1. Ovarian Tumors
د. ياسمين حمزة

2. Symptoms of ovarian cyst &tumours :
1-most ovarian tumours are asymptomatic & discovered accidentally as at antenatal care clinic or during routine gyn. Ex. or on invest. for other condition.
2- pain: a-its unusual complaint for uncomplicated ovarian cyst &tumour. b-dull aching back pain in malignant tumour if there is sacral root metastasis. C - acute or sub-acute abdominal pain when there is complicated ovarian cyst( torsion ,hemorrhage ,infection ,impaction).
3-abdominal enlargement when large tumour is present or when there is ascites present.

3. 4-pressure symptoms: on bowel causing indigestion ,loss of appetite ,vomiting &or constipation.
On bladder causing frequency or retention if press the urethra.
5- menstrual cycle disturbance :in hormone secreting tumours e,g androgen – secreting tumour causes amenorrhea or granulose cell tumour causes irregular bleeding.

4. Physical signs:
1-by abd. Or pv ex. smooth mobile mass ,separated from the uterus .
2-usual position behind the uterus but if large size as in dermiod cyst can felt in front the uterus &the mass dull on percussion with resonance on the sides.

5. Differential diagnosis of ovarian cyst &tumours:
1-ascites:transmitted thrill+ve ,shifting dullness +ve ,central resonance &lateral dullness
2-chronic pyosalpinx :bilateral ,associated with fever &O/E fixed tender mass.
3-broad ligament cyst: painless , O/E uterus pushed to the other side, immobile.
4-pedunculated fibroid: difficult to differentiated even by investigation.
5-chronic ectopic pregnancy: its neither ruptured nor resolved &it's difficult to differentiate as HCG return to normal.

6. 6- pelvic kidney: painless unless asso
6- pelvic kidney: painless unless asso. With UTI ,intraperitonial ,immobile & dx by IVP or U/S .
7- full bladder .
8-fecal mass.
9-mesenteric cyst :mobile only in one direction(from right hypochondrial to left iliac fossa &we can feel the lower border of the mass.
10-pseudocyesis:its false pregnancy ,no mass ,its psychological condition.
11-enlarged spleen &pancreatic cyst .

7. Complications of ovarian tumour &cyst :
1-Torsion: a tumour can only twist on its pedicel if the pedicel is long &the tumour is not fixed to other structures.
It may occur during pregnancy or labour,when torsion has occurred the twisting of the pedicle occludes first the vein and then the arteries at the stage when the veins are occluded but the arteries supply the tumor fills with the blood and becomes pulm color and if it is left untreated the tumor would become necrotic.
There is always severe lower abdominal pain sometime of slow onset but usually the torsion occurs rapidly the patient may vomit repeatedly there is little bleeding from the uterus O/E a firm tender swelling which separated from the uterus .
Treatment : is by laparotomy and removes the affected ovaries in young patient if the affected ovary is gangrenous then remove it if the patient present early and non-gangrenous then untwisting and remove the cyst.
Note: torsion most commonly occurs in dermoid cyst because it is large size

8. 2- Rupture :- spontaneous or traumatic.
Spontaneous:- may occur in large or rapidly growing tumor when having necrosis in the wall
Traumatic:- occur either during examination by PV or by blow to the abdomen .
If a small cyst or serous content there may be little or no pain (asymptomatic), but if the cyst is large or contain sebum or hemorrhagic content there will be severe pain with vomiting and a degree of shock O/E there is tenderness and rigidity .
Treatment:- if the cyst is a small only observation of the patient for few days because it is likely to be a follicular cyst but if the cyst is a large immediate laparotomy should be undertaken

9. 3-Haemorrahge :- if arterial there will be rapid enlargement of the cyst and pain similar to that of torsion it need immediate laparotomy .
4- infection acute abdomen (Localized peritonitis )
5-Impaction :-on rectum lead to constipation ,on urethra lead urine retention ,on bladder lead to incontinence need urgent treatment mostly surgical .

10. Etiology of ovarian tumors is unknown
Risk Factors:
1-The risk decrease in multiparous, breast feeding &contraceptive pills intake(infrequent ovulation).
2-The risk increase in nulliparous ,early onset menarche & late menopause(frequent ovulation).
3-Talk powder increase the risk(in deodorant ,powder or soap).
4-1st degree relative of affected lady has 20X risk.
5-Diet:increase with vit.A+animal fat(still unknown why).

