LM 9.3: Benign & Malignant Ovarian Neoplasms Flashcards
what are the 3 types of ovarian cyst?
- corpus luteum cyst
- theca lutein cyst
- follicular cyst
what is a corpus luteum cyst?
present typically as delayed menstruation, unilateral pelvic pain, and adnexal enlargement
the Luteal-phase cyst is a less common type in which there is spontaneous hemorrhage
what is a theca lutein cyst?
- associated with pregnancy
- usually bilateral
rsk factors include multiple gestation, trophoblastic disease, ovulation induction with clomiphene
they typically regress spontaneously
what are follicular ovarian cysts?
ovarian follicles that fail to rupture during follicular maturation
they can be symptomatic and present with unilateral lower abdominal pain and irregular bleeding
most resolve spontaneously within 6 weeks
ruptured cysts can cause acute pelvic pain but surgical intervention is rarely necessary
what are the 3 types of benign ovarian neoplasms?
- epithelial cell tumors
subtypes: serous cystadenoma and mutinous cystadenoma, Brenner cell tumor - germ cell tumor
- sex cord-stomal cell tumors
what are ovarian epithelial cell tumors?
the largest category in benign ovarian neoplasms
evidence suggests that they are derived from mesothelial cells lining the peritoneal cavity
three types:
1. serous cystadenoma
the most common type of benign epithelial ovarian neoplasms – treatment is surgical because there is a relatively high rate of malignancy
- mutinous cystadenoma
the second most common type of benign epithelial ovarian neoplasms
ultrasound shows very large tumors with multilocular septations
- Brenner cell tumor
what is a Brenner cell tumor?
a type of benign ovarian neoplasm
it’s an uncommon benign epithelial cell tumor which is solid, seen in older women, and occasionally occurs in association with mucinous ovarian tumors
what are germ cell tumors?
a type of benign ovarian neoplasm
typically present in reproductive-age women (80% occur during reproductive years)
most common type is benign cystic teratoma (aka dermoid cyst)
may contain differentiated tissue from all three embryonic germ layers, including skin, hair, bones, teeth
unusual variant is Struma Ovarii, which consists of functioning thyroid tissue
consider surgical treatment due to risk of ovarian rupture or torsion and if suspicion of malignancy (1%of mature cystic teratomas may contain squamous cell carcinoma)
what are sex cord-stomal cell tumors?
rare benign ovarian neoplasm derived from specialized sex cord stroma of developing gonad
typically considered solid tumors seen in all age groups
three types:
1. granulosa theca cell tumors
- Sertoli-Leydig cell tumors
- ovarian fibroma
what is a granulosa theca cell tumor?
a type of sex cord-stromal cell tumor that’s a benign ovarian neoplasm
primary female cell type producing estrogen leading to feminization
they can produce signs of precocious puberty in pediatric age group and vaginal bleeding in postmenopausal years
what is Sertoli-Leydig cell tumor?
a type of sex cord-stromal cell tumor that’s a benign ovarian neoplasm
primarily male cell type producing androgens leading to hirsutism or virulization
what is an ovarian fibroma?
a type of sex cord-stromal cell tumor that’s a benign ovarian neoplasm
the result of collagen production by spindle cells.
they occasionally presents with ascites and right pleural effusion (Meigs syndrome)
how do you manage benign ovarian neoplasms?
risk of malignant transformation increases with increasing age
surgical treatment should be considered if high risk for malignancy or torsion
can do conservative surgical treatment with cystectomy for benign tumors if future reproduction is desired
how prevalent is ovarian cancer?
ovarian cancer is the fifth most common cause of cancer death in women in the US
mortality rate is highest of all gynecologic malignancies due to difficulty detecting the disease before widespread dissemination
approximately 65-70% are diagnosed at an advanced state when the 5-year survival rate is approximately 20%
what are the risk factors for ovarian cancer?
incidence is higher in US and Western European countries
white women in the US are 250% more likely to develop ovarian cancer than African American women
presents most commonly in 5th and 6th decades of life
- nulliparity
- primary infertility
- early menarche
- late menopause
- personal history of breast cancer
- endometriosis
- BRCA 1 and BRCA 2 mutations
- Lynch syndrome
- long term suppression of ovulation may protect against epithelial cell tumors
how do ovarian cancers spread?
primarily by direct extension within the peritoneal cavity
how are malignant ovarian neoplasms categorized?
cell type of origin
how do we screen for ovarian cancer?
no effective screening tests for ovarian cancer
genetic testing is important for those with pertinent family history
how do you evaluate potential malignant ovarian neoplasms?
