Ovarian Cysts and Cancer

Question 1

SYMPTOMS:

1. Rupture
2. Haemorrhage
3. Torsion

Answer 1

1. Intense pain
   - usually with endometrioma/dermoid cyst
2. Pain, possible hypovolaemic shock
   - can haemorrhage into cyst or into peritoneal cavity
3. Severe pain
   - Infarction
   - needing urgent surgery and detorsion

Question 2

CLASSIFICATION OF OVARIAN TUMOURS:

1. Primary neoplasms
   a) Epithelial tumours
   b) Germ cell tumours
   c) Sex cord tumours
2. Secondary malignancies
3. Tumour-like conditions

Answer 2

1. a) - most common in postmenopausal women
   i) Serous cystadenoma/adenocarcinoma: serous adenocarcinoma is the most common malignant ovarian neoplams(50% malignancies)
   - bilateral in 20%
   ii) Mucinous cystadenoma/adenocarcinoma:
   Mucinous cystadenoma is 2nd most common benign epithelial tumour.
   - if ruptures, may cause pseudomyxoma peritonei
   iii) Endometroid carcinoma: 25% ovarian malignancies
   iv) Clear cell carcinoma: <10% ovarian malignancies
   v) Brenner tumours: usually small and benign

b) i) Teratoma/dermoid cyst: most common benign tumour usually arising in young premenopausal women(<30y).
- commonly bilateral(10-20%), rupture is very painful
- torsion more likely compared to other ovarian tumours.
ii) Dysgerminoma: female equivalent of seminoma. Associated with Turner’s syndrome. Most common ovarian malignancy in younger women, sensitive to radiotx.
- Secretes hCG and LDH.

c) i) Granulosa cell tumours: usually malignant and slow-growing.
- usually in postmenopausal women
- Serum inhibin as tumour markers for monitoring recurrence.
ii) Thecomas: usually benign and very rare
iii) Fibromas: Can cause Meigs’ syndrome(ascites, right pleural effusion, small ovarian mass)
- rare and benign
- cured by removal of mass
iv) Sertoli-Leydig cell tumour:
- benign
- Associated with Peutz-Jegher syndrome

2. • 10% of malignant ovarian masses
     - commonly from breast and GI tract(Krukenberg tumour)
3. a) Endometriotic cysts/endometrioma: chocolate cysts
   - result of endometriosis

b) Functional cysts:
- Follicular and lutein cysts
- Only in premenopausal women
- Follicular cyst is commonest type of ovarian cyst. Commonly regress after several menstrual cycles.
- COCP is protective
- For lutein cysts, they can be more symptomatic. More likely to present with intraperitoneal bleeding compared to follicular cyst. Observed via serial USS.
- If persistent apparently functional cyst >5 cm for >2 months, serum CA 125 measured and laparoscopy consider to remove/drain cyst

Question 3

COMMON OVARIAN MASSES:

1. Premenopausal
2. Postmenopausal

Answer 3

1. Premenopausal:
   - Follicular/lutein cysts
   - Dermoid cysts
   - Endometriomas
   - Benign epithelial tumour
2. Postmenopausal:
   - Benign epithelial tumour
   - Malignancy

Question 4

EPIDEMIOLOGY:

Answer 4

1. Peak incidence in 60s
2. About 90% are epithelial carcinomas
3. Germ cell tumours most common for women <30y

Question 5

RISK FACTORS:

1. Number of ovulations:
2. Genetic
3. Protective factors

Answer 5

1. • Early menarche, late mneopause, nulliparity
2. Familial(5%)
   - BRCA1(risk 30%), BRCA2(27%), If BRCA1 mutation present, risk approaches 50%. also associated with breast cancer.
   - prophylactic oophorectomy offered after completion of family.
   - HNPCC(Lynch’s syndrome) also associated with increased risk of bowel and endometrial cancer.(80% lifetime risk)
3. COCP, pregnancy, lactation

Question 6

CLINICAL FEATURES:

