Ovarian Cysts and Tumours Flashcards
What is an ovarian cyst?
A fluid filled sac within the ovary
They are common; especially in the premenopausal patients where benign, physiological cysts predominate throughout the menstrual cycle.
How do you judge if an ovarian cyst will turn malignant?
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.
Does ovarian cancer have a high mortality rate?
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.
What are the risk factors for ovarian cancer?
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.
- nulliparity
- early menarche
- late menopause
- HRT thats oestrogen only
- smoking
- obesity
- family Hx
- one first degree FHx 5%. two 7%, no FHX 1.5%
- genetics: BRCA1/2, HNNPC Hereditary nonpolyposis colorectal cancer (Lynch II Syndrome)
What are the protective factors of developing ovarian cancer?
- multiparity
- combined contraceptive methods
- breastfeeding
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%.
Hereditary nonpolyposis colorectal cancer (Lynch II Syndrome)
How do you calculate the Risk of Malignancy Index RMI?
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.
What RMI requires referral to a specialist gynaecologist?
> 250
<25 – low risk (3% risk, conservative); 25-250 – moderate risk (20% risk, laparoscopic oophorectomy), >250 – high risk (75% risk, full staging procedure)
What might give a CA125 false positive?
Ca125 – A carbohydrate antigen elevated in epithelial cancers (also up in heart failure, endometriosis and any condition causing peritoneal irritation), Score = serum level
What is the list of findings on US suggestive of Malignancy in the RMI? (5)
BAMMS
bilateral, ascites, multilocular, metastases, solid
- Multilocular cyst (Having many small cavities or cells.)
- Solid areas
- Metastases
- Ascites
- Bilateral cysts
What are the IOTA Group US findings suggesting a benign cyst? (5)
ASSun
1. unilocular cyst
2. solid components with the largest being <7mm
3. acoustic shadowing
4. smooth multilocular tumor <100mm
5. no blood flow
What are the IOTA group US findings indicative of a malignant cyst? (5)
- Irregular solid
- ascites
- at least 4 papillary structures
- multilocular with largest >100mm
- strong blood flow
What is a simple ovarian cyst?
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)
What are the symptoms of ovarian cysts?
- 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
What are the symptoms of ovarian cysts?
- 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
What are the types of Non-Neoplastic benign cysts?
Functional:
1. Follicular cysts
2. Corpus luteual cysts
Pathological:
1. Endometrioma/ chocolate cyst
2. polycystic ovaries
3. Theca lutein cyst
What are the benign neoplastic cysts?
- Epithelial
- serous cystadenoma
- mucinous cystadenoma
- brenner tumour - Benign germ cell tumours
- mature cystic teratoma (dermoid cyst) - Sex cord stromal tumours/ gonadal stromal tumours
- fibroma
- thecoma
- hilus cell tumour
These are normally less than 3cm and represent the developing follicle in the first half of the menstrual cycle
Follicular cyst
These are normally less than 5cm. These occur in the luteal phase of the menstrual cycle after the formation of the corpus luteum.
corpus luteal cyst
These are also called chocolate cysts and are present in those with endometriosis. There has been bleeding into the cyst resulting in the appearance.
endometrioma
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.
Polycystic ovaries
These result as a consequence of markedly raised hCG e.g. molar pregnancy. They regress upon resolution of the raised hCG.
Theca lutein cyst
reflects the most common type of malignant ovarian tumour and is usually unilocular with up to 30% being bilateral.
Serous cystadenoma
these are often multiloculated and usually unilateral.
Mucinous cystadenoma
