Benign ovarian tumours


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  • If ovulation does not occur, a clear fluid filled follicular cyst lined by granulosa cell may result.
  • Notice the smooth inner lining of this cyst, which is nothing more than a follicle which has gotten large but neither burst nor undergone atresia
  • When ovulation occurs , corpus luteum is formed that may become abnormally enlarged through internal hemorrhage or cyst formationVariable delay in onset of menses and confusion regarding possibility of ectopic pregnancy: acute abdomen
  • Ovary with hemorrhagic corpus luteum cystHemorrhagic corpus luteum with spider web like contentsHemorrhagic cyst with blood clot.Hemorrhagic cyst with unusual appearance simulating a neoplasm.
  • Sonogram from a patient with bilateral theca lutein cysts. The typical multilocular appearance is noted in the left ovary.
  • Ovarian Endometriomas demonstrating hypoechoic cystic structures with low amplitude uniformly distributed echotexture in the cavity of the cyst.
  • 1. Benign epithelial tumors of the ovary can reach massive proportions. The serous cystadenoma seen here fills a surgical pan and dwarfs the 4 cm ruler2.Here is a benign serous cystadenoma that demonstrates multiloculation. Note that the inner surface is, for the most part, smooth, with only a solitary papillation at the upper right.3. Ultrasound imaging4. Histopathological section: With few papillary projections from the surface
  • 1.Cut open section of mucinous cystadenoma..2. Histological section showing tall epithelial lining with pale staining nuclei at the basal pole.3. Variable echogenicity in the contents of an adnexal multilocular cyst
  • The photo below shows a well-developed tooth arising from the right side of the mural nodule ("Rokitansky nodule") that contains most of the solid teratomatous elements. The central portion of the nodule contains mostly cutaneous tissues (skin, sweat glands, and hair follicles), while the neural tissues extend into the wall toward the left.
  • 1. Mature cystic teratoma with typical long hyperechogenic lines and bright prominent spots representing hair in fluid.2. Mature cystic teratoma with Rokitansky nodule or 'dermoid plug'(arrow) with posterior acoustic shadowing.
  • grayish white and firmCut sectionMicroscopically – stellate or spindle shaped cells arranged in fusiform pattern. Hyalinisation is frequent. The elongated fibroblastic tumor cells have spindle-shaped nuclei and may contain small amounts of lipid in their cytoplasm 
  • Benign lesions can be managed by simple excision.t/t of malignant brenner tumours is unsettled, various forms of chemotherapy have been used with little success.Walthard cell rests are a benign cluster of epithelial cells most commonly found in the connective tissue of the Fallopian tubes, but also seen in the mesovarium, mesosalpinx and ovarian hilus. solid, sharply circumscribed and pale yellow-tan in colour. 90% are unilateral (arising in one ovary, the other is unaffected). The tumours can vary in size from less than 1 centimetre (0.39 in) to 30 centimetres (12 in). Borderline and malignant Brenner tumours are possible but each are rare.
  • Hyperplastic fibromatous matrix interspersed with nests of epitheloid cellsOn high magnification, they exhibit characteristic coffee bean nuclei (clearly visible in image). On low magnification, they resemble urothelial cell nests.
  • Contralateral ovary may harbour macroscopically undetectable gonadoblastoma.Associated with dysgerminomas in 50%cases and with malignant germ cell tumours in an additional 10% cases.
  • Using these rules the reported sensitivity was 95%, specificity 91%, positivelikelihood ratio of 10.37 and negative likelihood ratio of 0.06.
  • The morphology index (MI) presently used in the University of Kentucky Ovarian Cancer Screening Trial was published initially by Ueland and colleagues and is illustrated in Figure 49.3. Both morphologic complexity and tumor volume, as calculated by the prolate ellipsoid formula, were related directly to the risk of malignancyMorphologic abnormalities were easy to categorize, and interobserver variation was minimal. Risk of malignancy varied from 0.3% in ovarian tumors with a MI of <5 to 84% in tumors with a MI >=8. Using a MI >=5 as indicative of malignancy, the following statistical parameters were observed: sensitivity 0.981, specificity 0.808, PPV 0.409, and NPV 0.997. Therefore, morphologic indexing is a relatively accurate and cost-effective method to predict risk of malignancy in an ovarian tumor.
