The Ovary and Its Disorders. Flashcards
What are ovarian symptoms?
Ovarian masses are often silent and detected when large and cause distension, or incidentally on USS. Acute
presentation is associated with ‘accidents’.
Define ovarian cyst.
fluid filled sac in the ovarian tissue
Describe the aetiology of ovarian cysts.
- Endometrioma: cyst formed via endometrial tissue on the ovary
- Functional cysts (occur around ovulation)
- Follicular: unruptured Graffian follicle (failed rupture of dominant; failed degeneration of non- dominant)
- Luteal: following rupture, it reseals and distends with fluid
- Haemorrhagic: bleeding into a functional cyst
How common are ovarian cysts? What are the RFs?
- 8% of pre-menopausal woman have one
RF: PCOS, Obesity, early menarche, 1st trimester of pregnancy and endometriosis
How do ovarian cysts present?
- Presentation: lower abdo pain, deep dyspareunia, pressure symptoms, abdominal swelling, asymptomatic
- Acute accident: severe right/ left iliac fossa pain accompanied by vomiting in torsion. Includes:
- Torsion
- Haemorrhage
- Rupture
- Infection
How do we investigate ovarian cysts?
- Acute presentation: exclude pregnancy
- TVUSS 🡪 hyper/hypoechoic regions
- Bloods:
- FBC
- G&S
- CA-125
- bHCG, LDH, AFP 🡪 germ cell tumour
- Doppler ultrasonography
- Consider: MRI and laparoscopic investigation
- RMI should be calculated
- Ovarian torsion most likely to occur with mature cystic teratomas
- Rupture of endometriotic and dermoid cysts causes most severe symptoms
How should we manage a simple cyst?
- <50mmm 🡪 do not require follow-up, should resolve in 3 menstrual cycles
- 50-70mm 🡪 yearly USS
- 70mm+ 🡪 consider MRI or surgery
How do we manage a complex cyst?
- Complex cyst (multi-loculated):
Laparoscopy/laparotomy 🡪 discuss oophorectomy
How should we manage an acute presentation of an ovarian cyst?
- ABC approach
- Ovarian cystectomy with oophorectomy if there is any necrosis
- Broad spectrum Abx
How should we manage a Solid/persistent/growing cysts?
should always be removed
What are the complications of ovarian cysts?
Complications: cyst accident, subfertility, malignant change, oophorectomy
All ovarian cysts that are suspicious of malignancy in a postmenopausal woman, as indicated by a RMI I greater than or equal to 200, CT findings, clinical assessment or findings at laparoscopy, require a full laparotomy and staging procedure.
What is an ovarian cyst accident? How should they be managed?
- Rupture of contents of ovarian cyst into peritoneal cavity → intense pain, especially if endometrioma
or dermoid cyst - Haemorrhage into a cyst or peritoneal cavity also causes pain
- Torsion of the pedicle causes infarction of the ovary + tube with severe pain
o Urgent surgery and detorsion required
What are the disorders of ovarian function?
- PCOS: oligomenorrhoea + hirsutism + sub-fertility - Cysts = multiple, poorly developed follicles
- Premature menopause: last period before 40 years of age
- Problems of gonadal development: gonadal dysgeneses – most common = Turner’s Syndrome
How do we classify primary neoplasms?
Can be benign or malignant
Classified together as benign cyst can undergo malignant change
What are epithelial tumours? Who do they present in?
Tumour derived from epithelial layer covering the ovary (90%). Mainly postmenopausal women
How do we classify epithelial tumours?
By histology
What are the types of epithelial tumours? How do we manage them?
-
Borderline - malignant histological feature are present but not invasive
- May become malignant so surgery is advised .
- In younger women - close observation may be offered following removal of the cyst or unaffected overy to preserve fertility
- Recurrence can occur up to 20 yrs later.
-
Serous cystadenoma
(adenocarcinoma)
– most common malignant ovarian neoplasm 50% malignancies- Classed as high grade or low grade
-
Mucinous cystadenoma
(adenocarcinoma) → can become v large
– 3% of ovarian malignancies- Abdominal cavity fills with gelatinous mucin secretions
-
Pseudomyxoma peritonei
– borderline variant of
mucinous cystadenoma
→ filling of abdominal
cavity with mucinous
secretions -
Endometroid Carcinoma
– 10% of ovarian malignancies,
similar histologically to
endometrial Ca → poor prognosis - Clear cell carcinoma - malignant varinat that accounts for 10% of ovarian malignancies
-
Brenner Tumour
Rare, small, usually
benign
What are germ cell tumours and who do they present in?
Undifferentiated primordial
germ cells of gonad and present in young, premenopausal women.
What are the types of germ cell tumours? How do we manage them?
-
Teratoma (dermoid cyst)
- Common and benign
- Contains fully differentiated tissue of all cell lines (commonly hair and teeth)
- Commonly bilateral
- Asymptomatic
- Rupture = painful
- A malignant form, the solid teratoma, also occurs in this age group but v rare.
