OVARIAN TUMORSINTRODUCTION
Dr Anusha Rao P
PGY2 (OBG)
CAIMS
NORMAL OVARIES
• Normal size 5 x 3 x 3cm
• Variation in dimensions can result from
– Endogenous hormonal production(varies with age
and menstrual cycle)
– Exogenous substances, including OCs, GnRH
agonists, or ovulation-inducing medication, may
affect size
DIFFERENTIAL DIAGNOSIS OF ADNEXAL MASS
ORGAN CYSTIC SOLID
OVARY Functional cyst, Neoplastic cyst,
Benign, Malignant, Endometriosis
Neoplasm
Benign
Malignant
FALLOPIAN TUBES Tubo-ovarian abscess
Hydrosalpinx
Paraovarian cyst
Tubo-ovarian abscess
Ectopic pregnancy
Neoplasm
UTERUS Intrauterine pregnancy in a bicornuate
uterus
Pedunculated or
inteligamentous myoma
BOWEL Sigmoid or caecum distended with gas
or feces
Diverticulitis, Ileitis,
Appendicitis, Colonic cancer
MISCELLANEOUS Distended bladder, Pelvic kidney,
Urachal cyst
Abdominal wall hematoma or
abscess, retroperitoneal
neoplasm
Lifetime Risk of ovarian neoplasm
• A woman has 5–10% lifetime risk of
undergoing surgery for a suspected ovarian
neoplasm and
• 13–21% of these will be found to be have an
ovarian malignancy
OVARIAN MASSES
FUNCTIONAL INFLAMMATORY NEOPLASTIC OTHERS
FOLLICULAR CYST
CORPUS LUTEUM CYST
THECA LUTEIN
TUBO OVARIAN ABSCESS BENIGN
BORDERLINE
MALIGNANT
ENDOMETRIOMA
ENLARGED PCO
PAROVARIAN CYST
COMMON OVARIAN TUMOURS
Infancy Pre pubertal Adolescent Reproductive Perimenopausal
PostMenopausal
1 Functional cyst
Functional cyst
Functional cyst
Functional cyst Epithelial ovarian tumor
Neoplastic ovarian tumor
2. Germ cell tumor
Germ cell tumor
Germ cell tumor
Dermoid Functional cyst Functional cyst
3. Epithelial tumor
Epithelial tumor
Mets
Functional ovarian cysts
• Follicular cysts
• Corpus luteum cysts
• Theca lutein cysts
• Luteomas of pregnancy
By far the most common clinically detectable
enlargements of the ovary in the reproductive years.
All are benign and usually asymptomatic.
WHO CLASSIFICATION
I. Common Epithelial Tumors:• Serous tumors• Mucinous tumors• Endometrioid tumors• Clear cell tumors• Brenner tumors• Mixed epithelial tumors• Undifferentiated ca.• Unclassified epithelial tumors
II. Sex cord tumors:
• Granulosa-stromal cell tumors, theca cell tumors
• Androblastomas
• Gynandroblastomas
• Unclassified
III. Lipid cell tumorsIV. Germ cell tumors:• Dysgerminoma• Endodermal sinus tumor• Embryonal ca.• Polyembryoma• Choriocarcinoma• Teratoma• Mixed
V. Gonadoblastomas:
• Pure
• Mixed
VI. Soft tissue tumors (not specific to ovary)
VII. Unclassified tumors
VIII. Secondary tumors
IX. Tumor-like conditions
Simple ultrasound-based rules for the
diagnosis of ovarian cancer. Ultrasound Obstet Gynecol2008
RCOG 2011
CLINICAL PRESENTATION
• Asymptomatic – accidentally discovered on USG
• Chronic pattern of pain, increasing abdominal girth over months or weeks.
• Associated with secondary symptoms of anorexia, nausea, vomiting,
urinary frequency.
• Could be associated with primary or secondary amenorrhea, menstrual
irregularities, virilization, precocious puberty
• Become acutely symptomatic if undergoes torsion, rupture or
haemorrhage.
Benign ovarian neoplasms are indistinguishable clinically from malignant
counterparts
COMPLICATIONS
• Torsion
• Intracystic hemorrhage
• Infection
• Rupture
• Pseudomyxoma peritonei
• Malignancy
PHYSICAL EXAMINATION
• Abdominal and vaginal examination and the presence or absence of local lymphadenopathy
• Assess– Laterality
– Cystic Vs solid
– Mobile Vs fixed
– Smooth Vs irregular
– Ascites
– Cul-de-sac nodules
– Rapid growth rate
TVS• Pattern recognition is superior to all other scores.
• Subjective evaluation of ovarian masses based on pattern
recognition can achieve sensitivity of 88% to 100% and specificity of
62% to 96%.
• Adding doppler does not seem to yield much improvement in the
diagnostic precision, but increases the confidence with which a
correct diagnosis of benignity or malignancy is made.
DOPPLER EVALUATION
• Hypoxic tissue in tumors recruit low-resistance, high-flow blood
vessels
• Role in evaluating ovarian mass is controversial – as the ranges of
values of RI,PI,MSV between benign and malignant masses overlap.
PI<1, RI<0.4
• To overcome this, vascular sampling of suspicious areas (papillary
projections, solid areas, thick septations) using both 3D USG and
power doppler both has been evaluated and found effective.
• “Chaotic” vascular pattern in malignancy
OTHER IMAGING MODALITIES
• CT, MRI, PET not recommended in the initial evaluation
• CT scan: evaluating
– LN involvement,
– Omental mets, peritoneal deposits, hepatic mets,
– obstructive uropathy
– or a probable alternate primary site when cancer is suspected based
upon TVS
• MRI : differentiating non adnexal pelvic masses (like leiomyomata),
expensive and inconvenient.