  • Wenever possible conservative or minimally invasive surgery is preferred to preserve endocrine and reproductive function.
  • BOTs form a separate entity within the group of ovarian tumours
  • BOTs can be divided according to their epithelialcharacteristics as serous (50%),mucinous (46%),and mixed, endometrioid, clear cell, or Brennertumors (3.9%). Serous BOTs are bilateral in 30%of patients and can be associated with extraovarian lesions (so-called implants) in 35%. Theseimplants can be invasive or noninvasive depending on their microscopic appearance, which willin turn influence therapeutic options. MucinousBOTs are classified as intestinal (85%) or endocervical/Mullerian type (15%) depending on thenature of the epithelial lining. They can be associated with pseudomyxoma peritonei (10%), necessitating a thorough investigation of the GI tract with special attention to the appendix because thiscan be the primary tumor origin.Presenting symptoms of borderline ovarian tumorsBorderline tumors, as with other ovarian tumors, are difficult to detect clinically until they are advanced in size or stage. In one study, the most common presenting symptoms were abdominal pain, increasing girth or abdominal distention, and abdominal mass. Approximately 23% of patients were asymptomatic.
  • Without comprehensive surgical staging, the prognosis for an individual patient is difficult to predict.Many clinicians group stages II-IV together for prognostic consideration.Important component is description of the type of implants, as these have significant prognostic value.Preoperatively, borderline tumors are often presumed to be either benign or malignant ovarian masses; however, as with other ovarian masses, staging is performed surgically. Many sources recommend complete staging if a borderline tumor is found. Current guidelines include biopsy specimens of the pelvic peritoneum (cul-de-sac, pelvic wall, and bladder peritoneum), abdominal peritoneum (paracolic gutters and diaphragmatic surfaces), omentum, intestinal serosa and mesentery, and retroperitoneal lymph nodes (pelvic and para-aortic).
  • Borderline tumors are correctly diagnosed 58-86% of the time by frozen section, depending on the experience of the pathologist and the site of the operation (e.g. tertiary care vs community hospital).
  • Postoperative treatment for any stage is controversial; therefore, recommending reoperation for surgical staging alone is difficult.[3, 2] This being said, adequate staging is essential for determining the prognosis.
  • Patients with stage I disease confirmed by comprehensive staging have a recurrence rate of approximately 15%. The 5-year survival rate for such patients approaches 100%. However, the 10-year survival rate is 90-95%, depending on histologic findings.In patients with stage II-IV disease, the prognosis is different; an increased stage is associated with a worse prognosis and only age at diagnosis and the presence of invasive implants are shown to influence prognosis.In reported series, women who had serous tumors with noninvasive peritoneal implants demonstrated a mean 20% recurrence rate and a mean 7% death rate. In patients with recurrence, a median time to diagnosis of 3.1 years was reported if the recurrence was of the borderline type. In patients whose recurrence was invasive carcinoma, the median time to diagnosis was 8.3 years. It is believed that the former was a recurrence but that the latter was probably a new primary tumor. The cancer antigen 125 (CA-125) level was normal in 65% of the recurring cases (see the section Biomarkers and DNA Cytometry). Death was noted only when invasive carcinoma was noted in the recurrence.In patients with serous borderline tumors with invasive implants, the relapse rate was 31-45%, according to a study by Gershenson et al.[4] The median time from diagnosis to recurrence was 24 months, although the time to progression of disease was significantly longer in patients who had no macroscopic disease remaining at the time of initial operation.[4] Additionally, patients who received postoperative platinum-based chemotherapy had a significantly worse progression-free survival rate. However, the authors of this study believed that this finding might have been due to selection bias.Gershenson and colleagues' research indicated that the following factors had no effect on progression-free survival:AgeStageType of surgeryPostoperative treatmentCoexistence with noninvasive implantsNumber of invasive implantsNo statistically significant differences are found in survival between mucinous and serous tumors. Mucinous tumors are most often stage I at time of diagnosis, and it is quite unusual to find extraovarian disease in tumors of mucinous origin.
