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Gynecology 5th year, 5th & 6th lectures (Dr. Sallama Kamil)

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The lecture has been given on May 16th & 18th, 2011 by Dr. Sallama Kamil.

The lecture has been given on May 16th & 18th, 2011 by Dr. Sallama Kamil.

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  • 1. بسم الله الرحمن الرحيم Ovarian tumours By Dr. Sallama kamel
  • 2. The classification of ovarian cysts and tumours:
    • A.Non-neoplastic functional cysts:
    • -Follicular cysts.
    • -Leuteal cysts.
    • -Theca- lutein and granulosa lutein cysts.
    • -Endometriotic cysts.
    • B.Primary ovarian neoplasms:
    • 1. Epithelial tumours ( benign, borderline or malignant):
    • -Serous tumour.
    • -Mucinous tumour.
    • -Endometrioid tumour.-
    • -Clear cell ( mesonephroid ) tumour.
    • -Brenner tumour.
    • -Undifferentiated carcinoma.
  • 3. 2.Sex cord stromal tumours:
    • -Granulosa cell tumour.
    • -Theca cell tumour.
    • -Fibroma.
    • -Androblastoma: sertoli-leydig cell tumour.
    • -Gynandroblastoma.
    • 3.Germ cell tumour:
    • a. Benign:
    • -cystic Teratoma and
    • -solid teratoma.
    • b.Malignant:
    • -Dysgerminoma.
    • -Malignant change in cystic teratoma.
    • -Malignant solid teratoma.
    • -Non-gestational choriocarcinoma.
    • -Yolk sac tumour (endodermal sinus tumour).
    • C. Metastatic tumours:
  • 4.
    • Physiological cyst
    • -They are simply large versions of the cysts that forms in the ovary during the normal ovarian cycle.
    • -Most are asymptomatic and found incidentally on pelvic examination or ultrasound.
    • -They are most common in young women.
    • -They may be a complication of ovarian induction.
    • -They also occur in women with trophoblastic disease.
  • 5.
    • 1.Follicular cysts:
    •  it result from the non-rupture of a dominant follicle or the failure of atresia in a non-dominant follicle.
    • 2. Luteal cysts:
    •  Less common than follicular cyst.
    •  Are more likely to present with intra-peritoneal bleeding.
    •  They may also rupture.
    •  This is usually happens on day 20-26 of the cycle.
    • 3.Theca-lutein and granulosa lutein cysts.
    • -These occurs in association with Hydatidiform moles or
    • choriocarcinoma.
    • They are usually bilateral and usually resolve spontaneously after
    • evacuation of the mole.
    • -Similar cysts may formed if excessive doses of gonadotrophins or of
    • clomiphines are given to induce ovulation causing hyperstimulation
    • syndrome.
  • 6.
    • -In most of the cases physiological cysts resolve spontaneously and does not need any surgical interference unless they cause an acute symptoms or their size exceed 10cm.
  • 7. Epithelial tumours:
    • -These tumours arise from the ovarian surface epithelium.
    • -So they arise from the Coelomic epithelium overlying the embryonic gonadal ridge.
    • Since the epithelial covering of the ovary and the mullerian
    • duct ( from which the tubal, endometrial and cervical
    • epithelium are derived ) are both from coelomic epithelium ,
    • comparable metaplastic transformation into different types of
    • epithelium is possible.
    • -So the cells may differentiate to endocervical cells giving rise to mucinous cystadenoma .
    • -Differentiation into endometrial cells give rise to Endometrioid tumour .
    • -Differentiation to tubal epithelium give rise to serous cystadenoma.
    • -Differentiation along uro-epithelium give rise to Brenner tumour.
    • They are most common in women over 40 years old.
  • 8. 1.Serous cystadenoma:
    • -These are the most common epithelial tumours with a range from benign to the highly malignant .
    • -The benign form are called benign serous cyst.
    • -It is unilocular cyst with papilliferous processes on the inner surface and occasionally on the outer surface.
    • -The lining epithelium is cuboidal or columnar and may be ciliated.
    • -The cyst contain thin serous fluid.
    • -They are usually smaller than the mucinous tumour.
    • -They are often bilateral
    • -They occur most commonly in late reproductive and early postmenopausal life.
  • 9. Serous cyst adenoma
  • 10. The malignant form called Serous papilliferous carcinoma:
    • -This is the commonest primary ovarian carcinoma.
    • -It is bilateral in 50%.
