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Repro > Ovarian Cysts & Cancers > Flashcards

Ovarian Cysts & Cancers Flashcards

1
Q

DD for pelvic mass (16)

A

Pregnancy, bladder tumours, bladder distension, uterine fibroids, adenomyosis, carcinosarcomas, leiomyosarcoma, cervical cancer, ovarian mass, tubal mass, bowel tumours, appendiceal mass, hernias, diverticular abscess, pelvic kidney and ascitis

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2
Q

DD for tubal mass causing pelvic mass (3)

A

Hydrosaplinx, ectopic pregnancy or tuboovarian abscess

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3
Q

Ovarian masses can be caused by surface epithelium-stroma, germ cells or sex cord-stroma. The most common tumour comes from which cell type?

A

Surface epithelium-stroma

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4
Q

What are 5 types of surface epithelium-stroma cell tumours?

A

Serous, mucinous, endometrioid, clear cell, transitional cell

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5
Q

What are 5 tumours of germ cell origin?

A

Dysgermimoma, yolk sac, embryonal carcinoma, choriocarcinoma, teratoma

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6
Q

What are 6 tumours of sex cord-stroma origin?

A

Granulosa cell, thecoma, fibroma, sertoli cell, sertoli-leydig, steroid

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7
Q

What are 5 main investigations in abdo mass?

A

Urine HCG, Blood test for tumour markers, USS, MRI for premenopausal and CT for postmenopausal

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8
Q

What is CA-125 and why is it not always indicative of cancer as a tumour marker?

A

Glycoprotein that is elevated in patient with ovarian cancer. CA-125 is produced by mesothelial cells which also line the peritoneum, pericardium and pleural surface so CA-125 can be elevated in both benign/malignant ovarian/non-ovarian diseases

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9
Q

3 physiological conditions in which CA-125 is elevated

A

Ovulation, pregnancy and retrograde menstruation

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10
Q

When is CEA elevated?

A

CEA elevated in mucinous cancers, particularly of ovary or GI tract but also in other benign and malignant conditions

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11
Q

_____ may be elevated in breast, pancreatic, thyroid and lung malignancies

A

CEA

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12
Q

_______ be elevated in smoking, mucinous cystadenoma of ovary, cholecystitis, liver cirrhosis, diverticulitis, IBD, pancreatitis, pulmonary infections

A

CEA

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13
Q

_______ may be elevated in endometriosis, benign ovarian cysts, fibroids

A

CA-125

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14
Q

_______ may be elevated in non-ovarian malignant conditions e.g. malignant ascites, disseminated malignancies from pleural/peritoneal surfaces

A

CA-125

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15
Q

______ may be elevated in other non-malignant disease e.g. autoimmune disease, sarcoidosis, colitis, diverticulitis, chronic active hepatitis, cirrhosis, pericarditis, pancreatitis, renal disease

A

CA-125

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16
Q

What does the ratio CA125/CEA <25 make you suspect in the case of ovarian mass?

A

That ovarian mass is metastatic in nature because if ovarian cancer then CA125 would be higher

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17
Q

Alpha foeto-protein, HCG and LDH are tumour markers used in women <40 yrs. Alpha foeto-protein is raised in ___________ ____________, HCG is raised in _____________ and LDH is raised in _____________.

A

Alpha foeto-protein: embryonal carcinoma, HCG: choriocarcinoma, LDH: dysgerminoma

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18
Q

What are 5 features that point towards a benign ovarian cyst?

A

Unilocular, presence of solid component but <7mm, presence of acoustic shadows, multilocular but smooth, no blood flow

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19
Q

What are 5 features that indicate malignancy on ultrasound of ovarian cyst?

A

Irregular solid tumour, presence of ascites, at least 4 papillary structure, irregular multilocular-solid tumour, very strong blood flow

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20
Q

What are the 3 criteria in Risk of Malignancy Index (RMI)?

A

Menopausal status, ultrasonic feature, serum Ca125

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21
Q

Scoring system for RMI is (A) 1 for premenopausal, 3 for postmenopausal, (B) 0 for no USS feature, 1 for 1 feature and 3 for >1 feature and (C) absolute level of CA-125. How are these scores calculated?

A

A X B X C

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22
Q

RMI <30 = ___ in 100 OC?
RMI 30-200 = ___ in 100 OC?
RMI >200 = ___ in 100 OC?

A

RMI <30 = 3 in 100 OC
RMI 30-200 = 20 in 100 OC
RMI >200 = 75 in 100 OC

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23
Q

What is the use of further CT in ovarian cyst?

A

To assess spread of cancer and operability

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24
Q

What is the use of further MRI in ovarian cyst?

A

To characterise the ovarian cyst in a better way

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25
Q

What are the most common benign ovarian cysts? (3)

A

Functional ovarian cysts, endometriotic cysts and dermoid cysts

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26
Q

What are functional cysts related to?

