SM_222b: Ovary, Fallopian Tube, and Adnexal Mass Flashcards
Adnexa is ____
Adnexa is ovaries, fallopian tubes, upper portion of broad ligament, meso-ovarium and mesosalpinx, round ligament, ovarian ligament, and remnants of embryonic Mullerian duct
Fallopian tube has four sections: ____, ____, ____, and ____
Fallopian tube has four sections:
- Isthmus
- Ampulla
- Infundibulum
- Fimbria
Describe reproductive function of ovaries
Reproductive function of ovaries
- Produce immature female gametes (oocytes)
- Secrete female sex hormones including estrogens and progestins during the menstrual cycle
- Secrete inhibin, involved in the feedback control of pituitary FSH production
Describe endocrine function of ovary
Endocrine function of ovary
- Estrogen production
- Secondary target organs: bone, endothelium, and brain
Describe anatomy of the ovary
Ovary
- Surface epithelium
- Stroma: outer cortex containing follicles surrounded by granulosa and theca cells, inner medulla contains blood vessels and connective tissue
- Blood supply: ovarian artery and vein, uterine artery and vein
Describe clinical framework for evaluation of an adnexal mass
Clinical framework for evaluation of an adnexal mass
- Age of patient
- Clinical characteristics and exam findings
- Ultrasound imaging: size, simple, complex
- Serum tumor markers: CA125, bHCG, AFP, LDH, inhibin A/B
- Pertinent family history to suggest BRCA
Describe potential for malignancy in adnexa
Adnexa potential for malignancy
- Premenarchal: abnormal, malignant, germ cell
- Reproductive age: most common, benign, germ cell and epithelial
- Menopause: abnormal, malignant, epithelial / germ cell / stromal
Describe clinical and pelvic findings that are benign vs malignant
Clinical and pelvic findings that are benign vs malignant
- Benign: unilateral, cystic, mobile, smooth
- Malignant: bilateral, solid, fixed, irregular, ascites, cul-de-sac nodularity, rapid growth
Simple adnexal mass is ____, ____, and ____ on ultrasound
Simple adnexal mass is unilocular, hypoechoic, and has thin walls on ultrasound
Complex adnexal mass has ____, ____, ____, and ____ on ultrasound
Complex adnexal mass has internal echoes, septations, intramural nodules, and solid components on ultrasound
Describe indications for surgery of adnexal mass
Indications for surgery of adnexal mass
- Any adnexal mass > 10 cm
- Complex adnexal cyst > 5 cm
- Adnexal cyst > 5 cm with no resolution after 6-8 weeks
- Solid ovarian lesions
- Symptomatic for pain
Describe differential diagnosis for adnexal mass
Differential diagnosis for adnexal mass
- Sex cord-stroma: fibroma, thecoma, fibrothecoma
- Germ cells: teratoma, dysgenetic gonads, struma ovarii (thyroid tissue)
- Surface epithelium-stroma: serous, mucinous, endometrioid
____ are the most common clinically detectable ovarian enlargements during the reproductive years
Functional ovarian cysts are the most common clinically detectable ovarian enlargements during the reproductive years
Describe types of functional ovarian cysts
Functional ovarian cysts
- Follicular cyst: no ovulation
- Corpus luteum: post-ovulation, could be hemorrhagic
- Theca-lutein cyst: pregnancy
- Polycystic ovaries: > 10 follicles
Follicular cyst is ____, has ____, is lined by ____, and is up to ____ in size
Follicular cyst is follicle that is not ovulated, has clear fluid, is lined by granulosa cells, and is up to 10 cm in size
- Resolves in days to 2 weeks
Corpus luteum cyst is when ____, has ____, and there is a ____
Corpus luteum cyst is when ovulation occurs, has clear fluid or blood, and there is a variable delay in menses
- Resolves in 6-8 weeks
Describe ovaries in PCOS
PCOS
- Polycystic or sclerocystic ovaries
- Multipl follicles (≤ 10) with hyperplasia and luteinization of theca interna surrounding cysts and atretic follicles
- Thickened capsule
- Size: 2-5 x normal
PCOS characteristics are ___, ___, and ___
PCOS characteristics are menstrual dysfunction, hyperandrogenism, and concurrent metabolic disorders such as dyslipidemia and insulin resistance
Describe benign ovarian neoplasms
Benign ovarian neoplasms
- Classified by cell of origin: epithelial, germ cell, stromal cell
- Reproductive age: 90% benign, 10% malignant
- Postmenopausal: 25% malignant
- Rarely resolve spontaneously
- Often warrant surgery because of risk of ovarian torsion, desire for diagnosis (rule out malignancy)
- Can be treated with fertility-sparing surgery
Epithelial ovarian tumors are ____, ____, or ____
Epithelial ovarian tumors are serous, mucinous, or endometrioid
- Serous cystadenomas are the most common epithelial neoplasm
Serous cystadenoma is ____ and ____
Serous cystadenoma is unilocular or multilocular and sometimes bilateral
- Most common epithelial neoplasm
Mucinous cystadenoma is ____, ____, and ____
Mucinous cystadenoma is large, multicystic, and filled with mucin
Endometrioma is ____, contains ____, and is called ____
Endometrioma is associated with endometriosis, contains thick brown tar-like fluid, and is called a chocolate cyst
