Ovarian diseases Part 2.pdf ctftftfygugu

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1. BENIGN OVARIAN TUMOURS
& tumour-like mass
In young women,themost common tumoursare germ cells tumourswhile
in old women,themost common are epithelial tumours.

2. Presentation
1.Asymptomatic.
2.Pain.
3.Abdominal swelling.
4.Pressure effects.
5. Menstrual disturbance.
6.Hormonal effects.
7.Abnormal cervical smear.

3. Asmptomaticpresentation:
Many tumoursfound incidentlyduring investigation for another problem
or during pregnancy.
Physiological cysts detected more frequently .
50% of simple cysts less than 6cm in diameter will resolve spontaneously
within 6 months & another 25% within 2 years.

4. Pain:
Acute pain may result from ovarian cyst accident like torsion , rupture or
haemorrhage.
Torsion cause sharp intermittent pain due to ischemia usually in the iliac
fossa radiate to the upper inner thigh.
Haemorrhagecause pain due to stretching of the capsule.

6. Rupture & haemorrhagemay cause intraperitonealbleeding like ectopic
pregnancyresulting in hypovolemia. Treatment by emergency laparotomy
to stop the bleeding.
Chronic lower abdominal pain may result from pressure of benign tumour
or endometriosis or infection.

7. Abdominal swelling:
Patient rarely note this until the tumouris very large.
Benign mucinouscystadenomamay some times full the abdominal cavity.

8. Pressure effects:
Gastro-intestinal or urinary system symptoms may present.
In extreme cases , oedemaof the legs , varicose veins & haemorrhoidsmay
develop.

9. Menstrual disturbance:
This may be coincidental rather than due to tumourbut rarely sex cord
stromal tumoursmay cause precocious puberty,HMB& postmenopausal
bleeding.

10. Hormonal effects:
Oestrogencause precocious puberty, or postmenopausal bleeding.
Androgen secreting tumourscause hirsutism& acne at first then virilism
with deepening of voice & clitoris hypertrophy.
Very rarely, thyrotoxicosis due to thyroid hormone secretion.

11. Abnormal cervical smear:
Rarely abnormal cervical cytology due to often benign ovarian tumour.

12. MALIGNANT OVARIAN TUMOURS
90% of malignant ovarian tumoursare epithelial which are commonly
bilateral occurring at old age with mean age of 64 years.
10% of ovarian tumoursare secondary metastasis from other organs like
colon, stomach or breast.

13. Borderline malignant epithelial tumourshave features of malignancy &
can spread to the peritoneum & omentumbut characterize by non-
invading the basement membrane &they rarely recur after surgery.

14. EPIDEMIOLOGY
The incidence & mortality rate are affected by country of origin & race.
Epithelial ovarian tumoursare most common & most lethal in
industrilizedcountries(except Japan) & lowest incidence in non-
industrilizedcountries.
Germ cell tumoursare more common in black & oriental population
whom epithelial tumoursare less common.

15. Aetiology& Risk Factors
The cause is unknown but the following factors are involved in the
causation:
1.Environmental factors:Theseare not clearly defined.
High fat & low fiber diet associated with increased risk So,theincidence
increase in obese women.

16. 2.Incessant ovulation theory: continuous ovulation cause repeated trauma
to the ovarian epithelium leading to genetic mutation.
This is supported by increased incidence of EOC (epithelial ovarian cancer)
in nulliparous women, women with early menarche &/or late menopause
while decrease in multiparous & breast feeding women & in women who
have used oral contraceptive pills & the longer the duration of usage , the
greater the protection.

17. 3.Genetic factors:
There is familial predisposition for EOC.
Three heriditaryovarian cancer syndromes found:
1.BRCA 1 :breast cancer syndrome which account for 90% of all hereditary
cancers.
2.BRCA 2.
3.Lynch syndrome.

18. 4.Hormonal factors: excess gonadotrophinsecretion cause increase level of
oestrogenwhich lead to epithelial proliferation & malignant
transformation. There are reports claim the use of ovulation stimulants
for infertility to increase EOC but the association could be due to effect of
nulliparity.
Tubal ligation decrease the incidence & also hysterectomy with
preservation of the ovaries

19. 5.Endometriosis & PID shown to increase ovarian cancer & this suggest that
chronic inflammation has important role in the aetiologyof ovarian
cancer.

