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OSCE OBGYN > Ovarian Cysts and Tumours > Flashcards

Ovarian Cysts and Tumours Flashcards

1
Q

What is an ovarian cyst?

A

A fluid filled sac within the ovary

They are common; especially in the premenopausal patients where benign, physiological cysts predominate throughout the menstrual cycle.

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2
Q

How do you judge if an ovarian cyst will turn malignant?

A

The obvious concern of patients with ovarian masses is the presence of malignancy. The risk of malignancy index (RMI) is a tool used in practice to determine the likelihood of this which allows triage and referral to a cancer centre for treatment as indicated.

Ovarian cancer is the leading cause of death from gynaecological malignancy in the UK. It accounts for roughly 2 percent of total cancer cases with over half of cases diagnosed in women aged 65 and over.

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3
Q

Does ovarian cancer have a high mortality rate?

A

Ovarian cancer is the leading cause of death from gynaecological malignancy in the UK. It accounts for roughly 2 percent of total cancer cases with over half of cases diagnosed in women aged 65 and over.

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4
Q

What are the risk factors for ovarian cancer?

A

Ovarian cancers are believed to derive from surface epithelial irritation during ovulation. Therefore the more ovulation that occurs, the higher the risk of irritation and cancer.

  1. nulliparity
  2. early menarche
  3. late menopause
  4. HRT thats oestrogen only
  5. smoking
  6. obesity
  7. family Hx
    - one first degree FHx 5%. two 7%, no FHX 1.5%
    - genetics: BRCA1/2, HNNPC Hereditary nonpolyposis colorectal cancer (Lynch II Syndrome)
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5
Q

What are the protective factors of developing ovarian cancer?

A
  1. multiparity
  2. combined contraceptive methods
  3. breastfeeding
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6
Q

this is a rare syndrome with an associated increased risk of developing colorectal and endometrial cancers. It also confers a lifetime risk of developing ovarian cancer quoted at around 12%.

A

Hereditary nonpolyposis colorectal cancer (Lynch II Syndrome)

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7
Q

How do you calculate the Risk of Malignancy Index RMI?

A

RMI = U x M x CA125

US: 1= 1 feature from the list, 3 = more than 1 from list
M: 0 = premenopausal, 3 = postmenopausal
CA125: level of cancer antigen 125

So for a postmenopausal patient with a CA125 of 100 and bilateral lesions with solid areas identified on ultrasound her score would be 3 x 3 x 100 = 900.

Patients with a RMI >250 should be referred to a specialist gynaecologist.

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8
Q

What RMI requires referral to a specialist gynaecologist?

A

> 250

<25 – low risk (3% risk, conservative); 25-250 – moderate risk (20% risk, laparoscopic oophorectomy), >250 – high risk (75% risk, full staging procedure)

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9
Q

What might give a CA125 false positive?

A

Ca125 – A carbohydrate antigen elevated in epithelial cancers (also up in heart failure, endometriosis and any condition causing peritoneal irritation), Score = serum level

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10
Q

What is the list of findings on US suggestive of Malignancy in the RMI? (5)

A

BAMMS
bilateral, ascites, multilocular, metastases, solid

  1. Multilocular cyst (Having many small cavities or cells.)
  2. Solid areas
  3. Metastases
  4. Ascites
  5. Bilateral cysts
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11
Q

What are the IOTA Group US findings suggesting a benign cyst? (5)

A

ASSun
1. unilocular cyst
2. solid components with the largest being <7mm
3. acoustic shadowing
4. smooth multilocular tumor <100mm
5. no blood flow

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12
Q

What are the IOTA group US findings indicative of a malignant cyst? (5)

A
  1. Irregular solid
  2. ascites
  3. at least 4 papillary structures
  4. multilocular with largest >100mm
  5. strong blood flow
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13
Q

What is a simple ovarian cyst?

A

A simple ovarian cyst is one that contains fluid only.
A complex ovarian cyst is one that is not simple! It can be irregular and can contain solid material, blood or have septations or vascularity.

  • 15% postmenopausal
  • Functional in nature
  • Repeat scan in 6-8 weeks – spontaneous regression
  • Smooth surface, 5cm in diameter
  • Large ovarian cyst – 15cm (histology is important)
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14
Q

What are the symptoms of ovarian cysts?

A
  • Asymptomatic, pain or discomfort in lower abdomen, accident to ovarian cyst may cause severe pain, dyspareunia/dysmenorrhea, pressure on bowel/bladder, irregularity of menstrual cycle, abdominal fullness and bloating
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15
Q

What are the symptoms of ovarian cysts?

A
  • Asymptomatic, pain or discomfort in lower abdomen, accident to ovarian cyst may cause severe pain, dyspareunia/dysmenorrhea, pressure on bowel/bladder, irregularity of menstrual cycle, abdominal fullness and bloating
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16
Q

What are the types of Non-Neoplastic benign cysts?

A

Functional:
1. Follicular cysts
2. Corpus luteual cysts

Pathological:
1. Endometrioma/ chocolate cyst
2. polycystic ovaries
3. Theca lutein cyst

17
Q

What are the benign neoplastic cysts?

