Ovaries

Question 1

What are ovarian symptoms?

Answer 1

• Ovarian masses are often silent- only detected when large causing abdominal distention, or on ultrasound scan, acute presentation is associated with ‘accidents’
Ovarian cyst rupture- contents enters the peritoneal cavity causing intense pain
• Haemorrhage: into the cyst or peritoneal cavity often cause pain- can cause hypovolaemic shock
Torsion: of the pendicle, which is bulky due to the cyst, causes infaraction of the ovary +/- tube and severe pain- urgent surgery and detorsion is required if the ovary is to be saved

Question 2

What are disorders of ovarian function?

Answer 2

PCOS: common disorder causing oligomenorrhoea, hirsutism and subfertility- the cysts are small, multiple, poorly developed follicles
• Premature menopause- when the last period is reach <40yrs
• Problems of gonadal development- includes the gonadal dysgeneses, the most common is Turner’s
syndrome

Question 3

What are epithelial tumours?

Answer 3

• Derived from the epithelium covering the ovary- most common in post-menopausal women
• Borderline- histology may show ‘borderline’ malignant features, but invasion is not these tumours may become frankly malignant
in these tumours surgery is advised, but in younger women close observation may be offered following removal of only the cyst or affect ovary recurrence as a borderline or invasive tumour can occur up to 20 years later

Question 4

What is serous cystadenoma or adenocarcinoma?

Answer 4

the malignant variety is the most common malignant ovarian neoplasm (50%) benign and borderline forms also exist

Question 5

What is mutinous cystadenoma or adenocarcinoma?

Answer 5

can become very large, but less frequently malignant (10%)
a rare borderline variant is pseduomyoxma peritonei
this is where the abdominal cavity fills with gelatinous mucin secretions, in these cases an appendiceal primary tumour should be excluded

Question 6

What is endometrioid carcinoma?

Answer 6

this malignant variant accounts for 25% of ovarian malignancies
it is similar histologically to endometrial carcinoma, with which it is highly associated (20%)

Question 7

What is clear cell carcinoma?

Answer 7

malignant variant that accounts for less than 10% of ovarian malignancies
has a particularly poor prognosis

Question 8

What are Brenner tumours?

Answer 8

Rare- usually small and benign

Question 9

What are germ cell tumours?

Answer 9

originate from the undifferentiated primordial germ cells of the gonad
Teratoma or dermoid cyst
Dysgerminoma

Question 10

What is a teratoma or dermoid cyst?

Answer 10

common benign tumour usually arising in young pre-menopausal women
may contain fully differentiated tissue of all cell lines (hair and teeth)
commonly bilateral, seldom large and often asymptomatic, but rupture can be painful
a malignant form also occurs in this age group, but is very rare (solid teratoma)

Question 11

What is a dysgerminoma?

Answer 11

female equivalent of the seminoma

rare, but is most common ovarian malignancy in younger women, it is very sensitive to radiotherapy

Question 12

What are sex cord tumours?

Answer 12

• Sex cord tumours originate from the stroma of the gonad
• Granulosa cell tumours- usually malignant, but slow growing
rare and usually found in post-menopausal women
they secrete high levels of oestrogen and inhibin, which stimulate the endometrium causing
o Bleeding
o Endometrial malignancy
o Endometrial hyperplasia
o Precocious puberty
Serum inhibin levels are used as tumour markers to monitor recurrence

Question 13

What are the other types of sex cord tumours?

Answer 13

• Thecomas- very rare, usually benign and can secrete both oestrogens and androgens
• Fibromas- rare and benign
can cause Meigs’ syndrome – ascites and right pleural effusion are found in conjunction with a small ovarian cyst
effusion is benign and cured by removal of the mass

Question 14

What are secondary malignancies?

Answer 14

• The ovary is a common site for metastic spread-particularly from breast and GI tract
secondaries account for up to 10% of malignant ovarian masses
• A few contain ‘signet-ring’ cells- these are call Krukenberg tumours
• The primary malignancy may be difficult to detect- prognosis is very poor

Question 15

What is an endometriosis cyst?

Answer 15

endometriosis commonly causes altered blood to accumulate in ‘chocolate cysts’
in the ovary these are called endometriomas- rupture is very painful

Question 16

What are functional cysts?

Answer 16

follicular cysts (enlarged follicles) and lutein cysts (copora lutea) are found in pre- menopausal women
follicular cysts are protected against by the COCP as it inhibits ovulation
lutein cysts cause more symptoms
if symptoms are absent, treatment is not required and the cyst is observed using serial USS
if a functional cyst >5cm persists >2 months, CA125 is measured and laparoscopy considered to remove or drain the cyst

Question 17

What is carcinoma of the ovary?

Answer 17

• Ovarian cancer is often silent- therefore it presents late, meaning the disease is widely metastatic within the abdomen, the 10yr survival rate is 40-50%
rates increase with age and 85% of cases occur in women >50yrs, with the median age of diagnosis as 63yrs, the lifetime risk is 1 in 60 in the UK
• 95% overall are epithelial carcinoma
germ cell tumours are the most common if a women is <30yrs
primary peritoneal and fallopian tube CA are rare malignancies, but share similarities with ovarian CA

Question 18

What is the aetiology of carcinoma of the ovary?

Answer 18

• Benign cysts undergo malignant change, but a premalignant phase is not normally recognised
• There is an increased recognition that the majority of high-grade serious adenocarcinomas actually originate in the fallopian tubes, the most common of which is ovarian CA
• Women with a family history can be offered counselling and testing for genetic mutation in BRAC1 and BRAC2 genes, those with the mutations are offered prophylactic salpino-oophorectomy

Question 19

What are the risk factors for ovarian carcinoma?

Answer 19

• Risk factors relate to the number of ovulations- therefore early menarch, late menopause and nulliparity are risk factors
pregnancy, lactation and the use of the pill is protective
• Ovarian CA may also be familial (5%) via BRAC1, BRAC2 or HNPCC gene mutations- if two relatives are affected, the lifetime risk is 13% and if BRAC1 is present there is a 50% risk
• BRAC1 and BRAC2 gene mutations are also associated with breast cancer
whilst HNPCC (Lynch’s syndrome)
is associated with an increased risk of bowel (80% lifetime risk) and endometrial CA

Question 20

What are the clinical features of ovarian carcinoma?

Answer 20

• Symptoms are often initially vague and/or absent- so 70% of patients present with stage 3-4 disease
o Persistent abdominal distention- ‘bloating’
o Feeling full (early satiety) and/or loss of appetite
o Pelvic or abdominal pain
o Increased urinary urgency and/or frequency
• Many of the symptoms are similar to those of IBS
• It is important to ask about breast and GI symptoms- a mass may be metastatic from these sites
• Examination may reveal cachexia, an abdominal or pelvic mass and ascites- very large masses are likely to be malignant- breasts should also be palpated

Question 21

How does ovarian carcinoma spread?

Answer 21

• Ovarian adenocarcinoma spreads directly within the pelvis and abdomen via transcoelomic spread
lymphatic and blood-borne spread (rare) can also occur
• Staging is surgical and histological