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Ovarian Tumours

Ovarian Tumours. Max Brinsmead PhD FRANZCOG January 2012. Incidence. 1:10 women will undergo surgery during a lifetime because of suspected ovarian mass 10% turn out to be non ovarian The vast majority in pre menopausal women are benign. Ovarian tumours present as:. Pain Mass

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Ovarian Tumours

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  1. Ovarian Tumours Max Brinsmead PhD FRANZCOG January 2012

  2. Incidence • 1:10 women will undergo surgery during a lifetime because of suspected ovarian mass • 10% turn out to be non ovarian • The vast majority in pre menopausal women are benign

  3. Ovarian tumours present as: • Pain • Mass • An incidental finding But the most important thing to determine is whether: • It is functional or neoplastic? • Benign or malignant?

  4. 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?

  5. 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

  6. Ultrasound features of a Functional Ovarian Tumour • Thin walled • Usually no solid components • Usually no septa or thin walled septa • Usually <6 cm size • Usually avascular to colour Doppler • Change rapidly • And disappear within 6-8w • (A role for COC during this period not supported by Cochrane)

  7. Management Guidelines for a Simple Cyst in a Premenopausal Woman • Ignore if <30 mm size and asymptomatic • Repeat 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

  8. Clinical Features of a Neoplastic Ovarian Tumour: • Older women • Larger tumours • Solid/Cystic or multiple septate • Bilateral • Fixed, tender or craggy to palpation • Ascites present • Vascular to colour Doppler • Persist or enlarge (4m re evaluation for postmenopausal women) • Associated with positive tumour markers – CA125, CA19.9, CEA (AFP, HCG, LDH)

  9. Differential diagnosis for an Ovarian Tumour: • Full bladder • Pregnancy • Loaded caecum or sigmoid colon • Hydrosalpinx • Mesenteric cyst • Fiboid (subserosal) • Pelvic kidney etc • Paraovarian cyst

  10. Comprehensive DD of Adnexal Masses

  11. 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)

  12. Role of Ca 125 • Of most value in the evaluation of adnexal mass in postmenopusal women • Too many false positives in premenopausal women • Endometriosis, Adenomyosis, Fibroids & PID • Always of concern if >200 • Specific only for epithelial tumours • And only 50% sensitive for early stage disease

  13. 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

  14. Treatment of Ovarian Cancer: • Debulking surgery = TAH + BSO+Omentectomy • Chemotherapy • Radiotherapy • Special cases • Children • Young woman – no children • Advanced disease

  15. 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%

  16. 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)

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