Ovarian Tumors Guide for Medical Students

Ovarian tumors
For 4th Year Med. Students
Associate Clinical Professor Dr Aisha EL-Bareg, MD, PhD
Senior Consultant in (Obs & Gyn /Reproductive Medicine)
Faculty of Medicine, Misurata University, LIBYA
1Dr Aisha Elbareg31/08/201705:12‫م‬

Normal ovaries
 Dimensions (size) : 5 x 3 x 3cm
 Variation in dimensions can result from
 Endogenous hormonal production(varies with
age and menstrual cycle)
 Exogenous substances, including OCs, GnRH-
agonists, or ovulation-inducing medication,
may affect size

31/08/201705:12‫م‬ 4Dr Aisha Elbareg
A. Non-neoplastic
B. Neoplastic

A. Non-neoplastic lesions
1. Functional ovarian cysts
 Follicular cysts
 Corpus lutein cysts
 Theca lutein cysts
 Most common ovarian lesions in the
reproductive years
 All are benign and usually asymptomatic.
2. Endometriomas

Follicular cysts
 Cystic follicle of diameter >3 cm but rarely > 8 cm
 Most common functional cysts
 Lined by granulosa cells
 Found incidentally on pelvic exam
 Usually resolve within 4-8 weeks with expectant
management
 May rupture or torse causing pain and peritoneal
symptoms.

Follicular cyst

Corpus luteal cyst
 Less common than follicular cysts
 May rupture leading to hemiperitoneum
requiring surgical management
 Unruptured cysts may cause pain because of
bleeding into enclosed ovarian cavity.

Corpus luteal cyst

Theca lutein cysts
 Less common, Usually bilateral
 Results from over stimulation of the ovary by beta-
hCG.
 Do not commonly occur in normal pregnancy.
 Often associated with hydatidiform moles,
choriocarcinoma, multiple gestations, use of
ovulation induction medications.
 May be quite large (up to 30 cm), multicystic, and
regress spontaneously

Theca lutein cysts

Management of functional cysts
 Expectant, waiting for 2-3 cycles is appropriate.
 Combined oral contraceptives appear to be of no
benefit.
 Should cyst persist, surgical management is often
indicated (ovarian cystectomy).

Endometriomas
 They are pseudocysts formed by invagination
of the ovarian cortex, sealed off by adhesions
 They may completely replace normal ovarian
tissue. Cyst walls are usually thick and fibrotic
 Malignant transformation: 0.3% to 0.8 %
 Management: medical and/or surgical.

Endometriomas

B. Neoplastic ovarian lesions
 Primary ovarian tumor
 Nature
Benign
Border-line
Malignant
 Secondary ovarian tumor
Origin
•Epithelial
•Sex-cord-stromal
•Germ cell

1. Epithelial tumors (benign, borderline, malignant)
Serous tumour
Mucinous tumours
Endometroid tumour
Clear cell (Mesonephroid) tumour
Brenner’s tumour
Mixed tumour
Primary ovarian tumors

1. Epithelial ovarian tumors
Serous: 10% bilateral,
70% benign,
5-10% borderline,
20-25 malignant
Mucinous: huge size,
multilocular,
85% benign
Brenner : solid, benign

 Occur most commonly in late reproductive-early
menopausal life
 Simple serous cystademona
 Unilocular, thin-walled cyst with serous
 Bilateral 10%, turn to malignancy10%
 Papillary serous cystadenoma
 Unilocular or multilocular thin walled cyst
 Has intracystic or external papillae
 Contains serous fluid with blood
 Bilateral in 30-50%, malignant 30-50%
Serous tumor

Papillary serous cystadenoma

 The malignant form called
serous cystadenocarcinoma
serous papilliferous carcinoma
 Commonest primary ovarian carcinoma
 Bilateral in 50% of cases
 Exophytic papillary growth on the surface
Serous tumor

 Benign and border line tumors- it turns
malignant in 10%, bilateral in 10%
 Malignant- serous cystadenocarcinoma
 Have tendency to become huge mass
 Multilocular cysts containing mucin
 Clinical picture- Myoma peritonii
“Rupture of the cyst, leads to implantation of
the tumor cells on the peritoneum which
produces mucin leading intestinal obst.”.
Mucinous tumor

Mucinous cyst

 Rare: 2-3% of ovarian tumor.
 Usually benign, turns to malignancy in 5%
 Small, solid with smooth surface (like fibroma),
rarely bilateral
 Clinical pictures
 Can cause pressure on E producing cells in the
ovary leading to E production and abnormal uterine
bleeding
Brunner tumor

Brunner tumor

Epithelial tumor
4. other rare tumors
 Clear cell tumor (mesonephroid tumor)
 Endometriod tumor (associated with
endometrial adeno-carcinoma)

Primary ovarian tumor
2. Germ cell tumor
Benign:
• Mature cystic teratoma
• Mature solid teratoma
Malignant (3% of ovarian Ca)
• Immature solid teratoma
• Dysgerminoma
• Yolk sac tumour
• Non-gestational
Choriocarcinoma 2631/08/201705:12‫م‬

