good prognosis
• Bilateral in 35 – 50% of cases
2. Mucinous Tumors
• 15% of all primary ovarian carcinomas
• Bilateral in 10% of cases
• Grossly:
o Attains a large size up to 200 – 300 lbs.
o Generally multiloculated
o With firm solid areas
o Some have intracystic papillary excrescences
o Fluid content is usually mucoid but can also be watery
• Microscopically
o Epithelium consist of stratified tall columnar cells with basal nuclei similar with
the endocervix
o This cells contain mucin
o The more anaplastic the cells the less is the intracytoplasmic mucin
• Carcinoembryonic antigen (CEA) has been found to be present in the cyst fluid and in
tissue sections
• Therefore CEA can be used as a tumor marker in this type of ovarian tumor
• Pseudomyxoma peritonei is the accumulation of gelatinous material in the peritoneal
cavity associated with benign or malignant mucinous tumors
3. Endometrioid Tumors
• 16 – 30% of all ovarian carcinomas
• Frequently associate with CA of the endometrium
• Grossly
o Moderately solid tumors
o Usually yellowish tan or grayish with some cystic areas
o Fluid content is dark and hemorrhagic
o Papillary excrescences can be seen lining the inner surface of the cyst wall
• Microscopically
o A single or multiple layer of columnar or cuboidal cells are arranged in a
glandular pattern
o Tumor cells show varying degrees of pleomorphism, cellular atypia and stromal
invasion
4. Clear Cell Tumors
• 5 – 11% of all ovarian carcinomas
• Closely related to endometriosis and endometrioid carcinoma
• Histologically similar to the clear cell CA of the vagina and uterus of young patients
exposed to DES in utero
• Grossly:
o Appears as cystic masses with solid areas
• Microscopically:
o Solid sheets of cells with plenty of clear or vacuolated cytoplasm containing
glycogen, resembling renal carcinoma
o This cells make up the lining of the tubular glands
5. Brenner Tumors:
• Rare tumors of low malignant potential
• The epithelium does not invade the stroma
• Grossly:
o Rare epithelial tumors with unilocular or multilocular cyst with solid areas
• Microscopically:
o Nest of polygonal or round cells surrounded by fibrous stroma which may show
hyalinization or calcific changes
6. Undifferentiated/ Unclassified Tumors
• Sometimes the epithelial tumor is so anaplastic that it is not possible to assign the
tumor to any specific type
• More than 50% are bilateral
• Occurs mainly in young women who may present with hypercalcemia

Staging:
 Stage I: Growth Limited to the ovaries
– Stage Ia: Growth limited to one ovary; no ascitis. No tumor on the external
surface, capsule intact
– Stage Ib: Growth limited to both ovaries; no ascitis. No tumor on the external
surface; capsule intact
– Stage Ic: Tumor either Stage Ia or Ib, but with tumor on the surface of one or
both ovaries, or with capsule ruptured; or with ascitis present containing
malignant cells or with (+) peritoneal washings
 Stage II: Growth involving one or both ovaries with pelvic extension
– Stage IIa: Extension and/ or metastases to the uterus and/ or tubes
– Stage IIb: Extension to the pelvic tissues including the peritoneum within the
true pelvis
– Stage IIc: Tumor either Stage Iia or IIb, with tumor on the surface of one or
both ovaries; or with capsules present containing malignant cells; or with
positive washings
 Stage III: Tumor involving one or both ovaries, with peritoneal implants outside the
pelvis and/ or positive retroperitoneal or inguinal nodes. Superficial liver metastasis
qualifies as Stage III
– Stage IIIa Tumor grossly limited to the true pelvis, with negative nodes but
with histologically confirmed microscopic seeding of the abdominal peritoneal
surfaces
– Stage IIIb Tumor of one or both ovaries with histologically confirmed implants
on abdominal peritoneal surfaces, none exceeding 2 cm in diameter. Nodes are
negative
– Stage IIIc Abdominal implants > 2 cm in diameter and/ or (+) retroperitoneal/
inguinal nodes
 Stage IV Growth involving one or both ovaries with distant metastasis. If pleural
effusion is present, there must not be (+) cytology to allot a case to Stage IV.
Parenchymal liver metastasis equals Stage IV

• Treatment:
o For patients with stage I disease or for those with a borderline ovarian tumors
the mainstay in the management is surgical
o TAHBSO with surgical staging
o For patients with
 a more poorly differentiated tumor
 presence of malignant cells in the peritoneal washings or ascitic fluid
o Treatment Modalities:
 Radiation Therapy
 Chemotherapy
o 2 Look Operation:
nd

 to determine whether or not a patient who is clinically free of disease


indeed has no evidence of disease
 to give a second line of chemotherapeutic agents in the presence of a
gross or microscopic tumor
• Prognosis:
o clinical extent of the disease
o histology or cell type
o histologic grade
o size and amount of residual tumor
o patients nutritional and performance status