Epithelial Ovarian Cancer
Epithelial Ovarian Cancer
1. epithelial ovarian cancerÀÇ ±â¿ø
Ovarian cancerÀÇ ¾à 90%°¡ coelomic epithelium or mesothelium¿¡¼ ±âÀÎÇÑ´Ù.ÀÌ·¯ÇÑ cellsµéÀº primitive mesodermÀÇ »ê¹°·Î¼ metaplasia¸¦ °ÅÄ¥ ¼ö ÀÖ´Ù. Neoplastic transformationÀº À¯ÀüÀû ¼ÒÀÎÀÌ Àְųª oncogenic agent¿¡ ³ëÃâµÇ¾úÀ» °æ¿ì¿¡ »ý±ä´Ù.
2. Borderline epithelial ovarian tumor
¨ç ¿À·§µ¿¾È ³¼Ò¿¡ ±¹ÇѵǸç ÁÖ·Î premenopausal women¿¡¼ ¹ß»ýÇÏ¸ç ¿¹Èİ¡ ¸Å¿ìÁÁ´Ù. ³¼Ò¾ÏÀÌ 50-70¼¼ »çÀÌÀÇ ¿©¼º¿¡¼ ÁÖ·Î ¹ß»ýÇÏ´Â °Í¿¡ ¹ÝÇÏ¿© borderline tumor´Â °¡Àå ÈçÇϰԴ 30-50¼¼»çÀÌ¿¡¼ ¹ß»ýÇÑ´Ù.
¨è Metastasis´Â ÈçÄ¡¾ÊÀ¸³ª ¹ß»ýÇÒ ¼öµµ ÀÖ´Ù. À̰æ¿ì noninvasive or invasive formsÀ¸·Î ³ª´µ¸ç, invasive formÀÎ °æ¿ì º¹°³»¿¡¼ ÁøÇà ¹× Áõ½ÄÇÏ¿© ÀåÆó¼â¿Í »ç¸ÁÀ» ÃÊ·¡ÇÒ ¼öµµ ÀÖ´Ù.
¨é Borderline tumorÀÇ Áø´Ü±âÁØÀº ´ÙÀ½°ú °°´Ù
(¤¡) Epithelial proliferation with papillary formation and psedostratification
(¤¤) Nuclear atypia and increased mitotic activity
(¤§) Absence of true stromal invasion ( Áï without tissue destruction)
¨ê °Á¶µÇ¾î¾ß ÇÒ »çÇ×Àº bordeline tumorÀÇ 20-25%°¡ ³¼Ò¸¦ ¹þ¾î³ª¼ ÆÛÁø´Ù´Â °ÍÀ̸ç, À̰æ¿ì peritoneal implants´Â well-differentiated carcinoma¿Í ±¸ºÐÀÌ ¾î·Á¿ï ¼ö ÀÖ´Ù. ÀÌ °æ¿ì Áø´ÜÀº primary tumorÀÇ Á¶Á÷ÇÐÀû °Ë»ç¿¡ ÀÇÇϴµ¥, invasive cancer¿¡¼´Â stromal invasionÀÌ º¸ÀδÙ. Borderline¿¡¼µµ microinvasionÀÌ µå¹°°Ô º¸°íµÈ¹Ù´Â ÀÖ´Ù.
3. epithelial ovarian cancerÀÇ pathology
Table 33.1
75%°¡ serous histologic type, mucinous(20%), endometrioid(2%), clear cell(<1%), Brenner(<1%), undifferentiated carcinomas(<1%)
¨ç serous tumors
(¤¡) borderline serous tumors
l ¾à 10%¸¦ Â÷ÁöÇϸç 50%°¡ 40¼¼ ÀÌÀü¿¡ ¹ß»ýÇÑ´Ù. Serous boderline°¡Áö´Â ȯÀÚÀÇ 40%¿¡¼ extraovarian implants°¡Áö¸ç ÀÌÁß 40%°¡ °á±¹ »ç¸ÁÇÑ´Ù. º¹°À» ¹þ¾î³ ÀüÀÌ´Â ¿¹¿ÜÀûÀ̸ç, ÀåÆó¼â¿¡ ÀÇÇÑ »ç¸ÁÀÌ ÀÖÀ» ¼öÀÖ´Ù.
l Á¶Á÷ÇÐÀûÀ¸·Î invasive and noninvasive·Î ³ª´· ¼öÀÖÀ¸¸ç, non invasive implantsȯÀÚ 50¸íÁß 3¸íÀÌ »ç¸ÁÇÑ °Í¿¡ºñÇØ, invasive ȯÀÚ 6¸íÁß 4¸íÀÌ »ç¸ÁÇß´Ù´Â º¸°í°¡ ÀÖ¾ú´Ù.
(¤¤) Malignant serous tumors
l Tumor grade°¡ È®ÀεǾî¾ßÇÑ´Ù. Well-differentiatedÀÎ °æ¿ì´Â papillary and glandular structures°¡ predominantÇϸç HFP´ç 0-2°³ÀÇ mitosis¸¦ º¸ÀδÙ. Poorly differentiatedÀÇ °æ¿ì´Â solid sheets of cells, nuclear pleomorphismÀ» º¸À̸ç HPF´ç ´ë°³ 2-3°³ÀÇ mitoses¸¦ º¸ÀδÙ. Moderately differentiated´Â À§ 2°¡ÁöÀÇ Áß°£¸ð½ÀÀ» ¶è´Ù.
l 80%ÀÇ serous carcinomas¿¡¼ calcified psammoma bodies°¡ ¹ß°ßµÈ´Ù.
¨è Mucinous tumors : primary epithelial ovarian tumorÀÇ 8-10%¸¦ Â÷ÁöÇϸç mucin secreting epitheliumÀ¸·Î liningµÇ¾îÀÖ°í, ¸Å¿ì Å©±â°¡ Ä¿Áú ¼öÀÖ¾î¼ º¹°Àüü¸¦ Â÷ÁöÇÒ ¼öµµ ÀÖ´Ù.
(¤¡) Borderline mucinous tumors : ÀÌ´Â ÀÌÇØÇÒ ¼ö¾ø´Â ¼ö¼ö²²³¢ °°Àº tumor·Î¼ ÁÖ·Î endocervical mucus-secreting cells·Î ±¸¼ºµÇ¸ç, intestinal, serous, endometrioid epithelial foci¸¦ º¸ÀÏ ¼öÀÖ´Ù. Bordeline serous tumor¿¡¼´Â °¢°¢ÀÇ section¸¶´Ù ±ÕÀÏÇÑ ¸ð½ÀÀ» º¸À̳ª mucinous tumor¿¡¼´Â ±×·¸Áö ¸øÇÏ´Ù. Áï well-diffentiated section¿¡ ÀÎÁ¢ÇÏ¿© poorly differentiated focus°¡ ÀÖÀ» ¼öÀÖ´Ù.µû¶ó¼ °¡Àå ÀǹÌÀÖ´Â anaplastic alterationÀ» È®ÀÎÇϱâ À§ÇØ ¸¹Àº sectionsÀ» °Ë»çÇÏ´Â °ÍÀÌÁß¿äÇÏ´Ù.
(¤¤) Malignant mucinous carcinomas
l papillary proliferationsÀÌ serous tumors¿¡¼ ¸¸ÅÈçÇÏÁö´Â ¾ÊÀ¸³ª, ÀÌ·¯ÇÑ ¸ð½ÀÀÌ atypical proliferationÀÇ ±âº»ÀûÀÎ Áõ°ÅÀ̸ç, mucinous carinoma¿¡¼ mitotic activity¸¦ °¡Àå Á¤È®È÷ È®ÀÎ ÇÒ ¼öÀÖ°Ô ÇØÁØ´Ù.
l 8-10%¿¡¼´Â ¾çÃø¼ºÀ¸·Î ¹ß»ýÇϸç, 95-98%°¡ intraovarianÀÌ´Ù. 5-10%´Â Benign mucinous cysts·ÎºÎÅÍ ¹ß»ýÇÑ´Ù.
l ´ëºÎºÐ¿¡¼ intestinal type cellsÀ» Æ÷ÇÔÇϱ⠶§¹®¿¡ Á¶Á÷ÇÐÀû ¼Ò°ß¸¸ °¡Áö°í´Â G-I tractÀ¸·ÎºÎÅÍÀÇ metastatic carcinoma¿Í ±¸ºÐÀÌ ¾î·Æ´Ù. Primary ovarian neoplasmsÀÌ bowel serosa¸¦ involveÇÏ´Â °ÍÀº ÈçÇϳª bowel mucosa·Î ÀüÀ̵Ǵ °ÍÀº rareÇÏ´Ù. ¹Ý¸é¿¡ G-I tract originÀÎ °æ¿ì´Â vascular lymphatic spreadÅëÇÑ direct extension¿¡ ÀÇÇØ ovary involve°¡ ÈçÇÏ´Ù.
(¤§) Pseudomyxoma peritonei: psedomyxoma peritoneiÀÇ °æ¿ì neoplastic epitheliumÀº »ó´ç·®ÀÇ gelatinous mucinous materialÀ» ºÐºñÇÑ´Ù. ÀÌ´Â °¡Àå ÈçÇϰԴ ovarian mucinous carcinoma, a mucocele of the appendix, well-differentiated colon carcinomaÀÇ ÀÌÂ÷ÀûÀ¸·Î »ý±ä´Ù.
¨é Endometrioid tumors
(¤¡) Epithelial tumorsÀÇ 6-8%¸¦ Â÷ÁöÇϸç, endometriosis¿¡¼ º¸ÀÌ´Â ¸ðµç ¼Ò°ßÀ» º¸ÀδÙ. SampsonÀº ovarian adenocarcinomaÀÇ ¾î¶² ¿¹°¡ endometriosis¿¡¼ »ý°å´Ù°í ÇÏ¿´´Âµ¥, ±×ÀÇ ±âÁØ¿¡ ÀÇÇϸé typical benigh ES°¡ adenocarcinoma¿Í ¿¬°üÇÏ¿© ¹ß°ßµÇ¾î¾ß Çϸç, µÑ»çÀÌÀÇ transitionÀÌ È®ÀεǾî¾ßÇÑ´Ù°íÇÏ¿´´Ù. ÀÌ·¯ÇÑ ±âÁØ¿¡ ¸Â´Â adenocarcinoma´Â exellent prognosis¸¦ º¸ÀδÙ. Ovarian adenoca¿¡¼µµ uterine adenoca¿¡¼¿Í ºñ½ÁÇÏ°Ô ¾à 50%¿¡¼ squamous component¸¦ º¸ÀδÙ.endometriosisÀÇ malignant potentialÀº ¸Å¿ì ³·À¸¸ç, À̰æ¿ì ¾ç¼ºº´º¯ÀÇ Æ¯Â¡ÀÎhemorrhagic foci¸¦ º¸ÀÏ ¼öÀÖ´Ù. ´ë°³ serous or mucinous carcinoma¸¸Å Å©Áö´Â ¾Ê´Ù.
(¤¤) Borderline endometrioid tumors : tumors´Â endometial polyp or complex endometrial hyperplasia with crowding of glands¸¦ ´àÀ» ¼öÀÖ´Ù. ¾î¶² borderline tumor´Â prominent fibromatous component¸¦ °¡Áö´Âµ¥ ÀÌ °æ¿ì adenofibroma¶ó ÇÑ´Ù.
(¤§) Malignant endometrioid carcinomas
l Adenocarcinoma with benign-appearing squamous metaplasisÀÇ °æ¿ì excellent prognosisº¸ÀδÙ.
l ¹Ý¸é¿¡ mixed adenosquamous carcinomasȯÀÚ´Â ¸Å¿ì ³·Àº »ýÁ¸À²À» º¸ÀδÙ.
(¤©) Multifocal disease :
l ovarian endometrioid tumors´Â Á¾Á¾ endometrium¿¡ ºñ½ÁÇÑ º´º¯À» º¸ÀδÙ.ÀÌ·¯ÇÑ multifical disease¸¦ È®ÀÎÇÏ´Â °ÍÀº Áß¿äÇѵ¥ °¡·É uterus¿¡¼ ovary·Î ÀüÀÌµÈ °æ¿ì 30-40%ÀÇ 5³â »ýÁ¸À²À» º¸ÀÌ´Â °Í¿¡ ¹ÝÇØ synchronous multifocal disease°®´Â ȯÀÚ´Â 75-80%ÀÇ 5³â»ýÁ¸À²À» º¸À̱⠶§¹®ÀÌ´Ù.
l Á¶Á÷ÇÐÀûÀ¸·Î endometrium and ovarian tumor°¡ Â÷À̸¦ º¸ÀϽô °¡Àå °¡´É¼ºÀÌ ÀÖ±â´Â ÀÌ µÎÁ¾¾çÀº µÎ°³ÀÇ ´Ù¸¥ primary lesionsÀÌ´Ù. ¸¸¾à ±× µÑÀÌ ºñ½ÁÇÑ ¼Ò°ßÀ» º¸À̸ç, well-differentiatedÀ̰í, ´ÜÁö superficial invasion¸¸À» º¸ÀϽô endometrial tumors´Â separated primary tumor·Î °£ÁÖµÉ ¼öÀÖ´Ù.
¨ê Clear cell(mesonephroid) tumors : ¸ðµç ³¼ÒÁ¾¾ç¿¡¼ Â÷ÁöÇÏ´Â ºñÀ²Àº ¾à 3%Á¤µµ´Ù.