  • Preoperative transvaginal color Doppler ultrasonography has been used to assess the possibility of malignancy in ovarian masses. The rate of detection of intratumoral blood flow in borderline tumors (90%) is similar to that of malignant neoplasms (92%). The resistance and pulsatility indexes are also significantly reduced in carcinoma and borderline ovarian tumors compared with those of benign tumors.Although ultrasonography is useful in identifying the mass, this medium is not currently able to predict the final pathology of the tumor. It is neither sensitive nor specific enough to be used as a screening tool in the normal populations.
  • Computed tomography (CT) scanning should be considered preoperatively to identify possible foci of metastasis. CT scanning can also be useful when following the patient in the future. Again, as with ultrasonography, there are no distinguishing characteristics that clearly identify a borderline ovarian tumor.
  • CA-125 levels are not shown to aid in the diagnosis or follow-up care of patients with borderline tumors. However, preoperatively, it can be useful in counseling the patient as to what to expect in the operating room.At present there is little evidence to supportanalysis of serum tumor markers in routine follow-up of patients with borderline ovarian tumors
  • Surgical removal of BOTs is the cornerstone inthe management of BOTs, but a lot of debate existson the extent of the staging procedure and the surgical approach. Lately, the use of laparoscopy andconservative surgery, which is defined as surgerywith complete staging but withpreservation of theuterus and at least part of one ovary (Fig 1), is gaining popularity. However, the question arises aboutwhether this management is appropriate or whetherwe should be more cautious.
  • The accepted initial treatment of borderline ovarian tumors is surgical removal of the tumor and the performance of biopsies. However, the postoperative management protocol is far from clear. To date, no medical therapy has been shown to clearly improve outcomes.No consensus has been reached concerning treatment of patients with stage II-IV disease. Although these women still have high 5-year survival rates compared with their counterparts with true malignant ovarian cancer, an increased stage is associated with a worse prognosis. However, stage (II vs III vs IV), type of surgery, postoperative treatment, postoperative platinum-based chemotherapy, and even the number of noninvasive implants have no effect on progression-free survival. Only age at diagnosis and the presence of invasive implants are shown to influence prognosis.
  • Given the excellent prognosis for borderline ovarian tumors, hysterectomy and contralateral oophorectomy are not necessary (if the ovary appears normal) if the patient wishes to preserve fertility. If the patient is beyond childbearing age, then hysterectomy is a reasonable option. Removal of a normal, contralateral ovary should be based on existing data regarding ovarian physiology.[3]When a complex ovarian mass is discovered, surgery is often, if not always, indicated. Complete excision of the disease must be achieved if at all possible. Comprehensive staging should be a part of every operation. Although stage may or may not affect future treatment, it is of significant prognostic value and therefore is of value to the clinician and to the patient.In one study, 77% of patients with invasive peritoneal implants also had noninvasive implants. Comprehensive debulking and staging decreases the chance of a sampling error that could result in an inaccurate diagnosis and prognosis.In most instances, surgery is curative for patients with confirmed stage I disease. If the tumor is unilateral and adjacent to normal tissue, unilateral cystectomy can be performed; however, inspection of the capsule for signs of rupture should be performed before resection. If no normal adjacent tissue is present, oophorectomy or salpingo-oophorectomy should be performed. If the contralateral ovary is normal in appearance, a biopsy should not be performed on the adjacent ovary because of the risk of ovarian failure (if fertility is an issue).Owing to the high association between surface proliferations and peritoneal implants, exploration of the peritoneum should be extensive and thorough. If possible, carefully evaluate and remove the implants. The type of implant (ie, invasive, noninvasive) should be noted by pathology, as it has significant prognostic value.Contraindications to surgery include medical reasons (ie, the patient is too great a surgical risk secondary to other medical problems) or patient refusal. Otherwise, the masses should be surgically removed.
  • Various chemotherapy regimens have been used, but evidence is insufficient to determine exactly which therapy is indicated for borderline ovarian tumors. Many authors have used platinum-based agents, but with varying results. Some authors recommend platinum-based therapy for patients with invasive peritoneal implants because of their worse prognosis. Standard chemotherapy regimens for invasive ovarian cancer are used if any medical therapy is given. In patients without metastatic disease, chemotherapy is not indicated.An important area of research is postoperative chemotherapy. Little advantage has been reported after postoperative chemotherapy, but the number of patients studied has been small and the chemotherapeutic regimens used have been varied. The general consensus is that borderline tumors with noninvasive implants do not require any further therapy and should be observed. However, the benefit of treating tumors with invasive implants has been discussed. To date, no randomized data show a benefit.
