1. Pelvic Masses & Ovarian Cancer

2. Differential diagnosis of pelvic masses Investigations and management Benign ovarian cysts Ovarian cancer

3. Pre-pubertal 1.Functional cyst 2.Germ cell tumour Adolescent 1.Functional cyst 2.Pregnancy 3.Dermoid 4.Other germ cell tumour 5.Obstructing vaginal/uterine abnormality 6.Epithelial cell tumour

4. Reproductive 1.Pregnancy 2.Functional cyst 3.Fibroids 4.Epithelial tumour Perimenopausal 1.Fibroids 2.Epithelial tumour 3.Functional cyst

5. Postmenopausal 1.Ovarian tumour 2.Functional cyst 3.Other malignancy 4.Metastases

6. Diagnosis History and examination Ultrasound CT/MRI Tumour markers – CA125, CEA, CA19,9 hCg, alpha-fetoprotein

8. 50 % - asymptomatic 30% - menorrhagia Irregular bleeding Pressure effects

9. Management Depends on symptoms and fertility issues Reassure that risk of malignancy tiny Hysteroscopic removal (small submucosal) Myomectomy Embolisation Hysterectomy

10. Benign Unilocular Cyst

11. Septate Cyst

12. Ovarian Cancer

13. Dermoid

14. Haematocolpos

15. Imperforate hymen - haematocolpos

16. Management - Young women Small, simple, asymptomatic – leave alone and rescan 3 months later Complex – ovarian cystectomy or oopherectomy MDT involvement if any suspicious features

17. Management – older women Complex in older women – MDT involvement Further imaging Tumour markers TAH/BSO Simple, < 5cm, normal tumour markers – consider conservative management with repeat scan.

18. Fibroids Present in 25% of women More common: perimenopausal family history Afro-Caribbean women Sub-mucosal, subserosal, intramural

19. Ovarian Cancer 5 th, 6 th and 7 th decades Risk inversely correlated with parity. Genetic component – BRCA1 & BRCA2 Presents late – usually with a mass or ascites No premalignant stage - screening

20. Borderline tumours Epithelial Sex cord/stromal Germ cell Metastases

21. Epithelial Tumours Serous Most common Bilateral in 50% Cystic and solid components Mucinous Contain mucinous fluid Pseudmyxoma peritonei

22. Endometrioid 30% have a coexistent endometrial CA

23. Sex Cord/Stromal Tumours Granulosa Cell Secrete oestrogen – IMB or PMB Fibroma Usually unilateral Meig’s Syndrome Sertoli/Leydig Cell Young women (20’s) Secrete testosterone

24. Germ Cell Tumours Dysgerminoma Ages 10 – 30 May be raised hCG Yolk sac tumour Young women Raised alphafetoprotein, normal hCG Choriocarcinoma Secrete hCG Do not respond to chemotherapy Teratoma Usually benign -all 3 embryonic germ layers

25. Staging Ia – One ovary Ib – Both ovaries Ic – Ia/Ib with ruptured capsule, tumour on surface of capsule, + ve washings or ascites IIa – Extending to uterus and tubes IIb – Extending to other pelvic tissues IIc - IIa/IIb with ruptured capsule, + ve washings or ascites

26. IIIa – Pelvic tumour with microscopic peritoneal spread IIIb – Peritoneal spread < 2cm IIIc – Abdominal implants >2cm +/- positive retroperitoneal or inguinal nodes IV – Liver disease. Distant mets.

27. Management CT & CXR Baseline tumour markers Surgical staging Debulking surgery & adjuvant chemo Neoadjuvant chemo with interval debulking