20. CLINICAL FEATURES OF EOC
Complete history &examination is essential.
History: symptoms, past history or family history of malignancy are
important.
Also history of use of combined oral contraceptive pills & it’s duration.

21. Symptoms are usually vague & non-specific & mainly due to pressure
symptoms which make the presentation at late stage .
66% of the patients present at stage 3 or more & this affect the survival
rate.

22. Symptoms include:
1.Pelvic & abdominal pain.
2.Urinary symptoms like frequency or urgency.
3.Increased abdominal size.
4.Feeling full quickly after eating, persistent bloating, persistent abdominal
distension or change in bowel habit which mimic irritable bowel
syndrome.
5.Unexplained weight loss & fatigue.
6.Abnormal vaginal bleeding is the less common presenting feature.

23. It is recommended that a women presented with these symptoms may
offered serum CA125 testing & if found 35 IU/L or more, abdomino-pelvic
ultrasound should be done.

24. Examination:
Abdominal,pelvic& rectal examination may reveal fixed hard mass arising
from the pelvis.
Clinical ascitesmay be found.
Chest examination is important for pleural effusion.
Neck & inguinal area should be examined for enlarged lymph nodes.

25. Investigations:
1.Full blood count .
2.Blood urea, creatinine& electrolytes.
3.Liver function tests including total protein & albumin.
4.Chest X-ray is essential to assess the possibility of stage 4 ovarian cancer.
5.If suspected pelvic tumours, tumourmarkers like CA-125 which is elevated in
80% of EOC serous type and CA19-9 which increase n EOC mucinous type.
In young women,alph-fetoprotein ( endodermal yolk sac tuomurd, teratoma) & B-
hCG(dysgerminomaand choriocarcinoma) should be measured.
Carcinoembryonicantigen should also measured which is related to possible
primary gastrointestinal malignancy.

26. 6.Ultrasound preferably transvaginalis the most useful non-invasive test of
suspected malignancy.
The following findings raise the possibility of malignancy:
a.Multilocularcyst with thick wall.
b.Solidareas.
c.Bilaterallesions.
d. Metastasis.
e.Ascites.

27. By ultrasound findings ,Ca125 level, menopausal state, a risk of
malignancy index(RMI) can be calculated .

28. 7.CT-scan & MRI of abdomen & pelvis.
8.If the patient has abnormal vaginal bleeding, full assessment of the cervix
& uterus with endometrial biopsy as ovarian tumourmay be secondary to
them.
9.Ba-enema & colonoscopy if bowel symptoms present as there is possibility
of primary colo-rectal tumour.

29. Diagnosis of Adnexal Mass
Adnexal mass could be functional, benign or malignant & differentiation
between them can be difficult.
The aim of management is to decrease patient morbidity by:
1.Conservative management when possible.
2.Use of laparoscopic technique when appropriate & avoiding laparotomy.
3.To diagnose malignancy & proper management of it.

30. Adnexal mass may present with sever symptoms as in a case of cyst
accident or with mild symptoms or incidentally found.
It is important to distinguish between pre-menopausal & postmenopausal
women as risk of ovarian cancer is low in premenopausal women .

31. Pre-menopausal women with adnexal mass:
After history taking including risk factors like family history of ovarian
tumoursor cabreast , protective factors like COCP intake & symptoms
suggestive of endometriosis should be considered.
After careful examination , the following is done:
1.If ultrsoundcriteria showing simple cyst, then manage conservatively &
follow up by ultrasound as many cyst are functional usually resolve within 2-
3 cycles without intervention.

32. 2. If ultrasound not showing simple cyst, sent the patient for serum
CA125.Also, if ultrasound show complex mass especially if the patient less
than 40 years, sent for alpha-fetoprotein& hCG.
CA125 not only increase in EOC but may increase in other benign
conditions like endometriosis & pelvic infection . So, if CA125
increases(more than 35 IU/ml) but less than 200 IU/ml , do investigation to
detect other causes & repeat the test as rapidly rising level indicate
malignancy unlike static level.

33. If serum CA125 more than 200 unit/ml, the patient managed as highly
suspected malignancy & should be referred to gynecological oncologist.
Some centers prefer to manage all women presenting with adnexal mass
by using RMI .