A

Related to ovulation

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27
Q

Functional cysts are rarely >5cm in diameter & usually resolve spontaneously. However they may cause menstrual disturbance. True/false?

A

True

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28
Q

When would there be intervention for a funcitonal cyst?

A

When they are very big and causing a complication e.g. haemorrhage, rupture, acute torsion of ovary

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29
Q

How do endometriotic cysts present?

A

Severe dysmenorrhea/premenstrual pain, dyspareunia, associated with sub fertility, occasionally asymptomatic, acute abdomen if ruptures

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30
Q

O/E what do you find with endometriotic cysts?

A

Tender mass with modularity and tenderness behind uterus (because ovaries often join together in pouch of douglas behind uterus)

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31
Q

Ovaries have totipotential stem cells. What tissues may be found in dermoid cyst? AKA teratoma

A

Teeth, sebaceous material, hair, thyroid tissue (thyrotoxicosis)

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32
Q

Dermoid cysts are usually asymptomatic. When they are symptomatic how might they present?

A

Pelvic pain and dyspareunia

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33
Q

What are 3 factors to consider when treating benign ovarian cysts?

A

Symptoms, fertility & menopausal status

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34
Q

What are medical treatment options for treatment of benign ovarian tumours

A

GnRH analogues or oral contraceptives

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35
Q

What are surgical treatment options of benign ovarian tumours? (4)

A

Ovarian cystectomy, unilateral oopherectomy, bilateral oopherectomy or pelvic clearance

36
Q

What are borderline ovarian tumours?

A

Behave more like benign lumps, grow very slowly however can spread and spread as implant across surface rather than deeply invasive so better prognosis than ovarian cancer

37
Q

What is treatment for young women with borderline ovarian tumours?

A

Unilateral cystectomy/oopherectomy with close follow-up

38
Q

What is treatment for postmenopausal women with borderline ovarian tumours?

A

Pelvic clearance

39
Q

Ovarian cancer is often referred to as the silent killer. Why?

A

Is not usually symptomatic until disease has progressed quite far, often misdiagnosed as IBS, hormonal imbalances etc.

40
Q

What is lifetime risk of women developing OC?

A

2%

41
Q

NICE guidelines outline that if a woman reports any of the following symptoms more than 12 times per month, they should be referred for USS and CA-125. (4)

A

Bloating, early satiety/loss of appetite, pelvic/abdo pain and increased urinary urgency +/ frequency

42
Q

Ovarian cancer treatment is only surgery for _______ or ______, surgery followed by adjuvant therapy for ________ and neoadjuvant chemo followed by surgery for advanced stages.

A

Only surgery - stage 1A cancers or fertility sparing surgery in young women with germ cell tumours. Surgery + adjuvant therapy - early stages. Neoadjuvant chemo followed by surgery for advanced stages.

43
Q

Why do patients with ovarian cancers often find it difficult to lie down?

A

Because they often have ascites

44
Q

What is the aim of early stage ovarian cancer surgery?

A

Total macroscopic debulking of tumour for cytoreduction to improve prognosis, midline incision, do staging laparotomy, then removal of ovarian mass

45
Q

What is a staging laparotomy?

A

Examination of all surrounding tissues to find any more cancerous tissue as CT scan usually only detects lumps >1cm.

46
Q

Why is it particularly important to remove ovarian mass intact in early stage ovarian cancer surgery?

A

To prevent the cells from spilling out and spreading cancer

47
Q

What is classified as advanced ovarian disease?

A

Ovarian cancer beyond the pelvis, FIGO staging III and IV

48
Q

For advanced disease it is fairly impossible to do a complete cytoreduction. Therefore there are 2 approaches used for advanced disease, what are they?

A

Aggressive surgical cytoreduction with aim of leaving no residual disease or cytoreduction where residual deposits are no more than 1cm in diameter

49
Q

What is the goal of neoadjuvant chemo given before surgery in advanced stage III and IV ovarian cancer?

A

Goal is to shrink tumour size to make surgery less risky

50
Q

What is the usual neoadjuvant chemotherapy given in advanced stage ovarian cancer?

A

Usually 3 cycles of carboplatin and paclitaxel followed by repeat CT. If good response then interval debulking surgery and further 3 cycles of chemotherapy

51
Q

Where are secondary ovarian tumours usually from?

A

Breast, pancreas, stomach and GI

52
Q

What is the buzzword name for metastatic AKA secondary ovarian tumours & where do they usually metastasise from?

A

Kruckenberg tumour - characteristic signet ring histology, usually metastatic from stomach

53
Q

When should you suspect Krukenberg ovarian mets?

A

when CA 125/CEA is <25

54
Q

When is surgical treatment carried out for metastatic ovarian cancer?

A

Only when they are causing symptoms

55
Q

What are the 5 main groups of ovarian cysts?