CA-125 elevation in postmenopausal woman with a pelvic mass is highly suspicious for malignancy but is not diagnostic
CA-125 can be used to follow response to therapy and evaluate for recurrent disease but not for screening
pelvic ultrasound is the primary component of evaluation
simple, unilocular cysts less than 10cm in diameter confirmed by Trans-Vaginal Ultrasound are almost universally benign
what are the origins of the 3 main types of ovarian tumors?
- surface epithelium-stroma
serous, mutinous, endometriosis, clear cell, transitional cell
- sex cord-stroma
granuloma cell, theca, fibroma, sertoli cell, sertoli-leydig, steroid
- germ cells
dysgerminoma, yolk sac, embryonal carcinoma, choriocarcinoma, teratoma
how is ovarian cancer staged?
based on extent of spread of tumor and histologic evaluation of the tumor
approximately 2/3 of patients have advanced disease when they are diagnosed
what is a serous carcinoma?
a type of epithelial cell ovarian carcinoma
the most common type
approximately 50% are thought to be derived from their benign counterparts
as many as 30% are bilateral at time of presentation
typically multiloculated and often have psammoma bodie
what is a mutinous cystadenocarcinoma?
a type of epithelial cell ovarian carcinoma
mucinous cystadenocarcinoma makes up approximately 1/3 of epithelial tumors, but only 5% are cancerous
these tumors can be very large
may be associated with pseudomyxomatous peritonei which is widespread peritoneal extension with thick, mucinous ascites
Figure 35-10 Mucinous carcinoma arising within a 15-cm mucinous cystadenoma
what is the most common ovarian cancer in women younger than 20?
germ cell tumors
what are the types of germ cell tumors?
- functional
- producing hCG
- producing a-fetoprotein
what is a dysgerminoma?
a type of malignant germ cell tumor of the ovary
the most common type of germ cell tumor seen in patients with gonadal dysgenesis
they spread via lymphatics so must sample pelvic and paraortic lymph nodes at time of surgery
prognosis is generally excellent with 5-year survival rate of 90-95% when disease is limited to one ovary
what is an immature teratoma?
the malignant counterpart of benign cystic teratomas
has a characteristic solid and cystic architecture
immature teratomas contain a disorderly mixture of mature and immature tissues derived from the 3 germ layers (ecto, meso and endoderm)
rapid growth typically causes painful symptoms early due to hemorrhage and necrosis
what is an embryonal cell carincoma?
a type of malignant germ cell tumor of the ovary
embryonal cell carcinoma produces AFP and B-hCG
yolk sac tumor is a subtype which can have pathognomonic Schiller-Duval bodies
which tumors are gonadal stromal cell tumors?
- granuloma cell tumor
- Sertoli-Leydig cell tumors
3.
what is a granulosa cell tumor?
a type of malignant gonadal stromal cell tumor
it is the most common granulosa cell tumor
can occur in all ages but is more likely to be benign in older patients
can contribute to endometrial hyperplasia or carcinoma due to secretion of large amounts of estrogen
it is important to do endometrial sampling
what are Sertoli-Leydig cell tumors?
a type of malignant gonadal stromal cell tumor
rare, testosterone-secreting tumors
typically occur in older patients and can cause hirsutism and virilization
what are Krukenberg tumors?
mets to the ovary from infiltrative, mutinous carincoma of signet-ring cell type in diffuse gastric carcinoma
what are the benign diseases of the fallopian tubes?
- paraovarian cysts develop in the mesosalpinx
2. Hydatid cysts of Morgagni are paratubal cysts found near the fimbriated end of the fallopian tube
what is a carcinoma of the fallopian tube?
primary fallopian tube carcinoma is usually an adenocarcinoma
these tumors are often large and unilateral
most common presenting complaints are postmenopausal bleeding and abnormal vaginal discharge
hydrotubae profluens is profuse serosanguineous discharge seen with this condition
staging is surgical
overall 5-year survival rate is 35-45%
carcinoma metastatic to fallopian tube is far more common, typically from the uterus or ovary
how do you manage ovarian cancer?
