exam 2 - diseases of the ovary

adnexal mass is located in

ovaries

fallopian tubes

uterine ligaments

common reproductive-aged adnexal masses

physiologic cysts

benign neoplasms

when to evaluate patients after concern for malignancy

6 weeks after initial presentation

why is laproscopy preferred

shorter recovery

less blood

cheaper than laparotomy

physiologic enlargements of ovaries

follicular cysts

corpus luteum cysts

theca lutein cysts

endometrioma

PCOS

most common functional cyst

follicular

cause of follicular cyst

failure of ovulation

-secondary to disturbance in release of LH and FSH

-fluid from incompletely developed follicle is not reabsorbed and accumulates in follicle space

clinical findings of follicular cysts

usually asymptomatic, OR:

large = aching pelvic pain, dyspareunia, occasional AUB

most follicular cysts w/o treatment will

spontaneously resolve within 60 days

prevention of follicular cysts

OCPs - no ovulation = no follicle = no cyst

corpus luteum cysts

thin-walled uniocular cysts

occur after normal ovulation

cause of corpus luteum cysts

corpus luteum gets larger than 3cm

symptoms of corpus luteum cyst

-local pain or tenderness

-amenorrhea or delayed menstruation (can mimic ectopic)

-ovarian torsion if big - severely painful

-can rupture and bleed = acute abdomen

treating corpus luteum cyst

regress after 1-2 months

-OCP may help

-surgical intervention

indications of surgical intervention for corpus luteum cysts

control hemorrhage

perform detorsion of adnexa

theca lutein cysts are caused by

elevated hCG, from:

-hydatidiform mole

-choriocarcinoma

-fertility treatment

theca lutein cysts are

usually b/l

filled with clear, straw-colored fluid

abdominal symptoms with theca lutein cysts

minimal

-pelvic heaviness

-signs and sx of pregnancy, mainly hyperemesis

gestational trophoblastic neoplasia (GTN)

group of malignant neoplasms consisting of abnormal proliferation of trophoblastic tissue, can follow hydatiform mole or nonmolar pregnancy

hydatidiform mole

after aberrent fertilization

-presents like a pregnancy, positive test

-will see on first US

HM (hydatidiform mole) is a

premalignant disease

choriocarcinoma

can follow any pregnancy

aggressive and metastatic quickly

characteristic of invasive mole and choriocarcinoma

high levels of hCG

treatment of theca lutein cysts

spontaneously disappear...

-following termination of pregnancy w/ D+C

-treatment of choriocarcinoma

-discontinuing fertility treatment

can takes months to resolve

surgery for theca lutein cysts

only for torsion and hemorrhage

endometriomas

"chocolate cysts"

in patients with endometriosis

endometrial foci on ovarian surface get fibrous enclosure

endometrioma associated with

chronic pelvic pain

dyspareunia

dysmenorrhea

infertility

treatment of endometrioma

vaporize superficial lesions

excise >5cm

ovarian neoplasm is

a growth inside the ovary, not external coming off of it

ovarian neoplasms are usually

benign, especially in premenopausal women

postmenopausal ovarian neoplasm

almost 50% chance of CA

treatment of ovarian neoplasm

surgical exc w/ careful exploration of abdominal contents

ovarian neoplasm - epithelial tumor

most common

serous, mucinous, endmetrioid, clear cell, transitional cell

what is the most common true ovarian neoplasm

epithelial tumor

ovarian neoplasm: sex cord-stromal tumors

thecoma, fibroma, hilus cell tumor

ovarian neoplasms: germ cell tumors

mature cystic teratomas - "dermoid cyst"

40-50% of all benign neoplasms

primary ovarian tumor categories

epithelial

germ cell

sex cord-stromal

most prevalent category of ovarian cancer

epithelial

most epithelial tumors are

high grade serous (bad)

classic theory of epithelial ovarian cancer development

repeated trauma and repair of ovarian epithelium during normal ovulation with genetic alteration = malignancy

second theory of epithelial ovarian cancer development

high serum levels of LH, FSH, estrogen, androgen, or inflammatory factors causes epithelial proliferation = malignancy

why PCOS has high risk of ovarian CA

type I epithelial ovarian cancer

low-grade, moves stepwise with a benign precursor that is caught early

less common

type II epithelial ovarian cancer

high-grade serous carcinoma

Originate in fallopian tubes so they are not caught early

are most common with worse prognosis

most common type of epithelial ovarian cancer (EOC)

serous cystadenocarcinoma

2 types of serous cystadenocarcinoma

high-grade serous carcinoma (HGSC)

low-grade serous carcinoma (LGSC)

serous cystadenocarcinoma - HGSC (type II) is caused by

TP53 mutation

normally regulates proliferation

serous cystadenocarcinoma - HGSC (type II)

aggressive w/ poor prognosis

most deaths due to ovarian cancer

presentation of serous cystadenocarcinoma - HGSC (type II)

