Ovarian cysts and tumours Flashcards by Adele Atkins

What is an ovarian cyst?

Fluid filled sac in the ovary

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When are ovarian cysts common?

Premenopausal patients - physiological cysts predominate throughout the menstrual cycle

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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

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List the risk factors for ovarian cancer

Nulliparity 
Early menarche
Late menopause
Oestrogen only HRT
Smoking
Obesity  
Genetics - BRCA1/2, HNPCC (Lynch 2 syndrome)

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What are some protective factors of ovarian cancer

Multiparity
Combined contraceptive methods
Breastfeeding

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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

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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%

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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

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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

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At what RMI should patients be referred to a gynaecologist

> 250

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Describe the common presentations of ovarian cysts and tumours

Incidental/asymptomatic
Chronic pain
Acute pain
Bleeding per vagina

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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

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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

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What can ovarian tumour be divided into?

Non-neoplastic

Neoplastic

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What is a simple ovarian cyst?

One that contains fluid only

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What is a complex ovarian cyst

Irregular and can contain solid material, blood or have septations or vascularity

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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