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OVARIAN TUMOR
CLASSIFICATION
A) NON NEOPLASTIC (FUNCTIONAL CYST):
1) FOLLICULAR CYST
2) CORPUS LUTEUM CYST
3) THECA LUTEIN & GRANULOSA LUTEIN CYST
B) NEOPLASTIC (BENIGN & MALIGNANT ):
1) EPITHELIAL OVARIAN TUMOR
2) GERM CELL TUMOR
3) SEX CORD STROMAL TUMOR & STEROID CELL TUMOR
FOLLICULAR CYST
- (^) COMMONEST FUNCTIONAL CYST. WHEN CYSTIC FOLLICLE > 3 CM.
- (^) USUALLY SMALL AND MULTIPLE. RESOLVE IN 4-8 WEEKS.
- (^) ENVIRONMENTAL MILIEU IS HYPER ESTRONISM.
- (^) PRESENTING SYMPTOM: ASYMPTOMATIC OR VAGUE PAIN.
- (^) MANAGEMENT: 1)<3CM : NO FURTHER INVESTIGATION
2)<8CM : NORMAL CA 125 VALUE AND WITH FOLLOWING FEATURES:-
U/L , UNILOCULAR , FREELY MOBILE , CYSTIC , SMOOTH SURFACE ,
NO PAPILLA
PROJECTION, - THEN ORAL CONTRACEPTIVES ARE USED. - REPEAT
TVS AND CA
125 IN 3MONTHS OR 6 MONTHS.
3) IF CYST PERSISTING , REMOVAL OF CYST LEAVING BEHIND OVARIAN
TISSUE IF
POSSIBLE BY LAPARSCOPY OR –TOMY.
LUTEIN CYST
- (^) LEAST COMMON.
- (^) USUALLY B/L.
- (^) CAUSED BY EXCESSIVE CHORIONIC GONADOTROPHINS.
- (^) USUALLY ASSOCIATED WITH MOLAR PREGNANCY.
- (^) CAN ALSO BE SEEN WITH MULTIFETAL PREGNANCY, CHORIOCA, DM, RH SENSITIZATION, CLOMIPHENE CITRATE USE/HCG INDUCTION ETC.
- (^) IT MAY BE LARGE UP TO EVEN 30CM/MULTI CYSTIC > BUT USUALLY REGRESSES SPONTANEOUSLY.
NEOPLASTIC MASSES OF OVARY BENIGN MASS VS MALIGNANT MASS
- (^) BENIGN MASS:- U/L, MOBILE, CYSTIC, SMOOTH SURFACE
- (^) MALIGNANT MASS:- B/L, FIXED, SOLID, IRREGULAR SURFACE, RAPID GROWTH, ASCITES, POD NODULES. ** TVS FINDING : BENIGN > CYSTIC AREAS WITH MULTIPLE THIN OR THICK ECHOES AND REGULAR VASCULAR BRANCHING (DOPPLER) MALIGNANT >SOLID CYSTIC, IRREGULAR ECHOES AND NEOVASCULARISATION WITH LOW RESISTANCE FLOW, PI <1 (DOPPLER)
SEROUS TUMOUR
- (^) THREE TYPES- BENIGN, BORDERLINE AND SEROUS CARCINOMA.
- (^) PSAMMOMA BODIES (CONCENTRIC RINGS OF CALCIFICATION) ARE FOUND.
- (^) 40% OF SEROUS BORDERLINE TUMOURS ARE ASSOCIATED WHICH SPREAD BEYOND THE OVARY BUT STILL THEY ARE NOT CARCINOMA.
- (^) SEROUS CYSTADENOMA ARE OFTEN MULTI LOCULAR, 40% B/L , 40% CHANCE OF MALIGNANCY.
- (^) SEROUS CARCINOMA:
MUCINOUS TUMOUR
- (^) THREE TYPES:-BENIGN, BORDERLINE AND CARCINOMAS.
- (^) THEY ARE CYSTIC OVARIAN TUMOURS WITH MUCIN SECRETING EPITHELIUM. MAY REACH ENORMOUS SIZE.
- (^) MULTIPLE SECRETIONS FROM MANY AREAS IS REQUIRED TO IDENTIFY MOST MALIGNANT ALTERATION.
