1. Ovarian tumours

2. Plan
Non-neoplastic conditions
Ovarian neoplasms

3. 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

4. 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

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

6. 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

7. 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

8. 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

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

10. 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

11. 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

12. 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

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

14. 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%)

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

16. 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

17. 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

18. 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.

19. 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