- Surgical removal
-
Yolk sac tumour
- Highly malignant and present in young women/children.
-
Dysgerminoma
- Female equivalent of seminoma
- Most common malignancy in younger women
- Sensitive to radiotherapy
Define sex cord tumours. Who does it present in?
Tumour from the stroma of the gonad (the cells that hold the ovaries together and produce female hormones). Mainly young premenopausal or post-menopausal
What are the types of sex cord tumours?
-
Granulosa cell tumour
- Rare, malignant but slow growing
- post-menopausal women
- Secrete oestrogens and inhibin
- Stimulation of endometrium → PMB, endometrial hyperplasia and precocious puberty
- Serum inhibin used as a marker
-
Thecoma
- Rare, usually benign
- Secrete androgens or oestrogens
-
Fibroma
- Rare and benign
- Meig’s Syndrome: ascites and right pleural effusion found with small ovarian mass
- Cured by removal of the mass
What are secondary malignancies?
Ovary = common site for metastases, particularly from breast and GIT
Secondaries = 10% malignant ovarian masses
Describe the epidemiology of ovarian cancer.
In the United Kingdom each year, ovarian cancer is diagnosed in over 6500 women and causes approximately 4400 deaths.
Many women present with advanced disease with little prospect of cure.
The 5 year survival rate for advanced ovarian cancer between 2005–2009 was 43%
Describe the aetiology of ovarian cancers.
- Premalignant phase not normally recognised
- Risk factors relate to number of ovulations
o Early menarche
o Late menopause
o Nulliparity - Protective
o Pregnancy
o Lactation
o COCP - OCa may be familial via BRCA1, BRCA2 and HNPCC
o Two relatives affected, lifetime risk = 13.1%
o With BRCA1: 50%
Nulliparity, fertility tx, FH, Hx of breast cancer, high fat diet, HNPCC, Lynch syndrome, early menarche/late menopause, IUD, endometriosis
What are the clinical features of ovarian cancers?
- History
- Vague/absent symptoms
- 70% present with stage 3-4
- Sx include persistent abdominal distension, feeling full, loss of appetite, pelvic/abdominal pain,
increased urinary urgency or frequency - Many symptoms similar to IBS → unusual to present for first time in older women
- Ask about breast and GI symptoms as could be metastasis
- Examination
- Cachexia
- Abdominal/pelvic mass
- Ascites
How do ovarian carcinomas spread?
Ovarian adenocarcinoma spreads directly within the pelvis and abdomen = transcoelomic spread
Also lymphatic and blood-borne spread
What are the stages of ovarian cancers?
What tests should be done in a primary care setting?
For any woman who has normal serum CA125 (less than 35 IU/ml), or CA125 of 35 IU/ml or greater but a normal ultrasound:
assess her carefully for other clinical causes of her symptoms and investigate if appropriate
if no other clinical cause is apparent, advise her to return to her GP if her symptoms become more frequent and/or persistent.
Malignancy indices
Calculate a risk of malignancy index I (RMI I) score (after performing an ultrasound ) and refer all women with an RMI I score of 250 or greater to a specialist multidisciplinary team.
How should we establish the diagnosis in secondary care?
- Establishing Diagnosis (secondary care)
- Ca125 + USS
- Women under 40: measure AFP and hCG (both raised in germ cell tumours)
- Calculate risk of malignancy index (RMI)
- RMI = U x M x Ca125 level
- U = USS Score
- 1 point for each of the following characteristics:
- Multilocular cysts
- Solid areas
- Metastases
- Ascites
- Bilateral lesions
- 1 point, U =3; 2-5 points (max score) U=3
- M = menopausal status
- 1 = premenopausal
- 3 = postmenopausal
- All women with RMI >250 referred to specialist MDT
- CT abdo-pelvis is performed for initial assessment of extent of disease
How do we think of managing ovarian cancers?
- Adapt management to stage (may need to do additional ix)
- Support/Palliative care
When should systematic retroperitoneal lymphadenectomy be done?
Perform retroperitoneal lymph node assessment as part of optimal surgical staging in women with suspected ovarian cancer whose disease appears to be confined to the ovaries (that is, who appear to have stage I disease).
Lymph node assessment involves sampling of retroperitoneal lymphatic tissue from the para-aortic area and pelvic side walls if there is a palpable abnormality, or random sampling if there is no palpable abnormality.
Do not include systematic retroperitoneal lymphadenectomy (block dissection of lymph nodes from the pelvic side walls to the level of the renal veins) as part of standard surgical treatment in women with suspected ovarian cancer whose disease appears to be confined to the ovaries (that is, who appear to have stage I disease).
When should Adjuvant systemic chemotherapy for stage I disease be offered?
Do not offer adjuvant chemotherapy to women who have had optimal surgical staging and have low-risk stage I disease (grade 1 or 2, stage Ia or Ib).
Offer women with high-risk stage I disease (grade 3 or stage Ic) adjuvant chemotherapy consisting of 6 cycles of carboplatin.
Discuss the possible benefits and side effects of adjuvant chemotherapy with women who have had suboptimal surgical staging and appear to have stage I disease.