(¤¡) ÀÓ»óÀûÀ¸·Î hypercalcemia or hyperpyrexia¿Í °ü·ÃµÇ´Â °¡Àå ÈçÇÑ ³¼Ò Á¾¾çÀ̸ç, ´ë°³ÀÇ ±×·± °æ¿ì metastatic disease¿Í ¿¬°üµÈ´Ù. ´ë°³ ´ÜÃø¼ºÀÌ¸ç ³¼Ò¸¦ ¹þ¾î³ª¼ extentionÇÏÁö¾Ê´Â ÇÑ smooth surface¸¦ º¸ÀδÙ. Cystic and solid components°¡ ÈçÈ÷ ¿¬°üµÈ´Ù.
(¤¤) Malignant clear cell carcinomas: ±âº»ÀûÀÎ Á¶Á÷ÇÐÀû ¼Ò°ßÀº tubulocystic , papillary, solidÇÏ¸ç ±¸¼ºÀº clear cells and hobnail cellsÀÌ´Ù. Focal areas of endometriosis and endimetrioid carcinoma °¡ Á¾Á¾ »ý±æ ¼öÀÖ´Ù. Á¶Á÷ÇÐÀûÀ¸·Î´Â DES¿¡ ³ëÃâµÇ¾î ŒÀº ¿©¼ºÀÇ uterus or vagina¿¡¼ º¸ÀÌ´Â clear cell ca¿Í µ¿ÀÏÇÏ´Ù.
¨ë Brenner Tumors
(¤¡) Borderline Brenner tumor : epitheliumÀº stroma¸¦ ħ¹üÇÏÁö ¾Ê´Â´Ù.
l ¾î¶² ÀúÀÚµéÀº ¹æ±¤ÀÇ low-grade papillary transitional cell carcinoma¸¦ ´àÀº °æ¿ì¸¦ proliferating tumors¶óÇϰí, higer grade of transitional cell carcinoma in situ¸¦ borderline malignant Brenner tumors¶ó°í ´Ù½Ã ºÐ·ùÇϱ⵵ ÇÑ´Ù.
(¤¤) Malignant Brenner tumor: µå¹°°í, benign Brenner tumors°¡ invasive transitional cells ¿Í °øÁ¸Çϰųª ȤÀº ´Ù¸¥ carcinoma¿Í °øÁ¸ÇÏ´Â °æ¿ì¸¦ ¸»ÇÑ´Ù. Tissue infiltiltration¿¡ ÀÇÇØ destructionÀÌ ÀÖ°Ô µÈ´Ù.
(¤§) Transitional cell tumors
l recongnizable Brenner tumor°¡ ¾øÀÌ ¹æ±¤¿¡¼ »ý±â´Â transitional cell carcinoma¸¦ ´àÀº °æ¿ì¸¦ ovarian transitional cell carcinoma¶ó ÇÑ´Ù. ÀÌ·¯ÇÑ tumor°¡ 50%ÀÌ»óÀÇ transitional cell carcinoma¸¦ Æ÷ÇÔÇϸé Ç×¾ÏÄ¡·á¿¡ ´õ¿í sensitiveÇϸç, ´Ù¸¥ poorly diffentiated ovarian carcinomº¸´Ù ¿¹Èİ¡ ÁÁ´Ù.
l Transitional cell tumors°¡ malignant Brenner tumor¿Í ´Ù¸¥Á¡Àº ±×µéÀÌ Á¾Á¾ ´õ¿í advanced disease¿¡¼ ¹ß°ßµÇ°í, µû¶ó¼ »ýÁ¸À²ÀÌ ´õ ³ª»Ú´Ù´Â °ÍÀÌ´Ù.
¨ì Undifferentiated Carcinoma : large cell types°ú small cell typeÀ» Æ÷ÇÔÇÑ´Ù. Small cell typeÀº ÁÖ·Î ÀþÀº ¿©¼º¿¡¼ ¹ß»ýÇϸç hypercalcemia¸¦ º¸Àϼö ÀÖ°í, immunohistochemical stains¿¡ ÀÇÇØ lymphoma, leukemia, sarcomaµî°ú °¨º°ÇÒ ¼öÀÖ´Ù.
¨í Mesotheliomas
(¤¡) peritoneal malignant mesotheliomas´Â four categories·Î ºÐ·ùµÈ´Ù.
l Fibrosarcomatous
l Tubopapillary(papillary-alveolar)
l Carcinomatous
l mixed
(¤¤) ÀÌ·¯ÇÑ º´º¯µéÀº multiple intraperitoneal masses·Î ³ªÅ¸³ª¸ç ¾ç¼ºÁúȯ ¶§¹®¿¡ Hysterectomy with BSO½ÃÇàÇÑ ÈÄ¿¡ »ý±æ ¼öÀÖ´Ù. Malignant mesotheliomas´Â ovarian tumor implants and primary peritoneal mullerian neoplasms°ú °¨º°µÇ¾î¾ß ÇÑ´Ù.
¨î Peritoneal carcinomas : peritoneumÀÇ malignant transformationÀ» primary peritoneal carcinomas or primary peritoneal papillary serous carcinoma¶ó ÇÑ´Ù.
(¤¡) ÀÓ»óÀûÀ¸·Î ovarian carcinoma¿Í ºñ½ÁÇϸç, ¼ö¼ú½Ã¿¡ ³¼Ò Ç¥¸é¿¡ microscopic or macroscopic cancer°¡ ÀÖÀ¸¸é¼ »óº¹ºÎ ƯÈ÷ omentum¿¡ extensive disease°¡ ÀÖÀ» ¼öÀÖ´Ù.
(¤¤) Primary peritoneal tumor´Â primary ovarian serous tumors¿Í °¨º°ÀÌ ¸Å¿ì ¾î·Á¿ï ¼öÀÖ´Ù. borderline serous peritoneal tumors and serous peritoneal carcinomasÀÇ ¾î¶² °æ¿ì¿¡¼´Â ³¼Ò´Â Á¤»óÀ̰ųª minimally involvedµÇ°í, Á¾¾çÀÌ ÁÖ·Î uterosacral ligments, pelvic peritoneum, omentumÀ» predominantly affectÇÒ ¼ö ÀÖ´Ù.
(¤§) Borderline serous peritoneal tumorsÀÇ overall survivalÀº excellentÇϸç, ovarian borderline serous tumors¿Í °ßÁÙ¸¸ÇÏ´Ù. Áï 38¸íÀÇ borderline serous peritoneal tumorȯÀÚÁß 32¸íÀº no persistent disease, 4¸íÀº Àç¹ßÈÄ resection¿¡ ÀÇÇØ ÀßÁö³ÂÀ¸¸ç, ÇÑ¸í¸¸ÀÌ invasive serous carcinoma·ÎÁøÇàµÇ¾úÀ¸¸ç, ÇѸíÀÌ Á¾¾ç¿¡ ÀÇÇØ »ç¸ÁÇß´Ù.
(¤©) peritoneal serous carcinomas´Â moderately to poorly differentiated serous ovarian carcinomaÀÇ ¸ð½ÀÀ» º¸À̸ç, primary peritoneal endometrioid carcinoma´Â less commonÇÏ´Ù.
4. ovarian cancerÀÇ ¹ß»ý¿¬·É
¨ç Epithelial ovarian cancersÀÇ 80%ÀÌ»óÀÌ postmenopausal women¿¡¼ »ý±â¸ç, peak age´Â 62¼¼´Ù. 45¼¼ ÀÌÀü¿¡´Â ºñ±³Àû ÈçÄ¡ ¾Ê´Ù.
¨è Epithelial ovarian cancerÀÇ 1%¹Ì¸¸Àº 21¼¼ ÀÌÀü¿¡ »ý±â¸ç, ÀÌÁß 2/3°¡ germ cell tumors´Ù.
¨é Postmenopausal women¿¡¼ »ý±â´Â ovarian neoplasmÀÇ 30%°¡ malignancyÀÓ¿¡ ¹ÝÇÏ¿© premenopausal womenÀÎ °æ¿ì´Â ´ÜÁö ¾à 7%¸¸ÀÌ malignancy´Ù.
5. ovarian cancer screening
¨ç Transvaginal ultrasonography : early ovarian cancer detection¿¡ 95%°¡ ³Ñ´Â sensitivity¸¦ º¸ÀδÙ.
¨è CA 125 : stage I diseaseÀÇ 50%, stage II diseaseÀÇ 60%¸¦ detectionÇÒ ¼öÀÖ´Ù. CA125ÀÇ specificity´Â TV ultrasonography¿Í °°ÀÌ »ç¿ëµÇ°Å³ª ¹Ýº¹ÇÏ¿© ½Ã°£¿¡ °ÉÃÄ F/UµÇ¸é Çâ»óµÉ ¼öÀÖ´Ù.
¨é CA125¿Í Transvaginal ultrasonographyÀÇ false-positive results¸¦ °í·ÁÇÑ´Ù¸é, ƯÈ÷ premenopausal women¿¡¼´Â ÀÌ·¯ÇÑ °Ë»çµéÀº cost-effectiveness°¡ ¾øÀ¸¸ç, µû¶ó¼ ovarian cancer screeningÀ» À§Çؼ routineÇϰԻç¿ëµÇ¾î¼´Â ¾ÈµÈ´Ù.
6. epithelial ovarian cancerÀÇ genetic risk
Ovarian caÀÇ life time risk´Â ¾à 1.4%ÀÌ¸ç °¡Á··ÂÀÌ ÀÖ´Â °æ¿ì ´õ ³ô´Ù. ÇÏÁö¸¸ familial or hereditary patternÀº °Ü¿ì 5%¹Ì¸¸ÀÇ malignancy¸¸À» ¼³¸íÇØÁÙ ¼öÀÖÀ¸¸ç, ´ëºÎºÐÀº sporadicÇϰԻý±ä´Ù.
¨ç Site-Specific Familial Ovarian Cancer : °¡Á··ÂÀÌ ÀÖ´Â °æ¿ì epithelial ovarian cancer risk°¡ ´õ ³ô´Ù. °¡Á··ÂÀÌ ¾øÀ» °æ¿ì peak age°¡ ¾à 61¼¼ ÀΰͿ¡ ºñÇØ °¡Á··ÂÀÌ ÀÖÀ» ½Ã´Â ±×º¸´Ù ¾à 10³â Á¤µµ ÀÏÂï »ý±â¸ç, first-or sencond-degree relative°¡ 50¼¼ ÀÌÀü¿¡ epithelial ov.ca¸¦ º¸¿´´Ù¸é affected geneÀ» °¡Áú °¡´É¼ºÀÌ ¸Å¿ì ³ô´Ù.
(¤¡) First-degree relative(mother, sister or daughter)Áß 2¸íÀÌ epithelial ov.caÀÎ °æ¿ì female first-degree relative°¡ affected geneÀ» °¡Áú °æ¿ì´Â 50%Á¤µµ·Î ³ô°í, autosomal dominant mode¿Í ÀÏÄ¡ÇÑ´Ù.
(¤¤) First-degree relativeÇѸí, ±×¸®°í second-degree relative(grandmother, aunt, first cousin, or granddaughter)Áß ÇѸíÀÌ epithelial ov.caº¸ÀϽÿ¡µµ affected geneÀ» °¡Áú risk°¡ ³ô´Ù. ÀÌ °æ¿ì relative risk´Â °¡Á··ÂÀÌ ¾ø´Â °æ¿ì¿¡ ºñÇØ¼ 3-10¹è ³ô´Ù.
(¤§) First-degree relativeÁß ÇÑ¸í¸¸ÀÌ epithelial ov.caÀÎ °æ¿ì affected geneÀ» °¡Áú risk´Â ¾à°£ Áõ°¡Çϸç, relative risk´Â 2-4¹è ³ô´Ù.
¨è Breast/Ovarian Familial Cancer Syndrome : first-or second-degree relative¿¡¼ combination of epithelial ovarian and breast cancer°¡ Á¸ÀçÇҽô ÀÌ ÁõÈıºÀÌ °¡Á·¿¡ Á¸ÀçÇÒ ¼öÀÖ´Ù. ÀÌ·± ÁõÈıºÀÌÀÖÀ» ½Ã´Â ÀþÀº ³ªÀÌ¿¡ Á¾¾çÀ» º¸À̸ç, À¯¹æ¾ÏÀº ¾çÃø¼ºÀÏ ¼öÀÖ´Ù.
(¤¡) ¸¸¾à first-degree relativeÁß 2¸íÀÌ affectedµÇ¸é ovarian cancerÀÇ relative risk°¡ ÀϹÝÀκ¸´Ù 2-4¹è ³ô´Ù. Primary history of breast cancer º¸ÀÌ´Â ¿©¼ºÀº subsequent ovarian cancer incidence°¡ 2¹èÁõ°¡ÇÑ´Ù.
(¤¤) Breast/ovarian syndrome°ú ¿¬°üµÇ´Â gene locus´Â 17q chromosome¿¡ À§Ä¡Çϸç BRCA 1 geneÀÌ´Ù. BRCA 1 mutationÀº 1/800-1000²Ã·Î ¹ß»ýÇϸç, ÀÌ·¯ÇÑ mutationÀ» °¡Áø ¿©¼ºÀº cumulative life time risk°¡ breast cancer´Â 85-90%, ovarian cancer´Â 50%´Ù.
