Chapter 50: Anexal Masses - Ovarian and Adnexal Disease Flashcards
Define the adnexal space
- Adnexal space: Area between the uterine cornu and lateral pelvic wall. Contains the ovaries, fallopian tubes, and upper broad ligament and mesosalpinx and remnants of the mullerian duct. Most commonly affected are ovaries and fallopian tubes
At what ages are the ovaries palpable?
- Premenarchal ovaries should not be palpable
- Reproductive group – ovaries palpable about half the time
- Postmenopausal - Less responsive to gonadotropin, leading to surface follicular activity diminishment = non palpable within 3 years of normal menopause
Malignant potential of palpable ovaries in post menopausal women
o Take palpable ovaries in a postmenopausal woman seriously
o 1/4 will be malignant in this group, whereas only 10% in reproductive age women will be palpable
Etiology and presentation of a follicular cyst
When ovarian follicle fails to rupture, causing build up of hormone and enlargement. Only significant if it is large enough to cause pain or if it persists beyond one menstrual cycle. We are not sure why but the granulosa cells lining the cyst persist through the time when ovulation should have occurred and continue to enlarge in the second half of the cycle. Due to the thick layer, they sometimes won’t rupture. Can lead to amenorrhea and strange cycles due to the amount of estradiol, causing overstimulation of the endometrium
Imaging for follicular cyst?
o Imaging: US often warranted in reproductive age women with a cyst larger than 5cm.
We worry with the following findings: Thick septations, soft tissue elements, evidence of internal or external excrescences, and papillations
How long do follicular cysts last?
o Resolution: Most go away in 6 weeks. If not, consider something else.
If contraceptive given, it won’t shrink what you got, but can prevent further development
Rupture of follicular cyst
o Rupture: Causes pelvic pain and transient symptoms due to spillage of fluid into the cavity with hormones in it. Intervention not indicated since symptoms are transient
What are corpus luteul cysts?
o The other common type of functional ovarian cyst. Basically just the corpus luteum that has grown beyond 3cm. Related to the post-ovulatory (progesterone dominant) phase of the menstrual cycle
There are two variations of the corpus luteum cysts. One that is enlarged beyond the normal 14 days of having a corpus luteum and one that is larger during the later portion of the luteal phase.
Discuss the first variant, the one that just lasts a long time
Enlarged corpus luteum that continues to produce progesterone beyond the 14 days.
• Delayed menstruation from a few days to a few weeks, although usually just 2 weeks of the missed period. Dull achy persistent ipsilateral pelvic pain also present. Enlarged adnexa on Pelvic Exam.
• This triad is also seen in ectopic so keep on the differential
There are two variations of the corpus luteum cysts. One that is enlarged beyond the normal 14 days of having a corpus luteum and one that is larger during the later portion of the luteal phase.
Discuss the second variant, the one that we see late in the luteal phase
- Spontaneous hemorrhage with rupture in the luteal phase. Pt typically is not using oral contraceptives, has normal periods, with a sudden sharp pain late in the luteal phase.
- Surgery indicated with hemiperitoneum or hypovolemia. Otherwise, expectant management with pain control.
- At risk: Anticoagulation and clotting disorders
The last of the three functional ovarian cysts, theca lutein, presents how?
o Least common of the three. Associated with pregnancy. Usually bilateral, most commonly due to multiple gestations, trophoblastic disease, and ovulation that has been induced by clomiphine and hCG.
o Tend to regress spontaneously, but can get large and multicystic
Benign ovarian neoplasms are not in themselves malignant. How often do they become cancerous and when do we detect them?
Most cysts are functional, but about 25% can be benign masses with no functional component.
90% are benign in reproductive age group, with 25% malignant when including the post menopausal group
Due to no functional component usually, we only detect on physical exam or when they are large enough to cause a mass effect
Three types of benign ovarian neoplasms
o Three types: Epithelial cell, germ cell, and stromal cell
Let’s start with the epithelial based benign ovarian neoplasm. It also has three subtypes, which are:
Most common = Serous cystadenoma
2nd most common = Mucinous cystadenoma
Endometrioid (stupid really, essentially just uterine stuff)
How often are serous cystadenomas malignant potentially? How do we treat?
70% are benign. 10% have intraepithelial cellular characteristics which suggest they are of low malignant potential. 20% are frankly malignant.
High rate of becoming malignant = treat by surgical resection. In younger patient, consider preserving ovary.
Increased risk of malignancy in contralateral ovary, so in older patients, take both ovaries and potentially the uterus as well
Presentation and treatment for the second most common benign ovarian tumor, mucinous cystadenoma. How often are they malignant?
Malignancy rate of 15%
Become large, potentially filling entire pelvic cavity
US: Multilocular septations
Surgery to treat
What is a Brenner Cell Tumor? Malignant potential?
Uncommon benign epithelial tumor
Solid ovarian tumor 2/2 large amount of stroma and fibrotic tissue surrounding the epithelial cells
More common in older women. Sometimes occur in the setting of mucinous tumors of the ovary.
Small, rarely malignant
The second subset of benign ovarian tumors, germ cell, are known for having what inside of them?
o Contain hair and bones and stuff
o Tissue from all 3 embryonic tissue layers. Most common ectodermal origin, primarily squamos cell tissue such as skin appendages (sweat sebaceous glands, hair follicles, sebum (dermoid stuff, hence the name). Others includeCNS, teeth, cartilage, intestines, etc.
Imaging of germ cel ltumors
o Imaging: CT shows high density fat, making it bouyant and often leading to ovarian torsion (15%)
Who gets these germ cell tumors and what is the most common type?
o Most common = Benign cystic teratoma AKA dermoid cyst AKA dermoid
o 80% during reproductive years, median age of 30 years