- primary surgical therapy is typically indicated
principle of cytoreductive surgery or tumor debulking with rationale being that adjunctive radiation and chemotherapy are more effective when tumor masses are reduced to less than 1cm in size
surgical procedure includes aspiration of gross ascites or peritoneal washings using saline irrigation to evaluate for microscopic disease
inspection and palpation of the entire peritoneal cavity, including paracolic gutters, omentum, liver, and spleen, must be done to determine extent of disease
partial omentectomy is typically performed for histologic examination
sampling of pelvic and periaortic lymph nodes is also performed
- adjunctive treatment with chemotherapy is usually necessary due to advanced stage at presentation
first line is pacitaxel (Taxol) combined with carboplatin or cisplatin
radiation therapy has a limited role in management
- follow up consists of clinical history, examination, ultrasound and/or CT, and use of tumor markers as indicated, such as CA-125
which type of ovarian cyst is associated with pregnancy?
theca lutein cyst
what is the most common type of ovarian neoplasm?
serous cystadenoma
A 35-year-old African-American G0 woman has a family history of ovarian cancer. Her mother was diagnosed with ovarian cancer at age 50 and is in remission. The patient had onset of menarche at age 14. She has used oral contraceptives for a total of 10 years. She smokes ½ pack of cigarettes per day. She has diabetes mellitus and hypertension. Which of the following places the patient at greatest risk for developing ovarian cancer?
A. her race
B. family history of ovarian cancer
C. oral contraceptive use
D. late age of monarch
e. smoking
B. family history of ovarian cancer
A 6-year-old girl presents to your office as a referral from her pediatrician. She presented initially for vaginal bleeding. The pediatrician also noticed pubic and axillary hair growth and breast buds on physical exam. Which of the following types of tumors is the most likely cause of this patient’s precocious puberty?
granulosa theca cell tumor
A 26-year-old G1P1 woman presents to your office for right lower quadrant pain for the past few months. She has no family history of breast or ovarian cancer. Menarche was at age 12 and she has had regular periods since and has been on oral contraceptive pills for a total of 8 years now. On pelvic exam, you note a small left-sided adnexal mass and order a pelvic ultrasound. Ultrasound shows a simple, unilocular, 6cm mass. What is the best next step in management?
no further management is indicated
A 32-year-old Caucasian female presents to your office for routine visit. She is distressed because her best friend was recently diagnosed with ovarian cancer and she is concerned about getting cancer as well. She has had two prior term pregnancies, menarche was at age 13, she has no family history of ovarian or breast cancer, and has taken oral contraceptive pills for 15 years. Pelvic exam reveals normal-sized uterus, no adnexal masses or tenderness, and normal external genitalia. What is the best screening test for her?
nothing
what type of cells are the most common types of ovarian malignancies derived from?
mesothelial cells
A 77-year old female presents for recent excessive hair growth. She has noticed dark, coarse hair on her face, chest, and back which she did not have before the past few months. She underwent menopause 25 years ago. On pelvic exam, you notice a small left-sided adnexal mass. What type of tumor does this patient most likely have?
sertoli-leydig cell tumor
what are the 2 types of cysts?
- functional cysts (follicular and corpus lutein)
2. benign neoplastic cysts
what are functional ovarian cysts?
they originate from ovarian follicles created during follicle maturation and ovulation
seen mainly in reproductive age women and are formed due to intrafollicular fluid accumulation rather than cellular proliferation –> failure of ovulation, secondary to hormonal dysfunction prior to ovulation results in expansion of follicular antrum with serous fluid forming follicular cyst, whereas excessive hemorrhage from the vascular corpus luteum following ovulation creates corpus luteum cyst
based on pathogenesis and histology they are divided into:
1. follicular cysts
theca lutein cysts are uncommon type of follicular cyst –> formed due to luteinization and hypertrophy of theca interna layer secondary to conditions with increased LH or Beta HCG
- corpus luteum cysts
what are the risk factors for developing a functional cyst?
