Week 6 - F - Ovarian Cancer - Cysts, Endometriosis, Epithelial/Germ Cell/Stromal Tumours - Stages and Management

Question 1

Ovarian pathology may cause pain, swelling and endocrine effects The main groups of pathology are: * Cysts * Endometriosis * Tumours What is the most common ovarian cysts?

Answer 1

The most common ovarian cysts are functional cysts - these are usually follicular or luteal

Question 2

Ovarian cysts and PCOS are related conditions with many of the same symptoms, meaning that women often confuse the two, or wrongly believe that they have PCOS when they do not. What is the most significant difference between women with ovarian cysts and PCOS?

Answer 2

The most significant difference between the two conditions is that PCOS results in a substantial hormonal imbalance, which is not generally the case with ovarian cysts. PCOS - usually have abnormal insulin levels cause over tesosterone production preventing ovulation and causing hirsituism

Question 3

Ovarian cysts are sacs filled with fluid which are present in or on the ovaries. They are very common and as such, many women will develop them at some point in their lifetime. Most ovarian cysts occur naturally as a result of the normal menstrual cycle (functional cysts) and during the childbearing years. Usually, these cysts are harmless and will disappear on their own without the need for medical attention. What is the difference between follicular and luteal cysts?

Answer 3

Functional cysts form as a normal part of the menstrual cycle. There are several types of cysts: Follicular cysts -these cysts form when a sac forms but does not release the egg and then fills with fluid Luteal cysts - occurs when the sac releases the egg but then reseals and fills with fluid

Question 4

Functional cysts - enlarged or persistent follicular or corpus luteum cysts SO common they may be considered normal if <5cm. WHen do he cysts tend to be symptomatic? WHat are the symptoms? How long do the cysts usually take to resolve

Answer 4

Cysts tend to become symptomatic if they rupture causing pain due to rupture

Sometimes bleeding may occur also

The cysts usually resolve over 2-3 menstrual cycles

Pic shows a folliular ovarian cyst

Question 5

What is endometriosis? What are the symptoms?

Answer 5

It is when there are foci of endometrial glandular tissue outwith the endometrium Symptoms Pain before and during periods Dysparenuia Heavy or irregular bleeding Patients may also present with subfertiltiy

Question 6

Endometriosis can affect many different sites ie ovaries, pouch of Douglas, cervix, vagina and vula. What is it known when there is an endometrial cyst on the ovary?

Answer 6

When there is an endometrial cyst on the ovary this is known as a chocolate cyst

Question 7

WHat are the complications of endometriosis again?

WHat is used for the diagnosis of endometrioma? (ovaran endometriosis)

Answer 7

Complications

Subertility Adhesions Ectopic pregnancy can also cause malignancy

Diagnosis

• TVUS is usually best for diagnosis for endometrioma
• Diagnostic laproscopy may be used - also can treat

Question 8

What type of ovarianc cancer are those with endometriomas at risk of?

Answer 8

Endometrioid epithelial carcinomas

Question 9

What are the different broad categories for ovarian tumours ?

Answer 9

Epithelial Germ cell Sex cord / stromal tumours Metastases

Question 10

What are the different types of epithelial tumour? What are benign and malignant epithelial tumours known as?

Answer 10

Epithelial tumour types Serous Mucinous Endometrioid Clear cell Brenner Benign epithelial tumours - cystadenomas Malignant epithelial tumour - cystadenocarcinomas

Question 11

On histological examination of epithelial ovarian tumours, what are the tumours subdivided into?

Answer 11

Divided into benign, borderline or malignant epithelial ovarian tumour - this is done for all types of epithelial ovarian tumour

Question 12

There are different types of ovarian cancer with epithelial ovarian cancer (EOC) presenting as the most common type (~ 90%). What is the most common type of epithelial cancer tumour?

Answer 12

Serous ovarian cancer is the most common - and most aggresive supgroup of epithelial ovarian carcinoma

Question 13

Epithelial Ovarian Tumours categorised as benign, borderline or malignant Describe each category?

Answer 13

BEnign - cytology is normal and there is no abnormal proliferation - no stromal invasion also

Borderline - cytology abnormalities and proliferative No stromal invasion They are different to ovarian cancer because they don’t grow into the supportive tissue of the ovary (the stroma).

