Ovarian tumours

Plan Non-neoplastic conditions Ovarian neoplasms

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

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 <35

Ultrasound criteria: Most likely benign Unilocular Thin walled Smooth walls Echo free contents Unilateral Usually <8cm in diameter

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

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

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

Ovarian neoplasms Types: Behaviour: Epithelial Stromal Germ cell Metastatic Behaviour: Benign / borderline malignancy / malignant

Causes: Probably genetic factors Risk factors: age 40-65y 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

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

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

Ultrasound criteria for POTENTIALLY MALIGNANT Solid / semicystic Multilocular Thick walled Papillary growths on walls of cysts and tumour Bilateral Ascites

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%)

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

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

Histologic types of tumours Epithelial Serous, mucinous, endometroid, clear cell, mixed Stromal Granulosa, theca, G+T, sertoli, leydig S+L, mixed, lipoid Germ cell Dysgerminoma, yolk sac, embryonal, mixed Benign cystic teratoma

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.

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