ovarian pathology for undergraduates max brinsmead mb bs phd november 2014
TRANSCRIPT
Ovarian Pathology for Undergraduates
Max Brinsmead MB BS PhD
November 2014
Incidence
1:10 women will undergo surgery during a lifetime because of suspected ovarian pathology10% turn out to be non ovarianThe vast majority in pre menopausal women are benignOvarian cancer affects ≈ 1:100 women– And is the most common cause of death from
gynaecological malignancy
Ovarian pathology presents as:
PainMassBut most commonly as an incidental finding on imaging
When the most important thing to determine is whether:
It is functional or neoplastic?Benign or malignant?
Pathology of Functional Ovarian Cysts:
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
Especially if there are adhesions from PID or pelvic surgery
Endometrioma = ovarian endometriosis
A normal Corpus Luteum
Haemorrhage into a Corpus Luteum
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?
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
Ultrasound of a Follicular Cyst
Haemorrhage into a Corpus Luteum
Ultrasound of a malignant ovarian mass
Management Guidelines for a Simple Cyst in a Premenopausal Woman
Ignore if <30 mm in size and asymptomaticRepeat scan after 3 months for simple cysts 30 – 50 mm in size – Refer to a gynaecologist if still present
Further Investigations include…– Serum Ca 125– Further imaging by CT or NMR
Mechanisms of Pain with Ovarian Cyst
Rapid enlargementHaemorrhage or haemorrhagic ruptureLeaking sebaceous or endometrioma fluidTorsion– Requires tumour >5 cm on a thin pedicle– Torsion involves whole of the ovary and tube– Presents as “reverse renal colic”– Cervix will be deviated towards the tumour– Signs of “acute abdomen” or “acute pelvis”– Early surgery & untwisting may save the ovary
Clinical Features of a Neoplastic Ovarian Tumour:
Older women– 50% malignant for woman >50 years of age
Larger tumoursBilateralFixed, tender or craggy to palpationAscites presentSolid or Cystic with multiple septa & solid partsVascular to colour DopplerPersist or enlarge over timeAssociated with positive tumour markers – CA125, (CA19.9, CEA, AFP, HCG, LDH)
Differential diagnosis for an Adnexal Mass:
Full bladderPregnancyLoaded caecum or sigmoid colonParaovarian cystHydrosalpinxMesenteric cystFiboid (subserosal)Pelvic kidney etc.Other malignancy e.g. bowel
Pathology of Ovarian Neoplasms
Germ cell Tumours– Benign cystic teratoma = Dermoid – The most common neoplasm of young ♀– 15% bilateral over a lifetime– Malignant varieties includes Dysgerminoma (LDH), Teratocarcinoma,
Endodermal sinus Ca (AFP), ChorioCa (bHCG)
Epithelial– Cystadenoma (serous and mucinous)– Cystadenocarcinoma Serous– Mucinous– Endometroid– Clear cell adenoCa
Hormone-producing– Oestrogen-producing (granulosa cell benign or malignant)– Androgen-producing (Androblastoma)
Secondary Cancers (Stomach, Bowel, Breast etc.. Includes Krukenberg tumours)
Serous Cystadenoma
Serous Cystadenocarcinoma
Mucinous Cystadenoma
Role of Ca 125Of 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
Useful for monitoring response to treatment
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
A word about Polycystic Ovaries:
Are common– Up to 20% of women who are cycling spontaneously i.e.
not on the Pill
Can be unilateral or bilateralDo NOT cause pain
Test QuestionsThe most common neoplasm of the ovary in young women is a serous cystadenoma
CA125 is useful in screening for ovarian cancer in postmenopausal women
The lifetime risk for ovarian (& testicular) cancer is 1:50
Haemorrhage into a corpus luteum can cause a cyst > 6 cm in size
Progestogen-only contraception increases the risk of neoplasia in the ovary
False – Benign cystic teratoma or DermoidsFalse – only 50% positive for early stage disease
False – 1:100
True
False – increased risk of functional ovarian cysts
Which of the following is NOT a feature of benign tumour in ovary assessed with ultrasound?
Simple cyst
Thin walled
Multiple septa or solid areas
Less than 6 cm size
Present in both ovaries
Ascites
Changes rapidly over a few days or weeks
High blood flow on colour Doppler
Multiple septa and/or solid areasAscitesHigh blood flow on colour Doppler
Test QuestionsHaemorrhage into a corpus luteum can cause a solid-looking tumour with multiple septa
CA125 is elevated in patients with endometriosis
Ascites with an ovarian tumour is always a sign of malignancy
Torsion of an ovarian cyst will displace the cervix towards the pathology
Prophylactic oophorectomy is recommended in all women undergoing hysterectomy to remove all risk of ovarian Ca
Polycystic ovarian syndrome is a common cause of pelvic pain
TrueTrue – but only modest elevations <200False – see Meig’s syndromeTrue
False
False
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