- (^) BENIGN VARIETY:-LOBULATED, SMOOTH SURFACE, MULTILOCULAR, MAY BE B/L IN 10%.
- (^) PSEUDOMYXOMA PERITONEI:- IT IS A CLINICAL TERM TO DESCRIBE THE FINDINGS OF ABUNDANT MUCOID/GELATINOUS MATERIAL IN THE PELVIS AND ABDOMEN SURROUNDED BY A FIBROUS TISSUE. IT IS MOST COMMONLY SECONDARY TO WELL DIFFERIANTED APPENDICECAL MUCINOUS NEOPLASM,OTHER GIT PRIMARY, MUCINOUS TUMOUR ARISING IN AN OVARIAN MATURE TERATOMA.
SEX CORD STROMAL TUMOURS
- GRANULOSA CELL TUMOUR : SERUM INHIBIN (MARKER) AND CALL- EXNER BODIES. KNOWN AS THECOMA-FIBROMA CELL TUMOR. INCLUDES THECOMA, FIBROMA & UNCLASSIFIED GROUP.
- ANDROBLASTOMA : A) SERTOLI-LEYDIG CELL TUMOUR WELL DIFFERENTIATED MODERATE DIFFERENTIATED POORLY DIFFERENTIATED SERTOLI CELL TUMOR SERTOLI-LEYDIG CELL TUMOR LEYDIG CELL TUMOR B) GYNANDROBLASTOMA C) UNCLASSIFIED SEX CORD STROMAL
- GONADOBLASTOMA : BENIGN, COMPOSED OF GERM CELL AND SEX CORD STROMAL CELLS. IF LEFT IN SITU - GONADAL DYSGENESIS AND >50% WILL DEVELOP OVARIAN CA/DYSGERMINOMA.
ENDOMETROID TUMOUR
- (^) MAY BE BENIGN, BORDERLINE AND CARCINOMA.
- (^) MULTIFOCAL DISEASE.
- (^) 6-8% OF EPITHELIAL TUMOUR.
- (^) IT INCLUDES ALL THE BENIGN DEMONSTRATIONS OF ENDOMETRIOSIS.
- (^) BORDERLINE VARIETY MAY RESEMBLE AN ENDOMETRIAL POLYP OR COMPLEX ENDOMETRIAL HYPERPLASIA WITH GRANDULAR CROWDING.
DERMOID CYST ( BENIGN GERM CELL TUMOUR )
- (^) 30-40% OF OVARIAN TUMOURS. 15-20% B/L. OVARIAN TUMOUR IN PREGNANCY >20_40% MOST COMMON COMPLICATION- TORSION (15-20%).UNCOMMON- RUPTURE (1%).CHANCE OF MALIGNANCY-1%.
- (^) AGE -USUALLY IN REPRODUCTIVE AGE/25% IN POSTMENOPAUSAL AGE GROUP./ CAN OCCUR IN NEWBORN ALSO.
- NAKED EYE APPEARANCE :-A)CAPSULE SMOOTH AND TENSE. B)CONTENT IS PREDOMINANTLY SEBACEOUS MATERIAL WITH HAIR /MAY CONTAIN CSF FROM NEURAL TISSUES/THYROID TISSUE(STORMA OVARII).
- (^) CUT SECTION :- ONE AREA OF SOLID PROTUBERANCE CALLED ROKITANSKY’S PROTUBERANCE. WHICH IS COVERED BY SKIN, SEBACEOUS GLANDS, SWEAT GLANDS, TEETH AND BONES.
- (^) MICROSCOPIC EXAMINATION :-BESIDES DERMAL COMPONENTS-BONE/ CARTILAGE/ NEURAL TISSUE/ THYROID/ SALIVARY GLANDS TISSUE ARE ALSO FOUND ( HENCE DERMOID CYST NAME IS A MISNOMER ).
- (^) TREATMENT :-OVARIAN CYSTECTOMY EVEN IF A SMALL AMOUNT OF OV. TISSUE IS TO BE PRESERVED./ LAP CYSTECTOMY CAN BE DONE BUT THERE IS A CHANCE OF GRANULOMATOUS PERITONITIS /AND CHANCE OF RECURRENCE INCREASED. ** TORSION IS COMMON D/T FLOATING NATURE(HIGH FAT CONTENT) / IT USUALLY REST ON ANT. TO UTERUS.
