Ovarian disease Part 1.pdf زاالعلالغلغلغلغل

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1. OVARIAN CYSTS & TUMOURS

2. Each ovary is 3 cm.2 cm.1 cm in size in resting or
inactive state but increase in size during physiological
stimulus and they shrink after menopause.
The surface of the ovary is covered by flat single layer
of epithelialialcells.
Beneath the epithelia, there are the ovarian follicles
,with oocyte , granulosalayer and surrounded by theca
cells.

3. Differential diagnosis of a pelvic mass :
1-Gynaecological: pregnancy, benign or malignant
ovarian cyst, ectopic pregnancy, hydrosalpinx,
pyosalpinx, tubal malignancy, tubo-ovarian abscess,
fibroid, and uterine malignancy.
2-Gastrointestinal: intestinal obstruction,
diverticular/appendicular abscess, and malignancy.

4. 3-Urological: hydronephrosis, pelvic kidney, and bladder
malignancy.
4-Other: peritoneal cyst, psoas muscle abscess, and
lymphoma.

5. DISEASES OF THE OVARY
Ovarian mass could be:
1.Functional (physiological) cysts.
2.Inflammatory cyst (tubo-ovarian abscess).
3.Endometrioma (chocolate cyst).
4.Ovarian tumours(benign &malignant).

6. Functional Ovarian Cysts
They are also called physiological as they are enlarged
cysts occur during ovarian cycle .
Most of them asymptomatic & found incidentally
during pelvic examination or ultrasound scan.

7. They are most commonly seen in young women.
The incidence decreases by using combined oral
contraceptive pills.

8. It include the following :
1.Follicular cysts.
2.Corpus luteumcysts.
3.Theca lutealcysts.

9. FOLLICULAR CYSTS
They are the commonest ovarian cysts.
They result from non-rupture of dominant follicle or
failure of atresia of non-dominant follicle.
Normal follicle measure up to 2.5 cm. So,cystmeasure
3 cm or more but rarely grow larger than 10 cm.

10. They are lined by granulosacells.
They are usually simple, unilocular& unilateral cysts
but may be multiple as complication of ovulation
induction drugs .

12. Treatment if asymptomatic only observation& repeat
ultrasound as it usually resolve.
Rarely , if they cause symptoms or do not resolve
within 8-16 weeks , laparoscopic cystectomymay be
performed .

13. CORPUS LUTEUM CYSTS
They are less common than follicular cysts.Theyoccur
after ovulation.
In normal menstrual cycle, corpus luteummay reach
3cm in diameter.
Occasionally corpus luteumpersist without pregnancy
& increase up to 5cm diameter & usually regress after
that & disappear.

14. It is often asymptomatic & seen incidentally by
ultrasound & some times may present with pain due to
rupture of the cyst or haemorrhageinto the peritoneal
cavity which occur typically late in the menstrual cycle
on day 20-26.

15. Treatment expectant with analgesia & in 95% of the
cases it will disappear when ultrasound repeated at 6-8
weeks.
Management is conservative & occasionally , surgery
by laparoscopic ovarian cystectomy if the cyst persist
or increase in size.

16. Theca LutealCysts
They are associated with pregnancy especially multiple
pregnancy & often diagnosed incidentally during
routine ultrasound scan.
They develop in response to high level of chorionic
gonadotrophin.
They are some times multiple & bilateral in women
with gestational trophoplasticdiseases.
They usually resolve spontaneously.

17. OVARIAN TUMOURS
According to WHO,theyare classified into:
1.Epithelial ovarian tumours:
They arise from ovarian surface epithelium.Theyaccount
for majority of ovarian tumors(60-65% of all ovarian
tumours) & 90% of epithelial ovarian tumoursare
malignant.
They mostly present at postmenopausal women.

18. 2.Germ cells tumours:
They are the commonest tumoursunder the age of 30
years.Itaccount for 30% of all ovarian tumours&
mostly they are benign & only 2-3% of them are
malignant.

