卵巢癌 - 臺北榮民總醫院

Benign ovarian tumor
• Functional cyst
– most: no symptom, 4-12 wks: disappear, OCP/
progesterone
• Follicular cyst (most, < 8 CM)
– before mense, bilateral, multiple
– cystic follicle > 3 cm
• Corpus luteum cyst
– after ovulation
D20- D26【2004】
– rupture: R’t,
intercourse

• Thecal luteum cyst
– due to Beta-HCG (endo-/ecto-), bilateral
• Luteoma
– not true neoplasm
– Masculinization: [M] / [F]: 30% / 65%
– 母親及女嬰男性化 [2007]
• Granulosa cell tumor
– Fibroma
– Meig’ s syndrome (ascites, PE, fibroma) [200?]
• Epithelial cyst
– Mucinous cystadenoma – huge
– Serous cystadenoma – bilateral, 20 %,
Psamoma Body: fine calcification granulation

• Dermoid cyst
– 15% torsion(中等大小), 10 % bilateral, 1-3 % SCC
– WBC, abd. pain, tenderness -> surgery [1996]
– The most common tumor of the first decade of life
->>>>> dysgerminoma (malignancy)

Fluid-Fluid Level

Dermoid cyst (mature cystic teratoma: triphasic teratoma)
[1997] 毛髮, 牙齒, 軟骨, 皮膚附屬器官

註:Struma Ovarii
~ 甲狀腺組織 thyroid tissue
~ 為 monodermal teratoma 中的一種

• [2007] 下列何者為最常見的生殖細胞腫瘤(germ-cell tumor)?
– 惡性胚胎瘤(dysgerminoma)
– 絨毛膜癌(choriocarcinoma)
– 內胚層竇瘤(endodermal sinus tumor)
– 成熟性畸胎瘤(mature teratoma)
• [2008] 一位20 歲女大學生因急性腹痛而接受手術,取出卵巢腫瘤(如
下圖所示),則下列診斷何者最正確?
– 卵巢外孕 - 卵巢畸胎瘤 - 卵巢單純囊腫 - 卵巢黃體囊腫

Ovarian mass management
• Expectant
– Functional
• For resolution of functional
ovarian cyst
– No difference between
observation and OCP
• OCP
– Reducing the risk of
subsequent ovarian cyst
• Suspected ovarian torsion
– Surgical
• Exploratory
– avoid in a suspicion of
malignancy
• Size
– Before menopause
• 3.5X2x1.5 cm
– In early menopause
• 2x1.5x0.5 cm
– In late menopause
• 1.5x0.75x0.5 cm

[2006]
Unilocular: 3-6 M f/u
Solid part or > 8-10 cm: op
Multiloculate: pre-MC: karyotype, AFP
post-MC: 3-6 M f/u / OCP
Few than 1 ~ 2 % ovarian malignancy occur in children
10~35 % malignancy in children and adolescent (< 20 y/o)
Germ cell tumor : 50 ~ 70 % ovarian neoplasm (< 20 y/o) : 20% 成人

• Endometriosis
– presence of endometrial tissue (gland and stroma) outside
the uterus
– 7% of reproductive age women (25-45 y/o [1996] ) most
frequent site: ovary, uterosacral ligament, pelvic viscera .
peritoneum, uterus, CDS …
– Etiology
• 1.retrograde menstruation
• 2.ectopic transplantation of endometrial tissue
• 3.coelomic metaplasia
• 4.the induction theory
• 5.immunological factor
• 6.multifactorial gene (family history, first-degree)
– S/S: 經痛,不孕, 出血, 性交痛 (週期性血尿 xxxx [2000] )

• Endometrioma
– Chocolate cyst
– CA-125: PID, menses, myoma, endometriosis, pregnancy,
ovarian cancer, pancreatic/renal/hepatic disease ([2001]
EM hyperplasia xxxxxx)
Novak’s
Textbook

UT
chocolate

[2005] 下列何者能正確診斷出內膜異位症?
1.腹腔鏡. 2.超音波. 3.電腦斷層. 4.內診

Mild / Peritoneum / US ligament

Mild / Uterine Superficial

Severe / Adhesion Bands

Surgery

– American Society for Reproductive Medicine
• Stage 1(minimal): 1~5, stage 2 (mild): 6~15,
stage 3(moderate): 16~40, stage 4 (severe): >40
• Depth, appearance, size, adhesion
• Not degree of pain/ infertility
– [2002] 右側 5 cm卵巢深層endometrioma, 為stage ?

