Histogenetic classification of ovarian neoplasm

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I.    Neoplasms derived from coelomic epithelium

      A. Serous tumor

      B. Mucinous tumor

      C. Endometriod tumor

      D. Mesonephroid (clear cell) tumor

      E. Brenner tumor

      F. Undifferentiated carcinoma

      G. Carcinosarcoma and mixed mesodermal tumor

II.   Neoplasms derived from germ cells

      A. Teratoma

       1. Mature teratoma

              a. Solid adult teratoma

              b. Dermoid cyst

              c. Struma ovarii

              d. Malignant neoplasms secondarily arising from mature cystic teratoma

          2.  Immature teratoma (partially differentiated teratoma)

      B. Dysgerminoma

      C. Embryonal carcinoma

      D. Endodermal sinus tumor

      E. Choriocarcinoma

      F. Gonadoblastoma

III.  Neoplasms derived from specialized gonadal stroma

      A. Granulosa-theca cell tumors

          1.       Granulosa tumor

          2.       Thecoma

      B. Sertoli-Leydig tumors

          1. Arrhenoblastoma

          2. Sertoli tumor

      C. Gynandroblastoma

      D. Lipid cell tumors

IV.  Neoplasms derived from nonspecific mesenchyme

      A. Fibroma, hemangioma, leiomyoma, lipoma

      B. Lymphoma

      C. Sarcoma

V.   Neoplasms metastatic to the ovary

      A. Gastrointestinal tract (Krukenberg)

      B. Breast

      C. Endometrium

      D. Lymphoma

Stage of ovarian cancer

Stage I        Growth limited to the ovaries

Stage Ia      Growth limited to one ovary; no ascites present containing malignant cells; no tumor on the external surfaces; capsule intact

Stage Ib      Growth limited to both ovaries; no ascites present containing malignant cells; no tumor on the external surfaces; capsules intact

Stage Ic      Tumor either stage Ia or stage Ib but with tumor on the surface of one or    both ovaries; or with capsule ruptured; or with ascites present containing       malignant cells or with positive 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 other pelvic tissues

Stage IIc     Tumor either stage IIa or stag IIb but with tumor on the surface of one or both ovaries; or with capsule(s) ruptured; or with ascites present containing malignant cells or with positive peitoneal 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 equals stage III; tumor is limited to the true pelvis but with    histologically verified malignant extension to small bowel or omentum

Stage IIIa    Tumor grossly limited to the true pelvis with negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal    surfaces

Stage IIIb    Tumor of one or both ovaries; histologically confirmed implants of    abdominal peritoneal surfaces, none exceeding 2 cm in diameter; nodes negative

Stage IIIc    Abdominal implants 2 cm in diameter and/or positive retroperitoneal or    inguinal nodes

Stage IV     Growth involving one or both ovaries with distant metastasis; if pleural effusion is present, there must be positive cytologic test results to allot a case to stage IV; parenchymal liver metastasis equals stage IV 

Pre-operative survey

1. Tumor markers:  CA-125, AFP, CEA, £]-HCG, LDH, CA19-9 (for mucinous tumors)

2. Lower GI series survey
3. Panendoscope

4. Fr D&C + cervical biopsy

5. Breast exam (and/or mammography) 

Surgical therapy in ovarian cancer

1. Peritoneal washing cytology

2. Determination of extent of disease

a. pelvis

b. peritoneal surface

c. diaphragms

d. omentum

e. lymph node

3. Remove all tumors possibly plus pelvic, para-aortic lymph node sampling and omentectomy 

Adjuvant therapy

1. Chemotherapy as ovarian cancer protocol. 

Requirements for conservative management in epithelial ovarian cancer

1. Stage Ia

2. Well differentiated

3. Young woman of low parity

4. Otherwise normal pelvis

5. encapsulated and free of adhesions

6. No invasion of capsule, lymphatics, or mesovarium

7. Peritoneal washings negative

8. Adequate evaluaiton of opposite ovary and omental biopsy negative

9. Close follow-up probable

10. Excision of residual ovary after completion of childbearing (optional)

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