LEARNING OBJECTIVES

1. LEARNING OBJECTIVES By the end of this lecture you have Basic knowledge about the benign ovarian tumours Basic knowledge about the histological types of ovarian cancer Knowing the clinical presentation and clinical assessment Outline the treatment of the Ovarian cancer Have a plan for the follow up

2. Benign Ovarian Tumours

3. Benign Ovarian Tumours (cont.) Cystic Solid

4. Dysfunctional Ovarian Cysts • Follicle cysts of the ovary are the most common cystic structures found in healthy ovaries • Result from either failure of a dominant mature follicle to rupture or failure of an immature follicle to undergo the normal process of atresia. 

5. Solitary follicle cysts are common and occur during all stages of life, from the fetal stage to the postmenopausal period.

6. Treatment Generally, no treatment is required, and many of these cysts resolve spontaneously within 6-12 weeks.

7. Benign Epithelial Neoplastic Ovarian Cysts • Epithelial cystic tumors account for about 60% of all true ovarian neoplasms. • One third of all ovarian tumors are serous. • Two thirds of these serous tumors are benign.

8. Serous tumors are characterized by proliferation of epithelium resembling that lining the fallopian tubes. • They are virtually all cystic. • Most commonly seen in women in their 40s and 50s, and are bilateral in 15-20% of cases.

9. Mucinous epithelial tumors account for 10-15% of all epithelial ovarian neoplasms. • 75% are benign and are found in women aged 30-50 years. • They are usually smooth-walled; compared with the serous variety, they rarely are associated with true papillae. • Generally multilocular, and the mucus-containing loculi appear blue through the tense capsules.

10. These tumors can grow quite large, measuring up to 30 cm. • Most common in the third to fifth decades of life and are only rarely bilateral. • The larger varieties are associated with an increased risk of rupture, with resultant pseudomyxoma peritonei.

13. Treatment • For women of childbearing age, simple unilateral oophorectomy via laparoscopy or laparotomy is adequate, provided that the contralateral ovary appears grossly normal. • In women desiring future fertility who have stage IA low-risk ovarian cancer, conservative surgical therapy is appropriate, provided that close follow-up can be maintained. • At the completion of childbearing, usually the remaining ovary and uterus are removed.

14. Total abdominal hysterectomy and bilateral salpingo-oophorectomy (with or without staging) are reasonable options for women of perimenopausal age.

15. Benign Solid Ovarian Tumors • Solid epithelial ovarian tumors are almost invariably malignant. • Approximately 80% of epithelial tumors are of the serous type, 10% are mucinous, and 10% are endometrioid. • Rarer varieties including clear cell tumors, Brenner tumors, and undifferentiated ovarian carcinomas.

16. Brenner tumors are usually found incidentally at pathologic evaluation, often in conjunction with a mucinous cystadenoma or dermoid cyst. • They are relatively rare tumors and are most common in the fifth to sixth decades of life. • Brenner tumors may be benign, intermediate, or malignant transitional cell tumors. • These tumors are usually small, firm, and solid, and when confined to the ovary, they carry a good-to-excellent prognosis, depending on the malignancy status.

17. Common benign solid tumors include fibromas and thecomas. • Fibromas are the most common benign ovarian neoplasms. • These tumors occur most commonly in women of postmenopausal age. They are unilateral and are often at least 3 cm in size. • Fibromas are connective-tissue tumors that arise from the ovarian cortical stroma. • If the stroma is estrogenic or luteinized, the tumors are actually thecomas.

18. Solid mature teratomas are tumors consisting of differentiated tissue from all 3 germ layers. • Benign teratomas (mature teratomas or dermoid cysts) are likely to contain more of recognizable organic structures, such as thyroid, bronchial, and central nervous system tissue. • In dermoid cysts, ectodermal structures such as hair, teeth, and skin predominate.

19. Treatment • In most instances, simple excision of the solid tumors is adequate therapy, particularly for women of reproductive age. • Laparoscopic treatment of benign cystic teratomas of the ovaries is recommended (ie, laparoscopic ovarian cystectomy). • In this procedure, in premenopausal women, the contralateral ovary is preserved, and every effort is made to excise only the dermoid cyst itself, thereby leaving both ovaries in situ.