    • -The growth often penetrates the capsule and project on the external surface with dissemination of the cells into the peritoneal cavity giving multiple seedling metastases and ascites.
    • -The cyst contains many papillary processes which have proliferated so much that they almost fill the cavity and there may be exophytic papillary growth on the surface.
    • -The lining cells are multilayer and may invade normal tissues.
  • 11. Serous papilliferous carcinoma:
  • 12. 2.Mucinous cystadenoma:
    • -The 2 nd most common epithelial tumour.
    • -They are large, unilateral , multilocular cysts with smooth inner surface.
    • -The lining epithelium is columnar mucous-secreting cells.
    • -The cyst contain thick glutinous fluid.
    • Malignant mucinous cyst (Mucinous carcinoma):
    • Constitute 10% of ovarian cancers.
    • -On histological examination, 5% of mucinous cysts found to be malignant.
    • Epithelial tumours of borderline malignancy:
    • - mean that the tumour carry some of the features of malignancy( e.g. multilayering of cells and nuclear atypia).
    • -But there is no stromal invasion.
  • 13. 3.Endometrioid cystadenoma:
    • -These are very similar to ovarian endometriosis.
    • -They may be associated with pelvic pain and dyspareunia due to adhesions.
    • 4.Clear cell tumours( mesonephroid):
    • -They arise from serosal cells showing little differentiation, and are only rarely benign.
    • -The typical histological appearance is of clear or hobnail cells
  • 14. 5.Brenner tumours:
    • Macroscopically: a Brenner tumour resembles a fibroma, being a solid tumour with a white cut surface.
    • Histologically: -It consists of islands of round transitional-like epithelium in a dense fibrotic stroma giving a solid appearance.
  • 15. Germ cell tumours:
    • • • It is among the commonest ovarian tumours seen in women of less than 30years old.
    • ● Amongst women under 20 years ,up to 80% of ovarian malignancies are due to germ cell tumours.
    • • Overall only 2-3 percent are malignant .
    • • These tumours arise from a totipotential germ cell
    • • Thus they contain element of all three germ layer( embryonic differentiation).
    • Differentiation into embryonic tissues result in teratoma
    • (dermoid cyst).
    • • Differentiation into extra-embryonic tissues results in ovarian choriocharcinoma or endodermal sinus tumour.
    • • When neither embryonic nor extra-embryonic differentiation occurs, dysgerminoma results .
  • 16. Dermoid cyst (mature cystic teratoma)
    • -This is the commonest germ cell tumour and it is benign.
    • -It results from differentiation into embryonic tissues.
    • -It account for about 40% of all ovarian neoplasm.
    • -It is most common in young women and the median age of presentation is 30 years old.
    • -it contain a variety of tissues derived from the two or more of the primary germ layers..
    • -The dermoid cyst is usually unillocular cyst.
    • -Less than 15cm in diameter
    • -It is often lined by epithelium like the epidermis and contain skin appendages, teeth , sebaceous material , hair and nervous tissues, cartilage bone and thyroid tissues.
    • -The cavity of the cyst contain yellow greasy material.
  • 17.
    • -The majority of dermoid cysts (60%) are asymptomatic.
    • -However it may undergo torsion.
    • -Less commonly it may rupture spontaneously, either suddenly causing an acute abdomen and chemical peritonitis, or slowly causing chronic granulomatous peritonitis.
    • -During pregnancy, rupture is more common due to external pressure from expanding gravid uterus or to trauma during delivery.
    • Mature solid teratoma:
    • -These are tumours contain mature tissues just like the dermoid cyst but are solid.
  • 18. Mature cystic teratoma
  • 19. Malignant germ cell tumours:
    • These are rare tumours accounting for only 3% of ovarian cancers.
    • 1.Dysgerminoma:
    • 2.Yolk sac tumour ( endodermal sinus tumour). Secret alpha feto protein
    • 3.Immature Solid teratoma:
    • 4.Non gestational choriocarcinoma: secret HCG.
  • 20. sex cord stromal tumours:
    • -These account for only 4% of benign ovarian tumours.
    • -They occur at any age from prepubertal children to elderly, postmenopausal women.
    • -They secrete hormones and present with the results of inappropriate hormone effects.
    • 1.Granulosa cell tumours: secret estrogen.
    • 2.Theca cell tumours: also secret estrogen.
    • 3.Fibroma: -
    • Meig ’ s syndrome ( ascites , pleural effusion in association with a fibroma of the ovary) is seen in only 1% of cases.
    • 4.Sertoli- leydig cell tumours:
  • 21.
