Ovarian Tumours

Max Brinsmead MBBS PhD

November 2014

Incidence

1:10 women will undergo surgery during a lifetime because of suspected ovarian mass10% turn out to be non ovarianThe vast majority in pre menopausal women are benign

Ovarian tumours present as:

PainMassAn incidental finding

But the most important thing to determine is whether:

It is functional or neoplastic?Benign or malignant?

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?

Pathology of Functional Ovarian Tumours:

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

Endometrioma = ovarian endometriosis

Ultrasound features of a Functional Ovarian Tumour

Thin walledUsually no solid componentsUsually no septa or thin walled septaUsually <6 cm sizeUsually avascular to colour DopplerChange rapidlyAnd disappear within 6-8w

• (A role for COC during this period not supported by Cochrane)

Management Guidelines for a Simple Cyst in a Premenopausal Woman

Ignore if <30 mm size and asymptomaticRepeat scan after 3m for simple cysts 30 – 50 mm– Further Ix or laparoscopy if they increase in size– Repeat scan in 12m if unchanged and < 70 mm

Further Ix and or laparoscopy for cysts >70 mm– Ca 125– Further imaging (CT or NMR)

Laparotomy may be better for suspected dermoid >70 mm

Clinical Features of a Neoplastic Ovarian Tumour:

Older womenLarger tumoursSolid/Cystic or multiple septateBilateralFixed, tender or craggy to palpationAscites presentVascular to colour DopplerPersist or enlarge (4m re evaluation for postmenopausal women)Associated with positive tumour markers – CA125, CA19.9, CEA (AFP, HCG, LDH)

Differential diagnosis for an Ovarian Tumour:

Full bladderPregnancyLoaded caecum or sigmoid colonHydrosalpinxMesenteric cystFiboid (subserosal)Pelvic kidney etcParaovarian cyst

Comprehensive DD of Adnexal Masses

Pathology of Ovarian Neoplasms

Germ cell Tumours– Benign cystic = Dermoid (the most common neoplasm of young ♀ –

15% bilateral)– Malignant includes Dysgerminoma (LDH), Teratocarcinoma,

Endodermal sinus Ca (AFP), Chorioca (bHCG)

Epithelial– Cystadenoma (serous and mucinous)– Cystadenocarcinoma Serous– Mucinous– Endometroid– Clear cell adenoCa

Functional– E2 producing (granulosa cell benign or malignant)– Androgen producing (Androblastoma)

Secondary Cancers (Stomach, Bowel, Breast etc)

Role of Ca 125

Of most value in the evaluation of adnexal mass in postmenopusal womenToo many false positives in premenopausal women– Endometriosis, Adenomyosis, Fibroids & PID

Always of concern if >200Specific only for epithelial tumours– And only 50% sensitive for early stage disease

Staging of Ovarian Cancer:

Stage 1A - Confined to one ovary

1B - Ascites or +ve peritoneal cytology

Stage 2A - Involves uterus or tubes

2B - Involves other pelvic viscera

Stage 3A - Confined to pelvis

3B - to lymph nodes or upper abdominal implants >2cm

Stage 4 - Distant metastases

Treatment of Ovarian Cancer:

Debulking surgery = TAH + BSO+Omentectomy

ChemotherapyRadiotherapySpecial cases

• Children• Young woman – no children• Advanced disease

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

Any Questions or Comments?

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