Ovarian Cysts - Benign and Malignant Cysts Flashcards
What is a functional ovarian cyst?
A functional ovarian cyst is a sac that forms on the surface of a woman’s ovary during or after ovulation. It holds a maturing egg. Usually the sac goes away after the egg is released. If an egg is not released, or if the sac closes up after the egg is released, the sac can swell up with fluid.
Ovum Production
Normal ovary - Follicular Cyst
Histology specimen - corpus luteum with a bleed and cyst
What % of women in the community have an ovarian cyst?
10% of women in the community have an ovarian cyst
Ovarian cysts are the … most common cause of gynae admission
Ovarian cysts are the 4th most common cause of gynae admission
What % of all women in U.K. will be admitted with ovarian cysts by age 65 years?
4% of all women in U.K. will be admitted with ovarian cysts by age 65 years.
Ovarian cysts may be non-… or …
Ovarian cysts may be non-neoplastic or neoplastic
What % of ovarian cysts are benign?
90% of ovarian cysts are benign
Of surgically managed ovarian tumour/cysts:
- 13% in … group are malignant
- 45% in … group are malignant
- 13% in premenopausal group are malignant
- 45% in post-menopausal group are malignant
4 Symptoms of Ovarian Cysts include…
- Asymptomatic
- Pain
- Menstrual disruption
- Pressure
When should you worry about Asymptomatic Ovarian Cysts:
- What size in cm? (> …cm)
- What size with postmenopausal age group? (>…cm)
- What are some features to look for on USS? (complex)
- >8cm - tend to operate
- postmenopausal >5cm if certain features:
- Complexity of the cyst on USS
- Solid
- Septae
- Bilateral
- Free fluid
4 Complications of Ovarian Cysts
- T, R, H, I
- Torsion
- Rupture
- Haemorrhage
- Infection
Case Report 1 - Ovarian Cysts
- 22 y.o. Woman G0P0 (Gravidity, parity)
- Seen by G.P, With vague Right iliac fossa pain
- USS 5cm right ovarian cyst
- Later, Presented to A & E with lower abdominal pain
- Tenderness and guarding lower abdo
- Repeat USS No cyst, some free fluid - what has happened?
- cyst rupture - released contents into abdomen - guarding and tenderness across lower abd
- example below of ruptured cyst
Case Report 1 - Ovarian Cyst Rupture
- May be traumatic or spontaneous
- Symptoms depend on … and … of contents
- If mild … management is appropriate
- Sequelae include p.. and pseudomyxoma peritonei
- May be traumatic or spontaneous
- Symptoms depend on amount and character of contents
- If mild conservative management is appropriate
- Sequelae include peritonitis and pseudomyxoma peritonei
What is gravidity and parity?
Gravidity is defined as the number of times that a woman has been pregnant. Parity is defined as the number of times that she has given birth to a fetus with a gestational age of 24 weeks or more, regardless of whether the child was born alive or was stillborn.
Case Report 2 - Ovarian Cyst
- 29 y.o. Woman presents with acute lower right sided abdominal pain.
- Minimal abdominal signs
- Tender 6cm mass right adnexum
- USS haemorrhage into a cyst
- What should you do?
- Management determined by symptoms
- Conservative versus operative.
- Remember bleeding can be from the cyst rather than into it and can be dramatic.
- Endometriomas
- picture below shows whole ovary removed with tarry containing cyst at top- classic haemorrhagic cyst
C__ase Report 3 - Ovarian Cyst
- 72 y.o woman G3 P2
- Occasional left sided twinges
- Presents with acute abdominal pain with nausea and vomiting.
- Tachycardia and temperature 37.8C
- Lower abdo guarding and rigidity
- Leucocytosis
- Tender 10cm mass high on left side of pelvis
- USS 10cm ovarian mass. No doppler flow
- What has happened?
- Ovarian Cyst Torsion
- Usually ovarian infarction has already occurred at the time of surgery
- Salpingo-oophorectomy usual surgical treatment.
- ?Laparoscopic
- picture below - dead ovary after torsion
The Ovary
A Collage of Tissue Types
- different tissue types on ovary
- therefore, different tumours and cysts can arise
Types of Cysts (neoplasms) of the Ovary
- E…
- Benign
- Borderline
- Malignant
- G… Cell
- Benign
- Malignant
- S…
- Benign
- Malignant
-
Epithelial
- Benign
- Borderline - doesnt mean bordeline cancer - means it can spread but not invade like cancer, usually younger age
- Malignant
-
Germ Cell
- Benign
- Malignant
-
Stromal
- Benign
- Malignant
Case Report 4 - Ovarian Cyst
- 19 year old female presents with two year history of “fullness” in the right side of the pelvis.
- deep dysparunia, but increasing urinary frequency
- Periods normal
- otherwise fit and well
- mass felt in right adnexum
- USS: complex cystic mass ? called?
- Histology: what type of cyst? arises from where?
- How to manage?
- classical appearance of a dermoid cyst - arising from germ cell
- Laparoscopic ovarian cystectomy - to manage cyst
- Uneventful recovery
- Classic dermoid below
There are malignant versions of germ cell tumours of ovary, usually…
- What age?