    • Clinical presentation of ovarian tumours
    • -Asymptomatic.
    • -Pain.
    • -Abdominal swelling.
    • -Pressure effects.
    • -Menstrual disturbances.
    • -Hormonal effects.
    • -Abnormal cervical smear.
  • 22. 1.Asymptomatic:
    • Many benign ovarian tumours are found incidentally in the course of investigating another unrelated problem or during a routine examination.
    • 2.Pain :
    • -Acute pain from an ovarian tumour may result from
    • complication e.g. torsion, rupture, haemorrhage or infection.
    • -Torsion give rise to a sharp, constant pain caused by
    • ischaemia of the cyst and areas may become infarcted.
    • - Haemorrhage into the cyst may cause pain as the capsule is
    • stretched.
    • - Rupture of the cyst causes intraperitoneal bleeding mimicking
    • ectopic pregnancy (this happens mostly with a luteal cyst ).
  • 23. 3.Abdominal swelling:
    • -Patients seldom note abdominal swelling until the tumour is very large .
    • -A benign mucinous cyst may occasionally fill the entire abdominal cavity.
    • 4. pressure effects.
    • -Gastro-intestinal or urinary symptoms may result from pressure of large tumour.
    • -In extreme cases, oedema of the legs, varicose veins and haemorrhoids may result.
    • 5.menstrual disturbances:
    • Occasionally the patient will complain of menstrual disturbances but this may coincidence rather than due to the tumour.
  • 24. 6.hormonal effects :
    • -rarely Sex cord tumours may present with oestrogens effects such as precocious puberty, menorrhagia and glandular hyperplasia, breast enlargement and postmenopausal bleeding.
    • -Secretion of androgens may cause hirsuitism and acne initially progressing to frank virilism with deepening of the voice or clitoral hypertrophy.
  • 25. Diagnosis:
    • 1.Full history:
    • -Details of the presenting symptoms and a full gynaecological history
    • should be obtained with particular reference to the date of the last
    • menstrual period , the regularity of the cycle, any previous
    • pregnancies , contraception, medication and family history
    • ( particularly of ovarian, breast and bowel cancer ).
    • 2.Examination ( abdominal and pelvic examination):
    • -If the patient presented with acute abdomen look for evidence of
    • hypovolaemia.
    • -The neck , axilla and groins should be examined for lymphadenopathy.
    • -A malignant ovarian tumour may cause a pleural effusion.
    • -This is much less commonly found with benign tumour.
    • -Also some patient may have ankle oedema.
    • -The abdomen should be inspected for distension by fluid (ascites) or
    • by the tumour itself.
    • -A male distribution of hair may suggest a rare androgen-producing
    • tumours.
  • 26. Bimanual examination:
    • -This is an essential part of assessment.
    • -To palpate the mass , its mobility, consistency.
    • -Presence of nodules in the pouch of Douglas and the degree of tenderness.
    • -A cystic mobile mass is mostly benign,
    • while a hard, irregular fixed mass is likely to be malignant.
  • 27. Investigations:
    • 1.Ultrasound
    • -Trans-abdominal and trans-vaginal ultrasound can demonstrate the presence of an ovarian mass with reasonable sensitivity and specificity.
    • - However it can not distinguish reliably between benign and malignant tumours but solid masses are more likely to be malignant than the purely cystic mass.
    • -The use of colour- flow Doppler may increase the reliability of ultrasound.
    • -CT scan and MRI can be used but are more expensive.
  • 28. 2.Radiological investigations:
    • -A chest X- ray is essential to detect metastatic disease in the lungs or a pleural effusion .
    • -Occasionally an abdominal X-ray may show calcification, suggesting the possibility of a benign teratoma.
    • -A barium enema is indicated only if the mass is irregular or fixed, or if there are bowel symptoms.
    • 3.Blood test and serum markers:
    • - Elevated WBC count may indicate infection.
    • - Ca 125
    • Raised serum Ca 125 is strongly suggestive of ovarian carcinoma, especially in postmenopausal women.
  • 29.
    • - B-HCG level is elevated in women with choriocarcinoma.
    • -Oestradiol levels may be elevated in some women with physiological follicular cysts and sex cord stromal tumours.
    • -Androgens are increased with Sertoli-lydig tumours.
    • - Raised alpha-fetoprotein levels suggest a yolk sac tumour.
  • 30. Management of benign ovarian tumours:
    • This will depend upon the
    • -Severity of the symptoms.
