Ovarian Tumors

Dr. Hanan A Balobaid

Consultant Of Obs & Gyn
Jordanian Bord – KHMC- Jordan
Assistant Prof. Hodeida Univirsety
 Ovarian Mass/Adnexal Mass
This term implus to any of the
: following
Functional ovarian cyst )i(
Benign tumor )ii(
Border line tumor)iii(
Malignant tumor)iv(
Functional Cysts of ovary.1
cysts which arise due to temporary
hormonal disturbances ,
regress spontaneously :
functional ovarian cyst
• Follicular cyst ,
• corpus luteum cysts
• Theca lutein cysts
• are less common than follicular and
corpus luteum cysts.
• They are usually bilateral, multicystic
and larger in size, up to 25 cm
• In all cases the excessive luteinisation
is the result of the high output of
gonadotrophins
• They are associated with molar pregnancy,
choriocarcinoma, multiple pregnancy and are
also seen following ovulation induction with
clomiphene citrate or gonadotrophins ,
• No treatment is required for these cysts.
• The abnormal luteal tissue disappears
spontaneously when the cause is removed.
corpus luteum cyst

• A normal corpus luteum is considered cystic

if greater than 3 cm in diameter – this is
especially seen following the occurrence of
haemorrhage into its cavity.
• The corpus luteum of pregnancy frequently
forms quite a large cyst as it degenerates
between the second and third months .
• The single follicular cyst with granulosa cells
predominant is associated with the
production mainly of oestrogen.
• The polycystic ovaries which are found in the
polycystic ovary syndrome produce relatively
excessive amounts of androgens .
 Luteoma Of Pregnancy

• Luteoma Of Pregnancy Solid multiple foci of luteal

tissue are sometimes found in one or both ovaries
during pregnancy, either intrauterine or extra
uterine pergnancy.
• Luteomas represent hyperplastic conditions rather
than true neoplasms.
• These are separate from the corpus luteum of
pregnancy and vary in diameter from 8 to 20 cm.
Their cut surface is orange yellow to greyish yellow
in colour .
 Luteoma Of Pregnancy

• These tumours do not ordinarily give rise to

symptoms, and most have been discovered
accidentally at caesarean section or during
laparotomy in the early puerperium.
Symptoms
• The majority of cystic ovaries are
symptomless and are discovered incidentally
at operation or during pelvic examination ,
• Menstrual Disturbance Polymenorrhoea or
polymenorrhagia
• Amenorrhoea: Amenorrhoea or
oligomenorrhoea results when cystic ovaries
are androgenic.
• Pain: It is often stated that a cystic ovary
causes pain in the iliac fossa
• Dysmenorrhea may indicate endometriosis
and an associated endometrioma
• Intermittent or acute severe pain with
vomiting often accompanies torsion
• Other causes of acute pain include cyst
rupture or tuboovarian abscess.
• pressure or ache may be the sole symptom and
can result from ovarian capsule stretching or cyst
bulk.
• Infertility When cystic change is associated with
suppression of ovulation ,
• prepubertal or postmenopausal bleeding due to
excess estrogen production from granulosa cell
stimulation .
• Increased androgen levels produced by theca cell
stimulation can virilize women .
 Diagnosi
s

Tumor Markers b-
hCG , (CA125,
(CEA) , (CA19-9 ,
(LDH) , AFP
transvaginal sonography (TVS) .
Transabdominal scanning
transvaginal color Doppler
sonography ,
Computed tomography (CT) or
magnetic resonance (MR)
Management
Observation
• In prepubertal and reproductive-aged women, most
ovarian cysts are functional and spontaneously regress
within 6 months of identification.
• For postmenopausal women with a simple ovarian cyst,
expectant management also may be reasonable if
several criteria are met These are:
(1) sonographic evidence of a thin-walled, unilocular cyst;
(2) cyst diameter <5 cm;
(3) no cyst enlargement during surveillance; and
(4) normal serum CA125 level
 Case 1: Benign Mass in Reprodctive age
female
No need for measuring CA125 levels •
See the size of mass on USG

5-7 cm ≥ 7 cm
3-5cm
Follow with do surgery
Wait and watch
Serial USG remove it

If the cyst does not resolve or causes

Symptoms like pain and irregular menses
Then use combined oral pill for 3-6 cycles
 Case 2: Benign Mass in Extremes

Benign mass in extremes of age

Postmenopausal Prepubertal girl

Female Measure alpha
Measure CA 125 levels Feto protein/HCG
(suspecting epithelial cell tumor of (Suspecting
ovary) Germs cell tumor )
≥ 35 IU Raised
Do surgery Surgical
And remove it Mangement
 Case 3: Adnexal Mass in Pregnancy

