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Ovarian Pathology

Ovarian Pathology. Max Brinsmead PhD FRANZCOG October 2013. Incidence. 1:10 women will undergo surgery during a lifetime because of suspected ovarian pathology 10% turn out to be non ovarian The vast majority in pre menopausal women are benign Ovarian cancer affects ≈ 1:100 women

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Ovarian Pathology

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  1. Ovarian Pathology Max Brinsmead PhD FRANZCOG October 2013

  2. Incidence • 1:10 women will undergo surgery during a lifetime because of suspected ovarian pathology • 10% turn out to be non ovarian • The vast majority in pre menopausal women are benign • Ovarian cancer affects ≈ 1:100 women • And is the most common cause of death from gynaecological malignancy

  3. Ovarian pathology presents as: • Pain • Mass • But 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?

  4. 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

  5. A normal Corpus Luteum

  6. Haemorrhage into a Corpus Luteum

  7. 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?

  8. 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

  9. Ultrasound of a Follicular Cyst

  10. Haemorrhage into a Corpus Luteum

  11. Ultrasound of a malignant ovarian mass

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

  13. Mechanisms of Pain with Ovarian Cyst • Rapid enlargement • Haemorrhage or haemorrhagic rupture • Leaking sebaceous or endometrioma fluid • Torsion • 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

  14. Clinical Features of a Neoplastic Ovarian Tumour: • Older women • 50% malignant for woman >50 years of age • Larger tumours • Bilateral • Fixed, tender or craggy to palpation • Ascites present • Solid or Cystic with multiple septa & solid parts • Vascular to colour Doppler • Persist or enlarge over time • Associated with positive tumour markers – CA125, (CA19.9, CEA, AFP, HCG, LDH)

  15. Differential diagnosis for an Adnexal Mass: • Full bladder • Pregnancy • Loaded caecum or sigmoid colon • Paraovarian cyst • Hydrosalpinx • Mesenteric cyst • Fiboid (subserosal) • Pelvic kidney etc. • Other malignancy e.g. bowel

  16. 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)

  17. Serous Cystadenoma

  18. Serous Cystadenocarcinoma

  19. Mucinous Cystadenoma

  20. 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 • Useful for monitoring response to treatment

  21. 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%

  22. Preventing ovarian cancer: • Screening - Vaginal exams - Ultrasound - CA125 Have been disappointing – too many false positives • Prophylactic Oophorectomy - at hysterectomy (40% potential) - for genetically predisposed (BRAC carriers)

  23. 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 bilateral • Do NOT cause pain

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