Ovarian tumours Plan Nonneoplastic conditions Ovarian neoplasms 1

Ovarian tumours

Plan • Non-neoplastic conditions • Ovarian neoplasms

1 non-neoplastic conditions • 1. 1 functional cysts – Follicular cysts: follicle -> no ovulation -> persistent Gn. RH 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! – CA 125 usually <35

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

If most likely benign: • Most will undergo regression with menstruation – Can wait (not if pain is a problem) – Hormonal suppresion of Gn. RH stimulation • OC: best and convenient • or Provera 5 mg 2 x 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, h. CG – Treatment: laparotomy + adnexectomy • Bleeding • Rupture

1. 2 non-functional non-neoplastic cysts • • Endometriomas Theca-lutein cysts Par-ovarian cysts Residual ovarian syndrome: posthysterectomy; pain and dyspareunia: ovary stuck to the vault. – Surgical management: removal or suspension

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

• Uncommon but very important: Gynaecologic cancer with poorest prognosis • Causes: Probably genetic factors • Risk factors: age 40 -65 y – Own or family history of breast / ovary / endometrium / colon cancer – Never pregnant / infertility / low parity

• Protection: OCs, oophorectomy with strong family history • Screening: poor!! CA 125 + 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 1 cm behind – Interval cytoreduction: apparently inoperable: biopsy and chemo X 3, then surgery

Further treatment • Chemotherapy: for stages 1 c onwards: 6 courses • Prognosis: 5 years 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 -65 y, 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