Ovarian Masses

Question 1

Where anatomically are the ovaries and what are its attachments?

Answer 1

Occupy the ovarian fossa on the lateral pelvic wall overlying the ureter.

They are attached to:

• the broad ligament by the mesovarium
• the pelvic wall by the infundibulo pelvic ligament
• the uterus by the ovarian ligament

Question 2

How are ovarian masses usually identified?

Answer 2

As a incidental finding on USS.

If they are very large and cause abdominal distension.

Acutely associated with accidents, rupture, haemorrhage, torsion.

Question 3

In which group are epithelial tumours most common?

Answer 3

Most common in post menopausal women.

Can be both benign and malignant

Question 4

What are the different types of epithelial tumours?

Answer 4

Serous cystadenoma or adenocarcinoma: most common malignant ovarian neoplasm. (usually unilocular)

Mucinous cystadenoma or adenocarcinoma: 10% malignant multloculated and unilateral.

Endometriod carcinoma: often malignant and associated with endometrial carcinoma.

Clear cell carcinoma: relatively rare, malignant with a very poor prognosis.

Brenner tumours: rare, small, benign and unilateral.

Note: malignant epithelial tumours are commonly referred to as ovarian Ca

Question 5

Which group are germ cell tumours most common in?

Answer 5

Young premenopausal women.

Question 6

What are the different types of germ cell tumours?

Answer 6

Teratoma/dermoid cyst:
Usually benign, most common in young premenopausal women 90%. Often asymptomatic but can rupture which is very painful. May contain fully differentiated tissues (hair, teeth).

Can be malignant very rarely.

Dysgerminoma: rare but still most common ovarian malignancy in younger women.

Question 7

Where do sex chord tumours originate from?

Answer 7

Stroma of the gonad.

Question 8

What are the different causes of sex chord tumours?

Answer 8

Granulosa cell tumours: usually malignant, but slow growing. Secrete oestroddiol and inhibin. Causes bleeding, endometrial hyperplasia and endometrial malignancy. Inhibin is used as the tumour marker.

Thecomas: Very rare, usually benign secrete oestrogen and androgens and present with PV bleeding.

Fibromas: Rare and benign. Can cause meig’s syndrome: ascites, pleural effusion + small ovarian mass.

Question 9

What are the non neoplastic causes of ovarian masses?

Answer 9

Functional cysts (most common enlargement of the ovaries in reproductive years)

Pathological:

• Endometriotic cysts aka chocolate cysts/endometriomas
• PCOS
• Theca lutein cysts: multiple ovarian cysts occur in conditions with increased HCG

Question 10

What are the different types of functional cyst?

Answer 10

Follicular or lutein which are persistently enlarged follicles and corpora lutea.

They only occur in pre menopausal women.

Question 11

What is the tumour marker which is tested for in ovarian Ca?

Answer 11

CA125

Question 12

How do benign ovarian tumours present and how do you manage them?

Answer 12

May be symptomless or may cause lower abdominal pain in these scenarios just manage pain as most cysts will resolve spontaneously.

May present with acute abdomen in which cause manage with laparoscopy and send bloods for CA125

Question 13

How do you manage ovarian cysts based on size?

Answer 13

If cyst is less than 5 cm and simple. Monitor with USS and consider doing CA125.

If persistent but still less than 5cm and simple: biopsy.

If cyst is greater than 5cm or is dermoid: cystectomy ai to prevent any spillage as this can cause chemical peritonitis.

If suspicious findings at laparoscopy take biopsy for diagnosis and refer to cancer centre for a full staging laparotomy.

Question 14

What score is used to calculate post menopausal women’s ovarian ca risk and how should they be managed spending on there risk?

Answer 14

Risk of malignancy index (RMI)

Low RMI: USS and CA125 follow up 4 monthly for 1 year is normal

Medium RMI: Bilateral oophorectomy.

High RMI: Refer to Ca centre for full staging laparotomy

Question 15

In which group of women is ovarian Ca most common?

Answer 15

Post menopausal peak incidence is 75-84years.

Question 16

What is the aetiology of ovarian Ca?

Answer 16

Irritation of ovarian surface epithelium by damage during ovulation.

Question 17

What are the risk factors for developing ovarian Ca?

Answer 17

Null parity
Early menarche/late menopause
BRCA gene mutations
HNPCC gene

COCP decreases risk (stops ovulation)
Pregnancy decreases risk

Question 18

What measure can be done to prevent the risk of ovarian Ca in women who carry the BRCA gene?

Answer 18

Prophylactic salpingooopherectomy

Question 19

How do ovarian Ca present?

Answer 19

Initially vague may not present to later on.

Symptoms may include:

• Abdominal distension
• Early satiety
• Loss of appetite
• Abdominal pain
• Increased urinary frequency

Question 20

Which factors make an ovarian mass more likely to be malignant?

Answer 20

Rapid growth greater than 5cm 
Ascites
Bilateral masses
Appears solid on USS
Increase vascularity

Question 21

How should you investigate suspected ovarian Ca?

Answer 21

Initial investigation:
CA-125 in all women over 50 with abdominal symptoms

If raised USS pelvis and abdomen if ascites or mass urgent referral to secondary care.

FBC, U/e’s and LFTs

Secondary care:
If less than 40 AFP (alpha feta protein) and HCG used to identify those who have germ cell tumours.

RMI is calculated (US score, menopausal state, CA-125)

Full body CT

Other rare tumour markers can be tested for:
CEA (colorectal ca)
CA 19.9 (mucinous tumour)
Inhibin (granolas cell tumours)

Question 22

What are the different stages of ovarian Ca?

Answer 22

1. Ovaries only
2. Spread to pelvis
3. Spread to abdomen and pelvis
4. Distant mets including liver

Question 23

How is ovarian ca treated?

Answer 23

Surgery:
Diagnostic laparotomy followed by radical surgery.

Total abdominal hysterectomy, bilateral salpingoopherectomy, omentectomy, + lymph node removal.

Surgery followed up with chemotherapy. Monitoring is done with CA125.