~65 yo

b/l large cystic tumor with solid components and areas of hemorrhage and necrosis

most common epithelial ovarian cancer - broken down

serous

HGSC = 95%

LGSC = 5%

germ cell tumor of the ovary

5% ovarian cancer

good prognosis

in the 20s and 30s

tumor markers in germ cell tumors of the ovary

aide in diagnosis and monitoring response

immature teratomas - germ cell tumors of the ovary

malignant counterpart of mature cystic teratoma

most common germ cell malignancy

immature teratoma

immature teratomas are usually u/l or b/l?

u/l

sex cord-stromal tumors of the ovary

rare, only 1.2%

sex cord-stromal tumors of the ovary come from

normal stroma around oocyte

most common type of sex cord-stromal tumors of the ovary

granulosa cell tumors

unilateral

adult subtype of sex cord-stromal tumors of the ovary

95% of granulosa cell tumors between 50-54

juvenile subtype of sex cord-stromal tumors of the ovary

5%, before puberty

sex cord-stromal tumors of the ovary secrete high levels of

estrogen...

adult subtype: postmenopausal bleeding

juvenile subtype: percocious puberty

tumor markers of granulosa cell tumors - sex cord-stromal tumors of the ovary

inhibin

estrogen

AMH

metastatic disease of the ovary

around 5% of ovarian CA is due to metastasis with primary tumor in:

GI tract

Breast

Endometrium

BRCA 1 and ovarian cancer

39-46% risk

BRCA 2 and ovarian cancer

12-20% risk

Lynch II syndrome and ovarian cancer

5-10% risk

least common cancer of the female genital tract

primary carcinoma of the fallopian tube

most cancers of the fallopian tube are

papillary sarcomas, found b/l

BRCA 1 and 2 and fallopian cancer

much higher risk, should do salpingectomy alongside prophylactic oophorectomy

risk factors of ovarian cancer

age

early menarche or late menopause

family history

infertility (due to high circulating LH and FSH)

endometriosis

nulligravity

smoking

protective factors against ovarian cancer

OCPs (not ovulating)

tubal ligation

breastfeeding (not ovulating)

progesterone use

screening for ovarian cancer in general population

not possible, discuss b/l salpingectomy if already doing a tubal ligation or hysterectomy

screening for ovarian cancer in women with FHx

CA-125 and TVUS starting at 30-35 (or 5-10 years before earliest family member)

Consider OCPs (do not use if BRCA mutation high)

ACOG recommends salpingo-oophorectomy by 40 or conclusion of childbearing

early stage ovarian CA sx

poorly defined and vague

late stage ovarian cancer sx

increased abdominal girth

pelvic or abdominal pain

bloating

urinary sx

early satiety

pelvic exam of ovarian cancer

solid, fixed, irregular adnexal mass

this description indicated ovarian cancer

fixed bilateral masses and firm masses with nodularity

CA-125 normal upper limit

35

CA-125 can also be high in

other cancers

endometriosis, leimyoma, and PID

CA-125 is more useful in

postmenopausal women

normal CA-125 does not

exclude diagnosis of ovarian cancer

adnexal mass imaging

pelvic US

-determined benign or malignant, but definitive needs surgery

-angiogenesis by adding color flow doppler can indicate increased blood flow/vessels = malignancy

suspected ovarian CA pt should also get

CXR and mammogram

description of benign cyst

simple,

description of ovarian CA imaging

solid, or solid and cystic

multiple septations

reproductive age ddx

more likely ovarian cyst or endometrioma

mature teratomas are common ovarian neoplasms in 20-30 yo

prior to surgery for ovarian cancer

-imaging for metastasis (abd CT or MRI, maybe chest)

-baseline CA-125

-genetic testing in all women w/ ovarian cancer

surgical intervention in ovarian cancer

surgical staging and tumor removal required for all

standard staging for ovarian cancer surgery includes

-total hysterectomy

-b/l salpingo-oophorectomy

-pelvic and para-aortic lymph node dissection

-sample of ascites or peritoneal washing for cytology

-exploratory surgery of abdominal contents

treatment of ovarian cancer - non-surgical

all get chemo (unless pallative) 4-6 weeks after surgery

-CA-125 to follow treatment

-radiation not great

why is radiation not used for ovarian cancer, what is it good for?

not good b/c its solid and fixed and radiation is widespread

can be good in germ cell tumors, though

prognosis of ovarian cancer

although second most common GYN CA, it is most lethal

-prognosis is related to stage