- follicular cysts are found more frequently in those using LNG-IUS and progestin releasing implants –> low dose progestins do not completely suppress ovarian function, and dominant follicle may develop to form follicular cyst
- tamoxifen
- smoking
what are the symptoms of follicular cysts?
usually asymptomatic – most found incidentally during pelvic examination or imaging studies for another indication
they are mobile, cystic, non-tender and found lateral to the uterus
- pelvic pain
- pressure or torsion when they are large
how do you treat functional cysts?
- follicular cysts disappear spontaneously within 60 days without treatment, hence if asymptomatic and no suspicion of malignancy, they can be observed
- theca lutein cysts resolves spontaneously once the hormone source is removed
surgical excision is done if the cyst progressively enlarge or are large, >10 cm and persistent
what causes follicular cysts?
failure of ovulation which leads to expansion of the follicular antrum
what causes theca lutein cysts?
luteinization and hypertrophy of theca interna layer due to increased LH or Beta HCG
can be caused by:
1. gestational trophoblastic disease
- choriocarcinoma
- multifetal gestation
- placentomegaly
- ovarian hyper-stimulation during assisted reproductive techniques
what causes corpus luteum cysts?
excessive hemorrhage following ovulation
common in reproductive age women
which side of the body are ovarian cysts found?
- Follicular cysts can be unilateral or bilateral
- theca lutein cyst are bilateral
- corpus luteum cysts are unilateral
what would you see on an US of a follicular vs. corpus luteum cyst?
follicular cyst: round, anechoic lesions with thin, regular walls
corpus luteum cysts: “great imitators”, brightly colored ring due to increased vascularity on Doppler like in ectopic pregnancy “ring of fire”
what is the pneumonic for which ovarian tumors are epithelial vs. germ cell vs. sex cord stromal tumors?
My Sister Began Experiencing Cancer, Doctor Excised The Cancer, She felt Good
EPITHELIAL TUMORS Ⓜucinous Ⓢerous Ⓑrenner Ⓔndometrioid Ⓒlear cell
GERM CELL Ⓓysgerminoma Ⓔndodermal sinus Ⓣeratoma Ⓒhoriocarcinoma
SEX CORD STROMAL
Ⓢertoli/Leydig
Ⓕibroma
Ⓖranulosa thecal cell tumor
what are the most common benign ovarian neoplasms?
serious and mutinous cystadenomas
what are serious epithelial tumors?
40% of all ovarian tumors
2/3 of these are benign
most common: between age 40 and 60
bilateral in 20- 25%
unilocular or multilocular, have smooth lining surface, and contain thin, clear, yellow fluid
what are mucinous epithelial tumors?
20- 25% of all epithelial ovarian neoplasms
75% are benign
age between 30 to 50 years
bilateral in <5%
smooth walled, multiloculated, and mucus containing loculi appear blue
compared with serous cystadenomas, mucinous cystadenomas are less frequent, more likely to be multiloculated, are larger (attain an enormous size), are less often bilateral and often present with ovarian torsion
how do you diagnose which type of ovarian cyst a cyst is?
definitive diagnosis depends on pathologic evaluation to determine the cell type lining the cysts:
serous lining is similar to fallopian tube lining
mucinous lining cells collect mucin in their cytoplasm and resemble endocervical or gastrointestinal epithelium
what are the risk factors for ovarian cysts?
overweight and post menopausal women on hormone replacement therapy are at increased risk
what are the symptoms of serous and mucinous cystadenomas?
usually asymptomatic and found incidentally on pelvic examination or with ultrasound
as they enlarge they may produce symptoms like pelvic pressure or pain, bloating, urinary symptoms and can present with torsion
how do you treat serous and mucinous cystadenomas?
depends on many factors like age, size of the mass, ultrasound appearance, family history or other risk factors for ovarian cancer, and medical comorbidities
fit for surgery -> mass has to be removed
not fit for surgery -> observation with serial ultrasound at 6 months and then yearly
what is a teratoma?
a type of germ cell tumor that arise from germ cell and hence can have any of the three germ layers, ectoderm, mesoderm, or endoderm
what are the types of teratomas?
