OVARIAN TUMORSINTRODUCTION

Dr. Sourav Chowdhury

Senior Resident, IQCMC

MBBS, DGO

NORMAL OVARIES

• Normal size 5 x 3 x 3cm

• Variation in dimensions can result from

– Endogenous hormonal production(varies with age

and menstrual cycle)

– Exogenous substances, including OCs, GnRH

agonists, or ovulation-inducing medication, may

affect size

mesoovariumOvarian Ligament

Free Posterior Border

DIFFERENTIAL DIAGNOSIS OF ADNEXAL MASS

ORGAN CYSTIC SOLID

OVARY Functional cyst, Neoplastic cyst,

Benign, Malignant, Endometriosis

Neoplasm

Benign

Malignant

FALLOPIAN TUBES Tubo-ovarian abscess

Hydrosalpinx

Paraovarian cyst

Tubo-ovarian abscess

Ectopic pregnancy

Neoplasm

UTERUS Intrauterine pregnancy in a bicornuate

uterus

Pedunculated or

inteligamentous myoma

BOWEL Sigmoid or caecum distended with gas

or feces

Diverticulitis, Ileitis,

Appendicitis, Colonic cancer

MISCELLANEOUS Distended bladder, Pelvic kidney,

Urachal cyst

Abdominal wall hematoma or

abscess, retroperitoneal

neoplasm

Lifetime Risk of ovarian neoplasm

• A woman has 5–10% lifetime risk of undergoing surgery for a suspected ovarian neoplasm and

• 13–21% of these will be found to be have an ovarian malignancy

COMMON OVARIAN TUMOURS

Infancy Pre pubertal Adolescent Reproductive Perimenopausal

PostMenopausal

1 Functional cyst

Functional cyst

Functional cyst

Functional cyst Epithelial ovarian tumor

Neoplastic ovarian tumor

2. Germ cell tumor

Germ cell tumor

Germ cell tumor

Dermoid Functional cyst Functional cyst

3. Epithelial tumor

Epithelial tumor

Mets

Functional ovarian cysts

• Follicular cysts

• Corpus luteum cysts

• Theca lutein cysts

• Luteomas of pregnancy

By far the most common clinically detectable

enlargements of the ovary in the reproductive years.

All are benign and usually asymptomatic.

WHO CLASSIFICATION

I. Common Epithelial Tumors:• Serous tumors• Mucinous tumors• Endometrioid tumors• Clear cell tumors• Brenner tumors• Mixed epithelial tumors• Undifferentiated ca.• Unclassified epithelial tumors

II. Sex cord tumors:

• Granulosa-stromal cell tumors, theca cell tumors

• Androblastomas

• Gynandroblastomas

• Unclassified

III. Lipid cell tumorsIV. Germ cell tumors:• Dysgerminoma• Endodermal sinus tumor• Embryonal ca.• Polyembryoma• Choriocarcinoma• Teratoma• Mixed

V. Gonadoblastomas:

• Pure

• Mixed

VI. Soft tissue tumors (not specific to ovary)

VII. Unclassified tumors

VIII. Secondary tumors

IX. Tumor-like conditions

CLINICAL PRESENTATION• Age

• Parity

• Symptoms

• Signs

• On Examinations

– Abdominal• Inspection

• Palpation

• Percussion

– Pelvic

Benign ovarian neoplasms are indistinguishable clinically from malignant counterparts

PHYSICAL EXAMINATION

• Abdominal and vaginal examination and the presence or absence of local lymphadenopathy

• Assess– Laterality

– Cystic Vs solid

– Mobile Vs fixed

– Smooth Vs irregular

– Ascites

– Cul-de-sac nodules

– Rapid growth rate

COMPLICATIONS

• Torsion

• Intracystic hemorrhage

• Infection

• Rupture

• Pseudomyxoma peritonei

• Malignancy

• Full bladder

• Pregnancy

• Fibroid

• Chocolate cyst

• Encysted peritonitis

• Ascites

• Functional cyst of ovary

Diferrential Diagnosis

INVESTIGATION

Special

• Pattern recognition is superior to all other scores.

