Benign Ovarian Masses & Malignancies (Will be incomplete but still do)

Question 1

Give the definition of an ovarian cyst
How common is it?

Answer 1

Sac filled with liquid (or semi-liquid) in an ovary
On TVUS, nearly all pre-menopausal have cysts. If repeat taken in 6-8 weeks, most show spontaneous regression => they are functional and not neoplastic
Note: only 15% of postmenopausal women have cysts

Question 2

What are the symptoms associated with ovarian cysts
How does this differ from the symptoms of an ovarian malignancy?

Answer 2

1) Pressure Symptoms:
Abdominal/pelvic pain
Bloating/swelling
Abdominal fullness => Early satiety => Weight loss
Bladder => increased urgency and frequency, incomplete emptying
Bowel => Constipation, Tenesmus

2) Functional Symptoms:
Dysmenorrhoea
Dyspareunia
Irregular menstruation
Abnormal bleeds/oligomenorrhoea

3) Accident => Torsion, rupture, haemorrhage

Malignancy -> + Bleeding

Question 3

Give the etiology of ovarian malignancies:
What are the RFs and protective factors associated with ovarian malignancy associated with Ovarian malignancy?

Answer 3

Etiology: Incessant ovulation (ovulation without a period of suppression)

RF: increased ovulation
1) Nulliparity
2) Ovulation induction drugs (lotrazole, clomiphene citrate, GnRH)
3) Early menarche, late menopause
4) Family hx of BRCA 1 or HNPCC

Protective factors (suppress ovulation):
1) Parity
2) Oral contraceptive use
3) Breastfeeding (inhibits ovulation. Thats why hyperprolactinemia inhibits GnRH which then inhibits FSH for amenorrhoea)
4) Hysterectomy/tubal occlusion

Question 4

Name 5 ovarian cysts and what theyre associated with

Answer 4

1) Follicular cysts: Functional cysts that causes anovulation => infertility with risk of endometrial hyperplasia (anovulation is a RF)

2) Corpus luteum cyst: Progesterone secretion, cyst rupture more common

3) Theca Lutein Cysts: A/w complete molar pregnancy => very high beta hCG

4) Polycystic Ovaries: Anovulatory amenorrhoea, hiruitism, US findings

5) Endometrioma: Chocolate cysts - Thick brown viscous fluid often densely adherent to surrounding structures.

Question 5

What are theca cells

Answer 5

Cells surrounding granulosa cells which surround oocytes

Question 6

What US findings are associated with polycystic ovaries?

Answer 6

Enlarged ovary with thick fibrous capsule
Numerous atretic follicles
Theca Lutein Hyperplasia
!!!String of pearls appearance (multiple follicles on the periphery of ovaries)

Question 7

How would you manage benign cysts?

Answer 7

Based on size:
<50mm - Likely physiological => should regress withing 3 menstrual cycles
50-70mm - Annual US/ Cystectomy (w/bag to prevent seeding)
70+ - MRI +/- Surgical intervention Laparoscopy if no solid component, laparotomy if there is. Why? to prevent seeding

Question 8

You perform a hx and obtain findings consistent with ovarian pathology with pressure symptoms. State all the steps involves in the complete management (not treatment) of the patient. Its not much info, just list.

Answer 8

1) HX and Exam
2) US/RMI
3) IOTA Ultrasound Rules
4) If RMI >250, Refer to gynaecological oncology specialist centre
5) CTTAP/ MRI AP
6) Staging Laparotomy

Question 9

According to RMI, what US features would support the diagnosis of an ovarian malignancy?

Answer 9

PAMBS US features (0 = 0, 1 = 1, 2+ = 3)
P - Papillary projections
A - Ascites
M - Multilocularity
M - Malignancy
B - Bilateral
S - Solid areas

Question 10

What tumour markers are used in the diagnosis of ovarian malignancy?

Answer 10

CA 125
Ca 19-9
CEA
In young + alpha fetoprotein, hCG, LDG

Question 11

Only name 5 benign ovarian tumours (OSCE)

Answer 11

1) Epithelial cell tumours - Serous cystadenoma, Mucinous, Brenner
2) Stromal cell tumours - Thecoma
3) Germ cell tumours - Benign Cystic Teratoma, Struma Ovarii, Gonadoblastoma

Question 12

What is RMI?
What are its components and how will you score it?
Based on the score, how will you manage the patient?

Answer 12

Risk Malignancy Index:
RMI = US features x Menopausal Status x CA 125 score (U/ml)

<250: Conservative, repeat RMI every 4 months for one year (Risk <3%)
> 250: Full staging Laparotomy (Risk >75%)

Question 13

Go over the IOTA (International ovarian tumour analysis) Ultrasound rules?

