Ovarian tumours

Epidemiology:
o 3% of all female cancers
o 5th most common cause of death (f) cancer in women
o 3rd most common cancer of female genital tract (after
cervical & endometrial)
o Account for a large amount of deaths from female
genital tract cancers (as most ovarian cancers are
detected once they have spread beyond ovaries)
Can be:
o Benign
80%
Most in young women (20-45 yrs)
o Borderline
At slightly older ages
o Malignant
Older women (45-65 yrs)
Classification

Ovarian Ca symptoms
Bloating/Fullness/Pressure symptoms/ Tenesmus
o Occurs (F) growth of the tumour itself + presence of
ascites
o Most women experience bloating and fullness during the
run up to their menstruation (Premenstrual Syndrome).
However, only this quickly subsides upon menstruation.
But, with Ovarian Ca this feeling persists for 2-3 weeks
w/o relief.
Urinary symptoms
o Urgency/Frequency/Retention
Respiratory symptoms (F) fluid in pleural cavity
Only rarely this cancer causes pain
Examination
Height & Weight
General observations temp/pulse/RR
Examine heart & lungs checking for pleural fluid/ plus heart
& lung function for General Aneasthesia incase surgery is
needed
Abdominal exam ascites/masses (ovary, bladder)
o Omental mass (cake) common site for metastasis
o Supraclavicular nodes
Pleural effusion
Pelvic exam
o Speculum to inspect lower genital tract (Cervix,
vagina, vulva)
o Bimanual exam to assess for pelvic masses
Fixed/mobile mass
Investigations
FBC, U&Es, LFTs albumin
Ca125
o Significantly raised in Ovarian cancer (epitheliali
cnacers)
o Also raised moderately in endometriosis, pregnancy, any
cause of ascites (either renal or hepatic)
CEA raised in colorectal cancers, normal in ovarian cancers
CA19-9 Raised in mucinuous tumours; more likely to have
normal CA125
For rarer tumours: AFP, hCG, LDH
Trans-abdominal or Trans-vaginal US: Pelvic masses and
ascities
o Solid lesions
o Cystic lesions locularity
o Ascites (esp. in pouch of douglas)

o Bilateral or unilateral lesions

o Evidence of metastasis (esp. to omentum)
Metastasis is usually trans-coelomic
CXR
o Pleural effusion or lung mets
Calculate Risk of Malignancy Index (RMI) using CA125, US &
Age.
o Age (1 or 3)
o US (0,1,3)
o Value of CA125
Next calculate Stage of the disease: Using CT Chest, Pelvis,
Abdomen with contrast (allows you to see within & outside
bowel (Staging CT)
o CT used because it is better at looking at the heart/lungs
as it experiences less movement artifact

Management
Next, with RMI & CT staging, take results to MDT meeting
MDT makes a decision about next steps. The management
plan could be:
o Surgery + Chemo (In cases where it is obviously Ovarian
Cancer; no need to do histology biopsy)
Histerectomy + Bilateral Saplingo-oopherectomy
+ Omentectomy
Then, 6 cycles of chemotherapy (Carboplatin)
Paclitaxol may also be added if the patient can
tolerate it (but has side effects such as
neurotoxicity can cause peripheral sensory
neuropathy causing falls)
o First do Histology, then Chemo then Surgery (In
uncertain cases)
Tissue biopsy: Prove its ovarian cancer first
Then, 3 cycles of chemo (Carboplatin)
Then check for response to chemo via CT
(compare with first staging CT) + CA125 +
whether patient feeling better clinically
Next, Interval Debulking Surgery (IDS)
Finally, 3 cycles of chemo again
Sometimes ovarian cancer can actually be a secondary metastastic
deposit from primary.
Classically this is from the stomach
But, most commonly, it is from colon cancer (Crookenberg
cancer)

Follicular
cyst

Corpus
luteal cyst

Epidemiolog
y
Most
common
ovarian mass
Most
common
ovarian mass
in pregnancy

Stromal
Associated
hypertheco with:
sis
- obesity
- diabetes

Theca
lutein
hyperplasi
a of
pregnancy

PCOS

Postmenopau
sal women
Pregnancy

Associated
with:

Histological features

Clinical features

Subcortical cyst <2cm

May cause
spontaneous
sterile perotinitis
pain

Clear fluid
Stromal hyperthecosis
Cyst lined with yellow
cells (leutinised
granulosa cells) & may
contain red fluid (old
haemorrhagic fluid)
Hyperplasia and
vacuolization
(leutinisation) of theca
externa cells

May cause
spontaneous
sterile perotinitis
pain
Increased
androgens
hirsutism/
virilization/ HTN

In response to
pregnancy hormones
(gonadotropins),
proliferation of theca
cells and expansion of
the perifollicular zone
occurs.
As the follicles regress,
the concentric thecalutein hyperplasia may
appear nodular.
Superficial cortical
fibrotic thickening

LH/FSH ratio

- obesity
- diabetes
- acanthosis
nigricans
Reproductive
age women

Multiple large
subcortical cysts
Follicular hyperthecosis
(i.e. hyperplasia of
theca interna cells)

LSH:
- Increased
androgens
hirsutism,
virilisation (rare)
FSH:
- Reduced
oestrogens
chronic
anovulation and
follicular arrest,
oligomenorrhea
Conversion of
excess androgens
to oesterone by
peripheral fat cells
endometrial
gland hyperplasia/
cancer & breast
cancer PV
bleeding (PCB,
IMB)