  • Benign ovarian tumours

    2. 2. NORMAL OVARIES Normal 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
    3. 3. Lifetime Risk of ovarian neoplasm A woman has 5–10% lifetime risk of undergoing surgery for a suspected ovarian neoplasm and 13–21% of these will be found to be have an ovarian malignancy
    4. 4. DIFFERENTIAL DIAGNOSIS OF ADNEXAL MASS ORGAN CYSTIC SOLIDOVARY Functional cyst, Neoplastic cyst, Neoplasm Benign, Malignant, Endometriosis Benign MalignantFALLOPIAN Tubo-ovarian abscess Tubo-ovarian abscessTUBES Hydrosalpinx Ectopic pregnancy Paraovarian cyst NeoplasmUTERUS Intrauterine pregnancy in a bicornuate Pedunculated or uterus inteligamentous myomaBOWEL Sigmoid or caecum distended with gas Diverticulitis, Ileitis, or feces Appendicitis, Colonic cancerMISCELLANEOUS Distended bladder, Pelvic kidney, Abdominal wall hematoma or Urachal cyst abscess, retroperitoneal
    5. 5.  Differential diagnosis of the adnexal masses varies considerably with the age of the patients. In pre-menarchal girls and post-menopausal women adnexal mass should be considered highly abnormal – requires immediate investigation. In menstruating patients differential diagnosis is varied.
    6. 6. DIAGNOSTIC EVALUATION OF THE PATIENT WITH ANADNEXAL MASS Complete physical examination Pelvic ultrasound examination Computed tomography scan with contrast enhancement or intravenous pyelography Colonoscopy or barium enema study, if symptomatic Laparoscopy, laparotomy
    8. 8. COMMON OVARIAN TUMOURS Infancy Pre pubertal Adolescent Reproductive Peri Post Menopausal Menopausal1 Functional Functional Functional Functional Epithelial Neoplastic cyst cyst cyst cyst ovarian ovarian tumor tumor2. Germ cell Germ cell Germ cell Dermoid Functional Functional tumor tumor tumor cyst cyst3. Epithelial Epithelial Mets tumor tumor
    9. 9. Functional ovarian cysts Follicular cysts Corpus luteum cysts Theca lutein cysts Luteomas of pregnancy By far the most common clinically detectable enlargements of the ovary in the reproductive years. All are benign and usually asymptomatic.
    10. 10. Follicular cysts Cystic follicle is defined as Follicular cyst of diameter > 3cm Most common functional cysts. Rarely larger than 8cm. Lined by granulosa cells Found incidentally on pelvic examination Usually resolve within 4 – 8 weeks with expectant management May rupture or torse occasionally causing pain and peritoneal symptoms.
    11. 11. Follicular cysts
    12. 12. Corpus luteal cyst Less common than follicular cyst. May rupture leading to hemoperitoneum and requiring surgical management( more in patients taking anti coagulants or with bleeding diathesis) Unruptured cysts may cause pain because of bleeding into enclosed ovarian cyst cavity.
    13. 13. Corpus luteal cyst
    14. 14. Theca lutein cysts Least common Usually bilateral Result from overstimulation of the ovary by β- hCG Do not commonly occur in normal pregnancy Often associated with hydatidiform moles, choriocarcinoma, multiple gestations, use of clomiphene and GnRH analogues. May be quite large (up to 30 cm) , multicystic, and regress spontaneously.
