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Ovarian Tumors (Benign and Malignant)

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Ovary contain numerous cell types therefore has the most varied type of growth/cyst

Size/position not easily accessible.

No premalignant stage has been identified.

They can be

  • Physiologic, or
  • Pathologic

Could be during pregnancy

Usually occur within the reproductive age

Can present as acute abdominal emergency

Amenable to surgery-cystectomy or ovariectomy

Do not usually reoccur

Physiologic Benign Ovarian Tumors

  • Follicular Cysts:
  • Corpus-luteum Cysts
  • Theca – lutein-cyst

1. Follicular Cysts:

  • Common
  • Enlarged unruptured follicules
  • Linings secrete fluid
  • Usually < 5cm
  • Asymptomatic
  • Unilateral
  • Occasionally may cause menstrual irregularities
  • Rarely persist beyond 3 months
  • No treatment needed

2. Corpus-luteum Cysts

  • Normal corpus lutuem can become cystic especially following hemorrhage
  • Corpus luteum of pregnancy can become quite large
  • Can cause short period of amenorrhea and prolong bleeding
  • Treatment is usually conservative unless it becomes large, or undergoes complication.

3. Theca – lutein-cyst

  • Usually bilateral
  • Seen in association with trophoblastic dis
  • Ovulation induction drugs
  • May cause pain
  • Management usually conservative

Ovarian cysts in pregnancy

  • 1 in 1000-1500 pregnancy
  • 1 in every 10 are physiological
  • Management usually conservative
  • They often resolve

Pathological cysts in pregnancy

  • > 50% are cystic teratoma & mucinous cysts adenoma
  • Assessment— clinical, by USS
  • Surgery usually not done in 1st trimester
  • If problematic, surgery can be done 12-18 weeks
  • Otherwise can be done after delivery.

Pathologic (Neoplastic) Benign Ovarian Tumors

The ovarian tissue are constantly in a dynamic state.

Main tissues of the ovary are:

  • Epithelial cells from coelomic epithelium
  • Oocytes from primitive germ cell
  • Mesenchymal elements from gonadal stroma

Epithelial cell tumors are the commonest

Some can get really big (39kg the biggest in our center [UITH])

They are usually amenable to surgery and do not recur

What surgery is done is dependent on age and parity of patient

Classification

  • Epithelial tumors
  • Sex cord stromal tumors- granulosa cell, thecoma fibroma group, sertoli cell tumors
  • Germ cell tumors- dysgerminoma, endodermal sinus tumors, embryonal cell tumor, teratoma- immature and mature (dermoid cyst), carcinoid and mixed form
  • Gonadoblastoma

Epithelial Tumor

Commonest form of neoplasm, called adenomas

Examples are

  • Serous cyst adenoma
  • Mucinous cyst adenoma
  • Endometroid
  • Brenner
  • etc.

Serous cyst adenoma-

  • Common
  • From the totipotential cells of epithelium
  • Can be bilateral
  • Cells resemble endosalpinx

Mucinous cyst adenoma-

  • Resemble cells lining of endocervix
  • Totipotentail cells of epithelium of the ovary
  • Can attain very large size is the largest ovarian tumor
  • Secretes mucin
  • Can be bilateral.

Germ Cell Tumor

Dermoid cyst-

  • Germ cells arrested after 1st meiotic division
  • Commonest form of teratomas
  • Bilateral in 15-20%
  • 20-40% ovarian tumor in pregnancy
  • Contains sebaceous material, hair, CSF, teeth, bone
  • When it contains mainly thyroid tissue is called stroma ovarii (rare, can cause hyperthyroidism)
  • Common complication is torsion
  • Rupture not common

Clinical features/sign

Clinical features

  • Mainly during reproductive life
  • No correlation with parity
  • Most are asymptomatic
  • May have mass in lower abdomen, can become huge
  • Pain/discomfort
  • Menstrual pattern usually undisturbed
  • Patients often look healthy even in huge ones

Signs

  • May have edema, generally patient is very healthy despite the size such that she may be mistaken to be pregnant.
  • Abdominal distension
  • Vaginal examination, uterus usually separate, and mass is often mobile

Investigations

  • USS
  • Hemogram
  • Other special investigations
  • CT scan, cytology, Xray

Complications

  • Usually present as emergencies
  • Torsion – commonest
  • Rupture
  • Hemorrhage
  • Infection

Differential diagnosis

  • Full bladder
  • Pregnancy
  • Fibroid
  • Ectopic kidney

Treatment

Usually amenable to surgery

Exploratory laparatomy

What is done is dependent on age, parity

Can be

  • Cystectomy
  • Ovariectomy
  • TAH/BSO

Incidence

Ovarian cancer accounts for 3-4% of cancer in women but is the leading cause of death from gynecological cancer in the United States.

