presentation on ovarian mass

1. Ovaria
n
Mass
Specialist :Dr Vickneswaren
MO :Dr Shairah
HO : Dr Athirah & Dr Luqman
CME 11/3/2022

2. Case
Study
A 17-year-old girl presented to the emergency
department complainingof acute lower abdominal pain.
The painstarted suddenly,2 hours before, in the mid-
right lower abdomen.
Shealso complainedof diarrhea earlier that day, but
noother symptoms.
The patient had noremarkable medical history, no
surgeries, no medication other than hormonal
contraceptive pills,and no previous pregnancies.The
pain remained constant, without relief from
nonsteroidal anti-inflammatory treatment.

3. Common Presentations
Asymptomatic - chance finding (eg. On bimanual
examination or ultrasound).
Dull ache or pain in the lower abdomen, low back pain.
Dyspareunia.
Swollenabdomen,with palpable massarising out of the
pelvis,which is dull to percussion and does not disappear
if the bladder is emptied.
Pressure effects,
Eg.on the bladder, causing urinary frequency,
on venous return, causing varicose veins and leg oedema.

4. c ont..
Torsion, infarction or haemorrhage: Cause severe pain and
fever.
Rupture: maycause peritonitis and shock.
Rupture of mucinouscystadenomas may disseminate cells
which continue to secrete mucinand cause death by binding up
the viscera (pseudomyxoma peritonei).
Ascites - suggests malignancy or Meigs' syndrome.
Endocrine - hormone-secreting tumours maycause virilisation,
menstrual irregularities or PMB. This is uncommonthough.

5. Risk Factors of Ovarian Malignancy
Risk factors of ovarian malignancy?

6. Differential Diagnosis
Any other cause of pelvic pain –
eg. ;
• Tuboovrianabscess
• PCOS
• Endometrioma.
• Ovarian malignant tumour.
• Tuboovarian abscess
• Uterine mass (eg fibroid)
• Bowel - colonic tumour,
appendicitis/appendix
mass,diverticulitis.
• Pelvic malignancies- eg
retroperitoneal tumours, small
intestine tumours and
mesothelial tumours.
Gynecological Non-
Gynecological

7. Further examination..
On admission shewas hemodynamically stable, nofever, with
lower mid/right abdominal pain on palpation, without
peritoneal reaction.
Gynecological evaluation revealed a soft mass10cmin size in
the right lower abdominal quadrant, and noother signs.

8. General Examination
- ?cachexia – indicate malignancy
-vitals?
-Sepsis? – infected/ torsion/ ruptures cyst?
Breast examination – looking for?
Lungs - ?pleural effusion
Per abdomen
- ?Ascites – ovarian malignancy
- How to distinguish ovarian mass from other abdominal masses?
-Bimanual examination?
- Lymph nodes examination -? Which LN

9. Further examination..
Laboratory evaluation showed noanemia, noinflammatory
parameters and negative urinary pregnancy test (hemoglobin
12.2g/dL; C-reactive protein [CRP] 3.7 mg/L).

10. Investigations
Bloods
Urine
Imaging – USG? CT? MRI?

11. Other tumour markers
TUMOUR MARKER TUMOUR TYPE USES
CA 19-9
Epithelial ovarian cancer,
(mucinous) borderline
ovarian tumours
Pre-operative, f/up
CA 125
Non mucinousepithelial
ovarian carcinoma
Early signs of ovarian
cancer
Inhibin Granulosa cell tumours F/up
hCG
Dysgerminoma
Choriocarcinoma
Pre-operative, f/up
AFP Endodermal yolk sac
Pre-operative,
f/up
11

12. Risk of Malignancy Index (RMI)
◦ Calculated from menopausal status, pelvic ultrasound features and
CA125 level to triage pelvic masses into low, intermediate and high risk
of malignancy
◦ If at intermediate/high risk of malignancy - proceed with CT
scan or MRI
◦ CT scan - assessment of extrapelvic disease and staging
Other investigation
◦ Chest X-ray
◦ Paracentesis or pleural aspiration for cytological assessment or for
symptom relief
◦ Biopsy - Laparoscopy (omentum is a good site of biopsy) 12

13. RMI = U x M x CA125, where
U = ultrasound result, M = Menopausal status, CA125 level
in IU/ml
The ultrasound result is scored as 1 for each of the following
: multilocular, cysts, solid areas, metastases, ascites and
bilateral lesion
◦ U = 0 (for an ultrasound score of 0)
◦ U = 1 (for an ultrasound score of 1)
◦ U = 3 (for an ultrasounf score of 2-5)
Menopausal status
◦ 1 = pre-menopausal
◦ 3 = post- menopausal (woman who has had no period for > 1 year or a woman
over 50 who has has hysterectomy
Serum CA125 - measure in IU/ml
13

14. Interpretation
RMI > 250
High risk, refer to gynae specialist,
staging CT advised
RMI 25-200 Intermediate risk, MRI recommended
RMI < 25 Low risk, repeat assessment
14

15. Transvaginal Ultrasound
Right multilocular solid mass, measuring 10.8 ×10.2 × 12.5 cm

16. C ont..
left ovary (a) and uterus (b). Fluid in the pouch of Douglas
(arrowhead)

17. Color Doppler
Color Doppler :Suspiciousfor borderline tumor with torsion (twisted ovarian
pedicle)

18. IOTA Classification of Ovarian Cyst
IOTA classification of ovarian cyst
M-rule vs B-rule

19. Shewas referred for emergency laparoscopy, and a right salpingo-
oophorectomy was performed. Recovery, hospital discharge and
postoperative follow-up were uneventful. The final histopathology
analysis confirmed torsion of a serous borderline ovarian tumor.
(A) right adnexal torsion
(arrow) with moderate
amounts of bloody fluid in
the pelvis and (B) enlarged
right ovary and distal
fallopian tube.

