Obstetrics and Gynecology/Ovarian Neoplasia

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Epidemiology[edit | edit source]

  • With respect to general ovarian neoplasms, 30% of postemenopausal women with adenexal masses have malignant disease, compared to 7% in pre-menopausal women.

Benign Neoplasia[edit | edit source]

  • The vast majority of young women who present with adenexal masses have functional ovarian cysts.
  • Dermoid cysts and serous cystadenomas are tied with respect to the incidence of tumor etiology in reproductive age women.

Ovarian Cancer[edit | edit source]

  • The median age of diagnosis for ovarian cancer in Canada is 56 years of age.
  • 50% of ovarian masses in women over 50 years of age are malignant.
  • 75% of women are diagnosed at stage III cancer because of delayed presentation of ovarian cancer symptoms.
  • 1/70 women will develop ovarian cancer in their lifetimes.
  • Ovarian cancer is the leading cause of gynecological death in North America.
  • Ovarian cancer is the 5th most common malignancy in North America
  • 90% of all ovarian cancers are epithelial ovarian cancers, 80% of which are serous papillary carcinomas.
  • 10-15% of all ovarian cancers are hereditary in origin.

Etiology and Risk Factors[edit | edit source]

Possible etiologies of the adenexal mass:

  • Gastrointestinal tract: bowel cancer, constipation, bowel abscess
  • Urinary tract: full bladder
  • Obstetrical/Gynecological: pregnancy, hydrosalpinx, tubal cancer, fibroids, ovarian cancer

Benign Ovarian Tumors[edit | edit source]

  • Functional ovarian cysts arise from ovulatory failure, growth, and rupture of the graffian follicle.
  • Endometriomas arise from cyclic bleeding of ectopic endometrium.
  • Dermoid cysts arise from oocytes.

Epithelial Ovarian Carcinoma[edit | edit source]

Epithelial ovarian tumors arise from the peritoneal coverings of the ovaries.

Risk factors:

  • Nulliparity
  • Early menarche
  • Late menopause
  • Age over 40
  • Family history of breast, colorectal, or ovarian cancer
  • BRCA 1 or 2 mutations
  • Oral contraceptive use, hysterosalpingectomy, breast feeding, and tubal ligation are protective factors.

Clinical Presentation and Diagnostic Approach[edit | edit source]

Presentation of the Adenexal Mass[edit | edit source]

Women may present with

  • Most cases are discovered incidentally and present with vague symptoms
  • Postmenopausal bleeding
  • Dyspareunia
  • Acute pain in pelvis and lower abdomen
  • Urinary frequency, urgency
  • Constipation
  • Bowel obstruction
  • Ascites
  • Omental masses
  • Pleural effusion
  • Local lymphadenopathy
  • Palpable adenexal masses

Diagnostic Approach to the Adenexal Mass[edit | edit source]

  • Pelvic and abdominal ultrasound
    • Benign disease will usually present as a mass <8cm in size, cystic in consistency, and unilateral
    • Malignant disease will typically present as a mass >8cm in size, solid and cystic in consistency, and bilaterally. Furthermore, ascites, omental lesions, and enlarged lymph nodes may be visualized: all of which suggest a malignant etiology.
  • CT scanning (MRI rarely used for this purpose)
  • Ca-125 measurement (if required equipment)
  • CBC + differential: if anemic, thorough workup should be completed for a gastrointestinal pathology.
  • Creatinine
  • Laparotomy and biopsy. Laparotomy is performed according to the following guidelines
    • Cancer without evidence of spread: excision of lesion, omentum, and regional lymph nodes for staging
    • Cancer with evidence of abdominal spread: excision of all lesions greater than 1cm
      • Typically involves a total hysterectomy, salpingectomy,oophorectomy
      • If bowel obstructed or infiltrated, small and/or large bowel resection is indicated
  • Laparoscopy and biopsy if laparotomy not done.
  • Percutaneous aspiration and paracentesis with cytology performed.

Pathology, Histology, and Staging[edit | edit source]

Ovarian Cancer[edit | edit source]

  • Epithelial ovarian tumours (90% of ovarian cancer)
    • Serous papillary tumors (80* of ovarian cancer)
    • Mucinous
    • Endometrioma (high malignant potential)/clear cell
    • Mixed tumours
  • Germ cell tumours
    • Immature teratoma
    • Dysgeminoma (produces LDH)
    • Yolk sac tumors (produces AFP)
    • Embryonal carcinoma (AFP and hCG)
    • Choriocarcinoma (produces hCG)
  • Stromal tumours
    • Sertoli-Leydig (produces testosterone)
    • Granulosa cell (produces estrogen)

Staging[edit | edit source]

Simply put

  • Stage 1: confined to the ovary (survival 90% at 5yr)
  • Stage 2: confined to the pelvis (survival 60-75% at 5yr)
  • Stage 3: confined to the abdomen, without invasion of liver parenchyma (survival 30-40% at 5yr)
  • Stage 4: invasion of liver parenchyma and/or beyond (survival 10% at 5yr)

Management[edit | edit source]

Functional Ovarian Cyst[edit | edit source]

  • Reevaluate in 1-2 months. If no resolution in 6-8 weeks, refer to specialist.

Ovarian Cancer[edit | edit source]

  • If BRCA 1 positive, prophylactic surgery at age 35.
  • If BRCA 2 positive, prophylactic surgery at menopause.
    • There is approximately a 5-10% chance of finding tubal cancer at surgery.
  • Stage I, Grade I-II cancer, follow postoperatively (see operative indications in Approach. All other grades and stages may only be treated with chemotherapy (Carbo/Taxol).