Obstetrics and Gynecology/Ovarian Neoplasia
- With respect to general ovarian neoplasms, 30% of postemenopausal women with adenexal masses have malignant disease, compared to 7% in pre-menopausal women.
- 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.
- 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
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
- 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
Epithelial ovarian tumors arise from the peritoneal coverings of the ovaries.
- 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
Presentation of the Adenexal Mass
Women may present with
- Most cases are discovered incidentally and present with vague symptoms
- Postmenopausal bleeding
- Acute pain in pelvis and lower abdomen
- Urinary frequency, urgency
- Bowel obstruction
- Omental masses
- Pleural effusion
- Local lymphadenopathy
- Palpable adenexal masses
Diagnostic Approach to the Adenexal Mass
- 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.
- 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
- Typicaly 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
- Epithelial ovarian tumours (90% of ovarian cancer)
- Serous papillary tumors (80* of ovarian cancer)
- 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)
- 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)
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Functional Ovarian Cyst
- Reevaluate in 1-2 months. If no resolution in 6-8 weeks, refer to specialist.
- 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).