11. Epidemiology:
-increasing incidence.
-More in industrialized countries
-It represent 25% of all female genital tract malignancies.
-It represent 30% of all mortalities from genital tract malignancies
-It has bad prognosis.
Not:(in general ovarian tumors unfortunately are asymptomatic & by the time the disease extended beyond the ovaries & reaching adjacent)
Spread:
1-Local infiltration.
2-Peritonal spread by seedling.
3-Lymphatic(par aortic lymph node, thoracic duct& left supraventricular lymph node).
4-Heamatological: liver, lung & other organs.

12. Investigation:
1-U/S :advantage:-we can determine the solid or cystic nature of the mass ,size ,number ,thickness ,content (serous or hemorrhagic), ascites &any liver metastasis .
Disadvantage: a-cant diff. between benign &malignant mass.
b-can miss tumour less <2cm.
2-X-Ray: any evidence of distant metastasis &in dermiod cyst s.t may see teeth.
3-IVP: if suspect malignancy for ureter or UB involvement.
4-CT scan: detailed shape &size of the mass &any metastasis.
5- MRI:better than CT to determine the site ,shape &consistency any metastasis .

13. Clinical features suggestive of malignancy:
Age: the higher the age the more risk of malignancy. Also childhood tumour also regarded as malignant unless proven otherwise.
Pain: especially dull aching pain (metastasis to sciatic nerve).
Rapid growth tumour.
Solid tumour.
Bilateral tumour.
Fixation of tumour.
Ascites.
Edema of lower limb& varicose v.v.

14. Evidence of malignancy at operation :
Fungating through the capsule.
Solid or partially solid.
Large blood vessel over the tumour.
Hemorrhage inside the tumour.
Ascites especially if blood stained.
Adhesion to other organs.
Bilateral tumour.
Metastasis.
Detect primary tumour in bowel e.g. stomach.

15. Treatment: (mainly surgical)
Benign cyst :---if young <45y. do cystectomy or oophorectomy
---if >45y. do total abdominal hysterectomy & bilateral salpingo-oopherectomy(TAH&BSO).

16. Malignant mass:
Stage I :tumour confined to the ovaries ,do (TAH+BSO +omentactomy).
Stage II:tumour extend to pelvis ,do (TAH +BSO +omentactomy +chemotherapy).
Stage III & IV :tumour with distant metastasis ,do debulking surgery (in which remove as much as possible of the tumour TAH+BSO+omentactomy +remove any obvious masses even s.t do resection of small or large bowel if involved + radiotherapy with or without chemotherapy.

17. Note:
Radiotherapy : some ovarian tumours are radiosensitive but mainly poor response to radiotherapy .Radiotherapy is used as adjuvant or secondary therapy following surgery. Radiotherapy may provide the only hope of palliation for patient with a pelvic recurrence after treatment with surgery &chemotherapy .it includes:
1-Intra-abdominal (P37) &(Au189).
2-Deep x-ray therapy.

18. Second look laparotomy: indicated when there is clinical remission &no evidence of the tumour by examination &U/S .It provide more accurate information regarding tumour response . A negative second –look laparotomy allows the oncologist to stop treatment with chemotherapy .Recently second look laparoscopy is used.
Terminal care :it is not unusual for ovarian tumour to confined to peritoneum even in terminal stage so the problem of treatment is mainly abdominal :-ascites :is common &may require repeated paracentesis &s.t local chemotherapy to induce sclerosis.
-pain :use morphine or pethidine.
Chemotherapy:1-bleomycin 2-vinblastin 3-etoposide 4-cisplatin &Caro platinum.

19. Ovarian tumour in pregnancy :
1/1000 pregnancies ,10% functional ,85% benign ,5% malignant 1st trimester :smooth ,unilateral ,cystic ,<5cm observation till 2nd trimester to give time for functional cyst to disappear &decrease the risk of abortion ,also it may be a corpus luteal cyst that secret progesterone & maintain pregnancy. By 16 wk. the placenta will secret sufficient progesterone to maintain the pregnancy without the support of the ovary.

20. 2nd trimester: at 16wk laparotomy &removal is indicated if any multilocular ,>5cm with complication.
3rd trimester :if benign do laparotomy after delivery &cystectomy ,if malignant try to postponed treatment until after delivery of the fetus &treatment as non- pregnant strategy .