藥物治療 ( [1998] Estrogen and Tamoxifen xxxxx )
• NSAIDs
– 可以抑制導致疼痛的前列腺素,有效治療因子宮內膜異位而引起之經痛,
並減少發炎反應
• Danazol (Androgen/ Anti-gonadotropic agent)
– Pseudo-menopause
– 對減少子宮內膜異位症所造成之疼痛非常有效
– 會有體重增加,水腫,痤瘡,油脂性皮膚及多毛症的副作用
• 促性腺激素釋放素(GnRH agonist)
– Medical oophorectomy
– 現今廣泛使用於治療子宮內膜異位症之藥物
• 避孕藥
– Pseudo-pregnancy
– 避孕藥常為用來治療子宮內膜異位症所造成的慢性疼痛,它的治療作用是
抑制排卵,減少促性腺激素及月經量,促使異位的內膜脫落
• 黃體素
– 作用機轉是抑制下丘腦及腦垂體中樞,降低血液裡雌激素的濃度;並可直
接作用於子宮內膜,讓異位之內膜組織萎縮脫落。同時,可抑制血管增生
來減少內膜移植和腹腔內發炎

• [2004] endometriosis 的敘述, 何者為非 ?
– 1.estrogen dependent disease
– 2.endometrial tissue ectopic growth
– 3.family hx (7 x, if a first-degree relative)
– 4.no association with immune system.
• [2005] 28 y/o, infertility, bilateral ov tumor by sonar,
operation->endometrioma, tube: ok -> 以下何者非第一線之
後續治療 ?
– 1.pregnancy after operation
– 2.Danazol
– 3.GnRH-a
– 4.IVF.

• [2006] 目前治療輕度至中度子宮內膜異位症的藥物,下列那
一項錯誤?
– Progestins (黃體素)
– Dexamethasone.
– Danazol
– Gonadotropin-releasing hormone(GnRH)agonist
• [2008] 一位42 歲母親,20 年前罹患子宮內膜異位症曾接受手
術治療,現在她的大女兒也有相同疾病,她很擔心二女兒也
會有相同疾病。據你所知,子宮內膜異位症可能是下列那一
種疾病?
– Autosomal recessive with variable penetrance
– Polygenic multifactorial
– Spontaneous mutations
– No evidence of genetic inheritance

• [2008] 一位25 歲女性,訴說常常在月經的前兩天開始就
感到劇烈的下腹疼痛,疼痛並且一直持續到月經結束,這
已經持續有一年的時間。在此之前,她通常是在月經來的
第一天才會感覺到疼痛。她自行吃止痛藥,但無法改善症
狀。因此到婦產科醫院求診,經超音波檢查後,發現左側
卵巢有個6 公分的卵巢囊腫。她向來月經週期都很準時是
28 天,每次也都持續約5 天左右,經血量也沒什麼特別之
處。醫師在診查之後,心中已有初步臆斷,因此處方黃體
素給予治療。果然,投藥後疼痛症狀即稍有改善。你覺得
最可能的診斷是:
– 卵巢功能退化
– 子宮肌瘤
– 黃體囊腫
– 子宮內膜異位

Ovarian Cancer
Novak’s (Ch 35), 台北榮總實用婦產部手冊 (page 170)
• Incidence increases with age
Survival guide 4.0 (page 85)
• 60% of patients present advanced disease
• Overall 5-year survival rate: 38%
• Increased risk
– Advancing age (age 40 or 79: 15.7/100,000 or 54/100,000)
– Family history (RR 3.6, lifetime risk 5%-7%)
– Genetic lineage (lifetime risk 50%)
• BRCA1 (17), BRCA2 (13), HNPCC (lynch II), P53, Cmyc,
Ras, HER2/Neu

• Increased risk (續)
– Nulliparity (2X)
– Ethnicity (North America and Europe)
– Talc powder ? High-fat diet ? Fertility drugs ?
• Decreased risk
– Prolonged breast feeding
– Oral contraceptives
• [2004, 2005] OV ca, EM ca, ectopic, benign breast
disease, functional ov cyst, PID, myoma, colon ca,
endometriosis, dysmenorrhea
• [2005] 增加藥效 : BZD, Coffeine, Theophylline,
Alcohol, Diazepam. 減少藥效:Aspirin, Morphine
• Thrombosis, stroke, DVT, DM, HTN(mild), TG
– Multiparous
– Reproductive surgery (tubal ligation, TAH)

• Epithelial (most) -> CA-125
– Serous (75%) [2007]
– Mucinous (25%)
– Endometroid
– Clear cell (DES)
• Germ cell -> AFP, HCG-> dysgerminoma (most) ←→
mature cystic teratoma
• Stromal ->LDH, inhibin
• Metastatic (6-7%, 雙側) (krukenberg) -> CEA [2004]
– [1998] Stomach/ Breast/ Colon ca (bladder XXX)
– 1.presence of ovarian stromal invasion
– 2.mucin-producting signet-ring cell [2000]
– 3.ovarian stromal sarcomatoid proliferation

Endodermal sinus tumor (yolk-sac tumor) : Schiller-Duval body
Granulosa cell tumor : Coffee-bean nuclei, Call-exner body
Serous tumor : Psammoma body
Clear cell carcinoma : Hobnail cell
Mucinous tumor: Pseudomyxoma

