Download Case 05- Ovarian oncology and cysts Physiological cysts Follicular

Case 05- Ovarian oncology and cysts
Physiological cysts
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Follicular cyst
o Most common benign ovarian tumour
o Diameter up to 10cm, smaller cysts do not need intervention
o Can be caused by ovulation induction and gestational trophoblastic disease due to
gonadotropin overstimulation
o Pelvic ultrasound should be repeated in 4-6 weeks time
o If symptomatic or not resolved in 8-16 weeks, treat with
 wait until half way through pregnancy before removing the cyst
laparoscopically (lower chance of miscarriage)
 Symptoms are menstrual disturbances, endometrial hyperplasia
Luteal cyst
o More common on the right side, <3cm = corpora lutea
o Can rupture causing intraperitoneal bleeding on days 20-26 of menstrual cycle
o Sometimes, it fills with fluid or blood, creating a cyst that can grow to 6cm across.
o can rupture causing hemoperitoneum, hypotension, and peritonitis
 haemorrhagic corpus luteal cysts are usually seen in the first trimester, with
most resolving by 12 weeks' gestation
o Treatment is laparoscopy if ruptured or torsion
Germ cell tumours
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Happens more commonly in <30 years old
All three germ layers are present
Benign
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Dermoid cyst (25% of all ovarian tumours)
o Bilateral in 11%, 60% are asymptomatic
 3.5-10% can have torsion
 1-4% can rupture, risk is higher in
pregnancy and labour
o Unilocular cyst <15 cm in diameter, has predominantly ectodermal structures
 Skin, teeth, hair, nervous tissue, thyroid, bronchus, intestine
 Mesodermal structures can be present too: bone, cartilage, muscle
Mature solid teratoma
o Rare, less cystic than dermoid cyst
Malignant
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Dysgerminoma (2-5% of ovarian malignancy)
o <30 yo, 10% bilateral
o Mean diameter 15cm, spread via lymphatics
o Can coexist with choriocarcinoma, endodermal tumour or teratoma (10%)
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 Do beta hCG
o Pure dysgerminoma is mostly Stage 1=good prognosis
Choriocarcinoma
o Secretes beta hCG, usually diagnosis is done when haematological spread has
occurred
Yolk sac (endodermal)
o Usually in <40 yo
o Can rupture causing pain, aggressive and fast growing
 Diagnosed late, with extensive metastases
o Areas of necrosis, haemorrhage
o Often makes AFP, can be measured to monitor treatment
Teratoma
o about 20% of all malignant tumors, mainly in <20 yo
o gliomatosis peritonei, caused by rupture. Seeding of neural tissue in the peritoneum
 if the metastases are immature, it indicates a poorer prognosis
Epithelial tumours (60 to 80% of ovarian tumors)
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Most ovarian neoplasia are of this category, they are mesothelial in nature
Benign (more in <40 yo)
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Serous cystadenoma
o Bilateral in 10%, inner surface is cuboidal or columnar and maybe ciliated
o Usually smaller than mucinous cystadenoma
o Sometimes psamoma bodies (round collections of calcium) are present
Mucinous cystadenoma (10-15% of all ovarian tumours)
o Large unilateral, multilocular cysts
 Has columnar mucin secreting cells, produces thick glutinous
o pseudomyxoma peritonei is a rare complication, this follows preoperative rupture
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and spreading of tumour cells
 mucin in the peritoneum can cause bowel obstruction
 50% 5 year survival, 18% 10 year survival
 Treatment is surgically debulking the metastases and abdominal
chemotherapy
Endometrioid cystadenoma (5%)
o Most are malignant, edges are badly defined
o Looks like and can co-exist with endometriosis
Brenner tumours
o Wolffian metaplasia, usually benign and <2cm in diameter
o between 2 to 3 cm, solid, well circumscribed and may be calcified
o 75% occur in >40 yo
Clear cell (mesonephroid tumour)
o Rarely benign, almost all are malignant
Malignant
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Serous carcinoma
o Commonest malignant ovarian tumor (33% of ovarian tumours)
o Presents with ascites due to metastases
o Often bilateral
o Psamoma bodies often are seen
Mucinous carcinoma
o Multilocular, large like its benign counterpart but contains solid areas
 25cm cyst is not uncommon
o Pseudomyxoma peritonei
Endometrioid carcinoma
o Most are malignant, edges are badly defined
o Looks like and can co-exist with endometriosis
o 15% can have endometrial carcinoma, where both are separate primary tumours
(not metastasis)
Clear cell carcinoma
o Cannot be distinguished from the other surface epithelial tumors by their gross
appearances. They are partially cystic but may be entirely solid. Necrosis and
haemorrhage may be seen in the solid areas.
