Transcript Ovarian Tumours

Ovarian Pathology for
Undergraduates
Max Brinsmead MB BS PhD
November 2014
Incidence
1:10 women will undergo surgery during a
lifetime because of suspected ovarian
pathology
10% turn out to be non ovarian
The vast majority in pre menopausal
women are benign
Ovarian cancer affects ≈ 1:100 women
– And is the most common cause of death from
gynaecological malignancy
Ovarian pathology presents as:
Pain
Mass
But most commonly as an incidental finding
on imaging
When the most important thing to determine is
whether:
It is functional or neoplastic?
Benign or malignant?
Pathology of Functional Ovarian Cysts:
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
Especially if there are adhesions from PID or pelvic
surgery
Endometrioma = ovarian endometriosis
A normal Corpus Luteum
Haemorrhage into a Corpus Luteum
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?
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
Ultrasound of a Follicular Cyst
Haemorrhage into a Corpus Luteum
Ultrasound of a malignant ovarian mass
Management Guidelines for a Simple Cyst in a
Premenopausal Woman
Ignore if <30 mm in size and asymptomatic
Repeat scan after 3 months for simple cysts 30
– 50 mm in size
– Refer to a gynaecologist if still present
Further Investigations include…
– Serum Ca 125
– Further imaging by CT or NMR
Mechanisms of Pain with Ovarian Cyst
Rapid enlargement
Haemorrhage or haemorrhagic rupture
Leaking sebaceous or endometrioma fluid
Torsion
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–
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–
–
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Requires tumour >5 cm on a thin pedicle
Torsion involves whole of the ovary and tube
Presents as “reverse renal colic”
Cervix will be deviated towards the tumour
Signs of “acute abdomen” or “acute pelvis”
Early surgery & untwisting may save the ovary
Clinical Features of a Neoplastic Ovarian Tumour:
Older women
– 50% malignant for woman >50 years of age
Larger tumours
Bilateral
Fixed, tender or craggy to palpation
Ascites present
Solid or Cystic with multiple septa & solid parts
Vascular to colour Doppler
Persist or enlarge over time
Associated with positive tumour markers –
CA125, (CA19.9, CEA, AFP, HCG, LDH)
Differential diagnosis for an Adnexal Mass:
Full bladder
Pregnancy
Loaded caecum or sigmoid colon
Paraovarian cyst
Hydrosalpinx
Mesenteric cyst
Fiboid (subserosal)
Pelvic kidney etc.
Other malignancy e.g. bowel
Pathology of Ovarian Neoplasms
Germ cell Tumours
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Benign cystic teratoma = Dermoid
The most common neoplasm of young ♀
15% bilateral over a lifetime
Malignant varieties includes Dysgerminoma (LDH), Teratocarcinoma,
Endodermal sinus Ca (AFP), ChorioCa (bHCG)
Epithelial
– Cystadenoma (serous and mucinous)
– Cystadenocarcinoma Serous
–
Mucinous
–
Endometroid
–
Clear cell adenoCa
Hormone-producing
– Oestrogen-producing (granulosa cell benign or malignant)
– Androgen-producing (Androblastoma)
Secondary Cancers (Stomach, Bowel, Breast etc.. Includes Krukenberg tumours)
Serous Cystadenoma
Serous Cystadenocarcinoma
Mucinous Cystadenoma
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
Useful for monitoring response to treatment
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
A word about Polycystic Ovaries:
Are common
– Up to 20% of women who are cycling spontaneously i.e.
not on the Pill
Can be unilateral or bilateral
Do NOT cause pain
Test Questions
The most common neoplasm of
the ovary in young women is a
serous cystadenoma
CA125 is useful in screening for
ovarian cancer in
postmenopausal women
The lifetime risk for ovarian (&
testicular) cancer is 1:50
Haemorrhage into a corpus
luteum can cause a cyst > 6 cm
in size
Progestogen-only contraception
increases the risk of neoplasia in
the ovary
False – Benign cystic
teratoma or Dermoids
False – only 50% positive
for early stage disease
False – 1:100
True
False – increased risk of
functional ovarian cysts
Which of the following is NOT a feature of benign tumour in
ovary assessed with ultrasound?
Simple cyst
Thin walled
Multiple septa or solid areas
Less than 6 cm size
Present in both ovaries
Ascites
Changes rapidly over a few days
or weeks
High blood flow on colour
Doppler
Multiple septa and/or solid
areas
Ascites
High blood flow on colour
Doppler
Test Questions
Haemorrhage into a corpus
luteum can cause a solid-looking
tumour with multiple septa
CA125 is elevated in patients
with endometriosis
Ascites with an ovarian tumour
is always a sign of malignancy
Torsion of an ovarian cyst will
displace the cervix towards the
pathology
Prophylactic oophorectomy is
recommended in all women
undergoing hysterectomy to
remove all risk of ovarian Ca
Polycystic ovarian syndrome is a
common cause of pelvic pain
True
True – but only modest
elevations <200
False – see Meig’s
syndrome
True
False
False
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