benign ovarian tumours Gako PPT.pptxcccc

qweee

1. DR. Ngabonziza eugene Gynecology oncology

2. NORMAL OVARIES Normal size 5 x 3 x 3cm Variation in dimensions can result from Endogenous hormonal production(varies with age and menstrual cycle) Exogenous substances, including OCs, GnRH agonists, or ovulation-inducing medication, may affect size

3. Lifetime Risk of ovarian neoplasm A woman has 5–10% lifetime risk of undergoing surgery for a suspected ovarian neoplasm and 13–21% of these will be found to be have an ovarian malignancy

4. DIFFERENTIAL DIAGNOSIS OF ADNEXAL MASS ORGAN CYSTIC SOLID OVARY Functional cyst, Neoplastic cyst, Benign, Malignant, Endometriosis Benign Malignant FALLOPIAN Tubo- ovarian abscess Tubo- ovarian abscess TUBES Hydrosalpinx Paraovarian cyst Ectopic pregnancy Neoplasm UTERUS Intrauterine pregnancy in a bicornuate uterus Pedunculated or inteligamentous myoma BOWEL Sigmoid or caecum distended with gas or feces Diverticulitis, Ileitis, Appendicitis, Colonic cancer MISCELLANEOUS Distended bladder, Pelvic kidney, Urachal cyst Abdominal wall hematoma or abscess, retroperitoneal

5. Differential diagnosis of the adnexal masses varies considerably with the age of the patients . In pre- menarchal girls and post-menopausal women adnexal mass should be considered highly abnormal – requires immediate investigation . In menstruating patients differential diagnosis is varied.

6. DIAGNOSTIC EVALUATION OF THE PATIENT WITH AN ADNEXAL MASS Complete physical examination Pelvic ultrasound examination Computed tomography scan with contrast enhancement or intravenous pyelography Colonoscopy or barium enema study, if symptomatic Laparoscopy, laparotomy

7. OVARIAN MASSES FUNCTIONAL INFLAMMATORY NEOPLASTIC OTHERS FOLLICULAR CYST CORPUS LUTEUM CYST THECA LUTEIN TUBO OVARIAN ABSCESS BENIGN BORDERLINE MALIGNANT ENDOMETRIOMA ENLARGED PCO PAROVARIAN CYST

8. COMMON OVARIAN TUMOURS Infancy Pre pubertal Adolescent Reproductive Peri Menopausal Post Menopausal 1 Functional Functional Functional Functional Epithelial Neoplastic cyst cyst cyst cyst ovarian tumor ovarian tumor 2. Germ cell tumor Germ cell tumor Germ cell tumor Dermoid Functional cyst Functional cyst 3. Epithelial tumor Epithelial tumor Mets

9. Functional ovarian cysts Follicular cysts Corpus luteum cysts Theca lutein cysts Luteomas of pregnancy By far the most common clinically detectable enlargements of the ovary in the reproductive years. All are benign and usually asymptomatic.

10. Follicular cysts Cystic follicle is defined as Follicular cyst of diameter > 3cm Most common functional cysts. Rarely larger than 8cm. Lined by granulosa cells Found incidentally on pelvic examination Usually resolve within 4 – 8 weeks with expectant management May rupture or torse occasionally causing pain and peritoneal symptoms.

11. Follicular cysts

12. Corpus luteal cyst Less common than follicular cyst. May rupture leading to hemoperitoneum and requiring surgical management( more in patients taking anti coagulants or with bleeding diathesis) Unruptured cysts may cause pain because of bleeding into enclosed ovarian cyst cavity.

13. Corpus luteal cyst

14. Theca lutein cysts Least common Usually bilateral Result from overstimulation of the ovary by β- hCG Do not commonly occur in normal pregnancy Often associated with hydatidiform moles, choriocarcinoma, multiple gestations, use of clomiphene and GnRH analogues. May be quite large (up to 30 cm) , multicystic, and regress spontaneously.