1. Similar to IBS
2. Other symptoms
3. Clinical signs

Answer 6

1. Bloating, early satiety and abdominal distension, abdominal pain, diarrhoea, dyspepsia.
2. Urinary urgency, pelvic pain, appetite loss, breast and GI symptoms, fatigue, PV bleed
3. Cachexia, ascites, abdominal/pelvic mass, breast mass

Question 7

STAGING FOR OVARIAN CANCER:
Stage 1
Stage 2
Stage 3
Stage 4

Answer 7

Stage 1: Disease macroscopically confined to ovaries

1a: One ovary affected, capsule intact
1b: Both ovaries affected, capsule intact
1c: One/both ovaries affected and capsule not intact/malignant cells in abdominal cavity.

Stage 2: Disease beyond ovaries but confined to pelvis

Stage 3: Disease beyond pelvis but confined to abdomen:
- omentum, small bowel and peritoneum frequently involved. or positive retroperitoneal lymph nodes.

Stage 4: Disease beyond abdomen. eg: liver, distant mets.

Question 8

RISK F. FOR OVARIAN MASS BEING MALIGNANT:

Answer 8

1. Rapid growth, >5 cm
2. Ascites
3. Advanced age
4. Bilateral masses
5. Solid/septate nature on USS
6. Increased vascularity.

Question 9

INVESTIGATIONS:

Answer 9

1. Serum CA 125
   - woman >50y with many abdominal symptoms
2. USS abdomen and pelvis if serum CA 125 >35 IU/mL
   - Urgent referral if ascites and/or pelvic/abdominal mass detected
3. If woman <40y, measure AFP and hCG as might be germ cell tumour.
4. CT scan if necessary
   - staging and looking for liver metastasis

Question 10

RISK OF MALIGNANCY INDEX(RMI):

1. USS score(U)
2. Menopausal status(M)
3. Serum CA 125

Answer 10

RMI=U x M x CA 125

1. • 1 point for each of multilocular cysts, solid areas, intra-abdominal metastases, ascites, bilateral lesions.
     - U=0 for 0 pts. U=1 for US score of 1 pt. U=3 for US score of 2-5 pts.
2. M=1 if premenopausal. M=3 if postmenopausal.
   * RMI≥250 warrants referral

Question 11

MANAGEMENT:

1. Surgical
2. Chemotherapy
3. Radiotherapy

Answer 11

1. • Total hysterectomy + Bilateral salpingo-oophorectomy + partial omentectomy + peritoneal washings, biopsies of peritoneal deposits, retroperitoneal lymph node assessment.
     - If stage 1, retroperitoneal lymph nodes sampled but removed through block dissection for others.
     - If wish to preserve fertility and ‘borderline’ disease, can preserve uterus and unaffected ovary with meticulous staging and follow up.
     - neoadjuvant chemotherapy in advanced cases.
2. Done only after confirmed tissue diagnosis
   - if surgery not done, percutaneous image-guided biopsy or laparoscopy to obtain sample
   - if cannot obtain sample, monitor response using serum CA 125.
   - Indicated for ≥Stage 1c
   - Stage 1c: 6 cycles of carboplatin
   - Stages 2-4: Carboplatin/Cisplatin alone or +paclitaxel(taxol)
   - prolongs short-term survival and improves QOL
3. For dysgerminomas

Question 12

FOLLOW-UP AND PROGNOSIS:

Answer 12

1. Serum CA 125 during and after chemotherapy
2. CT scan for residual disease
3. Interval debulking of residual tissue
4. Poor prognostic indicators:
   - advanced stage
   - high grade
   - clear cell tumours
   - slow/poor response to chemotherapy
5. Common cause of death: bowel obstruction/perforation.
6. 5-year survival rates:
   1a: 85+%
   1c: 80%
   2: 70%
   3: 40%
   4: 10%

Overall <50%

Question 13

SERUM CA 125

Answer 13

1. Shed by epithelial cancers, pancreas, breast, lung, colon and ovary.
2. Also raised in: menstruation, endometriosis, PID, ectopic pregnancy, pancreatitis, renal failure, ascites, liver disease
3. Low positive in stage 1. Only 50% show raised Ca-125