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Granulosa stromal cell tumour



 Granulosa cell tumour

 Tumours in thecoma fibroma group

- Thecoma

- Fibroma

- Unclassified

 Sertoli cell tumour

 Sertoli leydig cell tumour

 Leydig cell tumour



Masculanising Tumors


Arrhenoblastoma /

Androblastoma Hilus cell Tumor

Adrenal cortical Tm/

Lipoid cell Tm of ovary



 Affect child bearing age

 Group (10 - 35 years)

It includes:


• Sertoli Cell Tumor (SCT)

• Leydig cell Tumor

 Sertoli - Leydig cell Tumor

 Seen in post-menopausal females

 Characterised by presence of Reinke's crystals

 Combination of granufosa cell tumour & arrheno blastoma


  • The endodermal sinus tumor is unilateral in 100% of cases
  • Granulosa cell tumors are unilateral in 98% of cases and bilateral in only 2% of cases

Tumor Markers of Ovarian Neoplasm


Epithelial cell Tumor-Serous variety

 CA 125

 Mucinous variety-Ca 19-9,CEA

 Both serous and mucinous variety- OCCA,OCA

Germ cell Tumors

(In individual tumors see flow chart given below)

 Alpha fetoprotein

 Lactic dehydrogenase

 Human chorionic gonadotropin

 Placental alkaline phosphatase

Granulosa cell tumor

 Inhibin


Radiological Features of Ovarian Tumors




Generally Bilateral

Generally Unilateral



Thick septations

Absent/thin septations

Intracapsular solid areas present

Intracapsular solid areas absent (clear)

Papillary growth on capsule present

Papillary growth on capsule absent

Ascites present

Ascites absent

Lymph nodes enlarged

Lymph nodes not enlarged

Omental caking present


Low resistance, high flow (increased vascularity)

High resistance, low flow


CA-125 is not diagnostic for epithelial ovarian CA, it is prognostic.


Conditions Associated with Increased CA-125


Normal value of Ca 125 is up to 35 U / mL

  • Pregnancy
  • Menses
  • Endometriosis
  • Epithelial ovarian CAs
  • Acute PID
  • Genital tuberculosis
  • Adenomyosis
  • Fibroids
  • Pancreatitis, hepatitis, appendicitis, and peritonitis (any abdominal organ + "it is")

Meigs' Syndrome


Ascites & right side hydrothorax in association with fibroma, thecoma, Brenner & granulosa cell tumor is called Meigs' syndrome. Ascites & hydrothorax when present in any other conditions is called Pseudo Meigs' syndrome.




Epithelial Cancer (for All Stages 1-4)


Staging laparotomy with cytoreductive surgery (hysterectomy, bilateral salpingo-oophorectomy, omentectomy, lymph node dissection, and removal of all the metastatic deposits), followed by six cycles of chemotherapy (cisplatin / carboplatin + paclitaxel).


Basic steps involved in surgical staging:

  1. Send free fluid for cytology
  2. If no free fluid, perform peritoneal washings and send it for cytology
  3. Palpate all the intra-abdominal organs
  4. Any suspicious area on peritoneal surfaces should be biopsied
  5. Sample the diaphragm either by biopsy or scraping
  6. Perform the infracolic omentectomy
  7. Evaluate the pelvic and para-aortic lymph nodes. Enlarged nodes should be respected. If no metastasis are present pelvic lymphadenectomy should be performed.

Germ Cell Cancer


Since it occurs in young age and since it is extremely chemosensitive, conservative surgery is advocated.


Staging laparotomy with unilateral salpingo-oophorectomy, followed by six cycles of chemotherapy (bleomycin, etoposide, and cisplatin).


Radiotherapy has no role in the management of ovarian CA.

Metastatic ovarian carcinoma

First Type

Second Type (Krukenberg Tumour)

• They are metastatic tumors from Intestine, Gall bladder, pancreas, corpus, and cervix

• They are most commonly bilateral

• They have irregular surface

• The method of ovarian infiltration is by surface implantation or retrograde implantation

• They are metastatic tumors from stomach (70%), large bowel (15%) and breast (6%)

• They are always bilateral. 0

• They have a smooth surface which may be slightly bossed.

• Always ari~e by retrograde lymphatic spread.

Management of an Adnexal Mass

Low Malignant Potential Tumors/Borderline Tumors

  • Approximately 10% of all epithelial tumors are borderline of which 30 % are of mucinous variety
  • Tumor cells display malignant characteristic histologically but no invasion is identified.
  • They remain confined to a single ovary for a very long time are slow growing and have a good prognosis (5 year survival >99%).
  • Common in age group-30-50 years unlike there malignant counterparts which are seen in age >50 years.
  • Metastasis is uncommon and occurs rarely
  • Treated with surgery, no proven benefit of chemotherapy.

Surgical Staging Procedures for Ovarian Cancer

  • Obtain ascites for cytologic evaluation
  • Washings from the pelvis, gutters, and diaphragm
  • Systematic exploration of all organs and surfaces
  • Hysterectomy Bilateral salpingo- oophorectomy
  • Infracolic omentectomy
  • Sampling pelvic and para-aortic lymph nodes Multiple biopsy specimens from peritoneal sites, Pelvic side walls, surfaces of the rectum and bladder, Cul- de-sac, Lateral abdominal gutters, diaphragm

Debulking, also called cytoreduction, is defined as removal of as much tumor as possible during surgical exploration. Optimal cytoreduction implies that tumor nodules no larger than 1 cm in diameter are left behind and survival improves as the amount of residual diseases decreases.

Primary cytoreductive surgery, or debulking is central in the treatment of advanced disease because maximal cytoreduction is one of the most powerful predictor of survival in patients with advanced cancer. The determination of residual disease does not include the" total volume of tumor cells left be- hind but rather the diameter of the largest single residual nodule.

Stage-wise Management of Ovarian Tumors

Low malignant potential tumors

Surgical staging.,

No post-operative treatment required

Stage I (A or B) Grade I and II


Surgical staging.

No post-operative treatment required

Note: In a young woman who wish to preserve fertility if intraoperative findings are consistent with stage I, unilateral salpingoopherectorny may be performed.

The uterus and the contralateral ovary can be removed later when the patient has completed child bearing.

Stage I (A or B) Grade III and all grades of

Stage IC and II

Surgical staging followed by three to six cycles of chemotherapy postoperatively.

Advanced ovarian cancer Stage Ill/IV


Surgical staging + cytoreduction or debulking surgery followed by six cycle of platinum based chemotherapy (carboplatin + paclitaxel preferred) each cycle given

after 3 weeks

Neoadjuvant therapy
i.e. initial treatment with chemotherapy followed by interval debulking surgery.



Patients with medical conditions which prohibit initial surgery. In patients in whom suboptimal debulking is likely.

In stage III tumors- Chemotherapy can also be given intra peritoneally.


  • Better compliance
  • Better results in overall survival


  • Increase in toxic events
  • Catheter related complications

The 'gold standard' for identifying residual disease is second look laparotomy.

Extra Edge:


Most common germ cell Tumor - Mature teratoma or Dermoid cyst (Benign in nature).


Most common malignant GCT - Dysgerminoma


Second most common malignant GCT - Endodermal sinus Tumor. (Yolk Sac tumor)


Most common benign Tumor of ovary - Dermoid cyst

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