• Subjective evaluation of ovarian masses based on pattern

recognition can achieve sensitivity of 88% to 100% and

specificity of 62% to 96%.

• Adding doppler does not seem to yield much improvement in

the diagnostic precision, but increases the confidence with

which a correct diagnosis of benignity or malignancy is made.

TVS

DOPPLER EVALUATION

• Hypoxic tissue in tumors recruit low-resistance, high-flow blood

vessels

• Role in evaluating ovarian mass is controversial – as the ranges of

values of RI,PI,MSV between benign and malignant masses overlap.

PI<1, RI<0.4

• To overcome this, vascular sampling of suspicious areas (papillary

projections, solid areas, thick septations) using both 3D USG and

power doppler both has been evaluated and found effective.

• “Chaotic” vascular pattern in malignancy

OTHER IMAGING MODALITIES

• CT, MRI, PET not recommended in the initial evaluation

• CT scan: evaluating

– LN involvement,

– Omental mets, peritoneal deposits, hepatic mets,

– obstructive uropathy

– or a probable alternate primary site when cancer is suspected based

upon TVS

• MRI : differentiating non adnexal pelvic masses (like leiomyomata),

expensive and inconvenient.

• ACOG GUIDELINES 2007

Differences Benign Malignant

1. Age More common in late child-bearing age

More common in post-menopausal age

2. Parity No correlation More with nulliparity or family H/O

3. Symptoms Gradual growth Rapid growth

4. Signs General cond. Uneffected Cachexia & pallor,jaundice, LN

5. Per abdomen More or less mobile, commonly cystic, border defined and smooth surface

Liver enlarged, firm and nodular. SOL- solid & heterogenous with restricted mobility, irregular surface with probable adhesions

Differences

Simple ultrasound-based rules for the

diagnosis of ovarian cancer.

Sonological Difference

TUMOR MARKERS

SENSITIVITY SPECIFICITY PPV NPV

61-90% 71-93% 35-91% 67-90%

CA-125

Most useful when non-mucinous epithelial cancers are present

Elevated in 80% of patients with epithelial ovarian Ca but only in 50% of patients

with stage I disease

Increased sensitivity in post menopausal women esp. when associated with

relevant clinical and USG findings

Cut-off of 30 u/ml, sensitivity of 81% and specificity of 75%

HE4

• HE4 is a precursor to the epididymal secretory protein E4 and in normal

ovarian tissue, there is minimal gene expression and production of HE4.

• As a single tumor marker, HE4 had the highest sensitivity for detecting

ovarian cancer, especially Stage I disease.

• Combined CA125 and HE4 is a more accurate predictor of malignancy

than either alone or to any other dual combination of markers

• HE4 levels(>70 pM) were found to be elevated in over half of the patients

with ovarian cancer with normal serum CA125 levels (>35 U/ml)

• HE4 when studied in the premenopausal group of patients was able to

discriminate benign tumors from malignancies

Moore et al. / Gynecologic Oncology, 2008

NEW SCORES

• ROMA: Risk of Ovarian Malignancy Algorithm

The dual marker algorithm utilizing HE4 and CA125 to calculate a ROMA value

In patients with stage I and II disease, ROMA achieved a sensitivity of 85.3% compared

with 64.7% for RMI

MOORE ET AL, AJOG 2010

• OVA 1:

FDA approved. Combination of 5 immunoassays

CA 125, transthyrettin, apo lipoprotein A1, transferrin, B2 microglobulin

Sensitivity : 93%, specificity: 43% PPV 42% NPV 93%

COMMUN ONCOL, 2010

Asymptomatic simple cysts

<5cms Likely physiological

(do not require follow up)

5-7 cms Yearly USG

>7cm Require further

imaging/surgical intervention.