• ACOG GUIDELINES 2007
TUMOR MARKERS
SENSITIVITY SPECIFICITY PPV NPV
61-90% 71-93% 35-91% 67-90%
CA-125
Most useful when non-mucinous epithelial cancers are present
Elevated in 80% of patients with epithelial ovarian Ca but only in 50% of patients
with stage I disease
Increased sensitivity in post menopausal women esp. when associated with
relevant clinical and USG findings
Cut-off of 30 u/ml, sensitivity of 81% and specificity of 75%
HE4
• HE4 is a precursor to the epididymal secretory protein E4 and in normal
ovarian tissue, there is minimal gene expression and production of HE4.
• As a single tumor marker, HE4 had the highest sensitivity for detecting
ovarian cancer, especially Stage I disease.
• Combined CA125 and HE4 is a more accurate predictor of malignancy
than either alone or to any other dual combination of markers
• HE4 levels(>70 pM) were found to be elevated in over half of the patients
with ovarian cancer with normal serum CA125 levels (>35 U/ml)
• HE4 when studied in the premenopausal group of patients was able to
discriminate benign tumors from malignancies
Moore et al. / Gynecologic Oncology, 2008
NEW SCORES
• ROMA: Risk of Ovarian Malignancy Algorithm
The dual marker algorithm utilizing HE4 and CA125 to calculate a ROMA value
In patients with stage I and II disease, ROMA achieved a sensitivity of 85.3% compared
with 64.7% for RMI
MOORE ET AL, AJOG 2010
• OVA 1:
FDA approved. Combination of 5 immunoassays
CA 125, transthyrettin, apo lipoprotein A1, transferrin, B2 microglobulin
Sensitivity : 93%, specificity: 43% PPV 42% NPV 93%
COMMUN ONCOL, 2010
Asymptomatic simple cysts
<5cms Likely physiological
(do not require follow up)
5-7 cms Yearly USG
>7cm Require further
imaging/surgical intervention.
RCOG 2011
Ovarian mass in reproductive age group
<5 cms. >/= 5 cms
USG USG
cystic
observationComplex,
solid, suspicious
Persistence or progression
surgery
Ovarian mass in childhood:History and physical examination
Appr. Imaging studies
Simple cyst- Observe and reassess
Solid or solid cystic
MRI and tumor markers
High suspicion of malignancy
Low suspicionof malignancy
Laparotomy laparoscopy
Frozen section Malignant –oophorectomy and staging
Benign - cystectomy
Ovarian cysts in postmenopausal women:
• Post menopausal gonad atrophies to a size of
1.5 X 1 X 0.5cm on average
• Shouldn’t be palpable on pelvic examination.
• Presence of palpable ovary must alert the
possibility of an underlying malignancy.
• Incidence in asymptomatic post menopausal
women –
1.5% by pelvic examination
3.3% to 14.5% by USG.
obstet gynecol survey, 2002
• Causes -10% functional
90% neoplastic (either benign or malignant)
ASSESSMENT
• It is recommended that ovarian cysts in postmenopausal women
should be assessed using CA125 and transvaginal grey scale
sonography.
• There is no routine role yet for Doppler, MRI, CT or PET.
RCOG 2010
SENSITIVITY SPECIFICITY
TVS 89% 73%
CA 125 81% 75%
RCOG
• Simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a
low risk of malignancy. It is recommended that, in the presence of a normal
serum CA125 levels, they be managed conservatively.
• Aspiration is not recommended for the management of ovarian cysts in
postmenopausal women.
• It is recommended that a ‘risk of malignancy index’ should be used to select
women for laparoscopic surgery, to be undertaken by a suitably qualified
surgeon.
• It is recommended that laparoscopic management of ovarian cysts in
postmenopausal women should involve oophorectomy (usually bilateral)
rather than cystectomy.
BORDERLINE OVARIAN TUMORS
They were not separately classified by the FIGO and the
WHO until the early 1970s.
• Borderline tumors make up approximately 15% of all
epithelial ovarian tumors.
• The mean age of occurrence is approximately 10 years
younger than that of women with frankly malignant
ovarian cancer.
Tumour subtypes
• 2 major histological tumor subtypes
– Serous(50%)
• (bilateral in 30%)
• Could be associated with extraovarian lesion : implants(35%)
– Mucinous (46%)
• Mucinous tumors do not have a clearly defined origin.
– Substantial information indicates that many tumors may
actually originate from the appendix; thus, this organ should
be removed at the time of surgery.
Histology and Cytology
• According to Dietel and Hauptmann, the histology of borderline
tumors is characterized by the following features:
– Epithelial multi-layering of more than 4 cell layers
– Not more than 4 mitoses per 10 high-power field (HPF)
– Mild nuclear atypia
– Increase in nuclear/cytoplasmic ratio
– Slight to complex branching of epithelial papillae and pseudopapillae
– Epithelial budding and cell detachment into the lumen
– No destructive stromal invasion - A major component in
differentiating malignant from borderline tumors
TUMOR STAGING
• Comprehensive staging : of significant
prognostic value and is performed surgically
• Borderline ovarian tumors are staged
according to the FIGO classification of ovarian
cancer.
International Federation Of Obstetrics And Gynecology (FIGO) staging
FIGO stage Definition
I Tumor confined to the ovary
II Peritoneal implants within the pelvis
III Peritoneal implants beyond the pelvis, Positive lymph nodes, or both
IV Liver parenchyma involvement, or tumor beyond the peritoneal cavity
TREATMENT
* No further chemotherapy (in all stages.)