¨é Lynch II Syndrome (hereditary nonpolyposis colon cancer, or HNPCC): ÀÌ´Â multiple adenocarcinomas¸¦ Æ÷ÇÔÇϴµ¥, familial colon cancer(known as the Lynch I syndrome)¹× ovarian, endometrial, breast cancersÀÇ high rate, ±×¸®°í G-I and G-U systemÀÇ malignanciesÀÇ combinationÀ» º¸ÀδÙ.ÀÌ·± °¡Á··ÂÀ» °¡Áø ¿©¼º¿¡¼ epithelial ovarian cancer risk´Â firsr-and secone-degree relativesÀÇ affected frequency¿¡ ÀÇÁ¸Çϳª, ´ë°³ ÀϹÝÀκ¸´Ù´Â Àû¾îµµ 3¹èÀÇ relative riskº¸ÀδÙ.
¨ê À§ÀÇ ¸ðµç syndromeÀÇ °æ¿ì¿¡ ¿©¼º¿¡¼ BRCA1 gene mutationÀÌ ÀÖ´ÂÁö¸¦ °Ë»çÇÏ´Â °ÍÀÌ À§Ç輺ÀÌ ÀÖ´Â ¿©¼ºÀ» ¾Ë¾Æ³»´Âµ¥ Áß¿äÇÑ ¿ªÇÒÀ» ÇÒ ¼öÀÖÀ¸¸ç, risk¸¦ ´õ Á¤È®È÷ °áÁ¤Çϱâ À§Çؼ´Â °¡Á··ÂÀ» Àû¾îµµ 3´ë¿¡ °Éó Æò°¡ÇÏ¿©¾ß ÇÑ´Ù. Epithelial ovarian cancerÀÇ Strong family historyÀÖ´Â ¿©¼ºÀÇ care´Â ±×³àÀÇ ³ªÀÌ , »ý½Ä°èȹ, À§Ç輺ÀÇ Á¤µµµîÀ» °í·ÁÇØ¼ °áÁ¤µÈ´Ù. ÀÌ·¯ÇÑ À§Ç豺¿¡¼´Â TV ultarsonography ¿Í CA125ÅëÇÑ screeningÀÌ ÃßõµÇ±âµµ ÇÑ´Ù. ÃÖ±Ù Á¦½ÃµÇ¾îÁö´Â recommendationÀº ´ÙÀ½°ú °°´Ù.
(¤¡) »ý½Ä´Éº¸Á¸À» ¿øÇÏ´Â ¿©¼ºÀº 6°³¿ù¸¶´Ù Áú½ÄÃÊÀ½ÆÄ¸¦ ½ÃÇàÇÏ¿©¾ß Çϸç, ´õ ÀÌ»óÀÇ ¾Ö¸¦ ¿øÄ¡ ¾ÊÀ¸¸é prophylactic oophorectomy°¡ °í·ÁµÇ¾îÁ®¾ßÇÑ´Ù. ºñ·Ï protective effect´Â ¸íȮġ ¾ÊÀ¸³ª, ¾Ö¸¦ °®±â ÀüÀÇ ÀþÀº ¿©ÀÚ¿¡°Ô´Â OC¸¦ »ç¿ëÇÒ ¼ö ÀÖ´Ù.
(¤¤) Familial ovarian or hereditary breast/ovarian cancer syndrome °¡Á··ÂÀÌ ÀÖ´Â ¿©¼º¿¡¼ ´õ ÀÌ»óÀÇ ÀÓ½ÅÀ» ¿øÄ¡ ¾ÊÀ¸¸é prophylactic BSO¸¦ ½ÃÇàÇØ¾ßÇÑ´Ù. ȯÀÚ¿¡°Ô ¼ö¼úÈÄ¿¡ À§Ç輺ÀÌ ¿ÏÀüÈ÷ ¾ø¾îÁö´Â °ÍÀÌ ¾Æ´Ï¸ç, peritoneal carcinomas°¡ Á¾Á¾ BSOÈÄ¿¡ »ý±æ ¼öÀÖÀ½À» ¼³¸íÇÏ¿©¾ßÇÑ´Ù.
(¤§) Lynch II syndrome°¡Á··ÂÀÌ ÀÖ´Â ¿©¼º¿¡¼µµ À§¿Í°°ÀÌ Ä¡·áµÇ¾îÁ®¾ß Çϸç, ÷°¡ÇÏ¿© ÁÖ±âÀûÀÎ screening mammography, colonoscopy, endometrial biopsy°¡ ÇàÇØÁ®¾ßÇÑ´Ù.
7. epithelial ovarian cancerÀÇ Áõ»ó ¹× ¡ÈÄ
¨ç Áõ»ó
(¤¡) ´ë°³ÀÇ È¯ÀÚµéÀº Àå±â°£ µ¿¾È Áõ»óÀÌ ¾ø´Ù. Áõ»óÀÌ ÀÖ´ÙÇÏ´õ¶óµµ Á¾Á¾ ¸ðÈ£ÇÏ¸ç Æ¯ÀÌÀûÀÌÁö ¸øÇÏ´Ù.
(¤¤) Early stage : PremenopauseÀÎ °æ¿ì ȯÀÚ´Â irregular menses¸¦ °æÇèÇÒ ¼öµµ ÀÖÀ¸¸ç, ¸¸¾à Á¾±«°¡ ¹æ±¤ ȤÀº Á÷ÀåÀ» ¾Ð¹ÚÇÏ¸é ºó´¢³ª º¯ºñ¸¦ È£¼ÒÇϱ⵵ÇÑ´Ù. Á¾Á¾ lower abdominal distention, pressure, dyspareunia°°Àº painÀ» È£¼ÒÇϱ⵵ ÇÑ´Ù. Rupture or torsionµî¿¡ ÀÇÇÑ ±Þ¼º Áõ»óÀº ÈçÄ¡¾Ê´Ù.
(¤§) Advanced stage : ´ë°³ÀÇ °æ¿ì ascites, omental metastasis, bowel metastasisµî°ú ¿¬°üµÈ Áõ»óÀ» º¸À̴µ¥, abdominal distention, bloating, constipation, nausea, anorexia, early satietyµîÀÌ ±×°ÍÀÌ´Ù. Postmenopausal¿¡¼´Â vaginal bleedingÀÌ »ý±æ ¼öÀÖÀ½¿¡ ºñÇØ premenoapausalÀÎ °æ¿ì´Â irregular or heavy menses¸¦ È£¼ÒÇÒ ¼öÀÖ´Ù.
¨è ¡ÈÄ
(¤¡) °¡Àå Áß¿äÇÑ signÀº ½Åü°Ë»ç¿¡¼ °ñ¹ÝÁ¾±«°¡ Á¸ÀçÇÏ´Â °ÍÀÌ´Ù. Solid,irregular, fixed pelvic mass´Â malignancy¸¦ °ÇÏ°Ô ½Ã»çÇÑ´Ù. °Ô´Ù°¡ »óº¹ºÎ Á¾±« ³ª º¹¼ö°¡ Á¸ÀçÇϸé Áø´ÜÀº ´õ¿í È®½ÇÇØÁø´Ù. Á¾Á¾ ȯÀÚ°¡ º¹ºÎÁõ»óÀ» È£¼ÒÇϱ⠶§¹®¿¡ pelvic examÀ» ÇÏÁö ¾ÊÀ» ¼öÀÖÀ¸¸ç, Á¾±«¸¦ ³õÄ¥ ¼öÀÖ´Ù.
(¤¤) Æó°æ ÈÄ Àû¾îµµ 1³âÀÌ Áö³ ¿©¼ºÀÇ ³¼Ò´Â À§ÃàµÇ°í ¸¸Á®ÁöÁö ¾Ê´Â´Ù. ¸¸¾à ÀÌ·¯ÇÑ ¿©¼º¿¡¼ palpable pelvic mass°¡ Á¸ÀçÇÒ ½Ã´Â ¾Ç¼ºÀ» °í·ÁÇØ¾ßÇϴµ¥ À̸¦ postmenopausal palpable ovary syndromeÀ̶ó ºÒ·Á¿Ô´Ù. ÇÏÁö¸¸ Æó°æ ÈÄ¿©¼º¿¡¼ 5cm¹Ì¸¸ÀÇ palpable mass°¡ ÀÖÀ» ½Ã ´Ü 3%¸¸ÀÌ malignancy¿´´Ù´Â º¸°íµµ ÀÖ´Ù.
8. epithelial ovarian cancerÀÇ Áø´Ü ¹× ¼ö¼úÀü °Ë»ç
¨ç Serum CA 125°¡ ¾ç¼ºÁ¾±«¿Í ¾Ç¼ºÁ¾±«ÀÇ °¨º°¿¡ µµ¿òÀ» ÁØ´Ù.
(¤¡) Postmenopausal women¿¡¼ ³¼ÒÁ¾±«°¡ ÀÖÀ¸¸é¼ CA125>95U/mlÀÎ °æ¿ì 96% positive value for malignancyº¸ÀδÙ.
(¤¤) Premenopuasal women¿¡¼´Â ES, PID, myoma°°Àº ÈçÇÑ benign condition¿¡¼µµ CA125°¡ Áõ°¡ÇÒ ¼öÀֱ⠶§¹®¿¡ Specificity°¡ ³·´Ù.
¨è Premonopausal woman¿¡¼ ³¼ÒÁ¾±«°¡ ÀÖÀ¸³ª mobile, cystic, unilateral, regular contour¸¦ º¸ÀÌ´Â °æ¿ì 2°³¿ù °£°ÝÀ» ³ÑÁö¾Ê°Ô ÁÖ±âÀûÀ¸·Î observationÇÏ´Â °ÍÀÌ reasonbleÇϸç, OCÅëÇÑ Hormone suppressionÀÌ »ç¿ëµÇ¾îÁú ¼öÀÖ´Ù. ¸¸¾à Á¾±«°¡ neoplasticÇÏÁö ¾Ê´Ù¸é regressÇØ¾ßÇϸç, ¸¸¾à regressÇÏÁö ¾Ê°Å³ª Å©±â°¡ Ä¿Áö¸é neoplasticÀÓÀ» °¡Á¤ÇÏ¸ç ¼ö¼úÀûÀ¸·Î Á¦°ÅµÇ¾îÁ®¾ßÇÑ´Ù.
¨é º´º¯ÀÇ Å©±âµµ Áß¿äÇÏ¿©, 8cmÀ» ÃʰúÇÏ´Â cystic mass´Â neoplastic °¡´É¼ºÀÌ ³ô´Ù. ¾Ç¼ºÀ» ½Ã»çÇÏ´Â ¼Ò°ß Áï predominantly solid, relatively fixed, irregular shapedÇҽô laparotomy¸¦ ½ÃÇàÇØ¾ßÇÑ´Ù.
¨ê Áø´ÜÀº exploratory laparotomy°¡ ÇÊ¿äÇÏ¸ç ¼ö¼úÀü¿¡´Â ÀÏ»óÀûÀÎ Çǰ˻ç¿Ü¿¡µµ chest x-ray, IVP¸¦ ½ÃÇàÇØ¾ß ÇÑ´Ù.abdominal and pelvic CT, or MRI´Â definite pelvic mass°¡ Á¸ÀçÇÒ ½Ã´Â ÇÊ¿äÄ¡¾Ê´Ù. ÇÏÁö¸¸ º¹¼ö°¡ ÀÖÀ¸¸é¼ pelvic mass°¡ ¾øÀ»½Ã´Â liver or pancreatic tumors¸¦ ã±âÀ§ÇÑ CT or MRI°¡ ÇÊ¿äÇÏ´Ù. ÀüÀÌ¿¡ ÀÇÇÑ Áõ»óÀÌ ÀÖÁö ¾Ê´ÂÇÑ Liver-spleen scans, bone scans, brain scansÀº ºÒÇÊ¿äÇÏ´Ù.
¨ë 45¼¼ ÃʰúÇϴ ȯÀÚ¿¡¼´Â primary colon cancer¿¡ ÀÇÇÑ ³¼ÒÀüÀ̸¦ R/OÇϱâ À§ÇÑ barium enema ³ª colonoscopy°¡ ÀûÀÀÀÌ µÈ´Ù. ÀÌ·¯ÇÑ °Ë»ç´Â stool¿¡¼ occult blood°¡ Àְųª ÀåÆó¼âÀÇ Áõ°Å°¡ Àִ ȯÀÚ¿¡°Ô¼´Â ¹Ýµå½Ã ½ÃÇàµÇ¾î¾ßÇÑ´Ù. Áõ»óÀÌ ÀÖÀ» ½Ã´Â upper G-I series or gastroscopy°¡ ÀûÀÀÀÌ µÈ´Ù. Breast mass°¡ ÀÖÀ» ½Ã´Â bilateral mammography°¡ ÀûÀÀÀ̵Ǵµ¥ ÀÌ´Â Á¾Á¾ primary breast cancer°¡ ³¼Ò·Î ÀüÀÌÇÏ¿© primary ovarian cancer·Î¿ÀÀ뵃 ¼öÀֱ⠶§¹®ÀÌ´Ù.
¨ì ºñ·Ï ovarian cancer detection¿¡¼ÀÇ °¡Ä¡´Â ¸Å¿ì Á¦ÇÑÀûÀ̳ª cervical cytology°¡ ¹Ýµå½Ã ½ÃÇàµÇ¾î¾ßÇÑ´Ù. Irregular menses or postmenopausal vaginal bleedingº¸À̴ ȯÀÚ´Â ¹Ýµå½Ã endometrial biopsy and endocervical curettage¸¦ ½ÃÇàÇÏ¿© ³¼ÒÀüÀ̸¦ °¡Áö´Â uterine or endometrial cancerÀÇ Á¸À縦 R/OÇØ¾ßÇÑ´Ù.