RCOG 2011

Ovarian mass in reproductive age group

<5 cms. >/= 5 cms

USG USG

cystic

observationComplex,

solid, suspicious

Persistence or progression

surgery

Ovarian mass in childhood:

History and physical examination

Appr. Imaging studies

Simple cyst- Observe and reassess

Solid or solid cystic

MRI and tumor markers

High suspicion of malignancy

Low suspicionof malignancy

Laparotomy laparoscopy

Frozen sectionMalignant –oophorectomy and staging

Benign - cystectomy

Ovarian cysts in postmenopausal women:

• Post menopausal gonad atrophies to a size of

1.5 X 1 X 0.5cm on average

• Shouldn’t be palpable on pelvic examination.

• Presence of palpable ovary must alert the

possibility of an underlying malignancy.

• Incidence in asymptomatic post menopausal women

–

1.5% by pelvic examination

3.3% to 14.5% by USG.

obstet gynecol survey, 2002

• Causes -10% functional

90% neoplastic (either benign or malignant)

ASSESSMENT

• It is recommended that ovarian cysts in postmenopausal women

should be assessed using CA125 and transvaginal grey scale

sonography.

• There is no routine role yet for Doppler, MRI, CT or PET.

RCOG 2010

SENSITIVITY SPECIFICITY

TVS 89% 73%

CA 125 81% 75%

RCOG

• Simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a

low risk of malignancy. It is recommended that, in the presence of a normal

serum CA125 levels, they be managed conservatively.

• Aspiration is not recommended for the management of ovarian cysts in

postmenopausal women.

• It is recommended that a ‘risk of malignancy index’ should be used to select

women for laparoscopic surgery, to be undertaken by a suitably qualified

surgeon.

• It is recommended that laparoscopic management of ovarian cysts in

postmenopausal women should involve oophorectomy (usually bilateral)

rather than cystectomy.

BORDERLINE OVARIAN TUMORS

They were not separately classified by the FIGO and the WHO

until the early 1970s.

• Borderline tumors make up approximately 15% of all

epithelial ovarian tumors.

• The mean age of occurrence is approximately 10 years

younger than that of women with frankly malignant ovarian

cancer.

Tumour subtypes

• 2 major histological tumor subtypes

– Serous(50%)

• (bilateral in 30%)

• Could be associated with extraovarian lesion : implants(35%)

– Mucinous (46%)

• Mucinous tumors do not have a clearly defined origin.

– Substantial information indicates that many tumors may

actually originate from the appendix; thus, this organ

should be removed at the time of surgery.

Histology and Cytology• According to Dietel and Hauptmann, the histology of borderline tumors is

characterized by the following features:

– Epithelial multi-layering of more than 4 cell layers

– Not more than 4 mitoses per 10 high-power field (HPF)

– Mild nuclear atypia

– Increase in nuclear/cytoplasmic ratio

– Slight to complex branching of epithelial papillae and pseudopapillae

– Epithelial budding and cell detachment into the lumen

– No destructive stromal invasion - A major component in

differentiating malignant from borderline tumors

TUMOR STAGING

• Comprehensive staging : of significant prognostic

value and is performed surgically

• Borderline ovarian tumors are staged according to

the FIGO classification of ovarian cancer.

International Federation Of Obstetrics And Gynecology (FIGO) staging

FIGO stage Definition

I Tumor confined to the ovary

II Peritoneal implants within the pelvis

IIIPeritoneal implants beyond the pelvis,

Positive lymph nodes, or both

IVLiver parenchyma involvement, or tumor

beyond the peritoneal cavity

TREATMENT

* No further chemotherapy (in all stages.)

Summary

Ovarian Mass

Reproductive Age <45yrs

Peri/Postmenopausal

3-5cm >5-7cm >=7cm

Do Nothing

Follow-upMRI or Surgery

RCOG guidelines-62 &34;2011 & 2010

TVS if not performed & CA-125

Calculate RMI

RMI<25 RMI>25-250 RMI>250

Simple U/L <5cm & CA-125 <30

Other cyst

F/U with TVS & CA-125 4monthly / 1yr

Laraoscopicremoval

Laparoscopy or laparotomyin Cancer unit

Laparotomyin other Sp.

Centre