Adnexal mass in pregnancy

Not causing Causing

symploms symptoms
2. Trimester
1. Trimester
(i) If cyst is ≥ 10cm or (ii)
Wait and watch
if has features of immediate
As most likely it is
malignancy on USG Surgery
acorpus luteum
Remove it /do surgery
the cyst resolves Irrespective
@14-20 weeks of
spontaneously by
pregnancy Gestional age
12 weeks
Benign ovarian Tumors )2(

Eplithelial
Germ Cell Sex Cord
Cell
Tumor Tumor
Tumor
 Epithelial tumours

• can be split into five basic histological groups

which resemble normal epithelia present in
the genitourinary tract,
• Serous tumours appear similar to the
epithelium of the fallopian tube,
• mucinous tumours similar to the
endocervical mucosa
• Brenner tumours contain cells suggestive of
the transitional epithelium of the bladder.
Epithelial Cell Tumor

( 2)
(1) Serous
Mucinous (3) Brenner
Tumor 90% cystadenom
cystadenom Tumors
a (75-80%)
a (5 %)
Serous cystadenoma
• Resmbies the epithelium of ovary or fallopian tube
• more like cillated epithelium of fallopian tube )
• Percentage of bilaterality 20%
• Malignant potential 40%
• Unilocular cyst (thin walled )filled with clear fluid
and is the commonest than Mucinous
• Histological pathological characteristic
PSAMMOMA body
• PSAMMOMA body has concentric fine granules seen
Mucinous cystadenoma

• Resembles glandular epithelium of cervix

• Bilaterality 10%
• Malignant ≤20%
• Mostiy multilocular cyst filled with mucinous
fluid ..and the largest tumor
• On cut section it gives a honey coob
appearance . No other Hp characteristic
• It is associated with pseudo myxoma
peretonei
• Serous and mucinous cystadenocarcinoma
are the most common types of invasive
epithelial ovarian cancers but again are
frequently mixed tumours.
• They comprise 60 per cent of all primary
tumours of the ovary and 9 per cent of those
that are malignant,
 Brenners tumor

• Resembles the transitional epithelium

suggestive of the transitional epithelium of
the bladder
• Mostly unilateral
• Mostly benign (malignant less 2%)
• Solid benign tumor with rubbery consistency
• Walthard cellrest and coffee bean nuclei
• It is associated with pseudo meig syndrome
 Germ Cell Tumor
• 5-8%
• : Teratoma
• Mature Dermoid cyst
• Immature
• = Yolk Sac Tumor/Endodermal Sinus tumor
• Embryonal tumor
DERMOID CYST
• Age group :Reproductive age group
• . But it can be seen in postmenopausal females
as well as new born girls .
• Dermoid ,cyst usually contains derivatives of
ectoderm endoderm and mesoderm most
ectoderm
• Characteristically they are unilocular cyst
containinig hair and cheesy sebaceous material
,teeth, bones, thyroid tissue and cartilage .
 Important One Liners

.M /C ovarian cyst diagnosed in pregnancy Dermoid cyst

M/C ovarian tumor to undergo torsion in pregnancy
Dermiod cyst
M/C time for ovarian cyst to undergo torsion in pregnancy
end of first trimester and/or puerperiutm
:If an ovarian cyst is detected during puerperium
Managemen should be surgical removal As it will have high
. chances of undergoing torsion
 sex Cord Tumor 3%

A. Estrogen Secreting Tumors

(i) Granulosa

(ii) Fibroma

(iii) Thecoma

B. Androgen Secreting Tumor

(i) Serto LI cell tumor

(ii) LEYDIG cell tumor

 Sex cord tumor
:granulosa cell tumor

• t is an estrogen secreting tumor

• At Various age groups it has different presentations :
• prepuberty – precocious puberty
• -Reproductive age - Menometrorrhgia
• - Menopausal age - Post menopausal bleeding
• Best prognosis in all ovarian tumors
 Borderline tumors
• Also called as low malignant potential tumors
• Seen at younger age group 30-50 yrs (whereas
malignant epithelial tumors are seen in ages 50-70
years)
• These tumors display malignant characteristic like :
• Nuclear atypia present
• Mitosis seen (<4/10per high power filed )
• Epithelial hyperplasia present
• But the characteristic which distinguishes term from
malignant variety is :Absence of stromal invasion
 MALIGNANT OVARIAN TUMORS