9. Ovarian epithelial cancersÀÇ spread pattern
Áַδ º¹°³»·ÎÀÇ exfoliation, lymphatic dissemination, hematogenous spreadº¸ÀδÙ.
¨ç Transcoelomic
(¤¡) °¡Àå ÈçÇÑ Ãʱâ dissemination¾ç»óÀº cancer cellÀÇ exfoliationÀ̸ç, peritoneal cavity surfaceµû¶ó implantÇÑ´Ù. À̰æ¿ì ÁÖ·Î º¹¼öÀÇ ¼øÈ¸°æ·Î¸¦ µû¸£´Âµ¥ º¹¼ö´Â È£Èí¿¡ ÀÇÇØ pelvis, up the paracolic gutters(ƯÈ÷ ¿À¸¥ÂÊ), along the intestinal mesenteries, to the right hemidiaphragm·Î ¿òÁ÷ÀδÙ.
(¤¤) µû¶ó¼ ÀüÀÌ´Â ÀüÇüÀûÀ¸·Î posterior culdesac, paracolic gutters, right hemidiaphragm, liver capsule the peritoneal surface of the intestines and their mesenteries , omentum¿¡¼ ÁÖ·Î »ý±ä´Ù.
(¤§) Intestinal lumenÀ» involveÇÏÁö´Â ¾ÊÀ¸³ª Á¡Â÷ÀûÀ¸·Î bowel loops¸¦ ±³Âø½ÃÄÑ functional intestinal obstruction¾ß±âÇÑ´Ù. À̸¦ carcinomatous ileus¶ó ÇÑ´Ù.
¨è Lymphatic
(¤¡) Advanced diseaseÀÎ °æ¿ì lymphatic ÅëÇØ pelvis and para-aortic lymph node·Î disseminationµÇ´Â °ÍÀº ÈçÇÏ´Ù. DiaphragmÀÇ ¸²ÇÁ°ü ¹× Èĺ¹¸·¸²ÇÁÀý ÅëÇØ¼ diaphragmÀ§·Î ÀüÀÌµÉ ¼öÀÖÀ¸¸ç ƯÈ÷ supraclavicular lymph nodes·Î°£´Ù.
(¤¤) Stage IIIÀÇ °æ¿ì 78%¿¡¼ Pelvic nodes·ÎÀÇ ÀüÀ̸¦ º¸¿´À¸¸ç, para-aortic nodes·ÎÀÇ ÀüÀÌ´Â stage IÀº 18%, II 20%, III 42%, IV 67%¿´´Ù.
¨é Hematogenous : ÈçÄ¡´Â ¾ÊÀ¸³ª lung and liver°°Àº vital organÀ¸·ÎÀÇ ÀüÀÌ´Â 2-3%¿¡¼ ¹ß»ýÇÑ´Ù. Áø´Ü´ç½Ã diaphragmÀ§¿¡ º´º¯À» °¡Áø ȯÀÚ´Â right pleural effusion°¡Áø´Ù.
10. ovarian epithelial cancerÀÇ ¿¹ÈÄ ÀÎÀÚ
¨ç Pathologic factors
(¤¡) morphology and histologic pattern(architecture and gradeÆ÷ÇÔ)°¡ Áß¿äÇÑ ¿¹ÈÄ ÀÎÀÚ´Ù. Histologic typeÀÌ Áß¿äÇÑ ¿¹ÈÄÀÎÀÚ·Î ¿©°ÜÁ®¿ÀÁö ¾Ê¾ÒÀ¸³ª ÃÖ±Ù clear cell ca°¡ ´Ù¸¥ typesº¸´Ù ¿¹Èİ¡ ³ª»Ú´Ù°í º¸°í µÇ¾ú´Ù.
(¤¤) Histologic grade°¡ Áß¿äÇÑ ¿¹ÈÄÀÎÀÚ·Î ¿©°ÜÁö³ª °üÂûÀÚ¸¶´Ù ¸¹Àº Â÷À̸¦ º¸À̱⠶§¹®¿¡ ±× °¡Ä¡´Â ¾ÆÁ÷ Á¤¸³µÇÁö ¾Ê¾Ò´Ù.
¨è Biologic factors
(¤¡) flow cytometry¸¦ »ç¿ëÇÑ °á°ú ovarian cancer´Â ÈçÈ÷ aneuploidº¸¿´À¸¸ç, ´õ ³ª¾Æ°¡¼ FIGO stage¿Í Ploid»çÀÌ¿¡´Â ¿¬°ü¼ºÀÌ ÀÖ¾ú´Ù. Áï low-stage cancers´Â diploid°æÇâÀÌ, high-stage cancer´Â aneuploid°æÇâÀÌ ÀÖ¾ú´Ù. Diploid tumors °¡Áø ȯÀÚ°¡ aneuploidȯÀÚº¸´Ù ÀǹÌÀÖ°Ô median survival ÀÌ ±æ¾ú´Ù.(5³â: 1³â) ¸¹Àº multivariate analysis¿¡ ÀÇÇϸé ploidy°¡ independent prognostis variableÀ̸ç one of the most significant predictors of survivalÀÌ´Ù.
(¤¤) 60°³ ÀÌ»óÀÇ proto-oncogenesÀÌ È®ÀεǾú´Ù. ÇÑ¿¬±¸¿¡ ÀÇÇϸé HER-2/neu oncogeneÀº epithelial ova caÀÇ ¾à 30%¿¡¼ expressedµÇ¸ç ¿¹Èİ¡ ³ª»Ú´Ù°í Çϸç, ¶Ç´Ù¸¥ ¿¬±¸¿¡ÀÇÇϸé HER-2/neu expressionÀÇ overall incidence´Â ¾à 11%¿´À¸¸ç µû¶ó¼ ¿¹ÈÄÀÎÀڷμÀÇ °¡Ä¡´Â ¸íÇÐÄ¡ ¾Ê´Ù°í ÇÏ¿´´Ù.
¨é Clinical factors
(¤¡) stage¿¡ ´õÇÏ¿©, the extent of residual disease after primary surgery, the volume of ascites, patient age, performance scaleµîÀÌ ¸ðµÎ°¡ independent prognostic variablesÀÌ´Ù.
(¤¤) Stage I ȯÀÚ¿¡¼ Tumor grade and dense adherence to the pelvic peritoneumÀÌ ¿¹ÈÄ¿¡ ÀǹÌÀÖ°Ô ³ª»Û ¿µÇâÀ» ¹ÌÃÆÀ¸¸ç, ¹Ý¸é¿¡ intraoperative tumor spillage or rupture´Â ±×·¸Áö ¾Ê¾Ò´Ù.
(¤§) Ovarian cancer°¡ ¼ö¼úÁß¿¡ rupture or spillageµÇ´Â °ÍÀº ¿¹Èĸ¦ ¾ÇȽÃŰÁö ¾Ê´Â ¹Ý¸é ¼ö¼úÀü¿¡ ÀÌ¹Ì ruptureµÈ °æ¿ì¶ó¸é ³ª»Û ¿¹Èĸ¦ º¸ÀδÙ.
11. ovarian epithelial cancersÀÇ Staging
Table 33.2
FIGO stage´Â surgicall exploration¿¡ ±âÃʸ¦ µÎ°í ÀÖÀ¸¸ç, ÀÌ·¯ÇÑ surgical stagingÀÌ Çâ¿ì Ä¡·á¸¦ °áÁ¤Áþ±â ¶§¹®¿¡ ¸Å¿ì Áß¿äÇÏ´Ù.
12. surgical stagingÀÇ technique
¨ç ¼ö¼úÀü¿¡ malignancy°¡ ÀǽɵǾú´ø °æ¿ì »óº¹ºÎ·ÎÀÇ Á¢±ÙÀÌ ´õ½¬¿î midline or paramedian abdominal incisionÀÌ ÃßõµÈ´Ù. Transverse incisionÀ» ÅëÇÑ ¼ö¼úÁß ¿¹»óÄ¡ ¸øÇÏ°Ô malignancy°¡ ¹ß°ßµÈ °æ¿ì¶ó¸é rectus muscle¸¦ ÀÚ¸£°Å³ª Ä¡°ñ¿¡¼ ¶¼³»ÁÜÀ¸·Î½á »óº¹ºÎ·ÎÀÇ Á¢±ÙÀ» ¿ëÀÌÇÏ°Ô Çϴµ¥ À̰ÍÀÌ ÃæºÐÄ¡ ¾ÊÀ» ½Ã´Â ÇǺÎÀý°³¸¦ ÇÑÂÊÀ¸·Î ¿¬ÀåÇÏ¿© J ¸ð¾çÀ¸·Î Àý°³ÇØÁØ´Ù.
¨è ³¼ÒÁ¾¾çÀº °¡´ÉÇÑ intactÇÑ »óÅ·ΠÁ¦°ÅÇÏ¿© µ¿°áÀýÆíÀ» ½ÃÇàÇÑ´Ù. ¸¸¾à ¾Ç¼ºÀ̸é surgical stagingÀ» ´ÙÀ½ ´Ü°è¿¡ µû¶ó ½ÃÇàÇÑ´Ù.
(¤¡) ¾î¶°ÇÑ free fluid(ƯÈ÷ cul-de-sac)µµ cytologic evaluationÇØ¾ßÇÑ´Ù.
(¤¤) Free fluid°¡ ¾øÀ» ½Ã´Â 50-100ml salineÀ» pelvic cul-de-sac, each paracolic gutter, beneath each diaphragm¿¡ instilling and recoveringÇÏ¿© cytology ³»º¸³½´Ù.
(¤§) All intra-abdominal surfaces and viscera¸¦ öÀúÈ÷ Á¶»çÇÑ´Ù. À̶§ ½Ã°è¹æÇâÀ¸·Î cecum¿¡¼ ½ÃÀÛÇÏ¿© paracolic gutter-> ascending colon to the right kidney->liver and GB->right hemidiaphragm->the entrance to the lesser sac at the paraaortic area->across the transverse colon to the left hemidiaphragm-> down the left gutterand descending colon to the rectosignmoid colon·Î Á¶»çÇϰԵȴÙ. Small intestine and its mesentery¸¦ Treitz ligament¿¡¼ cecum±îÁö Á¶»çÇÑ´Ù.
(¤©) º¹¸·¿¡ ÀÖ´Â ¾î¶°ÇÑ Àǽɽº·¯¿î ºÎÀ§³ª À¯ÂøÀº biopsyµÇ¾î¾ß ÇÑ´Ù. ¸¸¾à disease evidence°¡ ¾øÀ»½Ã´Â ¿©·¯ ºÎÀ§¿¡¼ biopsies¸¦ ½ÃÇàÇϴµ¥, cul-de-sac, both paracolic gutters, peritoneum over the bladder, intestinal mesenteries¿¡¼ biopsy½ÃÇàÇÑ´Ù.
(¤±) DiaphragmÀ» biopsyȤÀº scraping with a tongue depressor¹æ¹ýÀ¸·Î samplingÇÏ¿©¾ßÇϸç, cytologyÀ§ÇÑ sampleµµ È®º¸ÇÏ¿©¾ßÇÑ´Ù.
(¤²) OmentumÀ» transverse colonÀ¸·Î ºÎÅÍ Àý´ÜÇϴµ¥ À̸¦ infracolic omentectomy¶ó ÇÑ´Ù.¿ì¼± greater omentumÀÇ underside¿¡¼ ½ÃÀÛÇϴµ¥ transverse colonÀ¸·ÎºÎÅÍ a few millimeters¶³¾îÁ®¼ peritoneumÀ» Àý°³ÇÑ´Ù. Gastroepiploic vessels branches¸¦ Àâ°í °áÂûÇϰí Àß¶óÁØ´Ù. Infracolic omentum feedingÇÏ´Â ¸ðµç ÀÛÀº Ç÷°üµéµµ À§¿Í°°ÀÌ ÇØÁØ´Ù. Gastrocolic ligamentÀº Á¤»óÀ̶ó¸é Àý´ÜµÉ ÇÊ¿ä¾ø´Ù.
(¤µ) Pelvic and para-aortic nodes¸¦ evalutationÇϱâ À§ÇØ retroperitoneal spaces¸¦ Á¶»çÇÑ´Ù. Enlarged nodes´Â Á¦°ÅµÇ¾î¼ µ¿°áÀýÆí½ÃÇàÇÑ´Ù. ¸¸¾à ¾î¶°ÇÑ ÀüÀ̵µ ¾ø´Ù¸é formal pelvic lymphadenectomy°¡ ½ÃÇàµÇ¾î¾ßÇÑ´Ù.
13. surgical stagingÀÇ Á߿伺
¨ç Pelvis¿¡ ±¹ÇÑ µÇ¾îÀÖ´Ù°í ¿©°ÜÁö´Â stage I,IIȯÀڵ鿡¼ occult metastasis°¡ diaphragm biopsy¿¡¼´Â 7.3%, omentum¿¡¼´Â 8.6%, pelvic lymph nodes¿¡¼´Â 5.9%, aortic lymph nodes¿¡¼´Â 18.1%, peritoneal washing¿¡¼´Â 26.4%°¡ ¹ß°ßµÈ´Ù.
¨è Histologic grade°¡ occult metastasisÀÇ significant predictor´Ù.Áï primary surgical staging¿¡¼ grade IÀ̾ú´ø °æ¿ì 16%¿¡¼, grade II¿´´ø °æ¿ì 34%, grade III¿´´ø °æ¿ì additional surgical staging¿¡ ÀÇÇØ upstagedµÈ´Ù.
