Ovarian Tumours

Ovarian Tumours
Professor Bharat Bassaw

Classification of Ovarian Tumours
1. Epithelial
2. Sex cord/Stromal
3. Germ cell
Based on origin
4. Others
5. In pregnancy
Epithelial Tumours
a. Serous
b. Mucinous
c. Endometrioid
1. Epithelial
d. Brenner
e. Clear cell
NB. Tumour marker: CA-125, esp. serous cystadenocarcinoma.

Serous Tumours
BENIGN
Usually cystic, thin walled, unilocular
Smooth walls
Size: 3-30cm
Clear fluid
a. Serous
MALIGNANT
Usually large
Cystic and solid components
Blood-stained fluid
Mucinous Tumours
BENIGN
Almost always cystic
Usually large (15-30cm)
Thick parchment-like wall
Multi-locular
Clear tenacious mucoid material
Psammoma bodies
b. Mucinous
MALIGNANT
Cystic and solid or wholly solid
Areas of necrosis and haemorrhage
Mucoid material
Pseudomyxoma Peritonei
Associated with benign mucinous

cystadenoma
Accumulation of mucoid material in
peritoneal cavity with association with
appendix or intestine.
Mostly malignant
Endometriod Solid, partially cystic or wholly cystic
Mimics endometrial adenocarcinoma
Majority are benign

Small, solid, well -circumscribed nodules
Brenner Malignant form: pure transitional cell
carcinoma
Most likely malignant

Associated with fallopian tube adenocarcinoma
Clear-Cell Large
Mainly cystic and solid areas
Aggressive, poor prognosis
Sex Cord/ Stromal Tumours
Hormone-producing
Sex cord/ Stromal tumours
Granulosa
Cell
Usually solid, hard , Recurrence or metastases
rubbery In young girls, can lead to tend to occur late
precocious puberty commonly after 5 years
Yellow/Grey
Survival: 50-60%
Reproductive age:
Average size 12cm
abnormal uterine bleeding
Inhibin is tumor marker
Slow-growing, malignant
Postmenopause :
postmenupausal bleeding Call - Exner bodies
Produces oestrogen
Sex Cord/ Stromal Tumours
Solid, plump, pale, ovoid
Thecoma Most likely in postmenopausal

Produce oestrogen but can also secrete androgen
Usually benign
Fibroma Meig's syndrome (fibroma, ascites and pleural

effusion)
Can be benign or malignant

High levels of androgen
Androblastoma, Virilism
Leydig Cell, Usually in young women
Solid
Sertoli-Leydig Recurrence to omentum, abdominal lymph nodes
or liver
Germ Cell Tumours
Usually in young women
Germ Cell Tumours
Identical to seminoma in males
Highly radiosensitive
Arises in women between 10 to 30
years
Dysgerminoma Solid, about 12cm in diameter
Considered malignant
Survival rate is over 90%
Trophoblastic differentiation
Identical to gestational choriocarcinoma
on histology
Choriocarcinoma But do not respond well to
chemotherapy whereas gestational
choriocarcinoma responds well
Germ cell tumours
Also known as endodermal sinus tumors
Yolk Sac Secrete alpha feto-protein

Occurs mainly in young girls 4-20years
Highly aggressive
Rapid spread in abdomen and to distant sites
Tumour Tumour marker: AFP

Large masses
Schiller-duval body
Differentiation along germ lines esp ectodermal

(skin, appendages: hair, sebum)
2nd-3rd decades of life
Up to 10cm in diameter
Teratoma 10% bilateral

10%
About 1% malignant (squamous cell cancer)
Use term mature(benign) and immature(behaves
malignant)
Teratoma:
Rokitansky's tubercle
Any are asymptomatic but can cause abdominal
pain, distension, urinary or bowel complaints
If rupture occur chemical peritonitis results
Usually unilocular
Teeth in one third of cases
Monophyletic: differentiates along one cell line
characterized by stroma ovarii, vascular tissue to
thyroid gland
Pelvic hyperthyroidism
Others
Kruckenberg
Adenocarcinoma in association with tumour of stomach or bowel