20. Diagnostic imaging • Ultrasonography is the standard for identifying ovarian pathology. • Transvaginal ultrasonography is limited with regard to its role in assessing masses in neonates, children, and virginal adolescents. 

21. Ultrasonography can be used to evaluate material or fluid contained in a mass, as well as to assess the surface of the ovarian capsule. • Color-flow Doppler ultrasonography is useful for distinguishing between benign and potentially malignant lesions. • In most cases, computed tomography (CT) and magnetic resonance imaging (MRI) are unnecessary in the evaluation of an adnexal mass.

22. Ultrasonographic findings suggestive of malignancy include : • Ovarian mass with solid or complex components • Septations • Evidence of surface nodularity or papillae • Increased vascular flow • Heterogeneous echotexture

23. The presence of pelvic or abdominal ascites or pelvic or abdominal lymphadenopathy on CT or MRI further raises the index of suspicion for ovarian malignancy.

24. Laboratory studies • The cancer antigen 125 (CA-125) test • Alpha-fetoprotein (AFP) is another tumor marker that is elevated in the setting of endodermal sinus tumors, mixed germ cell tumors, immature teratomas, and embryonal carcinomas. 

25. The lactate dehydrogenase (LDH) level may be elevated in women with dysgerminomas. • Human chorionic gonadotropin (hCG) level may be elevated in women with choriocarcinomas, germ cell tumors, or embryonal cell tumors. • Testosterone levels may be elevated in patients with fibromas and Sertoli-Leydig tumors, and estradiol levels may be elevated in patients with thecomas or dysgerminomas.

26. Ovarian Lesions Before Birth and During Childhood Maternal ovarian cysts during pregnancy • Fairly common • largely as a result of excessive stimulation of human chorionic gonadotropin (hCG) by the corpus luteum. • The corpus luteum itself may then become quite large and undergo ovarian torsion.

27. Because pregnancy is a time of frequent USS evaluation, the other common ovarian cysts seen in the childbearing age group (eg, dermoid cysts, endometriomas, and, occasionally, malignant epithelial tumors) tend to be diagnosed more frequently during pregnancy.

28. Fetal cysts Both the maternal and fetal ovaries are exposed to excessive stimulation by human chorionic gonadotropin. Other maternal hormone levels are also high. The fetal pituitary gland is also producing follicle-stimulating hormone (FSH), which increases the size and number of fetal ovarian follicles. These factors may contribute to the formation of fetal ovarian cysts.

29. Often diagnosed in the third trimester during routine ultrasound surveillance. • These lesions are typically cystic (99%) and can be either simple or complex. The contralateral ovary also may be cystic. • Of all fetal cysts, 97% are functional, and the average size is approximately 3.4 cm. • Half of these cysts spontaneously resolve, and of the remainder, 25-40% undergo torsion.

30. The differential diagnosis of an adnexal mass detected in utero includes neoplastic lesions (eg, cystic teratomas, cystadenomas, granuloblastomas); mesenteric cysts; and gastrointestinal, genitourinary, or enteric duplication. • In the antenatal period, a conservative approach is recommended because many spontaneously resolve. • Although antenatal aspiration is an option, it has not shown any significant benefit and is not the standard of care.

31. Ovarian lesions in childhood • Childhood is a time of busy activity for the ovaries. • Histologically, the ovarian stroma is growing, causing the ovaries to enlarge. • When cysts manifest, they are usually small and simple. • The incidence of simple cysts increases with age, and most are caused by a failure of the follicle to undergo involution. • When smaller than 5 cm, these lesions may be followed conservatively.

32. Intervention should be considered for: cysts larger than 5 cm, lesions demonstrating solid components, those accompanied by pain, those associated with systemic endocrinologic signs, and those with complex components or internal septations. • When ovarian neoplasms are encountered in girls of this age group, they fall into the germ cell, epithelial cell, and stromal/sex chord familial classification. • The vast majority of ovarian lesions of childhood are of the germ cell variety, but only about 8% of ovarian tumors of childhood are malignant.

34. Ovarian lesions in adolescence • With the activation of the hypothalamic-pituitary-ovarian axis that accompanies menarche, an increase occurs in circulating gonadotropin, estrogen, and progesterone levels. • The axis of an adolescent may remain immature for some time after menarche; this results in frequent anovulatory cycles and ovulatory defects.