    15. 15. Theca lutein cysts
    16. 16. Management of functional cysts Expectant Watchful waiting for two or three cycles is appropriate. Combined oral contraceptives appear to be of no benefit. Should cysts persist, surgical management is often indicated. Oral contraceptives for functional ovarian cysts (Review) Cochrane Database of Systematic Reviews 2011
    17. 17. Endometriomas Most common site of involvement is the ovary. Endometriomas 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. USG: anechoic cysts to cysts with diffuse low-level echoes to solid- appearing masses. Fluid–fluid or debris–fluid levels may also be seen. They may be unilocular or multilocular with thin or thick septations Malignant transformation: 0.3% to 0.8% Management: medical and/ or surgical
    18. 18. Benign ovarian tumors Serous cystadenoma Mucinous cystadenoma Dermoid cyst Fibroma Thecoma Brenner‟s tumor
    19. 19. SEROUS CYSTADENOMA Generally benign Bilateral – 10% Risk of malignancy : 5 – 10 % borderline malignant 20 -25% malignant GROSS : multilocular with papillary components. MICRO : low columnar epithelium with cilia. Characteristic psammoma bodies (end products of degeneration of papillary implants)are found. Associated fibrosis may lead to “cystadenofibroma”
    20. 20. MUCINOUS CYSTADENOMA Have tendency to become huge masses Round to ovoid masses with smooth capsules that are usually translucent or bluish to whitish gray. Interior divided by discrete septa into loculi containing clear , viscid fluid. Epithelium – tall, pale staining, secretary with basal nuclei and goblet cells 5 – 10% are malignant
    21. 21. DERMOID CYST Often bilateral (15 -25%) GROSS: thick, opaque , whitish wall. CONTENTS: hair, bone, cartilage, and a large amount of greasy sebaceous material. MICROSCOPICALLY : all the three germ layers (ectoderm, mesoderm and endoderm) Malignant change occurs in 1-3%. Usually of a squamous type. Risk of torsion is 15% An ovarian cystectomy is almost always possible, even if it appears that only a small amount of ovarian tissue remains
    22. 22. FIBROMA Most common benign, solid neoplasms of the ovary. Compose approx 5% of benign ovarian neoplasms and 20% of all solid tumors of the ovary. Frequently seen in middle-aged women. Characterized by their firmness and resemblance to myomas Misdiagnosed as exophytic fibroids or primary ovarian malignancy Not hormonally active Fibromas may be associated with ascites or hydrothorax as a result of increased capillary permeability thought to be a result of VEGF Mieg’s syndrome (ovarian fibromas, ascites and hydrothorax) is uncommon and usually resolves after surgical excision.
    23. 23. THECOMA Solid fibromatous lesions that show varying degrees of yellow or orange discoloration Almost always confined to one ovary Usually >40 years, 65% after menopause May be hormonally active and hence associated with estrogenic or occasionally androgenic effects. Luetinised thecoma – younger, sclerosing peritonitis and ascites Leydeig cell thecoma – ass. with Reinke crystals Rarely malignant
    24. 24. BRENNER TUMOR Uncommon tumor grossly identical to fibroma Arise from Walthard cell rests ,also from surface epithelium, rete ovarii and ovarian stroma On microscopy – markedly hyperplastic fibromatous matrix interspersed with nests of epitheloid cells showing coffee bean pattern Considered uniformly benign. But scattered reports of malignant Brenner‟s available Endocrinologically inert, but could be ass. with virilization and endometrial hyperplasia
    25. 25. GONADOBLASTOMAS Gonadoblastoma is a rare benign tumor that has the potential for malignant transformation and affects a subset of patients with an intersex disorder or disorder of sex development (DSD). Contain both germ cells and sex cord stromal cells. Arise in patients with dysgenetic gonads - 46 XY f/b 45XO/ 46 XY mosaic. Presents usually as phenotypic female <30 years with primary amenorrhea and virilization. Treatment – laparoscopy or laparotomy with removal of b/l dysgenetic gonads. Further treatment depends on malignant germ cell component
    26. 26. CLINICAL PRESENTATION Asymptomatic – accidentally discovered on USG Chronic pattern of pain, increasing abdominal girth over months or weeks. Associated with secondary symptoms of anorexia, nausea, vomiting, urinary frequency. Could be associated with primary or secondary amenorrhea, menstrual irregularities, virilization, precocious puberty Become acutely symptomatic if undergoes torsion, rupture or haemorrhage.Benign ovarian neoplasms are indistinguishable clinically from malignant counterparts
    27. 27. COMPLICATIONS Torsion Intracystic hemorrhage Infection Rupture Pseudomyxoma peritonei Malignancy
    28. 28. PHYSICAL EXAMINATION Abdominal and vaginal examination and the presence or absence of local lymphadenopathy Assess  Laterality  Cystic Vs solid  Mobile Vs fixed  Smooth Vs irregular  Ascites  Cul-de-sac nodules  Rapid growth rate
    29. 29. TVS Pattern recognition is superior to all other scores. Subjective evaluation of ovarian masses based on pattern recognition can achieve sensitivity of 88% to 100% and specificity of 62% to 96%. Adding doppler does not seem to yield much improvement in the diagnostic precision, but increases the confidence with which a correct diagnosis of benignity or malignancy is made.
