Ovarian Tumours Max Brinsmead MBBS PhD November 2014

Incidence 1:10 women will undergo surgery during a lifetime because of suspected ovarian mass 10% turn out to be non ovarian The vast majority in pre menopausal women are benign

Ovarian tumours present as: Pain Mass An incidental finding But the most important thing to determine is whether: It is functional or neoplastic? Benign or malignant?

After the identification of a pelvic adnexal mass evaluation is usually by ultrasound but think… Is there a short history of symptoms? Is this a woman of reproductive age? Cycling spontaneously? Or using progestin-only contraception? A past history of “cysts” Pregnant? Had IVF?

Pathology of Functional Ovarian Tumours: A 2 cm “cyst” occurs every month = mature follicle Haemorrhage from or into a corpus luteum is common Failed follicular rupture can also result in a cyst Endometrioma = ovarian endometriosis

Ultrasound features of a Functional Ovarian Tumour Thin walled Usually no solid components Usually no septa or thin walled septa Usually <6 cm size Usually avascular to colour Doppler Change rapidly And disappear within 6-8w (A role for COC during this period not supported by Cochrane)

Management Guidelines for a Simple Cyst in a Premenopausal Woman Ignore if <30 mm size and asymptomatic Repeat scan after 3m for simple cysts 30 – 50 mm –Further Ix or laparoscopy if they increase in size –Repeat scan in 12m if unchanged and < 70 mm Further Ix and or laparoscopy for cysts >70 mm –Ca 125 –Further imaging (CT or NMR) Laparotomy may be better for suspected dermoid >70 mm

Clinical Features of a Neoplastic Ovarian Tumour: Older women Larger tumours Solid/Cystic or multiple septate Bilateral Fixed, tender or craggy to palpation Ascites present Vascular to colour Doppler Persist or enlarge (4m re evaluation for postmenopausal women) Associated with positive tumour markers – CA125, CA19.9, CEA (AFP,  HCG, LDH)

Differential diagnosis for an Ovarian Tumour: Full bladder Pregnancy Loaded caecum or sigmoid colon Hydrosalpinx Mesenteric cyst Fiboid (subserosal) Pelvic kidney etc Paraovarian cyst

Comprehensive DD of Adnexal Masses

Pathology of Ovarian Neoplasms Germ cell Tumours –Benign cystic = Dermoid (the most common neoplasm of young ♀ – 15% bilateral) –Malignant includes Dysgerminoma (LDH), Teratocarcinoma, Endodermal sinus Ca (AFP), Chorioca (bHCG) Epithelial –Cystadenoma (serous and mucinous) –Cystadenocarcinoma Serous – Mucinous – Endometroid – Clear cell adenoCa Functional –E2 producing (granulosa cell benign or malignant) –Androgen producing (Androblastoma) Secondary Cancers (Stomach, Bowel, Breast etc)

Role of Ca 125 Of most value in the evaluation of adnexal mass in postmenopusal women Too many false positives in premenopausal women –Endometriosis, Adenomyosis, Fibroids & PID Always of concern if >200 Specific only for epithelial tumours –And only 50% sensitive for early stage disease

Staging of Ovarian Cancer: Stage 1A - Confined to one ovary 1B - Ascites or +ve peritoneal cytology Stage 2A - Involves uterus or tubes 2B - Involves other pelvic viscera Stage 3A - Confined to pelvis 3B - to lymph nodes or upper abdominal implants >2cm Stage 4 - Distant metastases

Treatment of Ovarian Cancer: Debulking surgery = TAH + BSO+Omentectomy Chemotherapy Radiotherapy Special cases Children Young woman – no children Advanced disease

Prognosis for ovarian cancer: Overall 30 – 35% but this is because it presents late With modern gynaecological oncology (debaulking + aggressive combination chemotherapy) it should be >50%

Preventing ovarian cancer: Screening- Vaginal exams - Ultrasound & CA125 Have been disappointing – too many false positives Prophylactic Oophorectomy - at hysterectomy (40%) - for genetically predisposed (BRAC carriers) Prophylactic salpingectomy

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