SECTION OF DERMOID CYST
HISTORY AGE a)Usually in late child bearing age b)however, dermoid(90%) & mucinous Cyst adenoma are common in reproductive age group. c)Dermoid is more Common in pregnancy.(10%) PARITY -no correlation / whereas fibroid is associated with nulliparity.
SYMPTOMS
a)Asymptomatic b)Lower abdominal lump-gradually increasing. c)Heaviness in lower abdomen d)Dull aching pain in lower abd. e)Menstual abn usually not present, except : (^) In case of feminising tumour like granulosa cell tumour - menorrhagia,post menopausal bleeed, precocious puberty. (^) In masculinig tumour like , Sertoli-Leydig cell tumour - amenorrhoea. f)In neglected cases,cardio resp embaressment or GI symptoms can occur like nausea/indigestion.
CLINICAL EXAMINATION A) GENERAL CONDITION (^) USUALLY REMAINS UNAFFECTED. MAY BE CACHECTIC IN CASE OF HUGE MUCINOUS CYST. B) ABDOMINAL EXAMINATION (^) INSPECTION: -BULGING OF LOWER ABDOMEN/HUGE MASS FILLING ENTIRE ABDOMINAL CAVITY/EVERSION OF UMBILICUS/FLANKES ARE FLAT (FLANKES ARE FULL IN ASCITIS). (^) PALPATION :-CYSTIC/TENSE CYSTIC/SOLID(SOLID IN CASE OF FIBROMA,THECOMA, BRENNER). FREELY MOBILE FROM SIDE TO SIDE BUT RESTRICTED MOBILITY UP-DOWN. SURFACE-SMOOTH, USUALLY NON-TENDER. (^) PERCUSSION :-DULL IN CENTRE,RESONANT IN THE FLANKS.(IN ASCITIS JUST THE OPPOSITE). (^) AUSCULTATION:- FRICTION RUB MAY BE ELICITED (HISSING IN FIBROID,FHS IN PREGNANCY). C) BIMANUAL PELVIC EXAMINATION :-UTERUS FELT SEPARATED FROM MASS. MOVEMENT OF THE MASS FAILS TO MOVE CERVIX .LOWER POLE OF THE MASS CAN BE FELT THROUGH THE FORNIX.
MEIGS SYNDROME :-ASCITIS AND HYDROTHORAX IN CASES OF FIBROMA AND THECOMA OF OVARY, BRENNER TUMOUR, GRANULOSA CELL TUMOUR .SPONTANEOUS REMISSION OF ASCITIS AND HYDROTHORAX COMPONENT ON REMOVAL TO TUMOUR. PSEUDO MEIGS TUMOUR :-ASCITIS AND HYDROTHORAX BUT IN ABSCENE OF THE ABOVE CONDITIONS.
D/D OF A BENIGN OVARIAN TUMOR 1) FULL BLADDER : MAKE THE BLADDER EMPTY ROUTINELY. 2) PREGNANCY : PALPATION/ AUSCULTATION/ SONOGRAPHY. 3) PREGNANCY WITH FIBROID : MIMICS PREGNANCY AS OVARIAN CYST & FIBROID AS UTERUS. SONOGRAPHY NEEDED TO CONFIRM THE DIAGNOSIS. 4) FIBROID : CONFUSION WILL BE MORE IN CASE OF PEDUNCULATED SUB SEROUS AND DEGENERATED FIBROID. 5) CHOCOLATE CYST OF OVARY : H/O PAINFUL MENSES. 6) ENCYSTED PERITONITIS : FIXITY OF THE MASS WITH IRREGULAR ILL DEFINED MARGINS. 7) FUNCTIONAL OVARIAN CYST: IF < 8 CM – KEEP THE PATIENT WITH OCP FOR 3 MONTHS. REPEAT TVS >> FUNCTIONAL CYST WILL DISAPPEAR AND IN>OV.NEOPLASM_NO CHANGE.