    30. 30. Simple ultrasound-based rules for the diagnosis of ovarian cancer. Ultrasound Obstet Gynecol2008 RCOG 2011
    31. 31. DOPPLER EVALUATION Hypoxic tissue in tumors recruit low-resistance, high-flow blood vessels Role in evaluating ovarian mass is controversial – as the ranges of values of RI,PI,MSV between benign and malignant masses overlap. PI<1, RI<0.4 To overcome this, vascular sampling of suspicious areas (papillary projections, solid areas, thick septations) using both 3D USG and power doppler both has been evaluated and found effective. “Chaotic” vascular pattern in malignancy
    32. 32. OTHER IMAGING MODALITIES CT, MRI, PET not recommended in the initial evaluation CT scan: evaluating  LN involvement,  Omental mets, peritoneal deposits, hepatic mets,  obstructive uropathy  or a probable alternate primary site when cancer is suspected based upon TVS MRI : differentiating non adnexal pelvic masses (like leiomyomata), expensive and inconvenient.  ACOG GUIDELINES 2007
    33. 33. CA125 SENSITIVITY SPECIFICITY PPV NPV 61-90% 71-93% 35-91% 67-90%Most useful when non-mucinous epithelial cancers are presentElevated in 80% of patients with epithelial ovarian Ca but only in 50% of patientswith stage I diseaseIncreased sensitivity in post menopausal women esp. when associated withrelevant clinical and USG findingsCut-off of 30 u/ml, sensitivity of 81% and specificity of 75%
    34. 34. HE4 HE4 is a precursor to the epididymal secretory protein E4 and in normal ovarian tissue, there is minimal gene expression and production of HE4. As a single tumor marker, HE4 had the highest sensitivity for detecting ovarian cancer, especially Stage I disease. Combined CA125 and HE4 is a more accurate predictor of malignancy than either alone or to any other dual combination of markers HE4 levels(>70 pM) were found to be elevated in over half of the patients with ovarian cancer with normal serum CA125 levels (>35 U/ml) HE4 when studied in the premenopausal group of patients was able to discriminate benign tumors from malignancies Moore et al. / Gynecologic Oncology, 2008
    35. 35. NEW SCORES ROMA: Risk of Ovarian Malignancy AlgorithmThe dual marker algorithm utilizing HE4 and CA125 to calculate a ROMA valueIn patients with stage I and II disease, ROMA achieved a sensitivity of 85.3%compared with 64.7% for RMI MOORE ET AL, AJOG 2010 OVA 1:FDA approved. Combination of 5 immunoassaysCA 125, transthyrettin, apo lipoprotein A1, transferrin, B2 microglobulinSensitivity : 93%, specificity: 43% PPV 42% NPV 93% COMMUN ONCOL, 2010
    36. 36. INDICATIONS FOR SURGERY Any solid ovarian lesion Any ovarian lesion with papillary vegetation on the cyst wall Any adnexal mass >10cm in diameter Palpable adnexal mass in a premenarchal or postmenopausal women Torsion or rupture suspected
    37. 37. Ovarian mass in reproductive age group <5 cms. >/= 5 cms USG USG cystic Complex, observation solid, suspiciou sPersistence or progression surgery
    38. 38. Asymptomatic simple cysts <5cms Likely physiological (do not require follow up) 5-7 cms Yearly USG >7cm Require further imaging/surgical intervention. RCOG 2011
    39. 39. CYST ASPIRATION Diagnostic cytology has poor sensitivity to detect malignancy, ranging from 25% to 82% Not therapeutic, even when a benign mass is aspirated Approx. 25% of cysts will recur within 1 year Aspiration of a malignant mass may induce spillage and seeding of cancer cells into the peritoneal cavity
    40. 40. INDICATIONS OF FNAC Predominantly benign masses based on clinical, USG findings and CA125 levels, but a few findings are causing diagnostic dilemma – then FNAC helps to confirm the nature and aid in pre-op planning and counseling. Patients who have clinical and radiographic evidence of advanced ovarian cancer and who are medically unfit to undergo surgery- Malignant cytology will establish a cancer diagnosis, thereby permitting initiation of neo-adjuvant chemotherapy ACOG, 2007