A
  1. Epithelial
    - serous cystadenoma
    - mucinous cystadenoma
    - brenner tumour
  2. Benign germ cell tumours
    - mature cystic teratoma (dermoid cyst)
  3. Sex cord stromal tumours/ gonadal stromal tumours
    - fibroma
    - thecoma
    - hilus cell tumour
18
Q

These are normally less than 3cm and represent the developing follicle in the first half of the menstrual cycle

A

Follicular cyst

19
Q

These are normally less than 5cm. These occur in the luteal phase of the menstrual cycle after the formation of the corpus luteum.

A

corpus luteal cyst

20
Q

These are also called chocolate cysts and are present in those with endometriosis. There has been bleeding into the cyst resulting in the appearance.

A

endometrioma

21
Q

An ultrasound diagnosis. The ovaries contrain more than 12 antral follicles, or ovarian volume greater than 10ml. The classic ‘ring of pearls’ sign is seen on ultrasound scanning. PCO is present as one of the features of polycystic ovarian syndrome (Rotterdam criteria criteria). Isolated PCO does not equate to PCOS.

A

Polycystic ovaries

22
Q

These result as a consequence of markedly raised hCG e.g. molar pregnancy. They regress upon resolution of the raised hCG.

A

Theca lutein cyst

23
Q

reflects the most common type of malignant ovarian tumour and is usually unilocular with up to 30% being bilateral.

A

Serous cystadenoma

24
Q

these are often multiloculated and usually unilateral.

A

Mucinous cystadenoma

25
Q

unilateral with a solid grey or yellow appearance.

A

Brenner tumour

26
Q

10% are bilateral, usually occur in young women and occur frequently in pregnancy. As germ cell in origin they can contain teeth, hair, skin and bone.

A

Mature cystic teratoma (Dermoid cysts)

27
Q

the most common stromal tumour. Important to know about as up to 40% present with Meig’s syndrome which is the association between these tumours and ascites/pleural effusion.

A

Fibroma

28
Q

Management of ovarian cyst in the premenopausal?

A

<50mm, simple ovarian cysts – do not require follow up
* 50-70mm, simple ovarian cysts – yearly US follow-up
* >70mm, simple cysts – either further imaging (MRI) or surgical intervention
* Laparoscopic cystectomy < laparotomy

CA125 does not need to be undertaken when the diagnosis of a simple ovarian cyst has been made ultrasonographically. The CA125 can be raised by anything that irritates the peritoneum, so in premenopause there are numerous benign triggers for an increase.
Lactate dehydrogenase, alphafetoprotein and hCG should be measured in all women under 40 due to the possibility of germ cell tumours.
Rescan a cyst in 6 weeks. If it is persistent then monitor with ultrasound an CA125 3-6 monthly and calculate RMI.
If persistent or over 5cm consider laparoscopic cystectomy or oophorectomy.

29
Q

How would you manage cyst in the postmenopausal woman?

A

Low RMI (less than 25): follow up for 1 year with ultrasound and CA125 if less than 5cm.

Moderate RMI (25-250): bilateral oophorectomy and if malignancy found then staging is required (with completion surgery of hysterectomy, omentectomy +/- lymphadenectomy).

High RMI (over 250): referral for staging laparotomy

30
Q

ovarian malignancy bits?

A

1 per 70 women
pregnancy decreases risk by 50% (childbirth, breastfeeding)
OCP decreases risk by 40%

The clinical features of ovarian cancer are non-specific, and most patients present with late-stage disease. They are most often of the epithelial subtype

31
Q

What are the most common types of ovarian cancer?

A
  1. Epithelial
    - Serous cystadenocarcinoma – characterised by Psammoma bodies.
    - Mucinous cystadenocarcinoma – characterised by mucin vacuoles.
    (clear cell carcinoma, endometrioid carcinoma)

Other:
sex cord/stromal
germ cell
metastatic tumor

32
Q

Investigations in suspected ovarian cancer?

A

All patients with suspected ovarian cancer should have basic blood tests included FBC, U&E, LFT and albumin. (serum CA125)

In the UK, NICE recommends abdominal and pelvic ultrasound for pelvic masses, from which the RMI can be calculated.

In cases of confirmed cancer, chest x-ray and CT abdomen/pelvis should be undertaken for staging and pre-operative purposes.

33
Q

How do you manage ovarian cancer?

A
  1. Surgery - staging laparotomy for those with a high RMI with attempt to debulk the tumor
  2. Chemotherapy – recommended for all patients apart from those with early, low grade disease and uses platinum based compounds. (if cant tolerate use carboplatin) NO RADIOTHERAPY

3.Follow up – involves clinical examination and monitoring of CA125 level for 5 years with intervals between visits becoming further apart according to risk of recurrence. – every 3 months in first 2 years then every 6 months until 5 years

34
Q

How do you manage recurrent disease?

A

incurable, palliative care

35
Q

What is the prognosis of ovarian cancer?

A

(5-year survival) –
Stage 1 73%,
Stage 2 45%,
Stage 3 21%,
Stage 4 <5%

OSCE OBGYN (25 decks)

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