Ovarian cysts and tumours Flashcards
What is an ovarian cyst?
Fluid filled sac in the ovary
When are ovarian cysts common?
Premenopausal patients - physiological cysts predominate throughout the menstrual cycle
What tool is used in practice to determine the likelihhod of malignancy and allow triage and referral to cancer centre for treatment
The risk of malignancy index
List the risk factors for ovarian cancer
Nulliparity Early menarche Late menopause Oestrogen only HRT Smoking Obesity Genetics - BRCA1/2, HNPCC (Lynch 2 syndrome)
What are some protective factors of ovarian cancer
Multiparity
Combined contraceptive methods
Breastfeeding
Describe the BRCA1/2 mutations
Increase risk of breast/ovarian cancers
Ovarian cancer risk - 46% at age 70 in BRCA1 positive families and 12% in BRCA2 positive
Describe hereditary nonpolyposis colorectal cancer (Lynch 2 syndrome)
Rare syndrome with associated increased risk of developing colorectal and endometrial cancers
Confers a lifetime risk of developing ovarian cancer of 12%
Describe the risk of malignancy index
RMI = U X M X CA125 M = Menopausal status - premenopausal (1), post menopausal (3)
U = ultrasound score - Mulilocular cyst, solid areas, metastases, ascites, bilateral lesions - No features (0), 1 feature (1), 2 or more features (3)
CA125 - cancer antigen 125 - measured from a blood test, giving a value in units/ml
What would a RMI be for a postmenopausal lady with a CA125 of 100 and bilateral lesions with solid areas on US have?
900
3x3x100
At what RMI should patients be referred to a gynaecologist
> 250
Describe the common presentations of ovarian cysts and tumours
Incidental/asymptomatic
Chronic pain
Acute pain
Bleeding per vagina
When taking a history of suspected ovarian cancer what should you enquire about
Bloating Change in bowel habit Change in urinary frequency Weight loss IBS Bleeding per vagina
Describe the examination of someone with suspected pelvic mass
Resusictate any shocked patient presenting with ruptured cyst or torsion
Abdominal masses arising from pelvis
Ascites
Pelvis - bleeding or discharge or adnexal masses and cervical excitation
What can ovarian tumour be divided into?
Non-neoplastic
Neoplastic
What is a simple ovarian cyst?
One that contains fluid only
What is a complex ovarian cyst
Irregular and can contain solid material, blood or have septations or vascularity
Name some functional non neoplastic cysts
Follicular cysts
Corpus luteal cysts
Name some pathological non-neoplastic cysts
Endometrioma
Polycystic ovaries
Theca lutein cyst
Name some benign neoplastic epithelial tumours
Serous cystadenoma
Mucinous cystadenoma
Brenner tumour
Name some benign germ cell tumours
Mature cystic teratoma (dermoid cysts)
Name some sex-cord stromal tumours
Fibroma
Describe functional cysts
<3cm
Represent the developing follicles in first half of menstrual cycle
Describe corpus luteal cysts
<5cm
Occur in luteal phase of the menstrual cycle after formation of the corpus luteum
Describe endometrioma
Chocolate cysts
Present in those with endometriosis
Bleeding into the cyst
Describe polycystic ovaries
USS diagnosis
Ovaries contain >12 antral follicles or ovarian volume >10ml
Ring of pearls sign is seen on USS
PCO is present as one of the features of PCOS but isolated PCO does not equate to PCOS
Describe theca lutein cyst
Result as a consequence of markedly raised hCG
Regress upon resolution of the raised hCG
Describe serous cystadenoma
Reflects most common type of malignant tumour and is usually unilocular with up to 30% being bilateral
Describe mucinous cystadenoma
Multiloculate and usually unilateral
Describe Brenner tumour
Unilateral with solid grey or yellow appearance
Describe mature cystic teratoma (dermoid cysts)
10% bilateral
Usually occur in young women and occur frequently in pregnancy
As germ cell in origin can contain hair, teeth, skin and bone
Describe fibroma
Most common stromal tumour
40% present with Meigs syndrome
What is Meigs syndrome?
Association between fibromas and ascites/pleural effusions
Describe the management of ovarian masses in premenopausal women?
CA125 does not need to be undertaken when diagnosis of simple ovarian cyst has been made ultrasonographically
Lactate dehydrogenase, alpha-fetoprotein and hCG should be measured in all women <40 yrs due to possibility of germ cell tumour
Rescan cyst in 6 weeks - if persitent then monitor with USS and CA125 6-monthly and calculate RMI
If persistent or >5cm consider laparoscopic cystectomy or oophorectomy
What can CA125 be raised by?
Anything which irritates the peritoneum - in premenopausal there are multiple benign triggers for an increase
Describe the management of ovarian masses in post menopausal women
Low RMI (<25) - follow up for 1 yr with US and CA125 if <5cm
Moderate RMI (25-250) - bilateral oophorectomy and if malignancy found then staging is required - completion surgery of hysterectomy, omentectomy +/- lymphadenectomy
High RMI (over 250) - referral for staging laparotomy
When do most patients with ovarian cancer present?
At a late stage due to non-specific symptoms
Name two types of ovarian cancer
Epithelial subtypes:
- Serous cystadenocarcinoma
- Mucinous cystadenocarcinoma
What are serous cystadenocarcinomas characterised by?
Psammoma bodies
What are mucinous cystadenocarcinomas characterised by?
Mucin vacuoles
What investigations should patients with ovarian cancer have?
Bloods - FBC, U&E, LFT, albumin Imaging - Abdominal and pelvic USS RMI CXR CT AP - staging and pre-op purposes in diagnosed cancer
Describe the management of ovarian cancer
Surgery
Adjuvant chemotherapy
Follow up
Describe the triad for Meig’s syndrome
Ovarian fibroma
Pleural effusion
Ascites