Malignant - stromal invasion has occur

Question 14

Serous carcinomas are two distinct entities with different precursor lesions : high grade and low grade serous carcinomas What are the high grade serous carcinomas precurosr lesions? Where are they said to originate?

Answer 14

* High grade serous carcinomas precurosr lesions - serous tubal intraepithelial carcinomas * They essentially are tubal in origin

Although ovarian cancer is said to originate in the cells of the ovary, research shows that the origin of high grade serous ovarian cancers is in the fallopian tube of the female reproductive system and the cancer invades the ovaries1

Question 15

Malignant serous ovarian cystadenocarcinomas (serous carcinomas) are divided into low grade and high grade High grade precursor are serous tubal intrapeithelail carcinomas and essentially originate form tubal origin What are the low grade serous caricnomas precursor lesions?

Answer 15

Low grade serous carcinoma precursor lesion - serous borderline tumour

Question 16

What do endometrioid and clear cell carcinoma have a strong association with?

Answer 16

There is a strong association with endometriosis of the ovary here

Question 17

Endometrioid tumour are graded in the same way as uterine tumours How is that doctors grade uterine tumours?

Answer 17

They compare the unhealthy tissue with normal tissue Grade 1 50% solid tumour growth

Question 18

Most endometrioid carcinomas are low grade and early stage. What syndrome is there an association with here?

Answer 18

Endometrioid cancers have an association with Lynch Syndrome (hereditary nonpolyposis colorectal cancer) Hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch syndrome is an autosomal dominant genetic condition that has a high risk of colon cancer as well as other cancers including endometrial cancer (second most common), ovary, stomach, small intestine, hepatobiliary tract, upper urinary tract, brain, and skin.

Question 19

Due to not wanting to take a biopsy from the ovary for fear of spreading the cancer How is primary ovarian tumour diagnosis often made?

Answer 19

Often made with an ascitic fluid sample

Question 20

Brenner tumors are an uncommon subtype of the surface epithelial-stromal tumor group of ovarian neoplasms. The majority are benign, but some can be malignant What type of epithelium do Brenner tumours typically arise from?

Answer 20

These tumours typically arise form Transitional cell epithelium (urothelium)

Question 21

Germ cell tumour account for around 20% of all ovarian tumours What is the main type of germ cell tumour found in ovarian tumours?

Answer 21

These would be teratomas - they arise from primitive germ cells

Question 22

What is the benign mature teratomas usually? What are they said to contain? Are they well or poorly differentiated?

Answer 22

The benign mature teratomas are known as dermoid cysts They are said to contain sebum, hair, teeth, fat - basically they are totipotent They are well differentiated

Question 23

What is the most common malignant primitive germ cell tumour? (accounts for 1-2% of all ovarian tumours)

What women does it almost exclusively occur in?

Answer 23

This is dygerminoma

• Almost exclusively occurs in young children and young women average age being 22

Question 24

What are dysgerminomas associated with an increase in?

Answer 24

There is an associated increase i calcium levels with this tumour

Question 25

What are the different types of sex cord/stromal tumours?

Answer 25

Fibromas - benign Granulosa - potentially malignant - produce oestrogen Thecal/Leydig cells - produce androgens

Question 26

What syndromes are fibromas associated with?

Answer 26

Fibromsas are associated with Meig’s syndrome - pleural effusion, ascites and fibromas (can be other ovarian tumours also)

Question 27

Metastatic tumours may come from anywhere and are important to consider in all cases, especially when bilateral and small What are the commonest sites to metastasise from however?

Answer 27

Stomach, pancreas, breast and colon

Question 28

IN primary care (GP) What are signs of ovarian cancer? What are symptoms? WHat are red flag symptoms?

Answer 28

Signs -ascites and pelvic mass that isnt a fibroid - if these signs exist, can refer straight to gynae Symptoms - Age >50, bloating or distension, early distension, urinary symptoms Red flags - unexplained weight loss, fatigue, change in bowel habits

Question 29

If ovarian cancer is expected, a CA125 test is carried out? What does this concentration have to be to carry out an ultrasound of abdomen and pelvic? (usually TVUS but can do TAUS if needed)

If this is abnormal, what is calculated before referral to gynaecology?