Sex cord stromal tumors occur ____ and can produce ____
Sex cord stromal tumors occur equally across age and can produce hormones
- Estrogen producing: precocious puberty, irregular menses or postmenopausal bleeding
- Androgen producing: hirsutism, virilization
Fibroma is composed of ____ and has ____
Fibroma is composed of fibrous connective tissue and has solid masses
Thecoma involves ____ and ____ and is ____
Thecoma involves stromal hyperplasia and hyperthecosis and is hormonally active
Meig’s syndrome presents with ____, ____, and ____
Meig’s syndrome presents with ovarian mass (usually fibroma), ascites, and right sided pleural effusion
Germ cell tumors are derived from ____ and may contain ____
Germ cell tumors are derived from primary germ cells and may contain relatively differentiated structures
- Teratoma (hair, bone)
- Struma ovarii (thyroid)
____ is the most common tumor found in women of all ages
Teratoma is the most common tumor found in women of all ages
- Contains differentiated tissue from 3 embryonic germ layers: ectoderm, mesoderm, and endoderm
- Dermoid
Describe ovarian carcinoma
Ovarian carcinoma
- Second most common gynecologic cancer
- Most lethal gynecologic cancer
- 70% of patients are diagnosed at advanced stage: IIIc and IV
Describe malignant ovarian neoplasms
Malignant ovarian neoplasms
- Sex-stromal tumor: granulosa cell tumor, Sertoli-Leydig tumor
- Germ cell tumor: dysgerminoma, choriocarcinoma, yolk sac tumor, immature teratoma
- Epithelial ovarian cancer: serous, mucinous, endometrioid, and clear cell
Describe etiology of ovarian cancer
Etiology of ovarian cancer
- Incessant ovulation theory: epithelial damage and repair of surface with ovulation
- Increased risk with increased number of cycles: late menopause, early menarche, nulliparity, infertility
- Genetics (10%): BRCA, Lynch syndrome
Describe risk factors for ovarian cancerr
Risk factors for ovarian cancerr
- Increase risk: age, family history of ovarian / breast cancer, infertility / low parity, and personal history of breast cancer
- Decrease risk: OCPs, pregnancy, tubal ligation, and breast feeding
Ovarian cancer usually presents with ____ symptoms
Ovarian cancer usually presents with non-specific symptoms
- Bloating
- Indigestion
- Pelvic / abdominal pain
- Abdominal distention (ascites in 75%)
- Constipation
- SOB (pleural effusion)
Describe evaluation of suspected ovarian cancer
Evaluation of suspected ovarian cancer
- History and physical exam
- Pelvic exam
- Tumor markers: epithelial ovarian cancer (CA125), germ cell tumors (AFP, LDH, HCG), sex cord stromal tumors (inhibin)
- CT c/a/p
- Paracentesis if ascites
- Thoracentesis if pleural effusion
Exploratory laparotomy for ovarian cancer is used for ____, ____, ____
Exploratory laparotomy for ovarian cancer is used for establishing the diagnosis, staging, and tumor debulking
Describe FIGO ovarian cancer staging
FIGO ovarian cancer staging
- Stage I: confined to ovaries
- Stage II: limited to pelvis
- Stage III: spread to upper abdomen or lymph nodes
- Stage IV: distant spread (lungs)
____ is used to treat advanced stage ovarian carcinoma
Debulking is used to treat advanced stage ovarian carcinoma
- To remove as much tumor as possible: bowel resections, splenectomy, stripping of diaphragm
- Goal: residual disease less than 1 cm (survival advantage)
Advanced stage ovarian carcinoma is also treated with ____
Advanced stage ovarian carcinoma is also treated with chemo
- Response rates are favorable but recurrence rates are high
Germ cell tumors occur at ____ age and are described as ____
Germ cell tumors occur at younger age (16-20 years) and are solid rapidly enlarging masses
Describe germ cell tumor markers
Germ cell tumor markers
- Dysgerminoma: LDH
- Yolk sac tumor: AFP
- Choriocarcinoma: HCG
- Immature teratoma: mixed
Describe sex cord stromal tumors
Sex cord stromal tumors
- Older age (mean 52)
- Solid / cystic
- 95% unilateral
- Hormonally active: abnormal uterine bleeding, endometrial hyperplasia / cancer, virilization
- Sertoli-Leydig tumor
- Granulosa cell tumor
____ are ____ tumor suppressor genes implicated in hereditary breast and ovarian cancer syndrome
BRCA1 and BRCA2 are tumor suppressor genes implicated in hereditary breast and ovarian cancer syndrome
- DNA repair by homologous recombination
- Autosomal dominant inheritance with high penetrance
____ of ovarian cancer cases are attributable to an inherited syndrome
5-10% of ovarian cancer cases are attributable to an inherited syndrome
_____ is associated with a 95% reduction in the risk of ovarian / fallopian tube carcinoma and 50% reduction in risk of breast cancer
Prophylactic bilateral salpingo-oophorectomy is associated with a 95% reduction in the risk of ovarian / fallopian tube carcinoma and 50% reduction in risk of breast cancer
- Patients with BRCA1 or BRCA2 mutation
- After age 35 or when reproductive wishes completed
