ovarian cysts

1. Functional Cysts
Pathology:
• Follicular
o Granulosa cells
o Follicle fails to rupture and continues to grow
o Most common
• Corpus Luteum
o CL fails to involute and continues to grow
o ± Progesterone
o May be hemorrhagic
• Theca Lutein
o Overstimulation by β-HCG
o Large, bilateral, multicystic
o Moles, choriocarcinoma, multiples, GnRH analog
• Corpus Luteum of Pregnancy
o Normal CL of pregnancy enlarges
o Usually resolve after delivery
• Luteoma
o Virilization of mom
o Ambiguous genitalia in female fetus
o Usually resolve after delivery
Patient: Incidental on exam or ultrasound, pain
Inflammatory Tubo-Ovarian Abscess
Path: PID, scarring, pus → abscess
Patient: Fever, discharge, leukocytosis,
cervical motion tenderness, history of STDs
PCOS
Path: many ovarian cysts
Patient: hirsuit, irregular periods,
insulin resistance, infertility
Endometrioma
Path: ectopic endometrium; uni- or
multi-locular chocolate cyst
Patient: pelvic pain, dyspareunia, dysmenorrhea,
dyschezia, dysuria
EMERGENCIES
Rupture
Patient: Severe abdominal pain,
typically mid cycle, after
intercourse, hemoperitoneum
Treatment:
Stable – pain management
Unstable – surgery
Torsion
Patient: Sudden severe pain,
nausea and vomiting
U/S: Decreased blood flow
Treatment: Emergent surgery
Ectopic Pregnancy
Path: Implantation of pregnancy
outside uterus
Patient: missed period, + β-HCG,
pain, bleeding
Treatment: Surgery
Key Questions:
Fever (Abscess)
Nausea / vomiting (Torsion)
Vaginal discharge (STI, PID)
Constitutional (cancer)
History of infertility
Abnormal uterine bleeding (↑ E)
Virilization, hirsuitism (↑ T)
Thyroid issues (Struma Ovarii)
Family history of cancer
(BRCA/Lynch)
Tests:
β-HCG
Abdominal exam
Pelvic and rectovaginal exam
CBC
U/S – Abd & TV
Ca-125 in postmenopausal;
premenopausal if suspicious

2. Neoplasm
Pathology
• Surface Epithelial cells
o Serous (ciliated columnar serous cells of Fallopian tube)
▪ More common, bilateral, psamoma bodies
▪ Serous cystadenoma
▪ Serous papillary cystadenoma
▪ Serous cystadenocarcinoma
o Mucinous (endocervical glands)
▪ Larger, less common, unilateral
▪ Mucinous Cystadenoma
▪ Mucinous Cystadenocarcinoma
▪ Pseudomyxoma peritonei
o Endometroid tumors (Endometrium)
▪ Clear cell
▪ Cystadenofibroma
▪ Brenner – coffee bean nuclei
• Germ cell
o Teratoma (3 layers) – Mature or Immature
▪ Calcifications, complex mass on U/S
o Monodermal – struma ovarii (Thyroid)
• Sex cord cell tumors
o Sertoli – Leydig – produces Testosterone
o Granulosa – Theca – produces Estrogen
• Metastatic – from stomach, colorectal, breast
Pathology: Papillary cystadenocarcinoma
Patient: GI, dyspepsia, early satiety, anorexia, constipation, bloating, ascites, groin adenopathy, nodularity of the posterior cul-de-sac
U/S: complex adnexal mass, unilateral or bilateral, ascites
Jacobs et al. 1990. A risk of malignancy index incorporating CA 125, ultrasound and menopausal status for the accurate preoperative diagnosis of ovarian cancer. Br J Obstet Gynaecol. 1990
Oct;97(10):922-9.
www.Uptodate.com: differential diagnosis of adnexal mass; approach to patient with adnexal mass; Overview of sex cord-stromal tumors of the ovary; Epithelial carcinoma of the ovary, fallopian tube, and
peritoneum: Clinical features and diagnosis; Ovarian germ cell tumors: Pathology, clinical manifestations, and diagnosis
Image 1 http://www.scs.sk.ca/bjm/library/subjects/Science%2090%20Course/Unit%203%20Reproduction%20and%20Development/Ovary%20Diagram.jpg
Image 2 http://cdn.empowher.com/sites/default/files/herarticle/Screen%20Shot%202014-12-09%20at%202.10.00%20PM.png
http://d3jonline.tripod.com/24-Reproduction/Tumors_of_the_Ovary.htm http://www.slideshare.net/addisuga/ovarian-tumors-eyasu-pptx-ii-42415797
http://www.slideshare.net/salahroshdy/benign-ovarian-tumors http://www.slideshare.net/sravanthi_1786/benign-ovarian-tumours
http://www.radiologyassistant.nl/en/p4d85aa9a92bbb/diagnostic-work-up-of-ovarian-cysts.html
Risk of Malignancy Index
= Menopausal Status * Ultrasound * Ca-125
Criteria Categories Score
Menopausal Status Premenopausal 1
Postmenopausal 2
Ultrasound features:
multiloculated, solid areas,
bilaterality, ascites
0 features 0
1 feature 1
2+ features 3
Ca-125 - Value
RMI >200 = Sensitivity 85%; Specificity 97%