19. 3.Sex cord-stromal ovarian tumours:
They may occur at any age & many of them secret
hormones& account for 8% of all ovarian tumours.
4.Germ cell-sex cord-stromal tumours.
5.Mesothelial tumours.
6.Soft tissue tumours.

20. 7.Miscellaneous tumour.
8.Lymphoid & myeloid tumours.
9.Tumour-like lesions which include functional cysts.
10.Metastatic secondary ovarian tumours.

21. EPITHELIAL OVARIAN TUMOURS
These are the commonest ovarian tumours.
The incidence increase with increase age.
They could be benign ,borderline malignancy or
malignant.
Malignant epithelial tumoursare the most common
malignant ovarian tumoursoccurring at old age with
mean age of 64 years.

22. Epithelial ovarian tumourssubclassifiedinto:
a.Seroustumours: It could be
-Benign: serous cystadenomain which the inner surface
is cuboidal or columnar& may be ciliated similar to the
lining of the Fallopian tubes.The cyst fluid is thin &
serous.Treatmentby ovarian cystectomy or salpingo-
oophorectomy.
-Borderline malignancy: serous borderline tumours.
-Malignant: serous carcinoma. Most of them have both
solid & cystic elements.Theyare often bilateral.
Psammomabodies(calcospheroles) are often present.

23. b.Mucinous tumours: It could be:
-Benign: mucinous cystadenoma.Itis lined by columnar
mucus secreting cells similar to the endocervix
epithelium.The cyst contain fluid which is thick& gel-
like.They are typically unilateral & multilocular.They
are large in size & may reach huge size of 14 Kg or more.
Treatment by oophorectomy.
-Borderline malignancy: mucinous borderline tumours.
-Malignant: mucinous carcinoma.Usuallymutilocular
& large in size & diameter of 25 cm is common.

26. A rare complication is pseudomyxomaovariior
peritoneiin which a borderline malignant mucinous
cystadenomamay have seedling growth which
continue to secret mucincausing matting of the bowel
followed by intestinal obstruction.

27. c.Endometroidtumours: It could be:
-Benign: endometroidcystadenoma.Theyare difficult
to be differentiated from ovarian endometriosis with
lining similar to endometrium.
-Borderline malignancy: endometroidborderline
tmours.
-Malignant: endometroidcarcinoma.

28. d.Clearcell tumours: It could be:
-Benign: clear cell cystadenoma.
-Borderline malignancy: clear cell borderline tumours.
-Malignant: clear cell carcinoma.

29. e.Brennertumours: It was called transitional cell
tumour.Themajority are benign .
It could be:
-Benign Brenner tumour.
-Borderline Brenner tumour.
-Malignant Brenner tumour.

30. f. Seromucinoustumours: It could be:
-Benign: seromucinouscystadenoma.
-Borderline malignancy: seromucinousborderline
tumour.
-Malignant: seromucinouscarcinoma.

31. Germ Cells Ovarian Tumours
They account for 30% of all ovarian tumoursbut only
small proportion of them are malignant.
They are the most common ovarian tumoursin young
women with peak incidence at early twenties.

32. They are classified into :
1.Mature teratoma:composeof tissue derive from two or
three embryonic layers.
2.Immature teratoma.
3.Monodermal treatoma.
4.Dysgerminoma: all are malignant. 5-10% of them occur
in phenotypic females with abnormal gonads
(androgen insensitivity syndrome or gonadal
dysgenesis)

33. 5.Yolk sac tumours(endodermal sinus tumours) also
malignant.
6.Embryonal carcinoma:malignant.
7.Non gestational choriocarcinoma:malignant.
8.Mixed germ cell tumours.

34. These tumoursmay secret certain tumourmarkers in
which most yolk sac tumourshave elevated levels of
alpha-fetoprotein (AFP) but normal level does not
exclude this diagnosis.
Embryonalcarcinoma are very rare but they usually
secret B-hCG& may secret AFP.
Ovarian choriocarcinomasecret B-hCG.