15. Theca lutein cysts

16. Management of functional cysts Expectant Watchful waiting for two or three cycles is appropriate. Combined oral contraceptives appear to be of no benefit. Should cysts persist, surgical management is often indicated. Oral contraceptives for functional ovarian cysts (Review) Cochrane Database of Systematic Reviews 2011

17. Endometriomas Most common site of involvement is the ovary. Endometriomas are pseudocysts formed by invagination of the ovarian cortex, sealed off by adhesions. USG: anechoic cysts to cysts with diffuse low-level echoes to solid- appearing masses. Fluid–fluid or debris–fluid levels may also be seen. They may be unilocular or multilocular with thin or thick septations Malignant transformation: 0.3% to 0.8% Management: medical and/ or surgical

18. Benign ovarian tumors Serous cystadenoma Mucinous cystadenoma Dermoid cyst Fibroma Thecoma Brenner‟s tumor

19. SEROUS CYSTADENOMA Generally benign Bilateral – 10% Risk of malignancy : 5 – 10 % borderline malignant 20 -25% malignant GROSS : multilocular with papillary components. MICRO : low columnar epithelium with cilia. Characteristic psammoma bodies (end products of degeneration of papillary implants)are found. Associated fibrosis may lead to “ cystadenofibroma ”

20. MUCINOUS CYSTADENOMA Have tendency to become huge masses Round to ovoid masses with smooth capsules that are usually translucent or bluish to whitish gray. Interior divided by discrete septa into loculi containing clear , viscid fluid. Epithelium – tall, pale staining, secretary with basal nuclei and goblet cells 5 – 10% are malignant

21. DERMOID CYST Often bilateral (15 - 25%) GROSS: thick, opaque , whitish wall. CONTENTS: hair, bone, cartilage, and a large amount of greasy sebaceous material. MICROSCOPICALLY : all the three germ layers (ectoderm, mesoderm and endoderm) Malignant change occurs in 1-3%. Usually of a squamous type. Risk of torsion is 15% An ovarian cystectomy is almost always possible, even if it appears that only a small amount of ovarian tissue remains

22. FIBROMA Most common benign, solid neoplasms of the ovary. Compose approx 5% of benign ovarian neoplasms and 20% of all solid tumors of the ovary. Frequently seen in middle- aged women. Characterized by their firmness and resemblance to myomas Fibromas may be associated with ascites or hydrothorax as a result of increased capillary permeability thought to be a result of VEGF Mieg’s syndrome (ovarian fibromas, ascites and hydrothorax) is uncommon and usually resolves after surgical excision.

23. THECOMA Solid fibromatous lesions that show varying degrees of yellow or orange discoloration Almost always confined to one ovary Usually >40 years, 65% after menopause May be hormonally active and hence associated with estrogenic or occasionally androgenic effects. Leydeig cell thecoma – ass. with Reinke crystals Rarely malignant

24. BRENNER TUMOR Uncommon tumor grossly identical to fibroma Arise from Walthard cell rests ,also from surface epithelium, rete ovarii and ovarian stroma On microscopy – markedly hyperplastic fibromatous matrix interspersed with nests of epitheloid cells showing coffee bean pattern Considered uniformly benign. But scattered reports of malignant Brenner‟s available Endocrinologically inert, but could be ass. with virilization and endometrial hyperplasia

25. GONADOBLASTOMAS Gonadoblastoma is a rare benign tumor that has the potential for malignant transformation and affects a subset of patients with an intersex disorder or disorder of sex development (DSD). Contain both germ cells and sex cord stromal cells. Arise in patients with dysgenetic gonads - 46 XY f/b 45XO/ 46 XY mosaic . Presents usually as phenotypic female <30 years with primary amenorrhea and virilization. Treatment – laparoscopy or laparotomy with removal of b/l dysgenetic gonads. Further treatment depends on malignant germ cell component

26. CLINICAL PRESENTATION Asymptomatic – accidentally discovered on USG Chronic pattern of pain, increasing abdominal girth over months or weeks. Associated with secondary symptoms of anorexia, nausea, vomiting, urinary frequency. Could be associated with primary or secondary amenorrhea, menstrual irregularities, virilization, precocious puberty Become acutely symptomatic if undergoes torsion, rupture or haemorrhage. Benign ovarian neoplasms are indistinguishable clinically from malignant counterparts

27. COMPLICATIONS Torsion Intracystic hemorrhage Infection Rupture Pseudomyxoma peritonei Malignancy

28. PHYSICAL EXAMINATION Abdominal and vaginal examination and the presence or absence of local lymphadenopathy Assess Laterality Cystic Vs solid Mobile Vs fixed Smooth Vs irregular Ascites Cul-de- sac nodules Rapid growth rate

29. TVS Pattern recognition is superior to all other scores. Subjective evaluation of ovarian masses based on pattern recognition can achieve sensitivity of 88% to 100% and specificity of 62% to 96%. Adding doppler does not seem to yield much improvement in the diagnostic precision, but increases the confidence with which a correct diagnosis of benignity or malignancy is made.