Answer 29

CA125 measurement of greater than 35IU/ml then refer for ultrasound:

• Multilocular mass INtra-abdominal mets Complex mass with solid and cystic area Associated ascited Bilateral disease

If USS is abnromal then calculate RMI

• RMI = menopasual status x CA125 x USS

Question 30

Ovarian cancers are staged from 1 to 4 in the FIGO Staging (same for cervical and uterine cancer (FIGO - Federation of Gynecology and Obstetrics) Describe stage 1 of ovarian cancer?

Answer 30

Stage IA - tumour limited to one ovary but no cancer on the surface of the ovary Stage IB - tumour limited to both ovaries but no cancer on the surface of the ovary Stage IC - cancer is one or both ovaries plus any of: cancer present on surface, tumour has burst, surgical spillage or in abdominal fluid (asictes or peritoneal washings)

Question 31

Describe stage II of ovarian cancer?

Answer 31

Stage IIA - cancer has spread to uterus, fallopian tubes or both Stage IIB - cancer has spread to ther parts of the pelvis not including the uterus or fallopian tubes (bowel or bladder for example)

Question 32

Describe stage III of ovarian cancer

Answer 32

Stage IIIA - cancer has spread to the lining of the abdomen (periotneum) but is small that it is only visible under the micrscope Stage IIB - cancer has spread to the lining of abdomen (peritoneum) the microscope but is less than 2cm in greatest dimension but can be seen without microscope Stage IIC - cancer has spread to the lining of the abdomen (peirotneum) but is lager than 2cm in greatest dimension Stage IV is just distant mestatses

Question 33

Describe each of the FIGO stagings of ovarian cancer

Answer 33

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Question 34

What is the management of ovarian cancer? What stages of disease may not need chemotherapy? Whata re the chemotherapy drugs used?

Answer 34

Surgery Total abdominal hysterecotmy (via laparotomy) with bilateral salpingo-oopherectomy Fllow up with 6 months chemo - uusally combined carboplatin and paclitaxel Early stages may not require chemo - Stage IA and IB Ovarian cancer is rare in women younger than 40.

Question 35

In women with advanced stage, Stage IIA and above, what is the aim of surgery before chemo?

Answer 35

The aim of surgery is to remove as much tumour as possible (debulking) before chemo CT stages the cancer

Question 36

What class of drug is carboplatin and paclitaxel?

Answer 36

Carboplatin is a platinum based compound Paclitaxel is a taxane

Question 37

The fallopian tubes may also be affected with diseasse - slapngitis is inflammation of tube WHat may it be caused by?

Answer 37

Usually PID - due to chlamydia or gonorrhea

Question 38

Fallopian tubes can be affected by other things than PID potentially leading to a build up of fluid in the tube due to a blocked sital tube - this is a hydrosalpinx (serous or clear fluid) What are some of the causes of the blockage other than PID?

Answer 38

Endometriosis A cyst Serous tubal intraepithelial carcinoma Ectopic pregnancy

Question 39

Symptoms can vary. with hydrosalpinx Some patients have lower often recurring abdominal pain or pelvic pain, while others may be asymptomatic. As tubal function is impeded, infertility is a common symptom. With regards to ectopic, pregnancy, what is the commonest site?

Answer 39

The commonest site is the fallopian tube - typically the ampulla

Question 40

What is the surgical management of an ectopic pregnancy?

Answer 40

Confirm pregnancy

• If ruptured pregnancy - immediate laparatomy - clamp the bleeding artery

Laparoscopy is preferred if no rupture -

• Remove whole fallopian tube if contralateral tube is healthy - salpingectomy
• Remove only ectopic pregnancy if contralateral tube is unhealthy - salpingotomy

Question 41

What drug can be given for management of ectopic pregnacy?

Answer 41

Methotrexate - can be used for small early ectopics

Give methotrexate before laparoscopy to reduce risk of persistent trophoblastic disease

Consider diagnosis in any female of reproductive age with amenorrhoea and acute hypotension or an acute abdomen.