Ovarian tumours

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Ovarian tumours
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Plan

• Non-neoplastic conditions
• Ovarian neoplasms

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1 non-neoplastic conditions

• 1.1 functional cysts
• Follicular cysts follicle -gt no ovulation -gt
  persistent GnRH stimulation -gt cyst formation
• Corpus luteum cysts follicle -gt ovulation -gt
  persisting Progesterone producing cyst -gt
  eventual involution
• These cysts are confined to the reproductive
  years and to those not using hormonal c/c

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Functional cysts

• Can be asymptomatic / pain / menstrual
  irregularity
• Principle If a young woman complains of pain,
  EXAMINE.
• If cyst present Unilateral? Is it benign?
• Then Ultrasound!
• CA125 usually lt35

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Ultrasound criteria Most likely benign

• Unilocular
• Thin walled
• Smooth walls
• Echo free contents
• Unilateral
• Usually lt8cm in diameter

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If most likely benign

• Most will undergo regression with menstruation
• Can wait (not if pain is a problem)
• Hormonal suppresion of GnRH stimulation
• OC best and convenient
• or Provera 5mg 2x per day for 10 days
  (progesterone treatment)
• NSAIDs for pain
• And reassess after menstruation

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Complications of a cyst

• Torsion
• Mechanism
• clinical acute pain, nausea, faint
• Tenderness, mass, acute abdomen
• Diff dx Ectopic pregnancy
• Ultrasound, Hb, hCG
• Treatment laparotomy adnexectomy
• Bleeding
• Rupture

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1.2 non-functional non-neoplastic cysts

• Endometriomas
• Theca-lutein cysts
• Par-ovarian cysts
• Residual ovarian syndrome post-hysterectomy
  pain and dyspareunia ovary stuck to the vault.
• Surgical management removal or suspension

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Ovarian neoplasms

• Types
• Epithelial
• Stromal
• Germ cell
• Metastatic
• Behaviour
• Benign / borderline malignancy / malignant

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• Uncommon but very important Gynaecologic cancer
  with poorest prognosis
• Causes Probably genetic factors
• Risk factors age 40-65y
• Own or family history of breast / ovary /
  endometrium / colon cancer
• Never pregnant / infertility / low parity

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• Protection OCs, oophorectomy with strong family
  history
• Screening poor!! CA125 u/sound used low pick
  up and predictability
• Clinical picture
• History few complaints, non specific tired,
  pain, urinary and GIT complaints, abdominal
  distension, only 1 bleeds

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• Examination ascites, mass in abdomen and pelvis,
  solid, bilateral, tender
• Tests
• CA 125 useful as marker if patient has raised
  value
• FBC, sedimentation, UE, LFT, CXR, ultrasound
• Bowel diff dx Ba enema / colonoscopy / occult
  blood

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Ultrasound criteria for POTENTIALLY MALIGNANT

• Solid / semicystic
• Multilocular
• Thick walled
• Papillary growths on walls of cysts and tumour
• Bilateral
• Ascites

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Staging

• Surgical, also 1-4 system
• I confined to ovary / ovaries (15)
• II also uterus, tubes, bladder and rectal walls,
  pelvic peritoneum (10)
• III upper abdomen, peritoneum, omentum, lymph
  nodes (60)
• IV lungs, liver, other organs (15)

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Management

• Principle Surgery followed by chemotherapy
• Operations
• Staging laparotomy for confined disease TAH BSO
  omentectomy, nodes and ascites
• Cytoreduction for intraperitoneal spread aim to
  do same and not leave tumour larger than 1cm
  behind
• Interval cytoreduction apparently inoperable
  biopsy and chemo X 3, then surgery

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Further treatment

• Chemotherapy for stages 1c onwards 6 courses
• Prognosis 5years survival Stage I 90, Stage
  II 40, Stage III 30, Stage IV 10
• Causes of death
• Intestinal obstruction, metastases, cachexia
• Needs pain control and care, nutritional support
  and ascites control

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Histologic types of tumours

• Epithelial
• Serous, mucinous, endometroid, clear cell, mixed
• Stromal
• Granulosa, theca, GT, sertoli, leydig SL,
  mixed, lipoid
• Germ cell
• Dysgerminoma, yolk sac, embryonal, mixed
• Benign cystic teratoma

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Group characteristics

• Epithelial common, 45-65y, imitates other
  mullerian epithelia serous, mucinous,
  endometroid, clear cell. Can be Benign,
  borderline malignant or malignant
• Stromal rare, any age, low grade malignant
  behaviour hormone producing E G, T. A S, L
• Germ cell very rare children and adolescents,
  highly malignant, unilateral. Chemosensitive.

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Exception Benign cystic teratoma

• Most common ovarian tumour if children and young
  adults. Usually unilateral, few symptoms pain,
  torsion, bleeding.
• Contains tissue from all 3 embryonic layers
• On section hair, sebaceous material, bone and
  teeth
• Rx ovarian cystectomy with conservation of
  normal ovarian tissue