34. Postmenopausal women with adnexal mass:
It is recommended that RMI should be used.
RMI is the product of multiplication of CA125 level(in units per ml), the
ultrasound score (0,1 0r 3) and the menopausal state ( 1 if pre-menopausal ,
3 if postmenopausal). The ultrasound score is calculated by giving one point
for each of the following findings:
-Multilocularcyst.
-Solid areas.

35. -Bilateral lesions.
-Metastasis.
-Ascitis.
According to RMI, the patient will be categorize into low risk group when
RMI is less than 25 , moderate risk in which the RMI is between 25-250 &
high risk group when RMI is more than 250.
Management of each group varies according to the local practice but
generally accepted practice as follow:

36. Low risk: Risk of having malignancy is less than 3%.
-If the cyst less than 5 cm , it may be manage conservatively by repeat
ultrasound & CA125 measurement every 4 months for one year.
-If the cyst not fit with the above criteria or if the woman request surgery,
the laparoscopic surgery is acceptable.

37. Moderate risk: Risk of cancer is 20%.
-Management in cancer unit.
-Laparoscopic oophorectomy may be done.
-If malignancy discovered, then full staging procedure should be done.

38. High risk: Risk of cancer is greater than 75%.
-Management should be in cancer centrewith full staging procedure.

39. So, management depend on presentation ( if cyst accident with acute
presentation , surgical intervention needed) & risk of malignancy.

40. STAGING OF OVARIAN CANCER
Ovarian cancers are staged according to FIGO recommendation based on
findings at laparotomy (surgical staging) but preoperative assessment is
required to assess extraperitonealspread.
Accurate staging is important as it determine the prognosis & also the
need for adjuvant therapy.

41. Technique for surgical staging:
A midline vertical incision is essential to allow access to all abdominal &
pelvic organs & it should be performed whenever ovarian malignancy is
suspected.
The staging laparotomy(surgical staging) involve the following steps:
1.Sending asciticfluid or peritoneal washing for cytological assessment.
2.Performing total abdominal hysterectomy & bilateral salpingo-
oophorectomy.

42. 3.Omentectomy as the omentumis major site for abdominal metastasis.
4.Peritoneal biopsy of all suspicious areas or multiple random sampling if
all surfaces which look normal.
5.Diaphragmatic biopsy or scraping for cytological assessment.
6.Resection of pelvic & para-aortic lymph nodes.
7.Careful assessment of pelvic & abdominal organs like bowel, liver ,spleen
&lesser sac. Some times resection of the bowel or splenectomydone if
involved by the tumour.

43. Appendicectomyhas not yet universally accepted as part of standard
procedure but taken in consideration as the appendix is common site of
metastasis.

44. STAGES OF OVARIAN CANCER
Stage1:growth limited to the ovaries.
Stage 1a: growth on one ovary,noasciteswith intact capsule.
Stage 1b:growth involve both ovaries,noasciteswith intact capsule.
Stage 1c: tumouron stage 1a or 1b with ruptured capsule or ascitesor
positive peritoneal washing.

45. Stage 2:growth involve one or two ovaries with pelvic extension.
Stage 2a:metastasis to uterus or tube.
Stage 2b:extension to other pelvic tissues.
Stage 2c:tumour either stage2a or 2b but tumourwith ruptured capsule or
with ascitesor positive peritoneal washing.

46. Stage 3: growth involve one or both ovaries with peritoneal implants
outside the pelvis or positive retroperitoneal or inguinal nodes.
Stage 3a:tumour grossly limited to the pelvis but microscopic seeding of
abdominal peritoneum with negative nodes.
Stage 3b: tumourimplant on abdominal peritoneum not exceeding 2cm
with negative nodes.

47. Stage 3c:abdominal implants more than 2cm or positive retroperitoneal or
inguinal nodes.
Stage 4: growth involve one or both ovaries with distant metastasis(
pleural effusion or liver metastasis).

48. TREATMENT OF EOC
Management of ovarian cancer is a major challenge & require close team
work including medical & surgical oncologist, radiologists, pathologists in
addition to nurses & specialists in palliative care to optimize the quality of
life in the patient who present late in their remaining period of life.