2. Germ cell tumor
 Common in children and young females
 < 20 yrs, 80% of ovarian malignancies
Benign cystic teratoma (dermoid cyst)
 10 -15% of all ovarian tumors- young age
 bilateral in 15-25%
 Turns to malignant in 1-3%

 Gross appearance:
 Moderate in size: 10-15cm
 Thick, opaque, whitish, smooth surface
 Cut section
 cystic, unilocular, containing:
 Sebaceous material with offensive odor
 Rokitansky nodule showing- hair, bone, teeth
 Microscopic appearance-
 a mix of the 3 germ layers

Dermoid cyst

 Clinical picture:
 Mass found anterior to the uterus because
of the long pedicle
 A symptomatic but risk of torsion is 15%
Or rupture causing peritonitis
 Struma ovarii- teratoma containing thyroid
tissue that produce T4

2. Germ cell tumor
Dysgerminoma
 Rare, occurring usually in young ages.
 May occur in dysgenetic gonads.
 Gross appearance- unilateral, solid,
rapidly growing, with areas of hemorrhage
and necrosis.
 Low grade malignant tumour, spread only
by lymphatics.
 It is radiosensitive.

3. Choriocarcinoma
 Gestaional choriocarcinoma
 Non-gestational choriocarcinoma
 Tumor marker- HCG
4. Endodermal sinus tumor (yolk sac tumor)
 Highly malignant- radioresistent, need
strong combination of chemotherapy
 Causes acute abdomen- rupture, hage
 Tumor marker- AFP
2. Germ cell tumor

1. Granulosa cell tumour
2. Androblastoma
3. Gynadroblastoma
4. Thecoma
5. Fibroma
Sex-cord stromal tumor

Sex cord-stromal tumor
 Rare tumor
 Gross appearance- solid, yellowish with
smooth surface
 Usually unilateral
 low grade-malignant tumour
 Microscopic picture: granulosa cells with
coffee bean nucleus

 Clinical features
 The tumour produces E which causes
Precocious puberty
Irregular bleeding
Post menopausal bleeding
Endometrial hyperplasia and carcinoma

 5% of benign ovarian tumor
 Most common solid tumor
 Bilateral in 5% of cases
 It is benign, turns to fibrosarcoma in 0.5%
 Gross appearance:
 Lobulated, has long pedicle causing torsion
 cut sections shows: solid, whitish and
trabeculated
2. Fibroma

2. Fibroma
 Microscopic: fibrous tissue (spindle-shaped
cells)
 Clinical features
 Meig’s syndrome occurs in 1%. Consists of
fibroma, ascites, right hydrothorax.

3. Thecoma
 Solid fibromatous lesions, yellow or orange
discoloration
 Almost always confined to one ovary
 Usually > 40 years, 65% after menopause
 May be hormonally active: estrogen, androgen
 Lutinized thecoma: younger, sclerosing peritonitis
and ascitis
 Leydeig cell thecoma.
 Rarely malignant

 Rare tumour
 Gross appearance- it is usually small, solid,
yellow and unilateral
 microscopic features- sertoli-leyding cells
 Clinical features:
 production of androgen leads to
Defiminisation
Masculinisation
4. Androblastoma
Sertoli leydig cell tumour

Complication of ovarian tumors
 Torsion (axial rotation)
 Hemorrhage
 Rupture
 Infection
 incarceration
 Malignant changes
 Intestinal obstruction (commonest cause
of death)

Benign ovarian tumours
 Symptoms
 Asymptomatic, discovered accidentally
 Abdominal swelling- slowly growing
 Pelvic pressure as frequency of micuration
 Pain- in complicated tumour
 Menstrual abnormalities- if the tumour is
functioning (producing hormones)
 Progressive wasting- in case of huge mucinous
tumour

 Signs
 May be cachexia
 Abdominal examination
Pelvi-abdominal mass
Surface- smooth or lobulated if multilocular
Mobility- usually mobile
Consistency- usually cystic
Percussion- dull, fluid filling, ascitis

 Vaginal examination
 Mass felt on bimanual examination
 The mass felt separate from the uterus
 DD: 6 Fs
 fetus, fat, flatus, fluid, full bladder, fibroid

 USS, CT scan, and MRI
 Laparoscopy
 Boipsy and frozen section at exploratory
laparotomy
 Preoperative investigation- CBC, LFT, BS,
RFT, ECG..etc.
Investigation

Treatment
 Ovarian Cystectomy- young patient
 Oophorectomy- ovarian tissue is damaged or
torsion
 TAH+ BSO if associated with uterine pathology

Malignant ovarian tumour
(ovarian cancer)
 Common at extremes of age
 Risk factors
 Nullipara or late childbirth, Late menopause
 Past history of breast cancer
 Family history of ovarian ca. or breast ca.
 Hereditary breast & ovarian ca- HBOC. Presence of
BRCA 1&2
 Hereditary Nonpolyposis Colorectal Cancer
(HNPCC).
 Presence of a Y chromosomes-
Dysgerminoma
46

