Ovarian Pathology for Undergraduates

Max Brinsmead MB BS PhD

November 2014

Incidence

1:10 women will undergo surgery during a lifetime because of suspected ovarian pathology10% turn out to be non ovarianThe vast majority in pre menopausal women are benignOvarian cancer affects ≈ 1:100 women– And is the most common cause of death from

gynaecological malignancy

Ovarian pathology presents as:

PainMassBut most commonly as an incidental finding on imaging

When the most important thing to determine is whether:

It is functional or neoplastic?Benign or malignant?

Pathology of Functional Ovarian Cysts:

A 2 cm “cyst” occurs every month = mature follicle

Haemorrhage from or into a corpus luteum is common

Failed follicular rupture can also result in a cyst

Especially if there are adhesions from PID or pelvic surgery

Endometrioma = ovarian endometriosis

A normal Corpus Luteum

Haemorrhage into a Corpus Luteum

After the identification of a pelvic adnexal mass evaluation is usually by ultrasound but think…

Is there a short history of symptoms?Is this a woman of reproductive age?Cycling spontaneously?Or using progestin-only contraception?A past history of “cysts”Pregnant?Had IVF?

Ultrasound features of a Functional Ovarian Tumour

Thin walledUsually no solid componentsUsually no septa or thin walled septaUsually <6 cm sizeUsually avascular to colour DopplerChange rapidlyAnd disappear within 6-8w

Ultrasound of a Follicular Cyst

Haemorrhage into a Corpus Luteum

Ultrasound of a malignant ovarian mass

Management Guidelines for a Simple Cyst in a Premenopausal Woman

Ignore if <30 mm in size and asymptomaticRepeat scan after 3 months for simple cysts 30 – 50 mm in size – Refer to a gynaecologist if still present

Further Investigations include…– Serum Ca 125– Further imaging by CT or NMR

Mechanisms of Pain with Ovarian Cyst

Rapid enlargementHaemorrhage or haemorrhagic ruptureLeaking sebaceous or endometrioma fluidTorsion– Requires tumour >5 cm on a thin pedicle– Torsion involves whole of the ovary and tube– Presents as “reverse renal colic”– Cervix will be deviated towards the tumour– Signs of “acute abdomen” or “acute pelvis”– Early surgery & untwisting may save the ovary

Clinical Features of a Neoplastic Ovarian Tumour:

Older women– 50% malignant for woman >50 years of age

Larger tumoursBilateralFixed, tender or craggy to palpationAscites presentSolid or Cystic with multiple septa & solid partsVascular to colour DopplerPersist or enlarge over timeAssociated with positive tumour markers – CA125, (CA19.9, CEA, AFP, HCG, LDH)

Differential diagnosis for an Adnexal Mass:

Full bladderPregnancyLoaded caecum or sigmoid colonParaovarian cystHydrosalpinxMesenteric cystFiboid (subserosal)Pelvic kidney etc.Other malignancy e.g. bowel

Pathology of Ovarian Neoplasms

Germ cell Tumours– Benign cystic teratoma = Dermoid – The most common neoplasm of young ♀– 15% bilateral over a lifetime– Malignant varieties includes Dysgerminoma (LDH), Teratocarcinoma,

Endodermal sinus Ca (AFP), ChorioCa (bHCG)

Epithelial– Cystadenoma (serous and mucinous)– Cystadenocarcinoma Serous– Mucinous– Endometroid– Clear cell adenoCa

Hormone-producing– Oestrogen-producing (granulosa cell benign or malignant)– Androgen-producing (Androblastoma)

Secondary Cancers (Stomach, Bowel, Breast etc.. Includes Krukenberg tumours)

Serous Cystadenoma

Serous Cystadenocarcinoma

Mucinous Cystadenoma

Role of Ca 125Of most value in the evaluation of adnexal mass in postmenopusal womenToo many false positives in premenopausal women– Endometriosis, Adenomyosis, Fibroids & PID

Always of concern if >200Specific only for epithelial tumours– And only 50% sensitive for early stage disease

Useful for monitoring response to treatment

Prognosis for ovarian cancer:

Overall 30 – 35% but this is because it presents late

With modern gynaecological oncology (debaulking + aggressive combination chemotherapy) it should be >50%

Preventing ovarian cancer:

Screening - Vaginal exams- Ultrasound & CA125

Have been disappointing – too many false positives

Prophylactic Oophorectomy- at hysterectomy (40%)- for genetically predisposed

(BRAC carriers)

Prophylactic salpingectomy

A word about Polycystic Ovaries:

Are common– Up to 20% of women who are cycling spontaneously i.e.

not on the Pill

Can be unilateral or bilateralDo NOT cause pain

Test QuestionsThe most common neoplasm of the ovary in young women is a serous cystadenoma

CA125 is useful in screening for ovarian cancer in postmenopausal women

The lifetime risk for ovarian (& testicular) cancer is 1:50

Haemorrhage into a corpus luteum can cause a cyst > 6 cm in size

Progestogen-only contraception increases the risk of neoplasia in the ovary

False – Benign cystic teratoma or DermoidsFalse – only 50% positive for early stage disease

False – 1:100

True

False – increased risk of functional ovarian cysts

Which of the following is NOT a feature of benign tumour in ovary assessed with ultrasound?

Simple cyst

Thin walled

Multiple septa or solid areas

Less than 6 cm size

Present in both ovaries

Ascites

Changes rapidly over a few days or weeks

High blood flow on colour Doppler

Multiple septa and/or solid areasAscitesHigh blood flow on colour Doppler

Test QuestionsHaemorrhage into a corpus luteum can cause a solid-looking tumour with multiple septa

CA125 is elevated in patients with endometriosis

Ascites with an ovarian tumour is always a sign of malignancy

Torsion of an ovarian cyst will displace the cervix towards the pathology

Prophylactic oophorectomy is recommended in all women undergoing hysterectomy to remove all risk of ovarian Ca

Polycystic ovarian syndrome is a common cause of pelvic pain

TrueTrue – but only modest elevations <200False – see Meig’s syndromeTrue

False

False

Any Questions or Comments?

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