Ovarian and Fallopian Tube Pathology 5 Flashcards
What are the major considerations in the approach to the patient with an adnexal mass?
- Age of the patient
- Size and characteristics of the mass on both exam and imaging
- Presentation and associated symptoms
What are the most common adnexal masses in the following age ranges? 0-13, 13-51, postmenopausal?
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Premenarchal (ages 0-13)
- cancer
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Reproductive age (ages 13-51)
- functional ovarian cysts
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Benign neoplasms
- postmenopausal
- cancer
What are important characteristics of adnexal masses and how are they described?
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Imaging:
- simple: fluid filled, thin wall
- complex: cystic and solid, septae, surface excrescences, blood flow within the mass
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Exam:
- mobile versus fixed; smooth surfaced versus nodular
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Size:
- <5 cm (generally observe)
- 5-10 cm (usually remove)
- > 10 cm (always remove)
How do adnexal masses commonly present in terms of history, exam, imaging, lab tests?
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History: how is the patient presenting?
- in acute pain in the ER
- new intermittent pelvic pain
- changes in bowel or bladder
- asymptomatic
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Exam: abdominal and pelvic
- abdominal exam
- pelvic exam
- speculum exam
- bimanual exam
- rectovaginal exam
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Imaging
- Pelvic ultrasound
- CT or MRI
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Lab tests
- CBC
- chemistry panel
- urine pregnancy
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Tumor markers:
- ovarian cancer: CA-125, AFP, inhibin A &B, LDH, hCG
- other cancers: CA 19-9, CEA, CA 15-3 or CA 27.29
What are the common types of functional cysts of the ovary?
- Functional: related to ovulation
- The most common clinically detectable ovarian enlargements during the reproductive years
- Usually resolve spontaneously within 8-12 weeks
- Usually < 10 cm in size
- Examples:
- Follicular
- Theca-lutein
- Corpus luteum
- Polycystic ovaries
What are some distinguishing factors of follicular cysts?
- Follicle fails to rupture and the follicle continues to grow and fill with fluid
- Smooth, thin-walled, unilocular
What are distinguishing features of corpus luteum cysts?
- Corpus luteum fails to involute and continues to enlarge after ovulation
- Grossly yellow in color
What are distinguishing features of theca lutein cysts?
- Luteinized follicular cysts (= lipid accumulation)
- Results when a follicle is overstimulated by hCG hormone
- Usually bilateral
- Most commonly seen in pregnancy states
- Most asymptomatic
What are distinguishing features of PCOS?
•Polycystic ovarian syndrome (PCOS)
•Multicystic ovaries on ultrasound
•Two defining characteristics: menstrual dysfunction and hyperandrogenism
•Can also see metabolic disorders such as dyslipidemia and insulin resistance
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•Ultrasound criteria for establishing the diagnosis of PCOS are 10 or more cysts that are 2-8 mm in diameter and are peripherally arranged like a “string of pearls”
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•Rarely do polycystic ovaries require surgical management but they may be a source of an enlarged ovary on pelvic exam
What are the major types of benign ovarian neoplasms?
- Neoplasm = tumor; new and abnormal growth, may be benign or malignant
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May arise from any cell layer of the ovary
- Surface epithelium
- Germ cells
- Sex cord-stromal tissue
How are benign ovarian neoplasms treated and why?
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Usually managed surgically for the following reasons:
- rarely resolve spontaneously
- often appear complex or solid on imaging
- more likely to be symptomatic
What are the common epithelial neoplasms?
- Serous cystadenoma
- Mucinous cystadenoma
- Cystadenofibroma
- Endometrioma
- Brenner tumor
What are epithelial neoplasms of the ovary?
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Serous and mucinous cystadenoma
- two of the most common benign ovarian neoplasms
- can grow to enormous (> 20cm) sizes
- serous cystadenoma’s more often bilateral
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Endometrioma
- ectopic growth of endometrial tissue on an ovary
- typically contain thick brown fluid (old blood), described as “chocolate cysts”
- often stick to surrounding pelvic surfaces and can cause symptoms typical of endometriosis
- pelvic pain, dysmenorrhea, dyspareunia
- Most common benign cause of an elevated serum CA-125, an ovarian cancer tumor marker
What are common sex cord-stromal neoplasms of the ovary?
- Derived from the sex cords and specialized stroma of the developing gonad, including cells that produce hormones
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Examples
- Fibroma
- Fibroadenoma
- Fibrothecoma
- Sertoli – leydig cell tumor
What are some important features of fibromas of the ovary?
- Most commonly seen in postmenopausal women
- Average diameter 5-10 cm
- Most common benign solid tumor of the ovary
- Proliferation of ovarian fibrous/cortex tissue
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Meig’s syndrome:
- constellation of ovarian fibroma, ascites and a (right) pleural effusion
- seen in 1-3% of patients with fibromas
What are some important features of germ cell neoplasms of the ovary?
- Derived from primordial germ cells of the ovary (undifferentiated cells)
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Mature cystic teratoma (aka “dermoid” cyst)
- most common germ cell neoplasm
- often bilateral (15-25%)
- very frequent in younger patients (ages 10-30)
- can contain mature components of ecto-, meso- and endoderm
- teeth, hair, and sebum are the most common components
What are some major features of borderline tumors of the ovary?