 Protection against ovarian ca.
 High parity
 Lactation
 OCP
 because of inhibition of ovulation

 Gross appearance
 Bilateral- due to multifocal growth or
metastasis from the other ovary
 Solid areas in a cystic tumour
 Fungation through the capsule or short thick
papillae
 Areas of hemorrhage and necrosis

 spread
 Direct- tubes, uterus, bladder, intestine,
appendix, omentum
 Lymphatic spread
Para-aortic LN
To the other ovary by transfundal
lymphatics
 Blood spread- lungs, bones and brain
 Trans-luminal- to the peritoneium, liver and
diaphragm

 Early detection (screening)
 After menopause
 Bimanual examination - TVS - Color
doppler ultrasound
 Tumour markers-

Tumor markers
 Epithelial tumor
- CA125,
- OCAA (ovarian cancer associated Ag)
 Mucinous tumor
- CA19-9
- CEA (carcinoembryonic Ag)
 Yolk sac tumor
- alpha fetoprotein (AFP)
31/08/201705:12‫م‬ 51Dr Aisha Elbareg

 Diagnosis
 Symptoms
Presents in extreme of ages
Rapidly growing tumour
Pain and vague GIT symptoms
Postmenopausal bleeding

 Signs
Solid tumour or solid areas in a cystic tumour
Fixed tender tumour due to adhesions
Ascitis
Nodules in Douglas pouch or lung
metastasis
Unilateral lower limb edema or varicose
veins

 Signs at laparotomy
 Bilateral tumour
 Solid tumour or solid in a cystic tumour
 Fixed tumour, fungation through the
capsule
 Areas of hemorrhage, necrosis in the
tumour
 Blood stained ascitis containing malignant
cells

FIGO surgical staging
 Stage I confined to the ovary
 Ia: tumour confined to one ovary
 Ib: tumour is confined to both ovaries- no
ascitis
 Ic: Ia or Ib + ascitis containing malignant cells

 Stage II spread into the pelvis
 IIa: spread to the tube and/or the uterus
 IIb: spread to the other pelvic organs
 IIc: IIa or IIb + with ascitis containing
malignant cells
 Stage III intraperitoneal metastasis outside
the pelvis
 Stage IV distant metastasis
FIGO surgical staging

Investigation
 To confirm diagnosis- frozen section
 To detect spread
 Barium meal & enema, IVP
 Cystoscopy, proctoscopy
 CT scan, MRI
 Chest x-ray, liver, bone, brain scanning
 To assess general condition

Management
surgery
1. Exploration
2. Stage I
 TAH+BSO
 Omentectomy
 Appendicectomy
 Unilateral oophorectomy- young patient

Treatment
 Stage II & III
1. surgery
 One of the following
 TAH + BSO +Omentectomy+Appendicectomy
 Debulking- residual tumour <2cm
2. Postoperative chemotherapy
3. Postoperative radiotherapy
4. 2nd look laparatomy or laparoscopy
5. Palliative treatment

Treatment
 Stage IV
 Chemotherapy & palliative tt
Poor prognosis due to
 Lack of early symptoms, so 75% presents in stage III
 Diagnosis of pre-invasive lesion is difficult except by
biopsy
 The ovary is intraperitoneal thus, early spread to
intestine

Causes of death:
 Intestinal obstruction is the commonest
cause of death if untreated
 Distant metastasis
 Complications as- bleeding, infection, DVT

Ovarian tumour during pregnancy
 Affects 1:1500 pregnancy
 Benign cystic teratoma, simple serous cyst
 Effects of pregnancy on tumor
1. torsion
2. others- rupture, hemorrhage, infection

 Effect of ovarian tumour on pregnancy
 Malpresentation and non-engagement
 Abdominal discomfort in case of large
tumor
 Preterm labour
 Obstructed labour
 Abortion (very rarely)
Ovarian tumour during pregnancy

Treatment during pregnancy
 Complicated or malignant tumors
 Immediate operation at any time
 Uncomplicated benign tumors
 Small cyst (< 6cm)- follow up
 Large tumor
If 1st half of pregnancy: removal after
12 weeks
If 2nd half of pregnancy: removal in
purperium (1st week)

Treatment during pregnancy
 During labour
 If not obstructed
vaginal delivery and removal in peurperium
 If obsturcted
CS and removal of tumor
 During puerperium- immediate removal

Secondary ovarian tumour
 20% of ovarian cancer
 1ry lesion is usually in stomach, colon,
endometrium or breast
 Types
 Typical- resembles the 1ry tumor
 A typical “krukenberg tumor”

2ry tumour
 Krukenberg tumour
 Gross appearance
Bilateral, solid- ovaries are enlarged
with smooth surface and no adhesion
 Microscopic appearance
Signet ring cells- excess mucin
pushing the nucleus in one side

 Spread to the ovary
 Retrograde vascular or lymphatic
starting from the medulla
 Management; careful search for 1ry tumor
clinically or during laparotomy
2ry tumor

Ovarian Tumors Guide for Medical Students

Ovarian Tumors Guide for Medical Students

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