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Ovarian tumours

Ovarian tumours. Plan. Non-neoplastic conditions Ovarian neoplasms. 1 non-neoplastic conditions. 1.1 functional cysts Follicular cysts: follicle -> no ovulation -> persistent GnRH stimulation -> cyst formation

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Ovarian tumours

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  1. Ovarian tumours

  2. Plan • Non-neoplastic conditions • Ovarian neoplasms

  3. 1 non-neoplastic conditions • 1.1 functional cysts • Follicular cysts: follicle -> no ovulation -> persistent GnRH stimulation -> cyst formation • Corpus luteum cysts: follicle -> ovulation -> persisting Progesterone producing cyst -> eventual involution • These cysts are confined to the reproductive years and to those not using hormonal c/c

  4. Functional cysts • Can be asymptomatic / pain / menstrual irregularity • Principle: If a young woman complains of pain, EXAMINE. • If cyst present: Unilateral? Is it benign? • Then Ultrasound! • CA125 usually <35

  5. Ultrasound criteria: Most likely benign • Unilocular • Thin walled • Smooth walls • Echo free contents • Unilateral • Usually <8cm in diameter

  6. If most likely benign: • Most will undergo regression with menstruation • Can wait (not if pain is a problem) • Hormonal suppresion of GnRH stimulation • OC: best and convenient • or Provera 5mg 2x per day for 10 days (progesterone treatment) • + NSAIDs for pain • And reassess after menstruation

  7. Complications of a cyst • Torsion • Mechanism • clinical: acute pain, nausea, faint • Tenderness, mass, acute abdomen • Diff dx: Ectopic pregnancy • Ultrasound, Hb, hCG • Treatment: laparotomy + adnexectomy • Bleeding • Rupture

  8. 1.2 non-functional non-neoplastic cysts • Endometriomas • Theca-lutein cysts • Par-ovarian cysts • Residual ovarian syndrome: post-hysterectomy; pain and dyspareunia: ovary stuck to the vault. • Surgical management: removal or suspension

  9. Ovarian neoplasms • Types: • Epithelial • Stromal • Germ cell • Metastatic • Behaviour: • Benign / borderline malignancy / malignant

  10. Uncommon but very important: Gynaecologic cancer with poorest prognosis • Causes: Probably genetic factors • Risk factors: age 40-65y • Own or family history of breast / ovary / endometrium / colon cancer • Never pregnant / infertility / low parity

  11. Protection: OCs, oophorectomy with strong family history • Screening: poor!! CA125 + u/sound used: low pick up and predictability • Clinical picture • History: few complaints, non specific: tired, pain, urinary and GIT complaints, abdominal distension, only 1% bleeds

  12. Examination: ascites, mass in abdomen and pelvis, solid, bilateral, tender • Tests • CA 125: useful as marker if patient has raised value • FBC, sedimentation, U&E, LFT, CXR, ultrasound • Bowel: diff dx: Ba enema / colonoscopy / occult blood

  13. Ultrasound criteria for POTENTIALLY MALIGNANT • Solid / semicystic • Multilocular • Thick walled • Papillary growths on walls of cysts and tumour • Bilateral • Ascites

  14. Staging • Surgical, also 1-4 system • I: confined to ovary / ovaries (15%) • II: also uterus, tubes, bladder and rectal walls, pelvic peritoneum (10%) • III: upper abdomen, peritoneum, omentum, lymph nodes (60%) • IV: lungs, liver, other organs (15%)

  15. Management • Principle: Surgery followed by chemotherapy • Operations: • Staging laparotomy: for confined disease: TAH BSO omentectomy, nodes and ascites • Cytoreduction: for intraperitoneal spread: aim to do same and not leave tumour larger than 1cm behind • Interval cytoreduction: apparently inoperable: biopsy and chemo X 3, then surgery

  16. Further treatment • Chemotherapy: for stages 1c onwards: 6 courses • Prognosis: 5years survival: Stage I: 90%, Stage II 40%, Stage III 30%, Stage IV 10% • Causes of death • Intestinal obstruction, metastases, cachexia • Needs pain control and care, nutritional support and ascites control

  17. Histologic types of tumours • Epithelial • Serous, mucinous, endometroid, clear cell, mixed • Stromal • Granulosa, theca, G+T, sertoli, leydig S+L, mixed, lipoid • Germ cell • Dysgerminoma, yolk sac, embryonal, mixed • Benign cystic teratoma

  18. Group characteristics • Epithelial: “common”, 45-65y, imitates other mullerian epithelia: serous, mucinous, endometroid, clear cell. Can be Benign, borderline malignant or malignant • Stromal: rare, any age, low grade malignant behaviour; hormone producing: E: G, T. A: S, L • Germ cell: very rare; children and adolescents, highly malignant, unilateral. Chemosensitive.

  19. Exception: Benign cystic teratoma • Most common ovarian tumour if children and young adults. Usually unilateral, few symptoms: pain, torsion, bleeding. • Contains tissue from all 3 embryonic layers • On section: hair, sebaceous material, bone and teeth • Rx: ovarian cystectomy with conservation of normal ovarian tissue

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