Answer 13

Benign Rules:
Unilocular cyst
Solid component <7mm
Smooth multilocular <100mm
No blood flow
Acoustic shadowing

Malignant Rules:
>4 papillary structure
Irregular solid tumour
Irregular multilocular >100mm
Very strong blood flow
Ascites

Question 14

The tumour marker CA 125 is not specific to ovarian cancer. What else can result in an elevated CA 125?

Answer 14

Endometriosis and cardiac failure

Question 15

What population is most affected by ovarian malignancy?

Answer 15

Although cysts mostly occur in pre-menopausal women, malignancies mostly affect post-menopausal women

Question 16

What is the most common type of ovarian malignancy?
State 7 other types as well as the tumour markers associated with them if applicable

Answer 16

90% Epithelial tumours:
1) Serous cell -> CA 125
2) Mucinous -> CA19-9

10% Germ cell tumours (If younger)
1) Dysgerminomas - LDH
2) Yolk Sac - alpha fetoprotein
3) Choriocarcinomas -> beta hCG
4) Malignant Teratomas

Metastatic tumours from breast, colon/ rectum, stomach, endometrium

Sex cord tumours
1) Granulosa Thecal cells -> Oestrogen
2) Sertoli - leydig tumours -> Testosterone

Question 17

What is CEA found in?

Answer 17

Colorectal cancer => why we measure it

Question 18

What examination findings are consistent with ovarian malignancy?

Answer 18

Inspection: Abdominal distension (asymmetrical maybe) or symmetrical in ascites

Palpation:
Irregular abdomen, mass
Organomegaly
Lymphadenopathy (Para-aortic, pelvic LN)

Percussion:
Ascites (shifting dullness)
Pleural effusion

Question 19

What investigations would you conduct in the context off ovarian malignancy.
What is needed for diagnosis?

Answer 19

1) Labs: FBC, U&E, LFTs…

2) Tumour markers: CA125, CA 19-9, CEA,
In young: Alpha fetoprotein, LDH, hCG

3) Imaging
US for RMI/IOTA
CXR for pleural effusion, metastasis
CTTAP, MRIAP for metastasis

4) Cytology:
paracentesis/pleural tap to be sent to histology

Diagnosis is only via histological diagnosis obtained during Staging laparotomy + Peritoneal washings

Question 20

Discuss the FIGO staging of ovarian cancer

Answer 20

Stage I - Confined to a) one or b) both ovaries +/- c)ascites

Stage II - Spread to pelvic structures

Stage III - Peritoneal implants outside pelvis !incl. lymph nodes (c)!!

Stage IV - Distant Metastases - Liver/lung

Question 21

What is the primary surgery for ovarian carcinoma?

What are the aims?

What does the surgery involve?

Answer 21

Staging laparotomy is the diagnostic procedure for staging where a sample is obtained for histology and debulking surgery is to remove as much of the cancer as possible for maximal effectivity of adjuvant therapy.

Its goal is to confirm the diagnosis, stage the disease, and remove as much of the malignancy as possible to ensure maximal effectivity of adjuvant therapy

In primary debulking, There is removal of as much of the tumour as possible leaving deposits no more than 1cm
+ peritoneal washings
+/- Preventative measures TAH, BSO, Omentectomy, Lymphadenectomy (retroperitoneal)

Question 22

When is palliative care offered in ovarian cancer?
What is included in this?

Answer 22

In recurrent disease,
Chemotherapy to prevent pain
Radiotherapy to prevent bleeding

Question 22

What is the difference between standard and advanced chemotherapy?

What radiotherapy is used?

Answer 22

Standard: Platinum-based chemotherapy
Advanced: Taxol + platinum-based chemo

There is no role for radiotherapy in the treatment of ovarian cancer except in palliative care in recurrent disease

Question 23

What is the follow-up plan in the management of ovarian malignancy

Answer 23

3-monthly for 2 years, then 6-monthly until 5 years

Question 24

Give the full management plan of ovarian cancer after receiving an RMI score of >250.

Answer 24

1) Referral to gynaecology oncology centre with MDT approach
2) +/- Neoadjuvant platinum-based chemotherapy
3) Staging laparotomy to confirm diagnosis and stage disease
+ Debulking surgery to remove as much of the tumour as possible
+ peritoneal washings
+/- Preventative measures TAH, BSO, Omentectomy, Lymphadenectomy (retroperitoneal)
4) Adjuvant Chemotherapy
Standard: Platinum-based chemotherapy
Advanced: Taxol + platinum-based chemo
5) Followup: 3-monthly for 2 years, then 6-monthly until 5 years

Question 24

How would you manage recurrent disease in ovarian cancer?

Answer 24

Palliative care
Chemotherapy to prevent pain
Radiotherapy to prevent bleeding