    • -Age of the patient .
    • -The risk of malignancy.
    • -Her desire for future pregnancy.
    • The asymptomatic women:
    • The older women :
    • -Women over 50 years of age are more likely to have a malignancy so surgery is usually indicated.
  • 31.
    • In pre-menopausal women:
    • -Young women of less than 35 years are both more likely to wish to have further children and are less likely to have malignant epithelial tumour.
    • -A clear unilocular cyst of 3-10 cm identified
    • by ultrasound should be re- examined after
    • 12 weeks for evidence of diminution in size .
  • 32. - If the cysts persists, such women may be followed with a six-monthly ultrasound and Ca125 estimations.
    • -If the cyst does enlarge , laparoscopy or laparotomy may be indicated.
    • .A cyst of more than 10 cm is unlikely to be physiological or to resolve spontaneously and operation indicated.
    • -The use of combined oral contraceptive pills is unlikely to accelerate the resolution of a functional cyst.
    • The patient with symptoms:
    • If the patient present with severe acute pain or signs of
    • intraperitoneal bleeding an emergency laparoscopy or
    • laparotomy will be required.
  • 33. The pregnant patient:
    • -An ovarian cyst in pregnant women may undergo torsion or may bleed.
    • -The pregnant women with an ovarian cyst is a special case because of the risk of surgery to the fetus.
    • - Thus if the patient present with acute pain due to torsion or haemorrhage into an ovarian cyst or if appendicitis is a possibility, the correct course is to undertake a laparotomy regardless the stage of the pregnancy.
    • -The operation should be covered with by tocolytic drugs and performed in a center with intensive neonatal care.
    • -If asymptomatic cyst is discovered during the 1 st trimester , it is prudent to wait until after 14 weeks ’ gestation before removing it.
  • 34. -This avoids the risk of removing a corpus luteal cyst upon which the pregnancy might still be dependent.
    • -In the 2 nd and 3 rd trimesters , the management of an asymptomatic ovarian cyst may be either conservative or surgical.
    • -Cysts < 10cm , which have simple appearance on U/S , are unlikely to be malignant or to result in cyst accident and may therefore be followed by U/S.
    • -Many may resolve spontaneously .
    • -If the cyst unresolved 6 weeks postpartum , surgery indicated.
  • 35. -Malignancy is uncommon in pregnancy occurring in less than 3% of the cysts.
    • -However a cyst with a features suggestive of malignancy on
    • U/S , or one that is growing, should be removed surgically.
    • -The tumour marker C 125 is not useful in pregnancy since it may be
    • elevated in normal pregnancies.
    • Prepupertal girl:
    • -Ovarian cysts are uncommon and often benign.
    • -Teratoma and follicular cysts are the most common.
    • -Presentation may be abdominal pain, distension or precocious puberty.
    • -Management depends on:
    • -relief of symptoms.
    • -exclusion of malignancy and
    • -conservation of maximum ovarian tissue without depressing fertility.
  • 36. Types of surgery for apparently benign ovarian tumours:
    • For young women less than 35 years:
    • 1.Cystectomy ( removal of the cyst only).
    • 2.Oophorectomy( removal of the ovary with the cyst).
    • For woman more than 45 years with ovarian cyst more than 6cm in diameter it is advisable to do total abdominal hysterectomy and bilateral salpingo-oopgorectomy.
  • 37. Malignant disease of the ovary:
    • -Most ovarian tumours are of epithelial origin.
    • -They are rare before the age of 35 years, but the incidence increases with age to a peak in the 50-70 years.
    • -Most epithelial tumours are not discovered until they have spread widely.
    • -Surgery and chemotherapy forms the main stay of treatment.
    • The results are poor.
    • -The 5 year survival is less than 25%.
    • -Only 3 % of ovarian cancers are seen in women younger than 35 years and most are non-epithelial cancers such as germ cell tumours.
  • 38. Risk factors predisposing for ovarian cancer:
    • Continuous ovulation increase the risk as in:
    • 1.Nulliparity.
    • 2.Early menarche and Late menopause , both of these are associated
    • with long estimated numbers of years of ovulation.
    • 3.increasing age at first birth.
    • 4.The prolonged use of drugs for induction of ovulation.
    • 5.Exposure to environmental substances e.g. Talc and asbestoses.
    • 6.Family history of ovarian cancer:
    • There is a family history in 5-10 % of women with epithelial cancers.
    • A woman with one affected close relative has risk of 2.5%
    • With two affected close relatives the risk increase to 30-40%.