1. epithelial ovarian cancerÀÇ ±â¿ø
Ovarian cancerÀÇ ¾à 90%°¡ coelomic epithelium or mesothelium¿¡¼ ±âÀÎÇÑ´Ù.ÀÌ·¯ÇÑ cellsµéÀº primitive mesodermÀÇ »ê¹°·Î¼ metaplasia¸¦ °ÅÄ¥ ¼ö ÀÖ´Ù. Neoplastic transformationÀº À¯ÀüÀû ¼ÒÀÎÀÌ Àְųª oncogenic agent¿¡ ³ëÃâµÇ¾úÀ» °æ¿ì¿¡ »ý±ä´Ù.
2. Borderline epithelial ovarian tumor
¨ç ¿À·§µ¿¾È ³¼Ò¿¡ ±¹ÇѵǸç ÁÖ·Î premenopausal women¿¡¼ ¹ß»ýÇÏ¸ç ¿¹Èİ¡ ¸Å¿ìÁÁ´Ù. ³¼Ò¾ÏÀÌ 50-70¼¼ »çÀÌÀÇ ¿©¼º¿¡¼ ÁÖ·Î ¹ß»ýÇÏ´Â °Í¿¡ ¹ÝÇÏ¿© borderline tumor´Â °¡Àå ÈçÇϰԴ 30-50¼¼»çÀÌ¿¡¼ ¹ß»ýÇÑ´Ù.
¨è Metastasis´Â ÈçÄ¡¾ÊÀ¸³ª ¹ß»ýÇÒ ¼öµµ ÀÖ´Ù. À̰æ¿ì noninvasive or invasive formsÀ¸·Î ³ª´µ¸ç, invasive formÀÎ °æ¿ì º¹°³»¿¡¼ ÁøÇà ¹× Áõ½ÄÇÏ¿© ÀåÆó¼â¿Í »ç¸ÁÀ» ÃÊ·¡ÇÒ ¼öµµ ÀÖ´Ù.
¨é Borderline tumorÀÇ Áø´Ü±âÁØÀº ´ÙÀ½°ú °°´Ù
(¤¡) Epithelial proliferation with papillary formation and psedostratification
(¤¤) Nuclear atypia and increased mitotic activity
(¤§) Absence of true stromal invasion ( Áï without tissue destruction)
¨ê °Á¶µÇ¾î¾ß ÇÒ »çÇ×Àº bordeline tumorÀÇ 20-25%°¡ ³¼Ò¸¦ ¹þ¾î³ª¼ ÆÛÁø´Ù´Â °ÍÀ̸ç, À̰æ¿ì peritoneal implants´Â well-differentiated carcinoma¿Í ±¸ºÐÀÌ ¾î·Á¿ï ¼ö ÀÖ´Ù. ÀÌ °æ¿ì Áø´ÜÀº primary tumorÀÇ Á¶Á÷ÇÐÀû °Ë»ç¿¡ ÀÇÇϴµ¥, invasive cancer¿¡¼´Â stromal invasionÀÌ º¸ÀδÙ. Borderline¿¡¼µµ microinvasionÀÌ µå¹°°Ô º¸°íµÈ¹Ù´Â ÀÖ´Ù.
3. epithelial ovarian cancerÀÇ pathology
Table 33.1
75%°¡ serous histologic type, mucinous(20%), endometrioid(2%), clear cell(<1%), Brenner(<1%), undifferentiated carcinomas(<1%)
¨ç serous tumors
(¤¡) borderline serous tumors
l ¾à 10%¸¦ Â÷ÁöÇϸç 50%°¡ 40¼¼ ÀÌÀü¿¡ ¹ß»ýÇÑ´Ù. Serous boderline°¡Áö´Â ȯÀÚÀÇ 40%¿¡¼ extraovarian implants°¡Áö¸ç ÀÌÁß 40%°¡ °á±¹ »ç¸ÁÇÑ´Ù. º¹°À» ¹þ¾î³ ÀüÀÌ´Â ¿¹¿ÜÀûÀ̸ç, ÀåÆó¼â¿¡ ÀÇÇÑ »ç¸ÁÀÌ ÀÖÀ» ¼öÀÖ´Ù.
l Á¶Á÷ÇÐÀûÀ¸·Î invasive and noninvasive·Î ³ª´· ¼öÀÖÀ¸¸ç, non invasive implantsȯÀÚ 50¸íÁß 3¸íÀÌ »ç¸ÁÇÑ °Í¿¡ºñÇØ, invasive ȯÀÚ 6¸íÁß 4¸íÀÌ »ç¸ÁÇß´Ù´Â º¸°í°¡ ÀÖ¾ú´Ù.
(¤¤) Malignant serous tumors
l Tumor grade°¡ È®ÀεǾî¾ßÇÑ´Ù. Well-differentiatedÀÎ °æ¿ì´Â papillary and glandular structures°¡ predominantÇϸç HFP´ç 0-2°³ÀÇ mitosis¸¦ º¸ÀδÙ. Poorly differentiatedÀÇ °æ¿ì´Â solid sheets of cells, nuclear pleomorphismÀ» º¸À̸ç HPF´ç ´ë°³ 2-3°³ÀÇ mitoses¸¦ º¸ÀδÙ. Moderately differentiated´Â À§ 2°¡ÁöÀÇ Áß°£¸ð½ÀÀ» ¶è´Ù.
l 80%ÀÇ serous carcinomas¿¡¼ calcified psammoma bodies°¡ ¹ß°ßµÈ´Ù.
¨è Mucinous tumors : primary epithelial ovarian tumorÀÇ 8-10%¸¦ Â÷ÁöÇϸç mucin secreting epitheliumÀ¸·Î liningµÇ¾îÀÖ°í, ¸Å¿ì Å©±â°¡ Ä¿Áú ¼öÀÖ¾î¼ º¹°Àüü¸¦ Â÷ÁöÇÒ ¼öµµ ÀÖ´Ù.
(¤¡) Borderline mucinous tumors : ÀÌ´Â ÀÌÇØÇÒ ¼ö¾ø´Â ¼ö¼ö²²³¢ °°Àº tumor·Î¼ ÁÖ·Î endocervical mucus-secreting cells·Î ±¸¼ºµÇ¸ç, intestinal, serous, endometrioid epithelial foci¸¦ º¸ÀÏ ¼öÀÖ´Ù. Bordeline serous tumor¿¡¼´Â °¢°¢ÀÇ section¸¶´Ù ±ÕÀÏÇÑ ¸ð½ÀÀ» º¸À̳ª mucinous tumor¿¡¼´Â ±×·¸Áö ¸øÇÏ´Ù. Áï well-diffentiated section¿¡ ÀÎÁ¢ÇÏ¿© poorly differentiated focus°¡ ÀÖÀ» ¼öÀÖ´Ù.µû¶ó¼ °¡Àå ÀǹÌÀÖ´Â anaplastic alterationÀ» È®ÀÎÇϱâ À§ÇØ ¸¹Àº sectionsÀ» °Ë»çÇÏ´Â °ÍÀÌÁß¿äÇÏ´Ù.
(¤¤) Malignant mucinous carcinomas
l papillary proliferationsÀÌ serous tumors¿¡¼ ¸¸ÅÈçÇÏÁö´Â ¾ÊÀ¸³ª, ÀÌ·¯ÇÑ ¸ð½ÀÀÌ atypical proliferationÀÇ ±âº»ÀûÀÎ Áõ°ÅÀ̸ç, mucinous carinoma¿¡¼ mitotic activity¸¦ °¡Àå Á¤È®È÷ È®ÀÎ ÇÒ ¼öÀÖ°Ô ÇØÁØ´Ù.
l 8-10%¿¡¼´Â ¾çÃø¼ºÀ¸·Î ¹ß»ýÇϸç, 95-98%°¡ intraovarianÀÌ´Ù. 5-10%´Â Benign mucinous cysts·ÎºÎÅÍ ¹ß»ýÇÑ´Ù.
l ´ëºÎºÐ¿¡¼ intestinal type cellsÀ» Æ÷ÇÔÇϱ⠶§¹®¿¡ Á¶Á÷ÇÐÀû ¼Ò°ß¸¸ °¡Áö°í´Â G-I tractÀ¸·ÎºÎÅÍÀÇ metastatic carcinoma¿Í ±¸ºÐÀÌ ¾î·Æ´Ù. Primary ovarian neoplasmsÀÌ bowel serosa¸¦ involveÇÏ´Â °ÍÀº ÈçÇϳª bowel mucosa·Î ÀüÀ̵Ǵ °ÍÀº rareÇÏ´Ù. ¹Ý¸é¿¡ G-I tract originÀÎ °æ¿ì´Â vascular lymphatic spreadÅëÇÑ direct extension¿¡ ÀÇÇØ ovary involve°¡ ÈçÇÏ´Ù.
(¤§) Pseudomyxoma peritonei: psedomyxoma peritoneiÀÇ °æ¿ì neoplastic epitheliumÀº »ó´ç·®ÀÇ gelatinous mucinous materialÀ» ºÐºñÇÑ´Ù. ÀÌ´Â °¡Àå ÈçÇϰԴ ovarian mucinous carcinoma, a mucocele of the appendix, well-differentiated colon carcinomaÀÇ ÀÌÂ÷ÀûÀ¸·Î »ý±ä´Ù.
¨é Endometrioid tumors
(¤¡) Epithelial tumorsÀÇ 6-8%¸¦ Â÷ÁöÇϸç, endometriosis¿¡¼ º¸ÀÌ´Â ¸ðµç ¼Ò°ßÀ» º¸ÀδÙ. SampsonÀº ovarian adenocarcinomaÀÇ ¾î¶² ¿¹°¡ endometriosis¿¡¼ »ý°å´Ù°í ÇÏ¿´´Âµ¥, ±×ÀÇ ±âÁØ¿¡ ÀÇÇϸé typical benigh ES°¡ adenocarcinoma¿Í ¿¬°üÇÏ¿© ¹ß°ßµÇ¾î¾ß Çϸç, µÑ»çÀÌÀÇ transitionÀÌ È®ÀεǾî¾ßÇÑ´Ù°íÇÏ¿´´Ù. ÀÌ·¯ÇÑ ±âÁØ¿¡ ¸Â´Â adenocarcinoma´Â exellent prognosis¸¦ º¸ÀδÙ. Ovarian adenoca¿¡¼µµ uterine adenoca¿¡¼¿Í ºñ½ÁÇÏ°Ô ¾à 50%¿¡¼ squamous component¸¦ º¸ÀδÙ.endometriosisÀÇ malignant potentialÀº ¸Å¿ì ³·À¸¸ç, À̰æ¿ì ¾ç¼ºº´º¯ÀÇ Æ¯Â¡ÀÎhemorrhagic foci¸¦ º¸ÀÏ ¼öÀÖ´Ù. ´ë°³ serous or mucinous carcinoma¸¸Å Å©Áö´Â ¾Ê´Ù.
(¤¤) Borderline endometrioid tumors : tumors´Â endometial polyp or complex endometrial hyperplasia with crowding of glands¸¦ ´àÀ» ¼öÀÖ´Ù. ¾î¶² borderline tumor´Â prominent fibromatous component¸¦ °¡Áö´Âµ¥ ÀÌ °æ¿ì adenofibroma¶ó ÇÑ´Ù.
(¤§) Malignant endometrioid carcinomas
l Adenocarcinoma with benign-appearing squamous metaplasisÀÇ °æ¿ì excellent prognosisº¸ÀδÙ.
l ¹Ý¸é¿¡ mixed adenosquamous carcinomasȯÀÚ´Â ¸Å¿ì ³·Àº »ýÁ¸À²À» º¸ÀδÙ.
(¤©) Multifocal disease :
l ovarian endometrioid tumors´Â Á¾Á¾ endometrium¿¡ ºñ½ÁÇÑ º´º¯À» º¸ÀδÙ.ÀÌ·¯ÇÑ multifical disease¸¦ È®ÀÎÇÏ´Â °ÍÀº Áß¿äÇѵ¥ °¡·É uterus¿¡¼ ovary·Î ÀüÀÌµÈ °æ¿ì 30-40%ÀÇ 5³â »ýÁ¸À²À» º¸ÀÌ´Â °Í¿¡ ¹ÝÇØ synchronous multifocal disease°®´Â ȯÀÚ´Â 75-80%ÀÇ 5³â»ýÁ¸À²À» º¸À̱⠶§¹®ÀÌ´Ù.
l Á¶Á÷ÇÐÀûÀ¸·Î endometrium and ovarian tumor°¡ Â÷À̸¦ º¸ÀϽô °¡Àå °¡´É¼ºÀÌ ÀÖ±â´Â ÀÌ µÎÁ¾¾çÀº µÎ°³ÀÇ ´Ù¸¥ primary lesionsÀÌ´Ù. ¸¸¾à ±× µÑÀÌ ºñ½ÁÇÑ ¼Ò°ßÀ» º¸À̸ç, well-differentiatedÀ̰í, ´ÜÁö superficial invasion¸¸À» º¸ÀϽô endometrial tumors´Â separated primary tumor·Î °£ÁÖµÉ ¼öÀÖ´Ù.
¨ê Clear cell(mesonephroid) tumors : ¸ðµç ³¼ÒÁ¾¾ç¿¡¼ Â÷ÁöÇÏ´Â ºñÀ²Àº ¾à 3%Á¤µµ´Ù.