    41. 41. OPERATIVE MODALITIES Laparoscopy vs laparotomy – decision based on suspicion of malignancy and technical expertise No RCTs comparing recurrence rates following laparoscopy or laparotomy. The objective is to try cystectomy if possible. Laparoscopic surgery for benign ovarian tumours is associated with less pain, shorter hospital stay, and fewer adverse events than with laparotomy. Cochrane Database of Systematic Reviews 2009
    42. 42. The standards for laparoscopy in benign tumours1. careful examination of the external surface of the tumour and sampling of the peritoneal cavity2. avoidance of any tumoral rupture3. protection of the ovarian tumour with an endoscopic bag before removal
    43. 43. ROLE OF FROZEN SECTION The diagnostic accuracy of frozen section analysis is high for malignant and benign ovarian tumours, but accuracy is poor in the case of borderline ovarian tumors. Medeiros 2005
    44. 44. Ovarian mass in childhood: History and physical examination Appr. Imaging studies Simple cyst Solid or solid cystic - Observe and reassess MRI and tumor markers High suspicion Low suspicion of malignancy of malignancy Laparotomy laparoscopy Frozen sectionMalignant –oophorectomy Benign - cystectomyand staging
    45. 45. Post op surveillance in children• No specific lit. regarding recurrence rate esp.• Hence recommendations are at best empirical.• Should be followed up with annual USG.• In adults follow up with biannual USG is sufficient• Tumor markers are not regularly used
    46. 46.  Post menopausal gonad atrophies to a size of 1.5 X 1 X 0.5cm on average Shouldn‟t be palpable on pelvic examination. Presence of palpable ovary must alert the physician to the possibility of an underlying malignancy.
    47. 47.  Incidence in asymptomatic post menopausal women – 1.5% by pelvic examination 3.3% to 14.5% by USG. obstet gynecol survey, 2002 Causes -10% functional 90% neoplastic (either benign or malignant)
    48. 48. ASSESSMENT It is recommended that ovarian cysts in postmenopausal women should be assessed using CA125 and transvaginal grey scale sonography. There is no routine role yet for Doppler, MRI, CT or PET. SENSITIVITY SPECIFICITY TVS 89% 73% CA 125 81% 75% RCOG 2010
    49. 49. Calculation of RMI (Risk malignancyindex): It is an effective way of triaging patients into low , moderate, high risk for malignancy, according to which the referral to a higher centre and management protocol will differ. RCOG 2010
    50. 50.  It is recommended that a ‘risk of malignancy index’ should be used to select those women who require primary surgery in a cancer centre by a gynecological oncologist. RCOG Guideline No. 34 October 2003 Using a cut off point of 250, a sensitivity of 70% and specificity of 90% can be achieved.
    51. 51. RCOG Simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a low risk of malignancy. It is recommended that, in the presence of a normal serum CA125 levels, they be managed conservatively. Aspiration is not recommended for the management of ovarian cysts in postmenopausal women. It is recommended that a „risk of malignancy index‟ should be used to select women for laparoscopic surgery, to be undertaken by a suitably qualified surgeon.
    52. 52.  It is recommended that laparoscopic management of ovarian cysts in postmenopausal women should involve oophorectomy (usually bilateral) rather than cystectomy.
    53. 53. They were not separately classified by the FIGO and the WHO until the early 1970s. Borderline tumors make up approximately 15% of all epithelial ovarian tumors. The mean age of occurrence is approximately 10 years younger than that of women with frankly malignant ovarian cancer.
    54. 54. Tumour subtypes 2 major histological tumor subtypes  Serous(50%)  (bilateral in 30%)  Could be associated with extraovarian lesion : implants(35%)  Mucinous (46%) Mucinous tumors do not have a clearly defined origin.  Substantial information indicates that many tumors may actually originate from the appendix; thus, this organ should be removed at the time of surgery.