Rate – higher in developed countries (11.5-15.3 vs 3.3-7.8/100,000)

Life time risk of women with no familial risk is 1.4% (1 in 70)

Not common before 40 years

Peak incidence 65-75 yrs.

Etiological/risk factors

Etiological factors

Cause is unknown

Multifactorial

Theories of pathogenesis

  • Incessant ovulation.
  • Gonadotropin stimulation
  • Pelvic contamination

Risk Factors

Increased risk

Patient characteristics

  • Increasing age/Old age – 65-75 years of age
  • Personal history of breast/endometrial cancer

Genetic factors

  • Family history of ovarian cancer: 10-15% has familial tendency. 90% occur sporadically.
  • BRCA 1/2 mutations
  • Hereditary non-polyposis colorectal cancer (Lynch syndrome)

Reproductive factors

  • Nulliparity/Infertility
  • Early menarche
  • Late menopause
  • Polycystic ovarian syndrome
  • Endometriosis

Environmental factors

  • Obesity and high-fat diet (weak evidence)
  • Cigarette smoking (for mucinous ovarian cancer)

Race?

Reduced risks/protective factors

Reproductive factors

  • Use of oral contraceptives
  • Pregnancy/multiparity
  • Breastfeeding

Gynecological surgery

  • Salpingo-oophorectomy
  • Tubal ligation

Clinical Features

  • Usually early symptoms are non-specific
  • Up to 80% present late
  • Indigestion, bloating, easy satiety/anorexia
  • Pressure symptoms and pain in pelvis and back
  • Swelling from mass or ascites
  • Weight loss
  • Abnormal vaginal bleeding

Findings:

  • Cystic, smooth unilateral, mobile, non-tender (benign)
  • Fixed, bilateral, nodular, solid + ascites suggest malignancy

Types/classification

Wider variety of tumors than any other organ.

Based on tissue of origin (i.e histopathologic)

  • Epithelial – serous, mucinous, endometroid, clear cell, Brenner
  • Sex cord/stromal— granulosa- theca cell tumour, Sertoli-leydig cell tumour, unclassified.
  • Germ cell— Dysgerminoma, endodermal sinus tumor, embryonal carcinoma, teratomas, mixed tumor.
  • Soft tissue tumor not specific to ovary
  • Unclassified
  • Metastatic

Epithelial cell tumors

  • Derived from ovarian surface epithelial cells.
  • 90% of ovarian cancers
  • Serous cystadenocarcinoma (> 50%)
  • Bilateral (30-60%)
  • Up to 85% associated with extra ovarian spread at diagnosis
  • > 50% exceed 15cm in diameter
  • Histologically – endosalpinx
  • Mostly unilocular but can be multilocular (up to 1/3)/li>

Mucinous cysts adenocarcinoma

  • 10 - 15% all epithelial cancer
  • 35% borderline malignancy
  • Can attain very large size
  • Average size 18-20cm
  • Usually multilocular cyst filled with viscous mucin
  • Resembles epithelial Ca cells of endocervix
  • Note “pseudomyxoma peritonei”

Endometroid

  • 10-25% of epithelial Ca
  • Bilateral in 30-50%
  • Associated with endometriosis –about 10%
  • Cells – resemble endometrial cells/glands
  • Can have coexisting primary endometrial ca in up to 30%
  • Non epithelial tumors account for 10%

Germ Cell Tumours

  • Up to 25% of ovarian tumors but malignant ones are rare < 3%.
  • Malignancy more common in children and in reproductive age.