- immature teratoma which are malignant
- mature teratoma are benign and are three types
- mature cystic teratoma or benign cystic teratoma or dermoid cyst which are most common
- mature solid teratoma
- fetiform teratoma/ Homunculus - monodermal teratoma: composed solely or predominantly of only one highly specialized tissue type - struma ovarii has predominantly thyroid tissue
what are matureteratomas?
aka dermoid cysts are most common and comprise approximately 10- 25% of all ovarian neoplasms and 60% of all benign ovarian neoplasms
they typically grow slow and measure between 5 and 10 cm
bilateral in 10%, most appear unilocular with one area of localized growth which protrudes into the cystic cavity, Rokitansky’s protuberance
ectodermal elements predominate, hair, fatty secretions are often found within, at times bone and teeth are also identified
cyst is typically lined with keratinized squamous epithelium with abundant sebaceous and sweat gland
malignant transformation in 0.06 to 2%, most malignant cases are squamous cell carcinoma
how do you diagnose a teratoma?
US
shows fat fluid or hair fluid levels seen within the cyst and “Tip of the iceberg” sign which is the acoustic shadowing from the hyperechoic part of the dermoid cyst
how do you treat a teratoma?
surgical excision provides definitive diagnosis, relief of symptoms, prevents torsion, rupture, and malignant degeneration
for premenopausal women who desire future fertility: surveillance of cyst <6cm with ultrasound every 6 to 12 months initially
what are the complications of a teratoma?
- torsion
- acute periotonitis
- granulomatous peritonitis
what are the chances a dermoid tumor is malignant?
rare
what is a Brenner tumor?
aka transitional cell tumor
derived form surface epithelium of the ovary or the pelvic mesothelium through transitional cell metaplasia to form typical urothelium like components
mostly benign, unilateral with few proliferative and malignant tumor
they may be associated with estrogen production leading to endometrial hyperplasia
predilection for post menopausal women
associated with another epithelial ovarian neoplasm mostly serous and mucinous cystadenomas in 30% of the patients
what are the symptoms of Brenner tumors?
usually asymptomatic
among symptomatic patients, common symptoms include vaginal bleeding due to endometrial hyperplasia and pelvic pain
how do you diagnose Brenner tumor?
difficult to diagnose with imaging due to tumor’s nonspecific appearance and appear similar to other solid ovarian tumor
P63 is a specific tumor marker
grossly they are well circumscribed, with a hard or fibromatous, grey, white or yellow cut surface
how do you treat Brenner tumors?
surgical resection
what are sex cord stromal tumors?
a heterogenous group of rare neoplasms that originate from the ovarian matrix
cells within the matrix have the potential for hormone production, and nearly 90% of hormone producing ovarian tumors are sex cord stromal tumors –> these patients present with signs and symptoms of estrogen or androgen excess
what are ovarian fibromas?
benign ovarian tumor of sex cord/ stromal origin that are composed of spindle cells forming variable amount of collagen
accounts for 4% of all ovarian neoplasms
they are most common sex cord tumors, with malignant transformation in 1% of case
occur in all age groups, most frequent in middle aged women
what are the symptoms of ovarian fibroma?
usually asymptomatic and incidental finding
associated with ascites in 40% of cases and with pleural effusion in a small percent.
Meig’s syndrome consists of an ovarian fibroma with ascites and a pleural effusion(usually right side).
how do you diagnose a treat an ovarian fibroma?
ultrasound, CT, MRI
surgical excision.
what are thecomas?
benign ovarian tumors of sex cord/ stromal origin that secrete estrogen
accounts for 0.5 to 1% of all ovarian tumors, 80% of cases seen in post menopausal period
grossly, they are solid masses of varying sizes, mixture of fibroma and thecoma components, so called fibrothecoma
what is the clinical presentation of a thecoma?
similar to granulosa cell tumor, with uterine bleeding predominating
what do thecomas look like histologically
lipid laden stromal cells that are occasionally luteinized with a small component of fibroblasts
on gross examination they appear solid masses of varying sizes
how do you diagnose a thecoma?
ultrasound, CT, MRI
US is the imaging of choice, shows non specific features, secondary features of hyperestrogenism such as endometrial thickening may be seen
what is a gonadoblastoma?
rare benign tumor that has potential for malignant transformation
contains both germ cells and sex cord stromal cells
affects a subset of patients with an intersex disorder or disorder of sex development –> it arises in patient with dysgenetic gonads 46 XY, 45 XO/XY mosaic or 45 X0 –> patients presents as phenotypic female in 80% of cases and phenotypic male in 20%.
do gonadoblastomas have malignant potential?
though they are benign more than 50% have co-existing dysgerminoma which is malignant
what are the risk factors for a gonadoblastoma?