(¤¡) ÀÓ»óÀûÀ¸·Î hypercalcemia or hyperpyrexia¿Í °ü·ÃµÇ´Â °¡Àå ÈçÇÑ ³¼Ò Á¾¾çÀ̸ç, ´ë°³ÀÇ ±×·± °æ¿ì metastatic disease¿Í ¿¬°üµÈ´Ù. ´ë°³ ´ÜÃø¼ºÀÌ¸ç ³¼Ò¸¦ ¹þ¾î³ª¼ extentionÇÏÁö¾Ê´Â ÇÑ smooth surface¸¦ º¸ÀδÙ. Cystic and solid components°¡ ÈçÈ÷ ¿¬°üµÈ´Ù.
(¤¤) Malignant clear cell carcinomas: ±âº»ÀûÀÎ Á¶Á÷ÇÐÀû ¼Ò°ßÀº tubulocystic , papillary, solidÇÏ¸ç ±¸¼ºÀº clear cells and hobnail cellsÀÌ´Ù. Focal areas of endometriosis and endimetrioid carcinoma °¡ Á¾Á¾ »ý±æ ¼öÀÖ´Ù. Á¶Á÷ÇÐÀûÀ¸·Î´Â DES¿¡ ³ëÃâµÇ¾î ŒÀº ¿©¼ºÀÇ uterus or vagina¿¡¼ º¸ÀÌ´Â clear cell ca¿Í µ¿ÀÏÇÏ´Ù.
¨ë Brenner Tumors
(¤¡) Borderline Brenner tumor : epitheliumÀº stroma¸¦ ħ¹üÇÏÁö ¾Ê´Â´Ù.
l ¾î¶² ÀúÀÚµéÀº ¹æ±¤ÀÇ low-grade papillary transitional cell carcinoma¸¦ ´àÀº °æ¿ì¸¦ proliferating tumors¶óÇϰí, higer grade of transitional cell carcinoma in situ¸¦ borderline malignant Brenner tumors¶ó°í ´Ù½Ã ºÐ·ùÇϱ⵵ ÇÑ´Ù.
(¤¤) Malignant Brenner tumor: µå¹°°í, benign Brenner tumors°¡ invasive transitional cells ¿Í °øÁ¸Çϰųª ȤÀº ´Ù¸¥ carcinoma¿Í °øÁ¸ÇÏ´Â °æ¿ì¸¦ ¸»ÇÑ´Ù. Tissue infiltiltration¿¡ ÀÇÇØ destructionÀÌ ÀÖ°Ô µÈ´Ù.
(¤§) Transitional cell tumors
l recongnizable Brenner tumor°¡ ¾øÀÌ ¹æ±¤¿¡¼ »ý±â´Â transitional cell carcinoma¸¦ ´àÀº °æ¿ì¸¦ ovarian transitional cell carcinoma¶ó ÇÑ´Ù. ÀÌ·¯ÇÑ tumor°¡ 50%ÀÌ»óÀÇ transitional cell carcinoma¸¦ Æ÷ÇÔÇϸé Ç×¾ÏÄ¡·á¿¡ ´õ¿í sensitiveÇϸç, ´Ù¸¥ poorly diffentiated ovarian carcinomº¸´Ù ¿¹Èİ¡ ÁÁ´Ù.
l Transitional cell tumors°¡ malignant Brenner tumor¿Í ´Ù¸¥Á¡Àº ±×µéÀÌ Á¾Á¾ ´õ¿í advanced disease¿¡¼ ¹ß°ßµÇ°í, µû¶ó¼ »ýÁ¸À²ÀÌ ´õ ³ª»Ú´Ù´Â °ÍÀÌ´Ù.
¨ì Undifferentiated Carcinoma : large cell types°ú small cell typeÀ» Æ÷ÇÔÇÑ´Ù. Small cell typeÀº ÁÖ·Î ÀþÀº ¿©¼º¿¡¼ ¹ß»ýÇϸç hypercalcemia¸¦ º¸Àϼö ÀÖ°í, immunohistochemical stains¿¡ ÀÇÇØ lymphoma, leukemia, sarcomaµî°ú °¨º°ÇÒ ¼öÀÖ´Ù.
¨í Mesotheliomas
(¤¡) peritoneal malignant mesotheliomas´Â four categories·Î ºÐ·ùµÈ´Ù.
l Fibrosarcomatous
l Tubopapillary(papillary-alveolar)
l Carcinomatous
l mixed
(¤¤) ÀÌ·¯ÇÑ º´º¯µéÀº multiple intraperitoneal masses·Î ³ªÅ¸³ª¸ç ¾ç¼ºÁúȯ ¶§¹®¿¡ Hysterectomy with BSO½ÃÇàÇÑ ÈÄ¿¡ »ý±æ ¼öÀÖ´Ù. Malignant mesotheliomas´Â ovarian tumor implants and primary peritoneal mullerian neoplasms°ú °¨º°µÇ¾î¾ß ÇÑ´Ù.
¨î Peritoneal carcinomas : peritoneumÀÇ malignant transformationÀ» primary peritoneal carcinomas or primary peritoneal papillary serous carcinoma¶ó ÇÑ´Ù.
(¤¡) ÀÓ»óÀûÀ¸·Î ovarian carcinoma¿Í ºñ½ÁÇϸç, ¼ö¼ú½Ã¿¡ ³¼Ò Ç¥¸é¿¡ microscopic or macroscopic cancer°¡ ÀÖÀ¸¸é¼ »óº¹ºÎ ƯÈ÷ omentum¿¡ extensive disease°¡ ÀÖÀ» ¼öÀÖ´Ù.
(¤¤) Primary peritoneal tumor´Â primary ovarian serous tumors¿Í °¨º°ÀÌ ¸Å¿ì ¾î·Á¿ï ¼öÀÖ´Ù. borderline serous peritoneal tumors and serous peritoneal carcinomasÀÇ ¾î¶² °æ¿ì¿¡¼´Â ³¼Ò´Â Á¤»óÀ̰ųª minimally involvedµÇ°í, Á¾¾çÀÌ ÁÖ·Î uterosacral ligments, pelvic peritoneum, omentumÀ» predominantly affectÇÒ ¼ö ÀÖ´Ù.
(¤§) Borderline serous peritoneal tumorsÀÇ overall survivalÀº excellentÇϸç, ovarian borderline serous tumors¿Í °ßÁÙ¸¸ÇÏ´Ù. Áï 38¸íÀÇ borderline serous peritoneal tumorȯÀÚÁß 32¸íÀº no persistent disease, 4¸íÀº Àç¹ßÈÄ resection¿¡ ÀÇÇØ ÀßÁö³ÂÀ¸¸ç, ÇÑ¸í¸¸ÀÌ invasive serous carcinoma·ÎÁøÇàµÇ¾úÀ¸¸ç, ÇѸíÀÌ Á¾¾ç¿¡ ÀÇÇØ »ç¸ÁÇß´Ù.
(¤©) peritoneal serous carcinomas´Â moderately to poorly differentiated serous ovarian carcinomaÀÇ ¸ð½ÀÀ» º¸À̸ç, primary peritoneal endometrioid carcinoma´Â less commonÇÏ´Ù.
4. ovarian cancerÀÇ ¹ß»ý¿¬·É
¨ç Epithelial ovarian cancersÀÇ 80%ÀÌ»óÀÌ postmenopausal women¿¡¼ »ý±â¸ç, peak age´Â 62¼¼´Ù. 45¼¼ ÀÌÀü¿¡´Â ºñ±³Àû ÈçÄ¡ ¾Ê´Ù.
¨è Epithelial ovarian cancerÀÇ 1%¹Ì¸¸Àº 21¼¼ ÀÌÀü¿¡ »ý±â¸ç, ÀÌÁß 2/3°¡ germ cell tumors´Ù.
¨é Postmenopausal women¿¡¼ »ý±â´Â ovarian neoplasmÀÇ 30%°¡ malignancyÀÓ¿¡ ¹ÝÇÏ¿© premenopausal womenÀÎ °æ¿ì´Â ´ÜÁö ¾à 7%¸¸ÀÌ malignancy´Ù.
5. ovarian cancer screening
¨ç Transvaginal ultrasonography : early ovarian cancer detection¿¡ 95%°¡ ³Ñ´Â sensitivity¸¦ º¸ÀδÙ.
¨è CA 125 : stage I diseaseÀÇ 50%, stage II diseaseÀÇ 60%¸¦ detectionÇÒ ¼öÀÖ´Ù. CA125ÀÇ specificity´Â TV ultrasonography¿Í °°ÀÌ »ç¿ëµÇ°Å³ª ¹Ýº¹ÇÏ¿© ½Ã°£¿¡ °ÉÃÄ F/UµÇ¸é Çâ»óµÉ ¼öÀÖ´Ù.
¨é CA125¿Í Transvaginal ultrasonographyÀÇ false-positive results¸¦ °í·ÁÇÑ´Ù¸é, ƯÈ÷ premenopausal women¿¡¼´Â ÀÌ·¯ÇÑ °Ë»çµéÀº cost-effectiveness°¡ ¾øÀ¸¸ç, µû¶ó¼ ovarian cancer screeningÀ» À§Çؼ routineÇϰԻç¿ëµÇ¾î¼´Â ¾ÈµÈ´Ù.
6. epithelial ovarian cancerÀÇ genetic risk
Ovarian caÀÇ life time risk´Â ¾à 1.4%ÀÌ¸ç °¡Á··ÂÀÌ ÀÖ´Â °æ¿ì ´õ ³ô´Ù. ÇÏÁö¸¸ familial or hereditary patternÀº °Ü¿ì 5%¹Ì¸¸ÀÇ malignancy¸¸À» ¼³¸íÇØÁÙ ¼öÀÖÀ¸¸ç, ´ëºÎºÐÀº sporadicÇϰԻý±ä´Ù.
¨ç Site-Specific Familial Ovarian Cancer : °¡Á··ÂÀÌ ÀÖ´Â °æ¿ì epithelial ovarian cancer risk°¡ ´õ ³ô´Ù. °¡Á··ÂÀÌ ¾øÀ» °æ¿ì peak age°¡ ¾à 61¼¼ ÀΰͿ¡ ºñÇØ °¡Á··ÂÀÌ ÀÖÀ» ½Ã´Â ±×º¸´Ù ¾à 10³â Á¤µµ ÀÏÂï »ý±â¸ç, first-or sencond-degree relative°¡ 50¼¼ ÀÌÀü¿¡ epithelial ov.ca¸¦ º¸¿´´Ù¸é affected geneÀ» °¡Áú °¡´É¼ºÀÌ ¸Å¿ì ³ô´Ù.
(¤¡) First-degree relative(mother, sister or daughter)Áß 2¸íÀÌ epithelial ov.caÀÎ °æ¿ì female first-degree relative°¡ affected geneÀ» °¡Áú °æ¿ì´Â 50%Á¤µµ·Î ³ô°í, autosomal dominant mode¿Í ÀÏÄ¡ÇÑ´Ù.
(¤¤) First-degree relativeÇѸí, ±×¸®°í second-degree relative(grandmother, aunt, first cousin, or granddaughter)Áß ÇѸíÀÌ epithelial ov.caº¸ÀϽÿ¡µµ affected geneÀ» °¡Áú risk°¡ ³ô´Ù. ÀÌ °æ¿ì relative risk´Â °¡Á··ÂÀÌ ¾ø´Â °æ¿ì¿¡ ºñÇØ¼ 3-10¹è ³ô´Ù.
(¤§) First-degree relativeÁß ÇÑ¸í¸¸ÀÌ epithelial ov.caÀÎ °æ¿ì affected geneÀ» °¡Áú risk´Â ¾à°£ Áõ°¡Çϸç, relative risk´Â 2-4¹è ³ô´Ù.
¨è Breast/Ovarian Familial Cancer Syndrome : first-or second-degree relative¿¡¼ combination of epithelial ovarian and breast cancer°¡ Á¸ÀçÇҽô ÀÌ ÁõÈıºÀÌ °¡Á·¿¡ Á¸ÀçÇÒ ¼öÀÖ´Ù. ÀÌ·± ÁõÈıºÀÌÀÖÀ» ½Ã´Â ÀþÀº ³ªÀÌ¿¡ Á¾¾çÀ» º¸À̸ç, À¯¹æ¾ÏÀº ¾çÃø¼ºÀÏ ¼öÀÖ´Ù.
(¤¡) ¸¸¾à first-degree relativeÁß 2¸íÀÌ affectedµÇ¸é ovarian cancerÀÇ relative risk°¡ ÀϹÝÀκ¸´Ù 2-4¹è ³ô´Ù. Primary history of breast cancer º¸ÀÌ´Â ¿©¼ºÀº subsequent ovarian cancer incidence°¡ 2¹èÁõ°¡ÇÑ´Ù.
(¤¤) Breast/ovarian syndrome°ú ¿¬°üµÇ´Â gene locus´Â 17q chromosome¿¡ À§Ä¡Çϸç BRCA 1 geneÀÌ´Ù. BRCA 1 mutationÀº 1/800-1000²Ã·Î ¹ß»ýÇϸç, ÀÌ·¯ÇÑ mutationÀ» °¡Áø ¿©¼ºÀº cumulative life time risk°¡ breast cancer´Â 85-90%, ovarian cancer´Â 50%´Ù.