What is optimal surgical staging?
Optimal surgical staging constitutes: midline laparotomy to allow thorough assessment of the abdomen and pelvis; a total abdominal hysterectomy, bilateral salpingo-oophorectomy and infracolic omentectomy; biopsies of any peritoneal deposits; random biopsies of the pelvic and abdominal peritoneum; and retroperitoneal lymph node assessment
How do we manage advanced (Stage II to IV) ovarian cancer?
If performing surgery for women with ovarian cancer, whether before chemotherapy or after neoadjuvant chemotherapy, the objective should be complete resection of all macroscopic disease.
Stage 2-4: carboplatin or cisplatin alone or combination with paclitaxel
o 2/3 of women whose tumours initially respond to first-line chemo will relapse within 2 years of
completing tx
What are the different types of chemotherapy?
What is the follow up after ovarian cancer tx?
Levels of Ca125
CT scanning
Interval debulking of residual tissue
Chemotherapy prolongs short term survival and improves QOL
Poor prognostic indicators
o Advanced stage
o Poorly differentiated tumours
o Slow or poor response to chemotherapy
Death due to bowel obstruction or perforation
Prognosis improving for those detected early
What forms part of the palliative care on ovarian cancers?
Palliative care: achieve total care of the patient whose disease is incurable
Improve QOL
Address sx such as pain, nausea, bleeding, sx of obstruction & also psychological, social and spiritual
needs
Usually coordinated by GP, specialist practitioner e.g. macmillan nurse and specialist hospices/
gynaecology units
How do we control symptoms in ovarian cancer?
Symptom Control
Pain
o Analgesic ladder
o Co-analgesics = antidepressants, steroids and cytotoxics
o Opioid analgesia can be patient-controlled and usually accompanied by anti-emetics
o Alternative therapies e.g. acupuncture also used
Nausea and vomiting
o 60% patients with advanced carcinoma
o Due to opiates, metabolic causes (uraemia), vagal stimulation or psychological factors
o Antiemetics include anticholinergics, antihistamines, dopamine antagonists of 5HT-3 antagonists
Heavy vaginal bleeding
o Advanced cervical and endometrial cancer
o High dose progestogens
o Radiotherapy if not already used
Bowel obstruction and ascites
o Particularly in OCa
o Ascites – drained by repeated paracentesis
o Mx of obstruction at home – 1/3 spontaneous resolution
o Metoclopramide used if partial obstruction
o Can use dexamethasone for tissue oedema
o Complete obstruction: cyclizine and ondansetron for N&V, with hyoscine for spasm
o Surgical palliation indicated with acute, single-site obstruction
o Can insert stents in sigmoid or rectum
Terminal distress
o Last 24h
o Good symptom control with anxiolytics and analgesics without overlying sedating
Define ovarian torsion.
Ovarian torsion is a condition where the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa).
Who usually gets ovarian torsion?
Ovarian torsion is usually due to an ovarian mass larger than 5cm, such as a cyst or a tumour. It is more likely to occur with benign tumours. It is also more likely to occur during pregnancy.
Ovarian torsion can also happen with normal ovaries in younger girls before menarche (the first period), when girls have longer infundibulopelvic ligaments that can twist more easily.
What are the consequences of ovarian torsion?
Twisting of the adnexa and blood supply to the ovary leads to ischaemia. If the torsion persists, necrosis will occur, and the function of that ovary will be lost. Therefore, ovarian torsion is an emergency, where a delay in treatment can have significant consequences. Prompt diagnosis and management is essential.
A delay in treating ovarian torsion can result in loss of function of that ovary. The other ovary can usually compensate, so fertility is not typically affected. Where this is the only functioning ovary, loss of function leads to infertility and menopause.
Where a necrotic ovary is not removed, it may become infected, develop an abscess and lead to sepsis. Additionally it may rupture, resulting in peritonitis and adhesions.
How does ovarian torsion present?
- Sudden pelvic or abdominal pain, fluctuating, radiating to loin or thigh
- Nausea + Vomiting
- Pyrexia
- Tachycardia
- Generalised abdominal tenderness, localised guarding, rebound
- Cervical excitation, adnexal tenderness, adnexal mass
How do we diagnose ovarian torsion?
Pelvic ultrasound is the initial investigation of choice. Transvaginal is ideal, but transabdominal can be used where transvaginal is not possible. It may show “whirlpool sign”, free fluid in pelvis and oedema of the ovary. Doppler studies may show a lack of blood flow.
The definitive diagnosis is made with laparoscopic surgery.
How do we manage ovarian torsion?
Patients need emergency admission under gynaecology for urgent investigation and management. Depending on the duration and severity of the illness they require laparoscopic surgery to either:
- Un-twist the ovary and fix it in place (detorsion)
- Remove the affected ovary (oophorectomy)
The decision whether to save the ovary or remove it is made during the surgery, based on a visual inspection of the ovary. Laparotomy may be required where there is a large ovarian mass or malignancy is suspected.