30. Simple ultrasound- based rules for the diagnosis of ovarian cancer. Ultrasound Obstet Gynecol2008 RCOG 2011

31. OTHER IMAGING MODALITIES CT, MRI, PET not recommended in the initial evaluation CT scan: evaluating LN involvement, Omental mets, peritoneal deposits, hepatic mets, obstructive uropathy or a probable alternate primary site when cancer is suspected based upon TVS MRI : differentiating non adnexal pelvic masses (like leiomyomata), expensive and inconvenient. ACOG GUIDELINES 2007

32. INDICATIONS FOR SURGERY Any solid ovarian lesion Any ovarian lesion with papillary vegetation on the cyst wall Any adnexal mass >10cm in diameter Palpable adnexal mass in a premenarchal or postmenopausal women Torsion or rupture suspected

33. Ovarian mass in reproductive age group <5 cms. >/= 5 cms USG USG cystic observation Complex, solid, suspiciou s Persistence or progression surgery

34. Asymptomatic simple cysts <5cms Likely physiological (do not require follow up) 5-7 cms 4 monthly US >7cm Require further imaging/surgical intervention. RCOG 2011

35. CYST ASPIRATION Diagnostic cytology has poor sensitivity to detect malignancy, ranging from 25% to 82% Not therapeutic, even when a benign mass is aspirated Approx. 25% of cysts will recur within 1 year Aspiration of a malignant mass may induce spillage and seeding of cancer cells into the peritoneal cavity

36. INDICATIONS OF FNAC Predominantly benign masses based on clinical, USG findings and CA125 levels, but a few findings are causing diagnostic dilemma – then FNAC helps to confirm the nature and aid in pre- op planning and counseling. Patients who have clinical and radiographic evidence of advanced ovarian cancer and who are medically unfit to undergo surgery- Malignant cytology will establish a cancer diagnosis, thereby permitting initiation of neo- adjuvant chemotherapy ACOG, 2007

37. OPERATIVE MODALITIES Laparoscopy vs laparotomy – decision based on suspicion of malignancy and technical expertise No RCTs comparing recurrence rates following laparoscopy or laparotomy. The objective is to try cystectomy if possible. Laparoscopic surgery for benign ovarian tumours is associated with less pain, shorter hospital stay, and fewer adverse events than with laparotomy. Cochrane Database of Systematic Reviews 2009

38. The standards for laparoscopy in benign tumours careful examination of the external surface of the tumour and sampling of the peritoneal cavity avoidance of any tumoral rupture protection of the ovarian tumour with an endoscopic bag before removal

39. ROLE OF FROZEN SECTION The diagnostic accuracy of frozen section analysis is high for malignant and benign ovarian tumours, but accuracy is poor in the case of borderline ovarian tumors. Medeiros 2005

40. No specific lit erature regarding recurrence rate . Hence recommendations are at best empirical. Should be followed up with annual USG. In adults follow up with biannual USG is sufficient Tumor markers are not regularly used Post op surveillance in children

41. Post menopausal gonad atrophies to a size of 1.5 X 1 X 0.5cm on average Shouldn‟t be palpable on pelvic examination. Presence of palpable ovary must alert the physician to the possibility of an underlying malignancy.

42. Incidence in asymptomatic post menopausal women – 1.5% by pelvic examination 3.3% to 14.5% by USG. obstet gynecol survey, 2002 Causes - 10% functional 90% neoplastic (either benign or malignant )

43. ASSESSMENT It is recommended that ovarian cysts in postmenopausal women should be assessed using CA125 and transvaginal grey scale sonography. There is no routine role yet for Doppler, MRI, CT or PET. RCOG 2010 SENSITIVITY SPECIFICITY TVS 89% 73% CA 125 81% 75%

44. Calculation of RMI (Risk malignancy index): It is an effective way of triaging patients into low , moderate, high risk for malignancy, according to which the referral to a higher centre and management protocol will differ . RCOG 2010