Ovarian cysts Flashcards
1
Q
What pathologies can occur if the ovulation (maturation of a follicle) goes wrong?
A
- Follicular cysts
- when an egg is not released from the Graafian follicle
- normal physiological process protrudes from the ovaries
- Luteal cyst
- formed from the corpus luteum
very common (unless they are on the pill, or are post-menopausal)
2
Q
How do ovarian cysts present in the community?
A
- Ovarian cysts may be non-neoplastic or neoplastic
- 90% are benign
- Of surgically managed tumour 13% in the premenopausal group and 45% in the post-menopausal group are malignant.
3
Q
What are the symptoms of ovarian cysts?
A
- Asymptomatic
- Pain, discomfort
- Menstrual disruption
- failed menstruation
- Pressure effects
- increased urinary frequency
- may interrupt bowel movements - pressing on the sigmoid colon
4
Q
When should you worry about asymptomatic ovarian cysts
A
- >8cm
- >5cm in postmenopausal women (lower threshold)
- The complexity of the cyst on USS
- Solid mass within the ballon
- Septae
- Bilateral
- Free fluid - ovarian cancers produce fluids –> ascites
5
Q
What are the complications of Ovarian Cysts?
A
- Torsion
- ovary twists around it’s blood supply due to increased pull on the cyst on one side
- Rupture
- spontaneous during physical activity
- Haemorrhage
- causes pain
- Infection
- not very common
- unless there is already an infection present in surrounding organs/ tissue
6
Q
What would be the management for the following case?
- - 22 y.o. Woman G0P0
- - Seen by G.P. With vague RIF pain
- - USS 5cm right ovarian cyst
- - goes to A&E with sudden pain, guarding in RI region, no obvious rebound
- - repeat ultrasound shows- no cysts seen and some free fluid in the abdomen
A
The cysts has ruptured
- clinically stable, therefore - conservative management
- usually resolves itself within a few days with some abdominal sensitivity
- if the pain continues may want to take a surgical approach
- conservative as possible with a laparoscopic entry to remove the cysts
- If it was a very traumatic rupture of the cyst, she may lose the ovary
- Sequelae include:
- peritonitis- infection
- pseudomyxoma peritonei ‘jelly-belly’ : mucus-filled cysts ruptures
- needs to be washed out properly
7
Q
What would be the management for the following case?
- what could a differential for the pain be?
- 29 y.o. Woman presents with acute lower right-sided abdominal pain.
- Minimal abdominal signs
- Tender 6cm mass right adnexum
- USS haemorrhage into a cyst
A
- management determined by symptoms
- conservative management if applicable otherwise surgical to remove a cyst from the ovaries
- surgical approach indicated it there is severe pain or other complications
- bleeding can be from the cyst rather than into it- can be dramatic
- rupture the cysts and bleed outside the ovary –> severe abdominal bleeding
- if it bleeds into the cysts it can act as tamponade and be saw but not life-threatening
- Differential –> Endometriomas - tissue inside the uterus grows outside of the uterus
8
Q
What is the diagnosis and what would the management for the following case be?
- 72 y.o woman G3 P2
- Occasional left sided twinges
- Presents with acute abdominal pain with nausea and vomiting.
- Tachycardia and temperature 37.8C
- Lower abdo guarding and rigidity
- Leucocytosis
- Tender 10cm mass high on left side of pelvis,
- USS 10cm ovarian mass, No doppler flow
A
- Ovarian cysts
- differential of UTI
- High, left-sided pain is due to torsion of the ovary
- Treatment:
- Salpingo-oophorectomy (removal of ovaries and fallopian tube)
- if the ovaries have already infarcted
- can be untwisted and stitched down
- if it is caught fast enough
- Salpingo-oophorectomy (removal of ovaries and fallopian tube)
9
Q
What are the types of cysts (neoplasms) of the ovary
A
-
Epithelial layer
- Benign
- Borderline
- not borderline malignant, present as a neoplasm in their own right
- usually in younger women
- Malignant
-
Germ Cell layer
- Benign
- usually in younger women
- Malignant
- can occur in young woman
- Benign
- _Stromal layer (_hormone producing areas)
- Benign
- Malignant
10
Q
What is the diagnosis and what would the management be for the following case?