¨é Lynch II Syndrome (hereditary nonpolyposis colon cancer, or HNPCC): ÀÌ´Â multiple adenocarcinomas¸¦ Æ÷ÇÔÇϴµ¥, familial colon cancer(known as the Lynch I syndrome)¹× ovarian, endometrial, breast cancersÀÇ high rate, ±×¸®°í G-I and G-U systemÀÇ malignanciesÀÇ combinationÀ» º¸ÀδÙ.ÀÌ·± °¡Á··ÂÀ» °¡Áø ¿©¼º¿¡¼ epithelial ovarian cancer risk´Â firsr-and secone-degree relativesÀÇ affected frequency¿¡ ÀÇÁ¸Çϳª, ´ë°³ ÀϹÝÀκ¸´Ù´Â Àû¾îµµ 3¹èÀÇ relative riskº¸ÀδÙ.
¨ê À§ÀÇ ¸ðµç syndromeÀÇ °æ¿ì¿¡ ¿©¼º¿¡¼ BRCA1 gene mutationÀÌ ÀÖ´ÂÁö¸¦ °Ë»çÇÏ´Â °ÍÀÌ À§Ç輺ÀÌ ÀÖ´Â ¿©¼ºÀ» ¾Ë¾Æ³»´Âµ¥ Áß¿äÇÑ ¿ªÇÒÀ» ÇÒ ¼öÀÖÀ¸¸ç, risk¸¦ ´õ Á¤È®È÷ °áÁ¤Çϱâ À§Çؼ´Â °¡Á··ÂÀ» Àû¾îµµ 3´ë¿¡ °Éó Æò°¡ÇÏ¿©¾ß ÇÑ´Ù. Epithelial ovarian cancerÀÇ Strong family historyÀÖ´Â ¿©¼ºÀÇ care´Â ±×³àÀÇ ³ªÀÌ , »ý½Ä°èȹ, À§Ç輺ÀÇ Á¤µµµîÀ» °í·ÁÇØ¼ °áÁ¤µÈ´Ù. ÀÌ·¯ÇÑ À§Ç豺¿¡¼´Â TV ultarsonography ¿Í CA125ÅëÇÑ screeningÀÌ ÃßõµÇ±âµµ ÇÑ´Ù. ÃÖ±Ù Á¦½ÃµÇ¾îÁö´Â recommendationÀº ´ÙÀ½°ú °°´Ù.
(¤¡) »ý½Ä´Éº¸Á¸À» ¿øÇÏ´Â ¿©¼ºÀº 6°³¿ù¸¶´Ù Áú½ÄÃÊÀ½ÆÄ¸¦ ½ÃÇàÇÏ¿©¾ß Çϸç, ´õ ÀÌ»óÀÇ ¾Ö¸¦ ¿øÄ¡ ¾ÊÀ¸¸é prophylactic oophorectomy°¡ °í·ÁµÇ¾îÁ®¾ßÇÑ´Ù. ºñ·Ï protective effect´Â ¸íȮġ ¾ÊÀ¸³ª, ¾Ö¸¦ °®±â ÀüÀÇ ÀþÀº ¿©ÀÚ¿¡°Ô´Â OC¸¦ »ç¿ëÇÒ ¼ö ÀÖ´Ù.
(¤¤) Familial ovarian or hereditary breast/ovarian cancer syndrome °¡Á··ÂÀÌ ÀÖ´Â ¿©¼º¿¡¼ ´õ ÀÌ»óÀÇ ÀÓ½ÅÀ» ¿øÄ¡ ¾ÊÀ¸¸é prophylactic BSO¸¦ ½ÃÇàÇØ¾ßÇÑ´Ù. ȯÀÚ¿¡°Ô ¼ö¼úÈÄ¿¡ À§Ç輺ÀÌ ¿ÏÀüÈ÷ ¾ø¾îÁö´Â °ÍÀÌ ¾Æ´Ï¸ç, peritoneal carcinomas°¡ Á¾Á¾ BSOÈÄ¿¡ »ý±æ ¼öÀÖÀ½À» ¼³¸íÇÏ¿©¾ßÇÑ´Ù.
(¤§) Lynch II syndrome°¡Á··ÂÀÌ ÀÖ´Â ¿©¼º¿¡¼µµ À§¿Í°°ÀÌ Ä¡·áµÇ¾îÁ®¾ß Çϸç, ÷°¡ÇÏ¿© ÁÖ±âÀûÀÎ screening mammography, colonoscopy, endometrial biopsy°¡ ÇàÇØÁ®¾ßÇÑ´Ù.
7. epithelial ovarian cancerÀÇ Áõ»ó ¹× ¡ÈÄ
¨ç Áõ»ó
(¤¡) ´ë°³ÀÇ È¯ÀÚµéÀº Àå±â°£ µ¿¾È Áõ»óÀÌ ¾ø´Ù. Áõ»óÀÌ ÀÖ´ÙÇÏ´õ¶óµµ Á¾Á¾ ¸ðÈ£ÇÏ¸ç Æ¯ÀÌÀûÀÌÁö ¸øÇÏ´Ù.
(¤¤) Early stage : PremenopauseÀÎ °æ¿ì ȯÀÚ´Â irregular menses¸¦ °æÇèÇÒ ¼öµµ ÀÖÀ¸¸ç, ¸¸¾à Á¾±«°¡ ¹æ±¤ ȤÀº Á÷ÀåÀ» ¾Ð¹ÚÇÏ¸é ºó´¢³ª º¯ºñ¸¦ È£¼ÒÇϱ⵵ÇÑ´Ù. Á¾Á¾ lower abdominal distention, pressure, dyspareunia°°Àº painÀ» È£¼ÒÇϱ⵵ ÇÑ´Ù. Rupture or torsionµî¿¡ ÀÇÇÑ ±Þ¼º Áõ»óÀº ÈçÄ¡¾Ê´Ù.
(¤§) Advanced stage : ´ë°³ÀÇ °æ¿ì ascites, omental metastasis, bowel metastasisµî°ú ¿¬°üµÈ Áõ»óÀ» º¸À̴µ¥, abdominal distention, bloating, constipation, nausea, anorexia, early satietyµîÀÌ ±×°ÍÀÌ´Ù. Postmenopausal¿¡¼´Â vaginal bleedingÀÌ »ý±æ ¼öÀÖÀ½¿¡ ºñÇØ premenoapausalÀÎ °æ¿ì´Â irregular or heavy menses¸¦ È£¼ÒÇÒ ¼öÀÖ´Ù.
¨è ¡ÈÄ
(¤¡) °¡Àå Áß¿äÇÑ signÀº ½Åü°Ë»ç¿¡¼ °ñ¹ÝÁ¾±«°¡ Á¸ÀçÇÏ´Â °ÍÀÌ´Ù. Solid,irregular, fixed pelvic mass´Â malignancy¸¦ °ÇÏ°Ô ½Ã»çÇÑ´Ù. °Ô´Ù°¡ »óº¹ºÎ Á¾±« ³ª º¹¼ö°¡ Á¸ÀçÇϸé Áø´ÜÀº ´õ¿í È®½ÇÇØÁø´Ù. Á¾Á¾ ȯÀÚ°¡ º¹ºÎÁõ»óÀ» È£¼ÒÇϱ⠶§¹®¿¡ pelvic examÀ» ÇÏÁö ¾ÊÀ» ¼öÀÖÀ¸¸ç, Á¾±«¸¦ ³õÄ¥ ¼öÀÖ´Ù.
(¤¤) Æó°æ ÈÄ Àû¾îµµ 1³âÀÌ Áö³ ¿©¼ºÀÇ ³¼Ò´Â À§ÃàµÇ°í ¸¸Á®ÁöÁö ¾Ê´Â´Ù. ¸¸¾à ÀÌ·¯ÇÑ ¿©¼º¿¡¼ palpable pelvic mass°¡ Á¸ÀçÇÒ ½Ã´Â ¾Ç¼ºÀ» °í·ÁÇØ¾ßÇϴµ¥ À̸¦ postmenopausal palpable ovary syndromeÀ̶ó ºÒ·Á¿Ô´Ù. ÇÏÁö¸¸ Æó°æ ÈÄ¿©¼º¿¡¼ 5cm¹Ì¸¸ÀÇ palpable mass°¡ ÀÖÀ» ½Ã ´Ü 3%¸¸ÀÌ malignancy¿´´Ù´Â º¸°íµµ ÀÖ´Ù.
8. epithelial ovarian cancerÀÇ Áø´Ü ¹× ¼ö¼úÀü °Ë»ç
¨ç Serum CA 125°¡ ¾ç¼ºÁ¾±«¿Í ¾Ç¼ºÁ¾±«ÀÇ °¨º°¿¡ µµ¿òÀ» ÁØ´Ù.
(¤¡) Postmenopausal women¿¡¼ ³¼ÒÁ¾±«°¡ ÀÖÀ¸¸é¼ CA125>95U/mlÀÎ °æ¿ì 96% positive value for malignancyº¸ÀδÙ.
(¤¤) Premenopuasal women¿¡¼´Â ES, PID, myoma°°Àº ÈçÇÑ benign condition¿¡¼µµ CA125°¡ Áõ°¡ÇÒ ¼öÀֱ⠶§¹®¿¡ Specificity°¡ ³·´Ù.
¨è Premonopausal woman¿¡¼ ³¼ÒÁ¾±«°¡ ÀÖÀ¸³ª mobile, cystic, unilateral, regular contour¸¦ º¸ÀÌ´Â °æ¿ì 2°³¿ù °£°ÝÀ» ³ÑÁö¾Ê°Ô ÁÖ±âÀûÀ¸·Î observationÇÏ´Â °ÍÀÌ reasonbleÇϸç, OCÅëÇÑ Hormone suppressionÀÌ »ç¿ëµÇ¾îÁú ¼öÀÖ´Ù. ¸¸¾à Á¾±«°¡ neoplasticÇÏÁö ¾Ê´Ù¸é regressÇØ¾ßÇϸç, ¸¸¾à regressÇÏÁö ¾Ê°Å³ª Å©±â°¡ Ä¿Áö¸é neoplasticÀÓÀ» °¡Á¤ÇÏ¸ç ¼ö¼úÀûÀ¸·Î Á¦°ÅµÇ¾îÁ®¾ßÇÑ´Ù.
¨é º´º¯ÀÇ Å©±âµµ Áß¿äÇÏ¿©, 8cmÀ» ÃʰúÇÏ´Â cystic mass´Â neoplastic °¡´É¼ºÀÌ ³ô´Ù. ¾Ç¼ºÀ» ½Ã»çÇÏ´Â ¼Ò°ß Áï predominantly solid, relatively fixed, irregular shapedÇҽô laparotomy¸¦ ½ÃÇàÇØ¾ßÇÑ´Ù.
¨ê Áø´ÜÀº exploratory laparotomy°¡ ÇÊ¿äÇÏ¸ç ¼ö¼úÀü¿¡´Â ÀÏ»óÀûÀÎ Çǰ˻ç¿Ü¿¡µµ chest x-ray, IVP¸¦ ½ÃÇàÇØ¾ß ÇÑ´Ù.abdominal and pelvic CT, or MRI´Â definite pelvic mass°¡ Á¸ÀçÇÒ ½Ã´Â ÇÊ¿äÄ¡¾Ê´Ù. ÇÏÁö¸¸ º¹¼ö°¡ ÀÖÀ¸¸é¼ pelvic mass°¡ ¾øÀ»½Ã´Â liver or pancreatic tumors¸¦ ã±âÀ§ÇÑ CT or MRI°¡ ÇÊ¿äÇÏ´Ù. ÀüÀÌ¿¡ ÀÇÇÑ Áõ»óÀÌ ÀÖÁö ¾Ê´ÂÇÑ Liver-spleen scans, bone scans, brain scansÀº ºÒÇÊ¿äÇÏ´Ù.
¨ë 45¼¼ ÃʰúÇϴ ȯÀÚ¿¡¼´Â primary colon cancer¿¡ ÀÇÇÑ ³¼ÒÀüÀ̸¦ R/OÇϱâ À§ÇÑ barium enema ³ª colonoscopy°¡ ÀûÀÀÀÌ µÈ´Ù. ÀÌ·¯ÇÑ °Ë»ç´Â stool¿¡¼ occult blood°¡ Àְųª ÀåÆó¼âÀÇ Áõ°Å°¡ Àִ ȯÀÚ¿¡°Ô¼´Â ¹Ýµå½Ã ½ÃÇàµÇ¾î¾ßÇÑ´Ù. Áõ»óÀÌ ÀÖÀ» ½Ã´Â upper G-I series or gastroscopy°¡ ÀûÀÀÀÌ µÈ´Ù. Breast mass°¡ ÀÖÀ» ½Ã´Â bilateral mammography°¡ ÀûÀÀÀ̵Ǵµ¥ ÀÌ´Â Á¾Á¾ primary breast cancer°¡ ³¼Ò·Î ÀüÀÌÇÏ¿© primary ovarian cancer·Î¿ÀÀ뵃 ¼öÀֱ⠶§¹®ÀÌ´Ù.
¨ì ºñ·Ï ovarian cancer detection¿¡¼ÀÇ °¡Ä¡´Â ¸Å¿ì Á¦ÇÑÀûÀ̳ª cervical cytology°¡ ¹Ýµå½Ã ½ÃÇàµÇ¾î¾ßÇÑ´Ù. Irregular menses or postmenopausal vaginal bleedingº¸À̴ ȯÀÚ´Â ¹Ýµå½Ã endometrial biopsy and endocervical curettage¸¦ ½ÃÇàÇÏ¿© ³¼ÒÀüÀ̸¦ °¡Áö´Â uterine or endometrial cancerÀÇ Á¸À縦 R/OÇØ¾ßÇÑ´Ù.