• There are 2 theories related to development of

ovarian cancer :
i . Excessive estrogn : Ovarian cancer like
edometrial cancer an hyperestrogenic condtion.
ii. The theory of continuous ovuation :which
means As the Freguency of ovulation increases risk
of ovarian cancer also increases so based on these
two theories the risk factors and
protective factors for ovarian cancer are :
 Risk factors protective factors

Nulliparity Multiparity
Obesity Pregnancy
Early menarche Exercise
and late menpause Smoking as it inhibits
Clomiphene citrate or enzyme aromatase
Ovulation inducing drugs Anovulation OCP
Infertility /PCO Breast feeding
Workers in asbestos factory Tubal ligation and hysterctomy
Dysgenetic gonads (as they do not allow ovary to
)HRT +/- carcinogens
 Epidemiology
• Ovarian cancer is fifth leading cause of cancer related
death worldwide females, after –lung >breast > colorectal
>pancreas > ovarian cancer
• peak incidence 56 to 60 years
• 5-10% of epithelial ovarian cancers hereditary
predisposition .
• About 30% of ovarian neoplasia in postmenopausal
women are malignant whereas only about 7% of ovarian
epithelial tumors in premenopausal females are
malignant .
 Hereditary Breast and Ovarian Cancer

Most hereditary ovarian cancer are associated

with mutations in BRCA 1
located on chromosome 17 .
Small proportions have mutations in BRCA 2
gene located on chromosome 13 .
5-10% ovarian tumors are hereditary
 KEY POINTS
Women with BRCA gene
mutations have a life risk
,time of breast cancer of 82%

BRCA 1 Ovarian cancer (54%)

BRCA 2 Ovarian cancer (23%)

HNPCC Ovarian cancer (15%)

BRCA -1 is more carcinogenic than BRCA-2
Lynch II Syndrome /HNPCC-hereditary non
polyposis colorectal cancer (HNPCC)
It includes multiple adenocarcinomas and
involves a combination of familial colon cancer
(Lynch 1);
a high rate of ovarian, endometrial, breast
cancer; genitourinary cancer and hereditary
nonpolyposis coli.
 Recommendations for HEREDITARY Cancer

• Woman who wish to preserve their reproductive capacity

can undergo screening by transvaginal ultasonography every
6months, although the efficacy of this approach is not
established .
• Oral contraceptives should be recommended to young
woman before they embark on an attempt to have a family
but the risk of breast cancer and cervical cancer should be
kept in mind .
• Women who do not wish to maintain their fertility or who
have completed their families should be recommended to
undergo prophylactic bilateral salpingo - oophorectomy
after the age of 35, but definitely by age 40 years .
 Malignant ovarian tumor
A malignant epithelial tumor
1 serous cystadeno carcinoma
2 mucinous cystadeno carcinoma
3 clear cell carcinoma
4 endometroid tumor
B germ cell tumors
1. im mature teratoma
2. yolk sac tumor \ endodermal sinus tumor
3 . Choriocar cinoma
4. dysgerminoma
5. embryonal tumor
C sex . Cord tumor
1 granulosa cell tumor
 Debulking
• as Also called cytoreduction, is
defined as removal of as much tumor
as possible during surgical
exploration .
• Optimal cytoreduction implies that
tumor nodules no larger than 1.5 cm
in diameter are left behind and
survival improves as the amount of
resisdual diseases decreases .
Neoadjuvant therapy
•i.g. initial treatment
with chemotherapy
followed by interval
debulking surgery is
also suggested .
Conservative surgery in ovarian cancer is unilateral
salpingoopherectomy which has only few indication .
Rest in all cases radical surgery in the form of
bilateral salipingoopherctomy with .Total Abdominal
Hysterectomy is done.
Indications of conservative surgery in ovarian
cancer :
1. Borderline tumors
2. Germ cell tumor
3. Sex cord tumor in young female
4. Epithelial cell tumors in early stages in young
females .
 Important Points
Benign Malignant
M/C in reproductive age M/C in extremes of age History of
pain present Usually painless

Pain is seen in last stages

Mostly unilateral Mostly bilateral
Have cystic consistency Variable consistency
Tender Non tender(Old age
)adolescent age
 Characteristics of Benign vs Malignant Tumors