Signet-ring
Bilateral, solid
Metastases from
Breast
Fallopian tube
Endometrium
Many so-called primary ovarian cancers may be secondaries from Fallopian

tube.
Hence, salpingectomy or tubal ligation may prevent some ovarian cancers.
Ovarian tumours in pregnancy
Corpus Theca
luteal lutein
cyst fluid accumulates
cyst
can be very large
in corpus luteum
can rupture and

fragile (easy to
mimics a ruptured
rupture)
ectopic pregnancy
diagnosis usually
form due to raised
made at
beta - HCG with
laparotomy or
hydatidiform mole
laparoscopy
if corpus luteal cyst

is removed
bilateral
surgically, then
pregnancy will end
Treatment is to
treat H.Mole
usually suction
curettage
Simple
(follicular cyst)
Polycystic
Endometrioma
ovary
Other
Ovarian
tumours
1. Simple (follicular cyst)
benign
small
clear fluid
any produce oestrogen (can affect menses)
many will resolve spontaneously, but OCP may hasten disappearance
surgery if cyst is getting larger or causing symptoms
Ovarian cystectomy ( esp in young females)
2. Endometrioma
characteristic feature of severe endometriosis
may be large
dense peri-ovarian adhesion
pelvic pain and/or infertility
CA 125 is moderately elevated
treatment is usually surgical
does not respond well to medical treatment
3. Polycystic ovary
not the same as PCOS
tiny subcapsular cyst (2-9mm)
thickened capsule (tunica albuginea)
pearly - white
usually bilateral
PCOS
Ovarian volume >10mm
12 or more small cysts ("chain of pearls") on TVS
Oligomenorrhoea/Amenorrhea
anovulation
Hyperandrogenism : hirsutism, acne, seborrhoea
Any 2 of the above 3

PCOS
Hyperinsulinaemia (Insulin resistance)
tendency for diabetes mellitus and possible
metabolic syndrome
anovulation (Infertility)
obesity (high BMI) especially central or truncal
risk for endometrial cancer
PCOS : Treatment
Weight management
Oligomenorrhoea : OCP
Anovulation : ovulation induction (clomiphene)
Role of metformin
Surgery as last resort, electrocautery drilling of ovaries but

then may be effective for only about 1 year
Treatment of hirsutism : anti - androgen drugs, hair removal

Treatment of Ovarian Cancer
1. Surgery : Laparotomy (midline), staging
TAH, BSO, Omentectomy

Cytology
Debulking
2. Chemotherapy
Especially platinum drugs such as cisplatin or carboplatin

Most times as combination
Paclitaxel
3. Radiation: small role especially dysgerminoma
Prognosis generally not good with Ovarian cancer

Risk of Malignancy Index (RMI)
Risk of Malignancy Index (RMI)
RMI = U x M x CA 125
U = 0 (no features on ultrasound)

U = 1 (ultrasound score of 1)
U = 3 (ultrasound score of 2-5)
Ultrasound : multilocular cyst, solid areas, evidence of metastases , ascites , bilateral
M = 3 (postmenopausal)
CA- 125 (value in U/L)
If RMI <25 Risk of cancer is low (<3%)

25 - 250 about 20%
>250 75%
Accidents to ovarian cyst
Rupture
Torsion Malignant Haemorrhage
Infection
NB: It is important that we are aware of the boundaries of ovarian fossa.
OCP reduces risk of ovarian and endometrial cancer BUT the risk of breast
and cervical cancer is elevated.

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Ovarian Tumours

Professor Bharat Bassaw

NB. Tumour marker: CA-125, esp. serous cystadenocarcinoma.

Associated with benign mucinous

Majority are benign

Most likely malignant

Thecoma Most likely in postmenopausal

Fibroma Meig's syndrome (fibroma, ascites and pleural

Can be benign or malignant

Yolk Sac Secrete alpha feto-protein

Tumour Tumour marker: AFP

Differentiation along germ lines esp ectodermal

Teratoma 10% bilateral

Adenocarcinoma in association with tumour of stomach or bowel

Many so-called primary ovarian cancers may be secondaries from Fallopian

can rupture and

if corpus luteal cyst

Ovarian volume >10mm

12 or more small cysts ("chain of pearls") on TVS

Hyperandrogenism : hirsutism, acne, seborrhoea

Any 2 of the above 3

Anovulation : ovulation induction (clomiphene)

Surgery as last resort, electrocautery drilling of ovaries but

Treatment of hirsutism : anti - androgen drugs, hair removal

TAH, BSO, Omentectomy

Especially platinum drugs such as cisplatin or carboplatin

3. Radiation: small role especially dysgerminoma

Prognosis generally not good with Ovarian cancer

U = 0 (no features on ultrasound)

Ultrasound : multilocular cyst, solid areas, evidence of metastases , ascites , bilateral

CA- 125 (value in U/L)

If RMI <25 Risk of cancer is low (<3%)

Torsion Malignant Haemorrhage

NB: It is important that we are aware of the boundaries of ovarian fossa.

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