Ovarian Tumors (Benign and Malignant)

• 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.

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

• 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

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

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

• Full bladder
• Pregnancy
• Fibroid
• Ectopic kidney

Usually amenable to surgery

Exploratory laparatomy

What is done is dependent on age, parity

Can be

• Cystectomy
• Ovariectomy
• TAH/BSO

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 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

• 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

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’

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

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

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