A 
Follicular, (PCOS) 
Luteal, (corpus luteum) 
Endometrioticm 
Epithelial, 
Mesothelial
56
Q

What causes follicular cyst?

A

Can form when ovulation doesn’t occur so follicle doesn’t rupture but grows until it’s a cyst

57
Q

What cells line the thin walls of follicular ovarian cysts?

A

Granulosa cells

58
Q

What are 3 theories to explain the pathogenesis of ovarian endometriosis? (How it happens)

A

Regurgitation of endometrium through fallopian tubes,
Metaplasia of epithelial cells,
Vascular or lymphatic dissemination

59
Q

How can ovarian endometriosis appear macroscopically? (3)

A

Chocolate cysts,
Fibrous adhesions,
Peritoneal spots or nodules

60
Q

How does ovarian endometriosis appear microscopically?

A

Contains endometrial glands and stroma

May have haemorrhage, inflammation and fibrosis

61
Q

Outline 6 complications of ovarian endometriosis.

A 
Pain, 
Cyst formation, 
Adhesions, 
Infertility, (due to tubal damage and scarring) 
Ectopic pregnancy, (due to scarring) 
Malignancy (endometrioid carcinoma)
62
Q

Epithelial ovarian tumours are subdivided into bengin, borderline and malignant on what type of examination?

A

Histopathological examination

63
Q

What is another name for a transitional tumour and where normally are transitional cells?

A

Brenner - normally in lining of urinary system

64
Q

How are malignant serous carcinomas typed?

A

Low grade/high grade

65
Q

What are the most common types of epithelial ovarian tumours?

A

Serous, mucinous and endometrioid

66
Q

Serous, mucinous and endometrioid ovarian tumours resemble epithelial cells from which areas?

A

Serous - fallopian tube epithelial cells
Mucinous - endocervix epithelium
Endometrioid - glandular epithelium of uterus

67
Q

What is the defining feature for whether tumour is benign/borderline/malignant?

A

Stromal invasion presence - malignant has stromal invasion and others don’t

68
Q

What is the difference between grading in serous carcinoma of ovaries and serous carcinoma of uterus?

A

In uterus always high grade whereas in ovaries can be low or high grade

69
Q

What is the name of the precursor lesion of high grade serous carcinoma of the ovary?

A

Serous tubal intraepithelial carcinoma (STIC) - means it most likely is tubal

70
Q

What does a low grade serous carcinoma of the ovary develop from?

A

Serous borderline tumour

71
Q

Endometrioid carcinomas of the ovary are graded with the same G1-G3 system used for grading endometrioid carcinomas of the uterus. True/false?

A

True

72
Q

What two types of ovarian cancer are associated with Lynch syndrome (& which one in particular)?

A

Endometrioid and clear cell carcinoma, particularly clear cell

73
Q

How is primary diagnosis often made in pathology on ovary?

A

Ascitic fluid

74
Q

Brenner tumours are almost always malignant. True/false?

A

False - almost always benign

75
Q

Germ cell tumours account for approximately how much of all ovarian tumours and what is the most common type?

A

15-20% and most are teratoma

76
Q

What is the name of a teratoma that contains embryonic tissues?

A

Immature teratoma

77
Q

Give two examples of how teratomas can have somatic malignancy.

A

SCC from skin tissue or thyroid carcinoma from thyroid tissue

78
Q

What is the most common type of malignant germ cel tumours?

A

Dysgerminomas

79
Q

Dysgerminomas make up approx. 1-2% of all malignant ovarian tumours. What two groups are they almost exclusively in?

A

Children and young women

80
Q

Sex cord tumours: Fibromas and thecomas are ______ and may produce _______ causing uterine bleeding. Most common sex cord tumours are fibromas.

A

Benign - may produce oestrogen

81
Q

Sex cord tumours: granulosa cell tumours are all potentially ______ and may be associated with _____ manifestations

A

Malignant, oestrogenic manifestations

82
Q

Sex cell: Sertoli-Leydig cell tumours are rare and may produce _____

A

Androgens

83
Q

What are the four commonest metastatic tumours to ovaries?

A

Stomach,
colon,
breast,
pancreas

84
Q

Outline Figo Staging of Ovarian Cancer for 1A, 1B and 1C

A

1A: one ovary
1B: both ovaries
1C: ovarian surface/rupture/surgical spill/tumour in washings

85
Q

Outline Figo Staging of Ovarian Cancer for 2A and 2B

A

2A: extension on uterus/fallopian tube
2B: extension to other pelvic intraperitoneal structures

86
Q

Outline Figo Staging of Ovarian Cancer for 3A, 3B, 3C

A

3A: retroperitoneal lymph node metastasis or microscopic extrapelvic peritoneal involvement
3B: macroscopic extrapelvic peritoneal metastasis up to 2cm
3C: macroscopic extrapelvic peritoneal metastasis >3cm

87
Q

Outline Figo Staging of Ovarian Cancer for stage 4

A

Distant metastasis

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