- 19-year-old female presents with a two-year history of “fullness” in the right side of the pelvis.
- deep dyspareunia, but increasing urinary frequency
- Periods normal
- otherwise fit and well
- mass felt in right adnexum
- USS shows the following: complex cystic mass, with solid areas and fluid areas
A
- It is a dermoid cyst, originates from the germ cell layer
- contains, skin, hair, teeth
- Laparoscopic ovarian cystectomy
- contents should not be spilt into the abdomen else it will need to be washed out properly to prevent irritation
- uneventful recovery
- maybe malignant and would express tumour markers
- usually cured, and the ovary may need to be removed to ensure it hasn’t spread
11
Q
What is the diagnosis and what would be the treatment for the following case?
- 18 year old female. Nulliparous
- presents with recent onset of amenorrhoea
- noted also hair recession and hirsutism
- on examination: clitoromegaly and slightly tender 10cm mass in left side of the pelvis.
- USS show complex mass in pelvis mainly solid and vascular
- blood test ordered (what would you expect to see?)
A
- Stromal tumour
- Sertoli-leydig tumour, stage 1
- expect to see low oestrogen levels and increased testosterone levels
- signposted by amenorrhoea and hirsutism and clitoromegaly
- usually removed laparoscopically
- usually a good prognosis
- very slow-growing if not benign
12
Q
What can be used to indicate what type of ovarian tumours are presenting? i.e benign, borderline, malignant
A
- depends on the complexity seen in ultrasounds, imaging or histological samples
- having masses within the cysts,
- different septations, compartments
- Tumour markers
- CA125 if it is very high indicates cancer in women with a mass (hundred and thousands)
- if CA125 less than 35 is fine
- other conditions, pleurisy, ovarian torsion, ruptures cysts, endometriosis, fibroids if it effects the peritoneum or pleura etc. can increase the CA125
-
Risk of Malignancy Index
- MD x USSS, CA125
13
Q
Explain the Risk of Malignancy Index
A
- Menopausal Status (MS)
- premenopausal = 1
- postmenopausal = 3
- Ultrasound Score
- 0-1 level of complexity = 1
- 3 or more levels of complexity = 3
- CA125 value (may not need to be very high in older women with a high level of complexity )
- Needs to reach an RMI of 250 to be admitted into the cancer centre
14
Q
Where does ovarian cancer spread?
A
- Contralateral spread
- Small bowel
- Large bowl
- Omentum
- Diaphragm
- can spread lymphatically
- Liver
- Pleural Cavity
15
Q
How does Ovarian cancer present?
A
- a silent disease, 60-80% present at an advanced stage
- Symptoms of abdominal involvement
- Symptoms from distant metastases
- general malaise, weight loss
16
Q
What is the diagnosis and what would the treatment be for the following case?
- Patient aged 58 y.o. G3P2
- 6/12 of vague abdominal discomfort
- Recent nausea and poor appetite and 1 stone loss of weight.
- Increasing malaise and tiredness
-
On examination
- obese, large distended stomach
- CT shows: complex ovarian masses with ascites and upper abdominal disease
A
- Ovarian cancer with metastasis
- Surgery
- Staging / Debulking (when you remove as much of cancer as you can rather than just one big mass)
- Chemotherapy
- Carboplatin +/- Taxol:
- used to dry up the ascites, makes surgery easier- hopefully, all the cancer masses can be removed
- Carboplatin +/- Taxol:
- Bevacizumab (Avastin)
- targets a cancer cell vascular endothelial growth factor (VEGF) increasingly more targeted therapies