35. Benign mature teratomaare further divided into :
1.Cystic mature teratoma(Dermoidcyst) which is the
most common germ cell tumour.
2.Solid mature teratomawhich are rare& must be
differentiated from immature teratomawhich are
malignant.

36. Mature Cystic Teratoma(Dermoid
Cyst)
These are the most common ovarian germ cell
tumours.
It usually present at the age of 18-30 years.
Mostly they are unilateral but they are bilateral in 15%
of the cases.
They are usually unilocularless than 15 cm in diameter
with combination of all tissue types but ectodermal
structures predominent.

37. It often contain skin appendages like teeth, sebaceous
material ,nail,bone& hair.
Endodermal derivatives like thyroid, bronchus or
intestine may be found.
This will give characteristic appearance on X-ray due to
presence of teeth or bones.

40. Diagnosis may be incidental as the majority are
asymptomatic but 15% present acutely due to torsion
as they are the most common ovarian tumours
undergo this complication which lead to cut of blood
supply to ovarian tissue causing sever acute pain with
nausea.
Less commonly, the cyst may rupture spontaneously
causing acute pain with chemical peritonitis or slow
leaking causing chronic granulomatous peritonitis.

41. Treatment by surgical removal of the cyst either by
laparotomy or laparoscopy but it is essential that all
the tissue is removed to prevent recurrence.

42. MonodermalTeratoma
Occasionally only single tissue is present.
The classic examples are carcinoid tumours& stroma
ovariiwhich contain hormonally active thyroid
tissue.5-10% of stromaovariidevelop into carcinoma.

43. Sex Cord StromalOvarian Tumours
These are tumourscomposed of either granulosa
cells,thecacells,Sertolicells,Ledigcells,fibroblastsor
the precursors of these cells.
They may associate with oestrogenic, androgenic or
more rarely progestogeniceffects.

44. Many of them benign which may occur at any age from
prepubertalchildren to post-menopausal women.

45. A.Benignsex cord stromaltumours:
1.Fibroma.
2.Thecoma(theca cell tumours).
B.Malignantsex cord-sromaltumours:
1.Granulosa cell tumour.
2.Sertoli-Ledig tumours.

46. Fibroma
They are uncommon tumoursbut they are the most
common sex cord stromaltumours.
They are solid tumourscomposed of stromal
cells.Theyare hard,mobile&lobulatedwith glistening
white surface.
They present in older women around 50 years with
torsion due to heaviness of the involved ovary.

49. Occasionally, the patient may present with Meig
syndrome(pleural effusion, ascites & ovarian
fibroma).Following removal of ovarian fibroma, the
pleural effusion will often resolve)

50. Thecoma(Theca Cell Tumours)
Almost all benign& also derived from stromalcells.
They are also solid tumourstypically present in the sixth
decade.
Many of them produce oestrogencausing systemic effects as
postmenopausal bleeding.

51. Although they are benign,theymay cause endometrial
hyperplasia & then endometrial cancer.
If present in prepubertalgirl,itmay cause precocious
puberty.

52. GranulosaCell Tumours
These are mostly solid tumours.
Some of them produce oestrogen& some secret inhibin.
Inspiteof being malignant,theyare usually confined to the
ovary when diagnose & usually grow very slowly.

53. Sertoli_LedigCell Tumours
They are rare tumoursof law grade malignancy.
They are found arroundthe age of 30 years.
Many produce androgen causing signs of virilization.
They are usually small & unilateral.

54. Gonadoblastoma
This is a rare tumourconsist germ cell-sex cord-stromal
type.Theyusually occur in the second decade of life.They
rarely occur in normal ovaries in which 80% occur in
phenotypic female with virilism& 20% in phenotypic male
with developmental abnormalities of the external genitalia.