9. Ovarian epithelial cancersÀÇ spread pattern
Áַδ º¹°³»·ÎÀÇ exfoliation, lymphatic dissemination, hematogenous spreadº¸ÀδÙ.
¨ç Transcoelomic
(¤¡) °¡Àå ÈçÇÑ Ãʱâ dissemination¾ç»óÀº cancer cellÀÇ exfoliationÀ̸ç, peritoneal cavity surfaceµû¶ó implantÇÑ´Ù. À̰æ¿ì ÁÖ·Î º¹¼öÀÇ ¼øÈ¸°æ·Î¸¦ µû¸£´Âµ¥ º¹¼ö´Â È£Èí¿¡ ÀÇÇØ pelvis, up the paracolic gutters(ƯÈ÷ ¿À¸¥ÂÊ), along the intestinal mesenteries, to the right hemidiaphragm·Î ¿òÁ÷ÀδÙ.
(¤¤) µû¶ó¼ ÀüÀÌ´Â ÀüÇüÀûÀ¸·Î posterior culdesac, paracolic gutters, right hemidiaphragm, liver capsule the peritoneal surface of the intestines and their mesenteries , omentum¿¡¼ ÁÖ·Î »ý±ä´Ù.
(¤§) Intestinal lumenÀ» involveÇÏÁö´Â ¾ÊÀ¸³ª Á¡Â÷ÀûÀ¸·Î bowel loops¸¦ ±³Âø½ÃÄÑ functional intestinal obstruction¾ß±âÇÑ´Ù. À̸¦ carcinomatous ileus¶ó ÇÑ´Ù.
¨è Lymphatic
(¤¡) Advanced diseaseÀÎ °æ¿ì lymphatic ÅëÇØ pelvis and para-aortic lymph node·Î disseminationµÇ´Â °ÍÀº ÈçÇÏ´Ù. DiaphragmÀÇ ¸²ÇÁ°ü ¹× Èĺ¹¸·¸²ÇÁÀý ÅëÇØ¼ diaphragmÀ§·Î ÀüÀÌµÉ ¼öÀÖÀ¸¸ç ƯÈ÷ supraclavicular lymph nodes·Î°£´Ù.
(¤¤) Stage IIIÀÇ °æ¿ì 78%¿¡¼ Pelvic nodes·ÎÀÇ ÀüÀ̸¦ º¸¿´À¸¸ç, para-aortic nodes·ÎÀÇ ÀüÀÌ´Â stage IÀº 18%, II 20%, III 42%, IV 67%¿´´Ù.
¨é Hematogenous : ÈçÄ¡´Â ¾ÊÀ¸³ª lung and liver°°Àº vital organÀ¸·ÎÀÇ ÀüÀÌ´Â 2-3%¿¡¼ ¹ß»ýÇÑ´Ù. Áø´Ü´ç½Ã diaphragmÀ§¿¡ º´º¯À» °¡Áø ȯÀÚ´Â right pleural effusion°¡Áø´Ù.
10. ovarian epithelial cancerÀÇ ¿¹ÈÄ ÀÎÀÚ
¨ç Pathologic factors
(¤¡) morphology and histologic pattern(architecture and gradeÆ÷ÇÔ)°¡ Áß¿äÇÑ ¿¹ÈÄ ÀÎÀÚ´Ù. Histologic typeÀÌ Áß¿äÇÑ ¿¹ÈÄÀÎÀÚ·Î ¿©°ÜÁ®¿ÀÁö ¾Ê¾ÒÀ¸³ª ÃÖ±Ù clear cell ca°¡ ´Ù¸¥ typesº¸´Ù ¿¹Èİ¡ ³ª»Ú´Ù°í º¸°í µÇ¾ú´Ù.
(¤¤) Histologic grade°¡ Áß¿äÇÑ ¿¹ÈÄÀÎÀÚ·Î ¿©°ÜÁö³ª °üÂûÀÚ¸¶´Ù ¸¹Àº Â÷À̸¦ º¸À̱⠶§¹®¿¡ ±× °¡Ä¡´Â ¾ÆÁ÷ Á¤¸³µÇÁö ¾Ê¾Ò´Ù.
¨è Biologic factors
(¤¡) flow cytometry¸¦ »ç¿ëÇÑ °á°ú ovarian cancer´Â ÈçÈ÷ aneuploidº¸¿´À¸¸ç, ´õ ³ª¾Æ°¡¼ FIGO stage¿Í Ploid»çÀÌ¿¡´Â ¿¬°ü¼ºÀÌ ÀÖ¾ú´Ù. Áï low-stage cancers´Â diploid°æÇâÀÌ, high-stage cancer´Â aneuploid°æÇâÀÌ ÀÖ¾ú´Ù. Diploid tumors °¡Áø ȯÀÚ°¡ aneuploidȯÀÚº¸´Ù ÀǹÌÀÖ°Ô median survival ÀÌ ±æ¾ú´Ù.(5³â: 1³â) ¸¹Àº multivariate analysis¿¡ ÀÇÇϸé ploidy°¡ independent prognostis variableÀ̸ç one of the most significant predictors of survivalÀÌ´Ù.
(¤¤) 60°³ ÀÌ»óÀÇ proto-oncogenesÀÌ È®ÀεǾú´Ù. ÇÑ¿¬±¸¿¡ ÀÇÇϸé HER-2/neu oncogeneÀº epithelial ova caÀÇ ¾à 30%¿¡¼ expressedµÇ¸ç ¿¹Èİ¡ ³ª»Ú´Ù°í Çϸç, ¶Ç´Ù¸¥ ¿¬±¸¿¡ÀÇÇϸé HER-2/neu expressionÀÇ overall incidence´Â ¾à 11%¿´À¸¸ç µû¶ó¼ ¿¹ÈÄÀÎÀڷμÀÇ °¡Ä¡´Â ¸íÇÐÄ¡ ¾Ê´Ù°í ÇÏ¿´´Ù.
¨é Clinical factors
(¤¡) stage¿¡ ´õÇÏ¿©, the extent of residual disease after primary surgery, the volume of ascites, patient age, performance scaleµîÀÌ ¸ðµÎ°¡ independent prognostic variablesÀÌ´Ù.
(¤¤) Stage I ȯÀÚ¿¡¼ Tumor grade and dense adherence to the pelvic peritoneumÀÌ ¿¹ÈÄ¿¡ ÀǹÌÀÖ°Ô ³ª»Û ¿µÇâÀ» ¹ÌÃÆÀ¸¸ç, ¹Ý¸é¿¡ intraoperative tumor spillage or rupture´Â ±×·¸Áö ¾Ê¾Ò´Ù.
(¤§) Ovarian cancer°¡ ¼ö¼úÁß¿¡ rupture or spillageµÇ´Â °ÍÀº ¿¹Èĸ¦ ¾ÇȽÃŰÁö ¾Ê´Â ¹Ý¸é ¼ö¼úÀü¿¡ ÀÌ¹Ì ruptureµÈ °æ¿ì¶ó¸é ³ª»Û ¿¹Èĸ¦ º¸ÀδÙ.
11. ovarian epithelial cancersÀÇ Staging
Table 33.2
FIGO stage´Â surgicall exploration¿¡ ±âÃʸ¦ µÎ°í ÀÖÀ¸¸ç, ÀÌ·¯ÇÑ surgical stagingÀÌ Çâ¿ì Ä¡·á¸¦ °áÁ¤Áþ±â ¶§¹®¿¡ ¸Å¿ì Áß¿äÇÏ´Ù.
12. surgical stagingÀÇ technique
¨ç ¼ö¼úÀü¿¡ malignancy°¡ ÀǽɵǾú´ø °æ¿ì »óº¹ºÎ·ÎÀÇ Á¢±ÙÀÌ ´õ½¬¿î midline or paramedian abdominal incisionÀÌ ÃßõµÈ´Ù. Transverse incisionÀ» ÅëÇÑ ¼ö¼úÁß ¿¹»óÄ¡ ¸øÇÏ°Ô malignancy°¡ ¹ß°ßµÈ °æ¿ì¶ó¸é rectus muscle¸¦ ÀÚ¸£°Å³ª Ä¡°ñ¿¡¼ ¶¼³»ÁÜÀ¸·Î½á »óº¹ºÎ·ÎÀÇ Á¢±ÙÀ» ¿ëÀÌÇÏ°Ô Çϴµ¥ À̰ÍÀÌ ÃæºÐÄ¡ ¾ÊÀ» ½Ã´Â ÇǺÎÀý°³¸¦ ÇÑÂÊÀ¸·Î ¿¬ÀåÇÏ¿© J ¸ð¾çÀ¸·Î Àý°³ÇØÁØ´Ù.
¨è ³¼ÒÁ¾¾çÀº °¡´ÉÇÑ intactÇÑ »óÅ·ΠÁ¦°ÅÇÏ¿© µ¿°áÀýÆíÀ» ½ÃÇàÇÑ´Ù. ¸¸¾à ¾Ç¼ºÀ̸é surgical stagingÀ» ´ÙÀ½ ´Ü°è¿¡ µû¶ó ½ÃÇàÇÑ´Ù.
(¤¡) ¾î¶°ÇÑ free fluid(ƯÈ÷ cul-de-sac)µµ cytologic evaluationÇØ¾ßÇÑ´Ù.
(¤¤) Free fluid°¡ ¾øÀ» ½Ã´Â 50-100ml salineÀ» pelvic cul-de-sac, each paracolic gutter, beneath each diaphragm¿¡ instilling and recoveringÇÏ¿© cytology ³»º¸³½´Ù.
(¤§) All intra-abdominal surfaces and viscera¸¦ öÀúÈ÷ Á¶»çÇÑ´Ù. À̶§ ½Ã°è¹æÇâÀ¸·Î cecum¿¡¼ ½ÃÀÛÇÏ¿© paracolic gutter-> ascending colon to the right kidney->liver and GB->right hemidiaphragm->the entrance to the lesser sac at the paraaortic area->across the transverse colon to the left hemidiaphragm-> down the left gutterand descending colon to the rectosignmoid colon·Î Á¶»çÇϰԵȴÙ. Small intestine and its mesentery¸¦ Treitz ligament¿¡¼ cecum±îÁö Á¶»çÇÑ´Ù.
(¤©) º¹¸·¿¡ ÀÖ´Â ¾î¶°ÇÑ Àǽɽº·¯¿î ºÎÀ§³ª À¯ÂøÀº biopsyµÇ¾î¾ß ÇÑ´Ù. ¸¸¾à disease evidence°¡ ¾øÀ»½Ã´Â ¿©·¯ ºÎÀ§¿¡¼ biopsies¸¦ ½ÃÇàÇϴµ¥, cul-de-sac, both paracolic gutters, peritoneum over the bladder, intestinal mesenteries¿¡¼ biopsy½ÃÇàÇÑ´Ù.
(¤±) DiaphragmÀ» biopsyȤÀº scraping with a tongue depressor¹æ¹ýÀ¸·Î samplingÇÏ¿©¾ßÇϸç, cytologyÀ§ÇÑ sampleµµ È®º¸ÇÏ¿©¾ßÇÑ´Ù.
(¤²) OmentumÀ» transverse colonÀ¸·Î ºÎÅÍ Àý´ÜÇϴµ¥ À̸¦ infracolic omentectomy¶ó ÇÑ´Ù.¿ì¼± greater omentumÀÇ underside¿¡¼ ½ÃÀÛÇϴµ¥ transverse colonÀ¸·ÎºÎÅÍ a few millimeters¶³¾îÁ®¼ peritoneumÀ» Àý°³ÇÑ´Ù. Gastroepiploic vessels branches¸¦ Àâ°í °áÂûÇϰí Àß¶óÁØ´Ù. Infracolic omentum feedingÇÏ´Â ¸ðµç ÀÛÀº Ç÷°üµéµµ À§¿Í°°ÀÌ ÇØÁØ´Ù. Gastrocolic ligamentÀº Á¤»óÀ̶ó¸é Àý´ÜµÉ ÇÊ¿ä¾ø´Ù.
(¤µ) Pelvic and para-aortic nodes¸¦ evalutationÇϱâ À§ÇØ retroperitoneal spaces¸¦ Á¶»çÇÑ´Ù. Enlarged nodes´Â Á¦°ÅµÇ¾î¼ µ¿°áÀýÆí½ÃÇàÇÑ´Ù. ¸¸¾à ¾î¶°ÇÑ ÀüÀ̵µ ¾ø´Ù¸é formal pelvic lymphadenectomy°¡ ½ÃÇàµÇ¾î¾ßÇÑ´Ù.
13. surgical stagingÀÇ Á߿伺
¨ç Pelvis¿¡ ±¹ÇÑ µÇ¾îÀÖ´Ù°í ¿©°ÜÁö´Â stage I,IIȯÀڵ鿡¼ occult metastasis°¡ diaphragm biopsy¿¡¼´Â 7.3%, omentum¿¡¼´Â 8.6%, pelvic lymph nodes¿¡¼´Â 5.9%, aortic lymph nodes¿¡¼´Â 18.1%, peritoneal washing¿¡¼´Â 26.4%°¡ ¹ß°ßµÈ´Ù.
¨è Histologic grade°¡ occult metastasisÀÇ significant predictor´Ù.Áï primary surgical staging¿¡¼ grade IÀ̾ú´ø °æ¿ì 16%¿¡¼, grade II¿´´ø °æ¿ì 34%, grade III¿´´ø °æ¿ì additional surgical staging¿¡ ÀÇÇØ upstagedµÈ´Ù.