- slow or fast growing?
- Unilateral or bilateral? (usually)
- Express … markers
- curable?
- Young Women
- Often rapidly growing
- Usually Unilateral
- Express tumour markers
- Usually cured
Case Report 5 - ovarian cyst
- 18 year old female. Nulliparous (no babies)
- presents with recent onset of amenorrhoea
- noted also hair recession and hirsuitism
- on examination: clitoromegaly and slightly tender 10cm mass in left side of the pelvis.
- USS complex mass in pelvis mainly solid and vascular - classic for what type of tumour?
- blood test results
- remove how?
- stromal tumour
- Laparoscopy/ laparotomy to remove
- Sertoli-leydig tumour on histology
- stage one.
- Granulosa cell tumour most common
- Hormone producing because of stromal origin
- rarely bilateral
- prognosis for most is very good.
- Sertoli-leydig tumour on histology
- pic shown is cut through the tumour
Stromal Tumour - Ovary
- S…-L… tumours can produce testosterone
- Usually stage …
- … cell tumour most common
- Hormone producing because of stromal origin
- unilateral/bilateral?
- prognosis for most is …
- Sertoli-leydig tumours can produce testosterone
- Usually stage one
- Granulosa cell tumour most common
- Hormone producing because of stromal origin
- rarely bilateral
- prognosis for most is very good.
Epithelial Ovarian Tumours
- May be:
- Benign
- Borderline
- Malignant
- Benign
- can figure out which one due to it’s … complexity
- Benign
- Borderline
- Malignant
- Benign
- can figure out which one due to it’s USS complexity
Tumour markers help to distinguish whether ovarian tumours are benign, bordeline or malignant - which is the most common?
CA-125 (normal up to 35)
- other things can raise this though! if through the roof - usually diagnosis of cancer
Epithelial Ovarian Tumours - is it cancer?
- Tumour markers
- Risk of Malignancy Index = … x … x …
- Cut off for RMI?
- MRI
- Tumour markers
- Risk of Malignancy Index = Menopausal status (pre = 1, post = 3) x Ultrasound Score (0 or 1 complexity - 1 score, 2 or more - 3) x CA125 (tumour marker value)
- 250 is the RMI cut off for referral to cancer centre
- MRI
… is the RMI cut off for referral to cancer centre (ovarian tumours)
250 is the RMI cut off for referral to cancer centre
What is shown on this MRI?
Ovarian Cyst - complex
Complex Ovarian Cyst - what could this be?
Bordeline tumour or cancer
Management of Epithelial Ovarian Tumours - benign and borderline
- Tend to …
remove tumour - may just take cyst - in older women, take the ovary
Incidence of Cancer - Female
- __Breast cancer is the biggest worry - second, colon, third rectal cancer
- ovarian cancer - comes in fourth - why are we worried about it?
- 5 year survival rate - prognosis is poor compared to breast, uterus etc
- Age distribution - older she is, more likely to get cancer
Disease spread - ovarian cancer
Prognosis of Ovarian cancer is directly related to …
stage of disease
Presentation of Ovarian Cancer
- A silent disease - ..-..% present at advanced stage
- Symptoms of … involvement
- Symptoms from distant …
- General …, … loss
- A silent disease - 60-80% present at advanced stage
- Symptoms of abdominal involvement
- Symptoms from distant metastases
- General malaise, weight loss
Case 6 - Ovarian Cyst
- Patient aged 58 y.o. G3P2
- 6/12 of vague abdominal discomfort
- Recent nausea and poor appetite and 1 stone loss of weight.
- Increasing malaise and tiredness
- On examination: pic shown
- CT complex ovarian masses with ascites and upper abdominal disease
- What do we do?
- CT shown:
- widespread cancer
- Surgery
- Staging / Debulking.
- Chemotherapy
- Carboplatin +/- Taxol
- Bevacizumab (Avastin)
- targets a cancer cell vascular endothelial growth factor (VEGF)
Debulking procedure for ovarian cancer
The surgeon aims to remove as much of the cancer as possible if it has spread to other areas in your pelvis or abdomen.
Chemotherapy for Ovarian Cancer
- What is used?
- usually combination of carboplatin +/- Taxol
Screening for Ovarian Cancer
- FHx of Ovarian Cancer
- Life time risk
- 1 first degree relative with ovary or breast Ca
- 2 or more relatives
- Is screening beneficial?
- FHx of Ovarian Cancer
- Life time risk
- 1 first degree relative with ovary or breast Ca
- 2 or more relatives
- Screening is of no proven benefit so only for the really high risk and after counselling
Risk of ovarian cancer
- 1 in …
- …% life time risk
- increases to about ..-..% if one first degree relative (mum, sister, daughter)
- 2 or more relatives - … mutation? up to …% chance of cancer.
- Very high risk group - target for screening
- 1 in 70
-
1.2% life time risk
- increases to about 3-5% if one first degree relative (mum, sister, daughter)
- 2 or more relatives - BRCA mutation? up to 50% chance of cancer. Very high risk group - target for screening
Ovarian Cancer - Summary
- Insidious Disease but it is not silent
- Presents late
- Remissions are often possible
- Cures only in early stage disease