Physical examination Benign tumor Malignant tumor

Mobility Mobile & smooth Fixed, and have surface
irregularites
Consistency Cystic solid or firm
Laterality Unilateral Bilateral
Radigraphy
Size Usually < 10 cm size Any size
Septations < 2 mm thickness Multiple septations ≥ 3 mm in
size
Caicification seen in teratoma Usually absent
Omental caking Absent Seen
Intraoperative Unilateral cyst with no adhesion Solid areas with
adhesion Rupture may occur
Capsule intact Capsule is breached

tumor markers of ovarian cancer
• Tumor
• Epitheilal nonmucinous
• Tumor
• Mucinous tumor
• Yolk sac tumor
• Chelioccarcinoma
• Dysgerminoma
• Embrtyonal carcrioma
• Granulosa cell tumor
Also know :
Tumor Marker
CA125 Mainly alters Human
epididymal pattem 4,OVA1
CA19-9., CEA
Alta feto protein ( anti trypsin alphal
hcg
LDH , alkalin phosphate
HCG alpha feto protein
Inhibin
 Surgical Staging of ovarian cancer

• Steps of STAGING Surgical Laparotomy in Ovarian cancer .

• Open the abdomen by a midline Vertical incession (Remember :-it is not is not
transverse incision)
• Look all the organs
• Take samples
• Ascitic fluid is present
• If no ascitic fluid is present then do saline take the wash fluid
• Pelvic lymphnodes
• Scrapings of diaphragm
• Do biopsy (Multiple peritoneal biopsies)
• Do surgery :
• TAH + BSO +Infracolic metectomy (Note: Not omenta biopsy).
FIGO Staging of Ovarian Cancer (2014)

Stage 1 TUMOR CONFINED TO OVARIES

IA Tumor Iimited to 1 Ovary ,capsule intact, no
. Tumor on surface, negative washings
IB Tumor involves both ovaries rest like IA .
IC Tumor limited to 1 or both ovaries
IC1 Surgical spill (lntra operative capsule rupture)
IC2 capsule rupture surgery or tumor on ovarian surface .
IC3 Malignant ascites or peritoneal washings .
..
 Stage II

Tumor involves 1 or both ovaries with pelvic

extension (below the pelvic brim ) or primary
peritoneal cancer
IIA Tumor spreads to uterus or Fallopian tubes
IIB Spreads to other pelvic organs and pelvic nodes.
Stage III: Tumor involves 1 or both
ovaries with cytologically or
histoloically confirmed spread to the
peritoneum outside the pelvis and/or
metastasis to the retoperitoneal lymph
nodes
• III (Positive retroperitoneal lymph nodes and /or microscopic
metastasis beyond the pelvis .
• IIIA1 Positive retroperitoneal lymph nodes only para-aortic

• IIIA1 (i) Metastasis ≤ 10 mm

• IIIA1 (ii) Metastasis > 10 mm
• IIIA2 Microscopic extarpelvic (above the brim )peritoneal
involvement ± positive retroperitoneal lymph nodes
• IIIB Macroscopic extrapelvic peritoneal deposit ≤ 2 cm with
or without involvement of retroperitoneal lymph nodes
includes extension to capsule of liver /spleen.
• IIIC Macroscopic extrapelvic, peritoneal metastasis >2 cm
with or without involvement of retroperioneal lymph nodes
includes extension to copsule of liver / spleen .
STAGE IV: TUMOR INVOLVES 1 OR BOTH OVARIES
WITH CYTOIOGICALLY OR HISTOLOGICALLY
CONFIRMED SPREAD TO THE PERIONEUM OUSIDE
THE PELVIS AND/OR MEASTASIS TO THE
RETROPERITONEAL LYMPH NODES
IVA Pleural effusion with positive cytology
IVB Hepatic an / or splenic parenchymal
metastasis
Metastasis to extra –abdominal organs
Inguinal lymph nodes
 DISCUSSION ABOUT SOME
IMPORTANT OVARIAN TUMORS
• M /C benign tumor of ovary :Dermoid cyst
• M /C benign epithelial tumor of ovary: serous
cyst adenoma
• M /C solid benign tumor of ovary: fibroma
• M /C benign tumor of ovary in pregnancy =
Dermoid cyst
• M /C malignant tumor of ovary in pregnancy
= dygerminoma
 Metstatic Ovarian Carcinoma

First Type
They are metastatic tumors from lntestine
,GallBladder, pancreas corpus, and cervix
They are most commonly bilateral
They have irregular surface
The method of ovarian infiltration is by surface
implantation or retrograde implantation.
 Second Type (Krukenberg Tumor )

•They are metastatic tumors from

stomach(70%),large bowel (15%)and
breast (6%).
•They are are always bilateral.
•They have a smooth surface which may
be slightly bossed .
•Always arise by retrograde lymphatic
spread.
Tank You