35. Of the numerous benign ovarian lesions seen in girls of this age group, the functional cyst, the corpus luteum cyst, and the hemorrhagic cyst are the most common. 

36. Ovarian Lesions in Reproductive Years Fibroma The most common benign solid tumor of the ovary is the fibroma. Fibromas are derived from connective tissue and arise from the solid ovarian cortical stroma. Histologically, spindle cells are seen. Ultrasonographically, these tumors appear hypoechoic with attenuation of the ultrasound beam.

38. These tumors may undergo calcification and degeneration. • More than 90% are unilateral, and approximately 10-15% are found in association with ascites. • Fewer than 1% undergo malignant transformation to fibrosarcomas. • About 1% of cases are associated with Meigs syndrome, characterized by ovarian fibroma, ascites, and pleural effusion.

39. Tubo-ovarian abscess • Tubo-ovarian abscesses (TOAs) are an infectious component of the benign lesions seen in females of reproductive age (see Tubo-ovarian Abscesses). TOAs are present in 14-38% of patients hospitalized with pelvic inflammatory disease (PID). • Patients usually report abdominal and pelvic pain; may have nausea, vomiting, and diarrhea; and are often febrile. • Physical examination reveals bilateral tender adnexal masses and diffuse peritoneal signs

40. On imaging studies, TOAs may appear as complex, large, and often bilateral masses, with heterogeneous components on both ultrasonography and CT.Often, the ovarian outline lacks definition, and the periovarian tissue appears thickened. Pyosalpinges may reveal increased echoes within the purulent tubular fluid, and fluid may also be present in the cul-de-sac.

41. Treatment includes intravenous (IV) broad-spectrum and anaerobic antibiotic coverage until symptoms resolve. • Bilateral salpingo-oophorectomy, with or without hysterectomy, is a last resort and should only be undertaken acutely in the presence of severe sepsis.

42. Polycystic ovary syndrome • Currently, 2 of the following 3 criteria are required to establish the diagnosis of PCOS: • Polycystic ovaries (multiple small cysts, often around the periphery of the ovary—the classic “string of pearls” appearance) • Signs of androgen excess (eg, acne, hirsutism, temporal balding, male pattern hair loss, or clitoromegaly) • Menstrual irregularities (oligomenorrhea or polymenorrhea)

43. Ultrasonographic findings suggestive of PCOS commonly include the following: • Ovarian enlargement • Increased follicle count • Stromal echogenicity

44. Endometriomas • An estimated 1-10% of reproductive-age women may have endometriosis to some degree. • The differential diagnosis of endometriomas also includes hemorrhagic cysts, TOAs, and ovarian malignancies.

45. OVARIAN MALIGNANCY

47. The incidence rate for ovarian cancer between 2006 and 2010 was 12.5 cases per 100,000 women. Estimated new cases and deaths from ovarian cancer in the United States in 2014: New cases: 21,980 Deaths: 14,270

48. Causes and Risk Factors Oral Contraceptives and Cancer Risk Oral Contraceptives and Cancer Risk BRCA1 and BRCA2: Cancer Risk

49. Factors With Adequate Evidence of Increased Risk of Ovarian CancerHormone replacement therapyPerineal talc exposureObesity, weight gain and heightFactors With Adequate Evidence for a Decreased Risk of Ovarian CancerOral contraceptivesTubal ligationBreast-feedingRisk-reducing bilateral salpingo-oophorectomyAreas of UncertaintyOvarian hyperstimulation for infertility treatment

50. Cellular Classification of Ovarian Epithelial Cancer • Serous cystomas: • Serous benign cystadenomas. • Serous cystadenomas with proliferating activity of the epithelial cells and nuclear abnormalities but with no infiltrative destructive growth (low potential or borderline malignancy). • Serous cystadenocarcinomas. • Mucinous cystomas: • Mucinous benign cystadenomas. • Mucinous cystadenomas with proliferating activity of the epithelial cells and nuclear abnormalities but with no infiltrative destructive growth (low potential or borderline malignancy). • Mucinous cystadenocarcinomas.