- complete androgen insensitivity
- pure gonadal dysgenesis or Swyer syndrome
- mixed gonadal dysgenesis 45,X/ 46, XY
- subset of turners with 45 XO/XY mosaicism
- Fraiser syndrome, a rare 46 XY DSD caused by mutation in the Wilms tumor 1 gene
- 9p partial monosomy
what is the pathogenesis of a gonadoblastoma?
two essential findings that predispose these abnormal gonads to under neoplastic transformation into gonadoblastoma are:
- the karyotype has either macroscopic or molecular evidence of a Y chromosome
- gonads are nearly always intra-abdominally
how do you diagnose a gonadoblastoma?
- history
- PE
- karyotyping
tumor can frequently be diagnosed at birth by careful physical examination
in females with normal phenotype but virulization and all male with undescended testes, obtain a karyotype to exclude intersex disorder
females with androgen insensitivity syndrome present with primary amenorrhea with normal breast but absent axillary and pubic hair
how do you treat a gonadoblastoma?
bilateral gonadectomy
n patients with mixed gonadal dysgenesis it is performed as soon as the diagnosis is established
in patients with complete androgen insensitivity and male pseudohermaphroditism, gonadectomy should be performed after puberty but before 20 years due to negligible risk of gonadoblastoma before puberty
what are paraovarian cysts?
not neoplastic and either distended remnants of the paramesonephric duct or mesothelial inclusion cyst
asymptomatic and incidental finding; when symptomatic mimic ovarian cysts
what is the most common paramesonephric cyst?
hydatid of Morgagni
they are pedunculated and dangle from the fimbri
leiomyomas are most common paraovarian solid tumors
how do you diagnose a paraovarian cyst?
transvaginal sonography
cyst have thin, smooth walls and anechoic centers
sonography and MRI cannot differentiate between ovarian and paraovarian pathology
what is an adnexal mass?
a mass of the ovary, fallopian tube, or surrounding connective tissues
a common gynecologic problem, found in women of all ages, from fetuses to older adults, and a wide variety of types of masses
what are the symptoms of an adnexal mass?
can be symptomatic or incidental finding on pelvic examination or imaging
the type of mass is identified with pelvic imaging, use of biomarkers, and/ or surgical exploration and pathologic evaluation
symptomatic or incidental finding
type of mass is identified with pelvic imaging, use of biomarkers, and/ or surgical exploration and pathologic evaluation
what is a tubo-ovarian abscess?
an inflammatory mass involving the fallopian tube, ovary, and occasionally, other adjacent pelvic organs
may manifest as tubo-ovarian complex, where these structures are agglutinated or as a collection of pus, tubo-ovarian absces
a serious and life threatening condition which may rupture and result is sepsis, requiring aggressive medical and/ or surgical therapy
most common in reproductive age women, typically as a complication of pelvic inflammatory disease
what are the risk factors for tubo-ovarian abscess?
- multiple sexual partners
- 15-25 years old
- prior history of PID
what is the pathogenesis of a tubo-ovarian abscess?
ascending infection from the lower genital tract from sexually transmitted pathogen or from a endogenous flora, spreads to the fallopian tube and damage the endothelium resulting in edema of the infundibulum of the tube and tubal blockage
results in ischemia and necrosis causing pyosalphinx
the tubal structures adhere to and coalesce with the adjacent ovarian tissue forming a complex
necrosis inside the complex results in abscess formation.
which pathogens can cause a tubo-ovarian abscess?
a polymicrobial, mixture of aerobic, facultative and anaerobic organisms
- e. coli
- aerobic streptococci
- bacteroids fragilis
- prevotella
- peptostreptococcus
- actinomycetes israeli (associated with IUD associated tubo-ovarian abscess)
what are the symptoms of a tubo-ovarian abscess?
