Ovarian Cysts & Cancers Flashcards by Claire O'Regan

DD for pelvic mass (16)

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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DD for tubal mass causing pelvic mass (3)

Hydrosaplinx, ectopic pregnancy or tuboovarian abscess

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

Surface epithelium-stroma

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

Serous, mucinous, endometrioid, clear cell, transitional cell

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What are 5 tumours of germ cell origin?

Dysgermimoma, yolk sac, embryonal carcinoma, choriocarcinoma, teratoma

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What are 6 tumours of sex cord-stroma origin?

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

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What are 5 main investigations in abdo mass?

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

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

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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3 physiological conditions in which CA-125 is elevated

Ovulation, pregnancy and retrograde menstruation

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When is CEA elevated?

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

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

CEA

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

CEA

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

CA-125

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

CA-125

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

CA-125

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

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

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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 _____________.

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

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

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

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

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

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

Menopausal status, ultrasonic feature, serum Ca125

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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 X B X C

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

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

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What is the use of further CT in ovarian cyst?

To assess spread of cancer and operability

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What is the use of further MRI in ovarian cyst?

To characterise the ovarian cyst in a better way

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

Functional ovarian cysts, endometriotic cysts and dermoid cysts

What are functional cysts related to?

Related to ovulation

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

True

When would there be intervention for a funcitonal cyst?

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

How do endometriotic cysts present?

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

O/E what do you find with endometriotic cysts?

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

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

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

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

Pelvic pain and dyspareunia

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

Symptoms, fertility & menopausal status

What are medical treatment options for treatment of benign ovarian tumours

GnRH analogues or oral contraceptives

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

Ovarian cystectomy, unilateral oopherectomy, bilateral oopherectomy or pelvic clearance

What are borderline ovarian tumours?

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

What is treatment for young women with borderline ovarian tumours?

Unilateral cystectomy/oopherectomy with close follow-up

What is treatment for postmenopausal women with borderline ovarian tumours?

Pelvic clearance

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

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

What is lifetime risk of women developing OC?

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)

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

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

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.

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

Because they often have ascites

What is the aim of early stage ovarian cancer surgery?

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

What is a staging laparotomy?

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

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

To prevent the cells from spilling out and spreading cancer

What is classified as advanced ovarian disease?

Ovarian cancer beyond the pelvis, FIGO staging III and IV

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

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

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

Goal is to shrink tumour size to make surgery less risky

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

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

Where are secondary ovarian tumours usually from?

Breast, pancreas, stomach and GI

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

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

When should you suspect Krukenberg ovarian mets?

when CA 125/CEA is <25

When is surgical treatment carried out for metastatic ovarian cancer?

Only when they are causing symptoms

What are the 5 main groups of ovarian cysts?

``` Follicular, (PCOS) Luteal, (corpus luteum) Endometrioticm Epithelial, Mesothelial ```

What causes follicular cyst?

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

What cells line the thin walls of follicular ovarian cysts?

Granulosa cells

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

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

How can ovarian endometriosis appear macroscopically? (3)

Chocolate cysts, Fibrous adhesions, Peritoneal spots or nodules

How does ovarian endometriosis appear microscopically?

Contains endometrial glands and stroma | May have haemorrhage, inflammation and fibrosis

Outline 6 complications of ovarian endometriosis.

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

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

Histopathological examination

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

Brenner - normally in lining of urinary system

How are malignant serous carcinomas typed?

Low grade/high grade

What are the most common types of epithelial ovarian tumours?

Serous, mucinous and endometrioid

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

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

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

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

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

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

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

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

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

Serous borderline tumour

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

True

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

Endometrioid and clear cell carcinoma, particularly clear cell

How is primary diagnosis often made in pathology on ovary?

Ascitic fluid

Brenner tumours are almost always malignant. True/false?

False - almost always benign

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

15-20% and most are teratoma

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

Immature teratoma

Give two examples of how teratomas can have somatic malignancy.

SCC from skin tissue or thyroid carcinoma from thyroid tissue

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

Dysgerminomas

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

Children and young women

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

Benign - may produce oestrogen

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

Malignant, oestrogenic manifestations

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

Androgens

What are the four commonest metastatic tumours to ovaries?

Stomach, colon, breast, pancreas

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

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

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

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

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

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

Outline Figo Staging of Ovarian Cancer for stage 4

Distant metastasis