    • -Breast feeding reduce the risk.
    • -Also Oral contraceptive use reduces the risk by 50% after 5years of use.
  • 39. Staging of ovarian cancer (FIGO staging ):
    • The staging of ovarian cancer is a clinical staging
    • Stage 1 growth limited to the ovaries.
    • Ia growth limited to one ovary.
    • No ascites, no tumour on external surfaces ; capsule intact.
    • Ib tumour limited to both ovaries .
    • No ascites, no tumour on external surfaces; capsule intact.
    • Ic either stage 1a or 1b with ascites contain malignant cells or tumour on the surface of one or both ovaries.
    • Stage II : growth involving one or both ovaries with pelvic extension.
    • Stage III: growth involving one or both ovaries with peritoneal implants outside the pelvis or positive retroperitoneal or inguinal lymph nodes or superficial liver metastasis
    • Stage IV : growth involving one or both ovaries with distant
    • metastasis,parenchymal liver metastasis equal stage 1V.
  • 40. Spread of ovarian malignancies:
    • - direct spread: usually to the pelvic peritoneum and other pelvic organs ( uterus and broad ligament ).
    • -Lymphatic spread commonly involves the pelvic and the para-aortic nodes.
    • Spread may also involves the nodes of the neck or inguinal region.
    • -Haematogenous spread
    • -usually occurs late and involves mainly the liver, and lung.
    • -Bone and brain metastasis sometimes seen.
  • 41. Presentation and diagnosis:
    • - Vague abdominal pain or discomfort is the commonest presenting complaint.
    • -Distension or feeling a lump is the next most frequent.
    • -The patient may complain of:
    • *Indigestion.
    • *Urinary frequency.
    • *Weight loss.
    • -Or rarely abnormal menses or postmenopausal bleeding.
    • A hard abdominal mass arising from the pelvis is highly suggestive especially with ascites.
    • -A fixed, hard, irregular pelvic mass is usually felt best by combined vaginal and rectal examination.
    • The neck and groin should also be examined for enlarged nodes.
  • 42. Investigations :
    • 1.full blood count.
    • 2.Urea, electrolyte and liver function test.
    • 3.Chest x-ray.
    • 4.Sometimes, barium enema and colonoscopy is needed to differentiate between an ovarian and a colonic tumour or to assess bowel involvement.
    • 5.IVP (intravenous urography).
    • 6.Ultrasonography may help to confirm the presence of a pelvic .mass and detect ascites.
    • 7.Tumour markers e.g. Ca 125.
    • 8.In most women the diagnosis is uncertain before laparotomy is undertaken.
  • 43. Surgery :
    • -Surgery is the mainstay of both the diagnosis and the treatment of ovarian cancer.
    • -A vertical incision is required for an adequate exploration of the upper abdomen.
    • -A sample of ascitic fluid or peritoneal washings with normal saline should be taken for cytology.
    • -The pelvis and upper abdomen are explored carefully to identify metastatic disease.
    • -The therapeutic objective of surgery for ovarian cancer is the removal of all tumour tissues.
    • -This is usually possible in the majority of stage I and stage II, but impossible in advanced cases.
  • 44. To resect all visible tumour requires a total hysterectomy, bilateral salpingo-oophorectomy and infra-colic omentectomy.
    • -However , in a young , nulliparous woman with unilateral tumour and no ascites ( stage Ia ), unilateral salpingo-oophorectomy may be done after careful exploration to exclude metastatic disease , and curettage of the uterine cavity to exclude a synchronous endometrial tumour.
    • -If the is subsequently found to be poorly differentiated or if the washings are positive, a second operation to clear the pelvis will be necessary.
  • 45.
    • - For older women who complete her family a total hysterectomy and bilateral salpingo-oophorectomy is usually done.
    • Chemotherapy:
    • -Women with stage Ia or Ib and well or moderately differentiated tumours will not require further treatment.
    • -All other patient with invasive ovarian carcinoma require chemotherapy (stage II-IV – possibly stage Ic ).
    • -There is no evidence that adjuvant therapy affects the outcome in women with borderline tumour.
    • -Drugs used are Carboplatin, cisplatin and taxol.
  • 46. Prognosis:
    • Borderline tumour:
    • Long term prognosis excellent in most cases.
    • Invasive tumours- 5 year survival rates.
    • -90% for Stage Ia and 1b ( well or moderately differentiated ).
    • -10 % for stage III.
    • -23% overall.
  • 47.
    • THANK YOU