• Borderline tumor
– 30-50 y/o, pre-menopauseal women
– or low malignant potential (more atypia/
mitosis than benign ovarian tumor)
– 5 years survival rate: > 80 %, good prognosis
– pathology:
• 1.epithelial proliferation, papillary
formation, pseudostratification
• 2.nuclear atypia/ mitosis
• 3.absence of true stromal invasion

• [2003, 2005] S/S (most: no symptom)
– Abdominal pain
– Urinary frequency and urgency
– Constipation or diarrhea
– Abnormal vaginal bleeding
– Abdominal distension
– Increased abdominal girth
– Dyspnea
– Abdominal mass
– Pelvic mass
– Pleural effusion
– Ascites

• Survery
– Pelvic examination
– Transvaginal ultrasound (solid part, septum, papillary
growth, multilocular, ascites, > 6 cm)
– [2007] benign: cystic
– [2005] Color Doppler imaging (PI< 0.8, RI

• CA-125
– Elevated (>35) in 80% of all cases
– Elevated in only 50% of stage I cases
– Low specificity (PID, menses, myoma, endometriosis,
pregnancy, pancreatic / renal / hepatic disease)
– Most useful for follow-up
• Stage I [2001] 單側 ov ca+ascites. [1998] capsule有

• Stage II [to CDS, to broad ligament, to uterus]
• IIIA: microscopic peritoneal metastasis beyond pelvis
• IIIB: macroscopic peritoneal metastasis (< 2cm)
• IIIC: peritoneal metastasis beyond pelvis (> 2cm )
and/or regional node metastasis [1998, 1997]
• IV: distant metastasis (excludes peritoneal metastasis)
to liver parenchyma or malignant pleural effusion
(Lung> liver)

• Debulking surgery (Cytoreduction) = _____

• Primary goal [2003, 2005]
– resection of disease (移除所有可切除的病變)
– organ resection, if necessary
• Secondary goal
– optimal debulking
– removal of as much tumor as possible
– surgical cytoreduction (C/T)
– optimal &. suboptimal (1 cm)

• Preserve fertility
– stage IA/IB, grade 1/grade 2, non-clear cell
type
– unilateral salpingo-oophorectomy +
PALNS+unilateral PLND+
appendectomy+omentectomy
– no marked lesion over another ovary
– hold wedge resection
– bilateral ovarian cancer: both resection
– uterus: hysteroscopy + curettage

• Prognosis
–Stage
• I 5-year survival:85-90%
• II 5-year survival:80%
• III 5-year survival:15-20%
• IV 5-year survival:5%
– Suboptimal &. optimal debulking
• 5-year survival:10-20% vs 30-50% (

• Chemotherapy [2003, 2004, 2005]
– Paclitaxel + cisplatin/ carboplatin (T+P)
– Cyclophosphamide + cisplatin/ carboplatin (C+P)
– Bleomycin+Etoposide+Cisplatin (germ cell ov ca)
(BEP)
• Paclitaxel 175mg/m2, 3hrs 135mg/m2, 24hrs
• Cisplatin 50mg/m2
• Doxorubicin 50mg/m2
• Carboplatin AUC 4-5 or 5 –6
• Cyclophosphamide 600-750mg/m2
• Q3wks x 6 cycles
• IP (Intra-peritoneal C/T)
• IA/IB, grade 1: obs.
• IA/IB, grade 2: obs. or 3-6 C/T
• IC/ grade 3/ clear cell ca: 3-6 C/T
• 2nd debulking . 2nd looking operation [1996]

• [2007] 下列何因素不會增加卵巢癌的危險?
– 初經來得早.
– 停經時間較晚
– 使用口服避孕藥
– 低胎次(low parity)
• [2007] 卵巢癌最常見的組織型態為:
– 漿液性(serous).
– 黏液性(mucinous)
– 子宮內膜樣
(endometrioid).
– 亮細胞(clear cell)
• [?] 62 y/o, 停經 11 yrs, 6 cm ov tumor-> 血流,CA-125,colonoscopy
(tumor aspiration for biopsy xxxxxx)

Other ovarian tumor
• Dysgerminoma
– Bilateral: 10-15%
– Radiosensitive -> R/T
– Most ov. ca. associated with pregnancy
• Teratoma
– Immature: neural tissue ~ grade 1-3
– Malignant transformation: SCC: 1~3 %
• Endodermal sinus tumor (EST): yolk sac
– Very malignancy
– Always unilateral side [1998] 對側 xxxx
– Schllier-Duval body (中間一小血管被腫瘤細胞包圍著)
– Conservative DB + adjuvant C/T (60~70%)
• Sexual cord stromal tumor [1998]有何種類,分類
– 1.Granulosa-stromal tumor: 25% EM hyperplasia, 5% EM ca.
– 2.Sertoil-leydig cell tumor (androblastoma).
– 3.Thecoma. 4.Hilus cell tumor. 5.Gonadoblastoma.
[2002] 17 y/o, right ovarian
tumor (7 cm), biopsy:
schiller-duval body
[2005]