20. Acute management of cyst accident?
Mx of ovarian tumor
- Benign
- Malignancy

21. FIGO staging for ovarian carcinoma
Stage FIGO definition
Stage 1 Tumour confined to ovaries
1a Limited to one ovary, no external tumour, capsule intact, no ascites
1b Limited to both ovaries, no external tumour, capsule intact, no ascites
1c
Either 1a or 1b, but tumour on surface of ovary or with capsule ruptured or
with ascites positive for tumour cells
Stage 2 Tumour confined to pelvis
2b Extension to other pelvic organs
2c
As 2a or 2b but tumour on surface of ovary or with capsule ruptured or with
ascited positive for tumour cells
2a Extension and/or metastases to uterus or tube
21

22. Stage 3 Tumour confined to abdominal peritoneum or positive retroperitoneal or
inguinal lymph nodes
3a
Tumour grossly limited to pelvis with negative nodes, but histologically
confirmed microscopic peritoneal implants
3b Abdominal implants <2cm in diameter
3c
Abdominal implants >2cm in diameter or positive retroperitoneal or
inguinal lymph nodes
Stage 4 Distant metastases. Must have positive cytology on plueral effusion, liver
parenchyma
22

23. Surgery
◦ Aim : To stage accurately the disease and remove all visible tumour
◦ Surgery + platinum based chemotherapy ; advance ovarian Ca
◦ Ascites or peritoneal washing are sampled
◦ Total abdominal hysterectomy
◦ Bilateral salpingo-oophorectomy
◦ Omentectomy
◦ Further debulking - bowel resection, peritoneal stripping or
splenectomy
◦ Lymph node resection
23

24. If fertility is an issue especially in young patients with
early stage of epithelial ovarian cancer :
◦ Unilateral salpingo-oophorectomy, omentectomy, peritoneal
biopsies and pelvic/para-aortic node dissection with
endometrial sampling
If patient unfit/unwilling to have surgery/complete
debulking unlikely to be achieveable :
◦ Primary chemotherapy may be offerred
◦ If respond to chemotherapy, interval surgery can be carried out
after three cycles
24

25. Chemotherapy
◦ As a primary treatment, adjunct following surgery or for
relapse
◦ 1st line: Platinum compound (eg: carboplatin, cisplatin) with
paclitaxol
◦ Others : Bevacizumab
◦ 3 weeks apart for six cycles
Follow-up
◦ Ultrasound and CA125 measurement
◦ When recurs treatment is largely palliative
◦ If duration of remission > 6 month : carboplatin or other
chemotherapy agent such as taxol, topotecan
25

26. 1. Exfoliation
◦ Malignant cells --> peritoneal cavity --> implants develop anywhere following
normal circulation of peritoneal fluid
◦ Omentum - the most frequent location due to its marked vascularity
2. Lymphatic dissemination
3. Direct extension
4. Haematogenous spread - liver, lung parenchyma, brain, kidney in
patient with recurrent disease
26
PATTERNS OF SPREAD

27. Prognostic factors in ovarian Ca
;
◦ Stage of disease
◦ Volume of residual disease
post surgery
◦ Histological type and grade
of tumour
◦ Age at presentation
Ovarian cancer survival by
stage at diagnosis
FIGO stage 5-year survival (%)
Stage 1 80% to 90%
Stage 2 65% to 70%
Stage 3 30% to 50%
Stage 4 15%
27
PROGNOSIS

28. Anatomy of ovary
Types of ovarian tumor

29. Anatomy of Ovary
Normal size :5x3x3 cm
The broad ligament of the uterus,
which isitself part of the parietal
peritoneum, attaches to the
ovaries by a double-layered fold of
peritoneum called the mesovarium.
The ovarian ligament anchors the
ovaries to the uterus, and the
suspensory ligament attaches them
to the pelvic wall.
Eachovary contains a hilum,the
point of entrance and exit for
blood vesselsand nerves along
which the mesovarium is attached.

30. Blood supply to ovaries
Nerve supply to ovaries
Lympatic drainage from ovaries

31. Epithelial Cell Tumour
Serous
Mucinous
Endometroid
Clear Cell
Transitional Cell
Undifferentiated
Germ Cell Tumour
Dysgerminoma
Yolk sac tumor
(endodermal sinus tumor)
Mature Teratoma
Immature Teratoma
Embryonal C a &C horioC a
Mixed
Sex Cord Stromal
Tumour
Granulosa-stromal cells
Sertoli-stromal cell
WHO Classification of Ovarian Mass

32. SECONDARY TUMOR
32

33. Malignant tumors that metastasize to the ovary - always bilateral
Krukenbery tumour - metastatic mucinous/signet ring cell adenocarcinoma of the
ovaries that typically originates from primary tumours of the intestinal tract,
chracteristically the stomach
Average age of 45 years
P/w abdominal or pelvic pain, abdominal bloating, irregular bleeding and
dyspareunia
Mx : Treat the primary cancer
33
SECONDARY TUMOR

34. 34

35. THANK YOU