49. 1.SURGERY:
If the patient fit for anaesthesia, surgery is important for diagnosis,
staging & treatment.
The objective is staging & removal of all visible tumouras the most
important prognostic factor is no residual disease after laparotomy that is
why the operation should be done by expert gynecological oncologist.

50. The standard surgical procedure is as described in the staging
laparotomy.
When operating on young patient who want to preserve fertility, a frozen
section may be useful to diagnose malignancy. However, the heterogeneity
of ovarian malignancy result in under-diagnosis of many cases of
malignancy.

51. So, in a case of young patient want to keep her fertility, an initial
procedure would involve complete surgical staging as described before but
the uterus & contralateral ovary left in situ after careful inspection & after
final histopathologicalreport , decision is made whether completion of
surgery or adjuvant treatment should be made based on the advice of
cancer centreteam in consultation with the patient.

52. In advanced disease, surgical objective is tumourcytoreduction.
Cytoreductivesurgery involve performing TAH/BSO , complete
omentectomy& resection of metastasis.
Complete cytoreductionis the goal of surgery & if this is not possible, the
surgeon should try to reduce the tumourload to achieve (optimum) status
that is no residual disease more than 1 cm.

53. Timing of surgery:
Studies done to investigate whether primary surgery followed by chemotherapy or
surgery after 3-4 cycles of chemotherapy would lead to more complete
cytoreduction& better survival.
It was found that both approaches have similar survival rate. Presurgery
chemotherapy associated with lower morbidity.
Therefore,incase in which initial surgery involve biopsy only with no attempt of
cytoreductionof advanced disease, it is reasonable to give 3 cycles of
chemotherapy followed by surgery with further cycles to be given following
surgery.

54. Palliative surgery some times needed & the most common indication for it
is bowel obstruction which is a common feature of recurrent disease.
Surgery may involve bowel resection or intestinal bypass. However, the
median survival rate for patient undergoing palliative surgery for bowel is
3-12 months.

55. 2.CHEMOTHERAPY:
It can be given as primary treatment if the patient unfit for surgery or
following surgery or for relapse of the disease.
If the cancer at stage 1 & histologically of low grade malignancy ,
chemotherapy may be withheld but in practice ,most of the patients are
given postoperative chemotherapy.

56. First line chemotherapy is usually combination of platinum
compound(carboplatin) with paclitaxelfor 6 cycles 3weeks apart.
The patient is followed after chemotherapy by CT-scan to assess the
response with clinical examination &tumourmarker.

57. If the patient respond to chemotherapy, interval surgery some times done
for debulkingof the residual tumour(secondary cytoreductive
surgery).This also done in case of localized recurrence.
Second look surgery is planned laparotomy at the end of chemotherapy to
assess & resect any residual disease but recent studies show no survival
benefit & now it’s not standard management.

58. SURVIVAL FROM EOC
The prognostic factors include:
1.Stage of the disease:5 years survival of stage 1 is 70-90% & decrease to30%
in stage 3.
2.Volume of the residual disease post surgery.
3.Histological type & grade of the disease.
4. Age at presentation.

59. Treatment of Borderline Ovarian
Tumours
About 15% of epithelial tumoursare borderline( low malignant potential)
& they have very good prognosis.
They tend to affect younger women.
Surgical resection is the primary treatment. Premenopausal women who
wish to preserve fertility may be treated by conservative surgery .
Recurrence rate is 7% in women treated by conservative surgery.So, long
term follow up is advised.

60. TREATMENT OF MALIGNANT SEX
CORD STROMAL TUMOURS
Granulosacell tumoursare the commonest of them. They are of low
malignant potential & good prognosis.
Treatment based on the patient age & wishes to preserve fertility.
If young who present early, unilateral salpingo-oophorectomy with uterine
sampling & staging is enough.
If old woman, full surgical staging should be done.
There is no effective chemotherapy& late recurrence may occur.

61. TREATMENT OF MALIGNANT
GERM CELL TUMOURS
They occur mainly in young women.
Dysgerminomais the commonest & they are bilateral in 20% of the cases.
There is usually need to preserve fertility . So, salpingo-oophorectomy &
assess the contra-lateral ovary which if involve(as in 20% of
dysgerminoma) ,it should be removed.
Postoperative chemotherapy usually given.Themost common regime used
is combination of cisplatin, bleomycin& etoposide(BEP).