- acute lower abdominal pain
- fever/chils
- vaginal discharge
presentation vary, these variation were illustrated in one of the largest series of women with TOA, 40% afebrile at presentation, 25% had chronic pain rather than acute pain, 23% had normal white blood cell counts.
women with ruptured abscess classically present with an acute abdominal and signs of sepsis – ruptured TOA may sometimes be life-threatening requiring immediate surgical exploration
how do you evaluation for a tubo-ovarian abscess?
pelvic ultrasonography and pelvic CT
US shows complex multi-locular masses that often obliterate the normal adnexal architecture and/ or cul-de-sac anatomy
CT is preferred when there are associated gastrointestinal tract pathology like appendicitis, abscess associated with inflammatory bowel disease
when is surgery indicated for a tubo-ovarian abscess?
when patient has acute abdomen or signs of sepsis and abscess rupture is suspected
in postmenopausal women as TOA might be associated with gynecologic malignancy
how do you treat treat a tubo-ovarian abscess?
antibiotics is indicated in patients who are hemodynamically stable with no signs of a ruptured TOA, abscess <9 cm in diameter, adequate response to antibiotics and premenopausal
continue antibiotics for 2 weeks or till cyst is gone
patients require close observation for at least 48 to 72 hours due to the potential for abscess rupture and ensuing sepsis
invasive surgery is indicated if patient do not respond to or worsen on antibiotics after 48 to 72 hours
what are the signs that antibiotics aren’t working to treat a tubo-ovarian abscess?
- new onset or persistent fever
- persistent or worsening abdominopelvic tenderness
- enlarged pelvic mass
- new onset, persistent
- further elevation of the white blood cell count, signs of sepsis
what is ovarian hyper-stimulation syndrome?
occurs when the ovaries are hyperstimulated and enlarged due to fertility treatment resulting in the shift of serum from the intravascular space to the third space, mainly to the abdominal cavity
in its severe form which is rare, it is a life threatening condition as it can cause venous and arterial thromboembolic events including stroke
what is the pathogenesis of ovarian hyper-stimulation syndrome?
in the spontaneous normal ovulatory cycle, hypothalamic pituitary ovarian feedback mechanisms limit follicle recruitment to a small number of early antral follicle, followed by selection of a single dominant follicle that ovulates in response to mid cycle LH surge
OHSS can be viewed as an exaggeration of a physiologic process –> ovarian stimulation with exogenous gonadotropins results in an exuberant ovarian response
exogenous HCG, human chorionic gonadotropin plays a key role in the pathogenesis of OHSS
exogenous HCG induces massive luteinization of granulosa cells, which produces vasoactive substances like vascular endothelial growth factor (VEGF) which leads to exaggerated perifollicular neovascularization exhibiting increased permeability
escape of follicular fluid and perifollicular blood containing large amounts of VEGF into the peritoneal cavity and its subsequent absorption into the general vascular bed results in functional impairment of blood vessels – this results in massive third space fluid shift resulting in edema, ascites, hydrothorax, and /or pericardial effusion with intravascular hypovolemia
this will lead to impairment of cardiac, renal, pulmonary and liver function
what are the symptoms of ovarian hyper-stimulation syndrome?
early symptoms are usually mild to moderate and begins four to seven days after the ovulatory dose of hCG
late OHSS begins at least nine days after ovulatory dose and is more severe because of rising hCG of pregnancy.
how do you prevent ovarian hyper-stimulation syndrome?
OHSS can be prevented by recognizing patients with risk factors, modifying treatment when indicators of OHSS risk develop, and use an alternative to standard dose hCG or GnRH agonist
how do you treat ovarian hyper-stimulation syndrome?
it’s a self- limiting disease
symptoms may prolong if pregnancy occurs, treated by conservative and symptomatic approach
those with severe and critical OHSS requires hospitalization
mild symptoms are managed on an outpatient basis with analgesics and avoid heavy physical activities.
moderate symptoms are managed with oral fluids of one to two liters per day, diuretics contraindicated due to worsening of hypovolemia, daily weight, and abdominal circumference measurement (sign of fluid accumulation) and urine output recording
hospitalization is mandatory for severe OHSS and those with following criteria: hematocrit >45%, leukocytes >25,000/ L, and creatinine >1.6mg/dL
