222. Ovarian, Fallopian Tubes, Adnexal Masses

Question 1

What consists of the adnexa (7)

Answer 1

Ovary
F Tube
Mesoovarium
Mesosalpinx
Utero-ovarian and infundibulopelvic ligaments (contain blood supply)
upper portion of broad ligaments

Question 2

What signs in CP mean malignancy?

How to distinguish simple vs complex cysts in US?

What are 4 indications for surgery?

Answer 2

CP: bilateral, solid, fixed, irregular, with ascites, cul-de-sac nodularity, rapid growth

Simple Cysts: usually benign: unilocular, hypoechoic thin walls
Complex Cysts: internal echoes, septations, intramural nodules, solid components

Surgical Indications:

1. Any Mass >10cm
2. Mass >5cm w/o resolution after 6-8 weeks
3. Solid Ovarian Lesions
4. Sx for Pain (worry ovarian torsion)

Question 3

Benign Ovarian Neoplasms

• when are masses usually benign?
• when is surgical tx warranted?
• types of Epithelial Ovarian Tumors (3)
• types of Sex Cord Stromal Tumors (2)
• What is Meig’s Syndrome
• types of Germ Cell Tumors (1)

Answer 3

Masses 90% benign in reproductive years (more malignant post-mp)

Surgery: to lower risk of ovarian torsion, increase definitive dx (r/o malignancy) [can preserve fertility]

Epithelial Ovarian Tumors

1. Serous Cystadenoma: most common epithelial neopasm, simple unilocular/multilocular, may be bilateral
2. Mucinous Cystadenoma: large, multicystic, filled with mucin
3. Endometrioma: assoc w/ endometriosis, “chocolate cyst”

Sex Cord Stromal Tumors
- any age, can make androgens/E
1. Fibroma: fibrous C.t. Solid masses
2. Thecoma: stoma hyperplasia, hyperthecosis, hormonally active (more rare)
MEIGS SYNDROME: ovarian mass (thecoma), ascites, R Side Pleural Effusion

GCT

1. Teratoma: most common tumor in women of any age (dermoid)
   - differentiated germ tissue from 3 embryonic germ layers (ectoderm, mesoderm, endoderm) = hair, sebaceous, teeth, may irritate peritoneum if rupture

Question 4

Ovarian Carcinoma

• epidemiology
• etiology (2)
• PGen’s
• RFs
• sx
• tx
• prognosis

Answer 4

Ovarian Carcinoma: 2nd most common GYN cancer, MOST LETHAL CYN CANCER, (70% present advanced stage)

• low 5 yr survival (45%)
• E: Incessant ovulation theory (high epithelial damage and repair with ovulation, more risk with more cycles), Genetics (BRCA, Lynch Syndrome)
• PGEN: Atypical endometriosis (causes endometrioid ca and clear cell ca); E inclusion cysts and STIC cause high grade serous ca
• RFs: higher risk with age, FamHx, infertility/low parity, personal hx with breast cancer (lower risk with OCP, pregnancy, tubal ligation, breast feeding = suppress ovulation)
• sx: non-specific (bloating, indigestion, pelvic/abd pain, abd distention, constipation, SoB)
• staging: I (ovary), II (pelvis), III (upper Abd or LN), IV (distant spread - lungs)
• tx: early: surgery and chemo
  advanced: primary surgical debulking, adjuvant chemo (carboplatin and taxol)
• HIGH RECURRENCE RATE, (but good response rate)

Question 5

Epithelial Cell Tumors

• demographic
• tumor marker

Germ Cell Tumors

• tumor marker
• demographic

Sex Cord Stromal Tumor

• demographic
• tumor marker
• unique feature

Answer 5

ECT: 50s-60s (>40yo)
CA125 tumor marker (not always present)

GCT: younger age (16-20yo), solid rapidly enlarging mass (AFP, LDH, hCG)

Sex cord Stomal Tumor: older age (52), solid or cystic unilateral mass, hormonally ACTIVE (abnormal bleeding, endometrial hyperplasia/cancer, virilization), INHIBIN+