o May be a variant of endometrioid tumour, as they frequently co-exist
o Strong association with endometriosis
Borderline epithelial tumour
o Most are confined in the ovary, usually serous or mucinuous
o Good prognosis even if metastases are found, they often regress when primary
lesion is removed
Sex cord stromal tumours (3% of all ovarian tumor)
Benign
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Theca cell tumour
o Almost all are benign, incidence is high in 60yo
 5-10 cm
o Has systemic effects
 Precocious puberty, postmenopausal bleed, endometrial hyperplasia and
cancer
Fibroma
o ~50yo
o commonest ovarian stromal tumor
o Meig’s syndrome is rare (1%): ascites and pleural effusion
 40% of fibroma> 6cm
Sertoli-leydig cell tumour
o ~30yo
o Rare, <0.2% of all ovarian tumours
o 75% make androgen, many non-functional, some make oestrogen
Malignant
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Granulosa cell tumour
o Usually solid, but can develop cysts
o 75% of pure granulosa cell tumors are functional and makes estrogen
Fibrosarcoma
o Very rare
Sertoli-leydig cell tumour (rare)
o 50% makes male hormones
Gynandroblastoma
o producing both ovarian (granulosa and/or theca) and testicular (Sertoli and/or
Leydig) cells or tissue
Natural history of Ovarian Cancers
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2/3 present with cancer spread beyond the pelvis because of insidious and non-specific
symptoms or fast growing tumour
Metastases commonly happen via
o Direct (peritoneum, omentum, peritoneal surface of bowels)
o Lymphatic (pelvic and para-aortic nodes)
o Haematological (brain, lungs)
Risk factors
o Nulligravida
o Obesity (>30 BMI)
o Tubal ligation (protective)
o Clomiphene citrate for infertility treatment
o HRT
o Family history (BRCA 1 and 2)
o History of breast cancer
HOPC
o Abdominal pain or discomfort
o Abdominal distension or lump (77%)
o Bowel changes (70%), urinary frequency (34%), weight loss, menstrual changes
Examination findings
o Pelvic mass +/- enlarged lymph nodes (groin, neck)
o Hormonal changes
Investigations
o FBE, EUC
o ultrasound pelvis + CA 125 can combine to give an estimate on the risk of
malignancy
o definitive diagnosis is made using laparotomy
Treatment
o Laparotomy with vertical incision
 Objective is to remove all macroscopically visible neoplastic tissues
 Usually involves total hysterectomy, bilateral salpingooophorectomy and infracolic omentectomy if the cancer has spread
extensively
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If the tumour is unilateral and low stage (no spread): unilateral
salpingo-oophrectomy will suffice
 Do sampling of peritoneal fluids or saline washing
o Interval bulking
 For unresectable disease, it is possible to laparotomy after an initial
chemotherapy. Chemotherapy is then resumed as soon as possible after
surgery
o Any ovarian cancers with Stage >1c should have adjuvant therapy
 Chemotherapy
 5-6 cycles at 3-4 weekly intervals
 Platinum based chemo drugs are best
o Caboplatin, paclitaxel (Taxol, usually in combination with
carboplatin as first line regime and is not platinum based)
 Radiotherapy
 Experimental, not usually used in practice
 occasionally used for women with ovarian cancer, especially if it is
confined to the pelvic cavity
Prognosis
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The 5-year survival rates are as follows: Stage I - 73%, Stage II - 45%, Stage III - 21%,
Stage IV - Less than 5%
Characteristics
Benign
Malignant
Germ cell tumours
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<30 years old
2-3% malignant, but 33%
for <20 yo
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Dermoid cyst
Mature teratoma
Epithelial tumours
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Most ovarian cancers are
in this category
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Serous cystadenoma
Mucinous cystadenoma
Endometrioid cystadenoma
Brenner tumours
Clear cell
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Sex cord stromal tumours
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Most common ones are
granulosa and theca
tumours, produces steroid
hormones (usually
oestrogen)
In general, have better
prognosis compared to
other ovarian tumours
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Granulosa cell tumour
Theca cell tumour
Fibroma
Sertoli-leydig cell tumour
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Dysgerminoma
Choriocarcinoma
Yolk sac (endodermal)
Teratoma
Serous carcinoma
Mucinous carcinoma
Endometrioid carcinoma
Clear cell carcinoma
Borderline epithelial
tumour
Granulosa cell tumour
Theca cell tumour
Fibrosarcoma
Sertoli-leydig cell
tumour
Gynandroblastoma
References
http://atlasgeneticsoncology.org/Tumors/OvarSexCordStromID5223.html
http://www.babycenter.com.au/pregnancy/complications/ovariancystexpert/
http://www.med-ed.virginia.edu/courses/path/gyn/ovary3.cfm#germ
http://www.cancer.org/cancer/ovariancancer/detailedguide/ovarian-cancer-risk-factors