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 pathology 10% turn out to be non ovarian The vast majority in pre menopausal women are benign Ovarian cancer affects ≈ 1:100 women –And is the most common cause of death from gynaecological malignancy

Ovarian pathology presents as: Pain Mass But 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 walled Usually no solid components Usually no septa or thin walled septa Usually <6 cm size Usually avascular to colour Doppler Change rapidly And 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 asymptomatic Repeat 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 enlargement Haemorrhage or haemorrhagic rupture Leaking sebaceous or endometrioma fluid Torsion –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 tumours Bilateral Fixed, tender or craggy to palpation Ascites present Solid or Cystic with multiple septa & solid parts Vascular to colour Doppler Persist or enlarge over time Associated with positive tumour markers – CA125, (CA19.9, CEA, AFP,  HCG, LDH)

Differential diagnosis for an Adnexal Mass: Full bladder Pregnancy Loaded caecum or sigmoid colon Paraovarian cyst Hydrosalpinx Mesenteric cyst Fiboid (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 125 Of most value in the evaluation of adnexal mass in postmenopusal women Too many false positives in premenopausal women –Endometriosis, Adenomyosis, Fibroids & PID Always of concern if >200 Specific 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 bilateral Do NOT cause pain

Test Questions The 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 Dermoids False – 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 areas Ascites High blood flow on colour Doppler

Test Questions Haemorrhage 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 True True – but only modest elevations <200 False – see Meig’s syndrome True False

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