- Also called tumors of low malignant potential (LMP)
- Epithelial tumors (serous, endometrioid, mucinous)
- Tend to remain confined to the ovary for long periods of time but have the ability to metastasize (as a borderline tumor) and sometimes recur a low grade ovarian cancer
- Most common in pts between 30-50 yrs
- Frequently diagnosed at an early age and associated with an excellent prognosis
What is the epidemiology of epithelial ovarian cancers?
- Most common type of ovarian cancer
- Most common in the 5th and 6th decades of life
- Typically presents in advanced stages (stages III and IV), no good screening test
- Histologic subtypes: serous, mucinous, endometrioid, clear cell
What are the risk factors of epithelial ovarian cancer?
- Age
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Reproductive and endocrine factor - “Incessant ovulation” theory: epithelial damage & repair associated with ovulation
- increased risk of cancer with increased # of ovulatory cycles
- late menopause
- early menarche
- increased risk of cancer with increased # of ovulatory cycles
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Genetic predisposition
- genetic mutations account for 10-15% of epithelial ovarian cancer
- cumulative probability of developing ovarian CA by age 70:
- between16-48% in Hereditary Breast & Ovarian CA Syndrome (usually associated with BRCA1 and BRCA2 mutations)
- ~12% in patients with Lynch Syndrome
How can epithelial ovarian cancer be prevented?
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Oral contraceptives
- 36% risk decrease with ever-use
- 8-10% decrease for every year of use
- Recommend ≥ 5 years of use
- Protection may last for up to 10 years
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Tubal ligation
- studies show decreased risk (30-50%) of ovarian CA after tubal ligation
- mechanism unclear
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Breastfeeding
- decrease the # of ovulatory cycles
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Pregnancy
- decrease the # of ovulatory cycles
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Surgical removal of the fallopian tubes and ovaries
- mainly for women with a genetic risk of ovarian cancer
What are some important serum or tumor markers of epithelial ovarian cancer?
- CA 125
- is elevated in greater than 80% of advanced epithelial ovarian cancers
- is elevated in 25-50% of stage I cancers
- has poor specificity (NOT VERY ACCURATE), especially in premenopausal women; can be elevated in a number of benign conditions
- NOT a screening test for the general population
What are the symptoms of epithelial ovarian cancer?
- Historically called “silent killer” because symptoms were not thought to develop until disease was very advanced
- Recent studies disprove this; women with ovarian cancer do have symptoms as early as 3-6 months before disease is detected
- Important points when asking about symptoms:
- persistent
- change from normal
- occur almost daily for > 2-3 weeks
What are some important findings for epithelial ovarian cancer?
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Symptoms
- abdominal or pelvic pain
- abdominal distention or bloating
- early satiety
- urinary frequency
- constipation or diarrhea
- fatigue
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Signs
- abdominal or pelvic mass
- pleural effusion
- ascites
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Evaluation
- examination
- imaging
- ultrasound and/or CT scan
- serum tumor markers
Describe the FIGO staging for ovarian cancer.
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Stage I: growth limited to the ovaries
- Stages IA – IC
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Stage II: growth involving one or both the ovaries with pelvic extension
- Stage IIA – IIC
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Stage III: same as Stage II with peritoneal implants outside the true pelvis and/or (+) retroperitoneal nodes
- Stage IIIA – IIIC
- Stage IV: growth involving one or both the ovaries with distant metastasis
What is the general management strategy for epithelial ovarian cancer?
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Surgery
- determine the extent of disease (stage)
- remove as much tumor burden as possible
- goal of < 1 cm residual tumor burden
- alleviate symptoms
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Adjuvant chemotherapy
- kill any residual small volume disease
- *In most cases patients need both surgery and chemotherapy to have a shot at a cure
What are the surgical procedures for epithelial ovarian cancer?
- Surgical Staging (stages I and II)
- pelvic washing
- total hysterectomy, bilateral salpingo-oophorectomy
- try and remove the mass intact
- pelvic and para-aortic lymph node sampling
- peritoneal and omental biopsies
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Surgical Debulking (stages III and IV)
- remove ascites
- total hysterectomy, BSO
- remove the bulk of disease from the pelvis and abdomen, which sometimes necessitates:
- omentectomy
- peritoneal stripping
- splenectomy
- bowel resection
What are the benefits of cytoreductive (debulking) surgery?
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Physiologic
- remove ascites
- improved GI function
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Tumor Perfusion
- removal of bulky, poorly-vascularized tumor
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Cell Kinetics: improve conditions for chemotherapy to work
- Gompterzian Growth - improve growth fraction (smaller tumors divide more quickly, more susceptible to being killed with chemo)
- Goldie-Codman hypothesis – tumor cells develop resistance, reasons to use more than one drug
What are options of chemotherapy of epithelial ovarian cancer?
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After staging or debulking surgery:
- Carboplatin
- Paclitaxel
- given IV or IP, usually for 6-8 cycles
- outpatient, usually very well tolerated and very effective
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Recurrent ovarian cancer
- many “second line” chemotherapy drugs used to prolong life; cure is no longer a possibility
- possible for women with recurrent ovarian cancer to live > 5 years on and off chemotherapy