    55. 55. Histology and Cytology According to Dietel and Hauptmann, the histology of borderline tumors is characterized by the following features:  Epithelial multi-layering of more than 4 cell layers  Not more than 4 mitoses per 10 high-power field (HPF)  Mild nuclear atypia  Increase in nuclear/cytoplasmic ratio  Slight to complex branching of epithelial papillae and pseudopapillae  Epithelial budding and cell detachment into the lumen  No destructive stromal invasion - A major component in differentiating malignant from borderline tumors
    56. 56. TUMOR STAGING Comprehensive staging : of significant prognostic value and is performed surgically Borderline ovarian tumors are staged according to the FIGO classification of ovarian cancer.
    57. 57. INACCURATE STAGING Pathologic diagnosis is difficult to confirm by frozen section. The diagnosis of borderline ovarian cancer is based on surgical staging. There is no accurate way to predict the final pathology of ovarian tumors from laboratory or imaging studies alone.
    58. 58. PROGNOSIS Excellent overall prognosis 60% chance of having stage I disease when diagnosed. 95% of borderline ovarian tumors have diploid deoxyribonucleic acid (DNA) If the tumor is aneuploid, the recurrence rate is high Although TP 53 positivity and HER2 over expression in invasive cancer have been associated with a worse prognosis, the same gene profile has conferred a survival advantage in borderline tumors. Invasive implants
    59. 59. Recurrence and Survival Stage I disease confirmed by comprehensive staging have a recurrence rate of approximately 15%. The 5-year survival rate for such patients approaches 100%. With stage II-IV disease, the prognosis is different; an increased stage is associated with a worse prognosis and only age at diagnosis and the presence of invasive implants are shown to influence prognosis.
    60. 60. IMAGING - USG Intratumoral blood flow in borderline tumors (90%) is similar to that of malignant neoplasms (92%). The resistance and pulsatility indexes are also significantly reduce
    61. 61. IMAGING - CT Preoperatively to identify possible foci of metastasis. CT scanning can For follow up of the patient in the future. However,no distinguishing characteristics that clearly identify a borderline ovarian tumor.
    62. 62. IMAGING - MRI In a retrospective study looking at MRI characteristics of known borderline tumors, Bent et al the investigators were not able to identify any key imaging characteristics that would distinguish borderline tumors from other ovarian tumors. MRI appearances of borderline ovarian tumours. Clin Radiol. Apr 2009;64(4):430-8.
    63. 63. BIOMARKERS CA-125 levels are not shown to aid in the diagnosis or follow-up care In mucinous borderline ovarian tumors serum CA 19-9 probably is a more accurate marker than CA 125 for the early detection of recurrence
    64. 64. TREATMENT
    65. 65. Treatment Most important factors in deciding treatment options is stage of the disease. Proper staging consists of a  thorough exploration of the entire abdominal cavity with peritoneal washings,  infracolic omentectomy,  removal of all macroscopic suspicious peritoneal lesions, and  multiple peritoneal biopsies.
    66. 66.  No consensus concerning treatment of patients with stage II-IV disease The postoperative management protocol is far from clear. To date, no medical therapy has been shown to clearly improve outcomes An increased stage is associated with a worse prognosis Stage (II vs III vs IV), type of surgery, postoperative treatment, postoperative platinum-based chemotherapy, and even the number of noninvasive implants have no effect on progression-free survival. Only age at diagnosis and the presence of invasive implants are shown to influence prognosis.
    67. 67.  Owing to the high association between surface proliferations and peritoneal implants, exploration of the peritoneum should be extensive and thorough. If possible, carefully evaluate and remove the implants. The type of implant (ie, invasive, noninvasive) should be noted by pathology, as it has significant prognostic value. “Lymphadenectomy can be omitted for BOTs, even for the advanced disease, because there is no difference in recurrence or survival rate.” Gynecol Oncol 98:390-395, 2005
    68. 68. * No further chemotherapy (in all stages.)
    69. 69. CHEMOTHERAPY Evidence is insufficient to determine exactly which therapy is indicated for borderline ovarian tumors. Platinum-based agents used, but with varying results Borderline tumors with noninvasive implants do not require any further therapy and should be observed.