Sex Cord Stromal Tumors

From cells in the gonad, in gonadal mesenchyme or the stroma 5-8%

Granulosa Cell Tumour

  • Most common (70%)
  • Hormonally active
  • Can occur in any age group, but more in post-menopausal
  • Precocious puberty in young girls
  • Post-menopausal bleeding in elderly
  • Irregular bleeding in reproductive age.

Sertoli-Leydig cell tumour

  • Rare
  • Potentially malignant
  • Virilization may occurs if androgens are produced.

Fibromas

  • From stromal cells, composed of fibrous tissue
  • > 40% are up to 10cm
  • Rarely malignant

NOTE: Meigs syndrome- an uncommon presentation where a benign ovarian tumor presents along with ascites and pleural effusion. About 1% of ovarian tumors can present as Meigs syndrome.

Secondary Tumors

  • Usually from GIT, from breast, uterus/cervix
  • Note Krukenberg tumours – secondarily from stomach: usually solid, contain ‘signet cells’

Differential diagnosis

Influenced by age of patient

Characteristics of mass on exam

Colonic tumor

Kidney (pelvic)

Retroperitoneal tumor

Mesenteric tumor

Blood:

  • FBC
  • E,u,Cr
  • Serum CA125 (elevated in >80% epitehelial)

Radiological:

  • Ultrasound – can help to differentiate benign & malignant
  • Plain xray abdomen/chest
  • IVU
  • Barium enema,/Barium swallow & follow through
  • CT scan – retroperitoneal nodes
  • MRI

Staging

Surgical Evaluation

The staging of ovarian cancer is done during exploratory laparotomy

  • Ascitic fluid or peritoneal washing
  • Complete exploration
  • Removal of intact tumor
  • Sampling from peritoneal seedling
  • Sample peritoneal surface
  • Pelvic & para-aortic nodes biopsies
  • Debulking procedure if possible

Staging of Ovarian Tumor

I— Limited to ovary/ovaries

  • Ia – one ovary involved; no ascites, no tumor on surface, capsule intact
  • Ib – both ovaries
  • Ic – a or b with ovarian surface tumour, ruptured capsules, malignant ascites or the positive peritoneal washing

II— Extension of the growth to pelvis

  • IIa – fallopian tube + uterus
  • IIb – extension to other pelvic tissues
  • IIc – a or b with surface tumor, ruptured capsule, ascites, or positive peritoneal washing

III– Disease extension to the abdominal cavity

  • IIIa – abdominal peritoneal surface with microscopic metastasis
  • IIIb – Metastasis < 2cm
  • IIIc – Metastasis > 2cm or positive para-aortic or inguinal lymp nodes.

IV– Distant metastasis

  • Malignant pleural effusion
  • Pulmonary parenchymal disease
  • Liver/spleen parenchyma metastasis
  • Metastasis, +ve supraclavicular nodes

Treatment

Surgery

Surgery is the main treatment modality for ovarian cancer.

Epithelial Cancers: > 70% has stage III

Stages I – II: Total abdominal hysterectomy, bilateral salpingo-oophorectomy and infracolic omentectomy.

  • Post-operative: chemotherapy

Stage IV – Inoperable – usually debulking if possible, followed by chemotherapy

  • Note: interval debulking

Conservative Surgery

Young women with early stage (Ia) cancer or borderline tumor who wishes to have family

Important to stage properly

Unilateral salpingo-oophrectomy is done

Removal of other ovary after completing family

Chemotherapy

Germ cell

  • Responds well to chemotherapy
  • Single agent – cisplatinum
  • Combination agent – platinum based adriamycin/cyclophosphomide
  • Taxol – also very good.

Radiotherapy

Use limited

Pure dysgerminomas – radiosensitive

Can be given as palliative treatment

Poor – because of late diagnosis

Depends on stage/size of residual tumors (> 2cm).

5 years survival

Stage I – up to 70%

Stage II – 45%

Stage IV < 5%

Ovarian screening

No single standard

Those with strong history

Rectovaginal examination annually

Transvaginal ultrasound (TVS)

Ca 125 test

Prophylactic oophorectomy can be done

These are epithelial tumor which are intermediate in behavior and histological features between malignant and benign tumor

10-15%

Have good prognosis

Management of early stage is conservative surgery

But any spread out of pelvis is treated with total surgery.


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