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Ovarian cysts

Functional cysts

  • Commonest type of ovarian cyst
  • Present as follicular, corpus luteal or theca luteal cysts
  • Benign and usually resolve spontaneously
  • May be an incidental finding on a clinical or radiological investigation
  • Symptoms result from pressure or rupture
  • Differential diagnosis includes:
    • Tubo-ovarian abscess
    • Ectopic pregnancy
  • Most regress in 6-10 weeks

Functional ovarian cyst

Mature cystic teratoma

  • Account for 10% of ovarian neoplasms
  • Develop from totipotential cells
  • Have well differentiated mesodermal and ectodermal elements
  • 10% are bilateral
  • Cystic teratomas have a smooth capsule and may grow to 30 cm in diameter
  • May contain bone, hair, teeth
  • Functioning thyroid tissue may cause thyrotoxicosis (struma ovarii)
  • Malignant transformation is rare
  • Treatment is by ovarian cystectomy

ovarian teratoma containing teeth

Ovarian germ cell tumours

  • In adolescents and young women the majority of ovarian neoplasms are germ cell tumours
  • Approximately 25% of these tumours are malignant
  • If functioning they can present with precocious puberty or early menarche
  • Tumour markers such as CEA, alpha-fetoprotein or beta-HCG may be increased
  • CA125 is usually not raised in germ cell tumours
  • Types of malignant tumour include:
    • Dysgerminoma
    • Embryonal carcinomas
  • Treatment is usually by surgical debulking and chemotherapy

Ovarian carcinoma

  • Arise from ovarian or coelomic epithelium
  • 75% are serous and 20% are mucinous
  • Risk factors include:
    • Advancing age
    • Nulliparity
    • Family history (BRCA1 and BRCA2)
    • Possibly fertility drugs
  • Role of screening is currently under investigation

Clinical features

  • Clinical features are non-specific
  • Early features include urinary frequency, abdominal discomfort
  • Later features include distension, early satiety and anorexia
  • Abdominal mass and ascites are late features

Staging

  • Ovarian carcinoma spreads by three routes
    • Trans-coelomic
    • Lymphatic
    • Haematogenous
  • The staging of the disease is surgical
  • 20-40% of patients are upstaged after surgical intervention

FIGO staging of ovarian cancer

  • Stage 1 - Tumour limited to ovaries
  • Stage 2 - Involvement of one or both ovaries with pelvic extension
  • Stage 3 - Involvement of one or both ovaries with extension beyond the pelvis
  • Stage 4 - Involvement of one or both ovaries with distant metastases

Ovarian cystadenocarcinoma

Picture provided by Guillermo Alvarez, Monterrey, Mexico

Management

  • Thorough surgical staging should be undertaken of all patients
  • For Stage 1 disease a unilateral salpingo-ophorectomy should be performed if future fertility required
  • Otherwise Stage 1 disease should be treated with a total abdominal hysterectomy and bilateral salpingo-ophorectomy +/- omentectomy and peritoneal biopsies
  • For Stage 2 and 3 disease surgical debulking should be performed
  • This should be followed by chemotherapy
  • The role of a second-look laparotomy and further debulking is controversial

Bibliography

Moss C,  Kaye S B.  Ovarian cancer:  progress and continuing controversies in management.  Eur J Cancer 2002;  38:  1701-1707.

Ozols R F.  Update on the management of ovarian cancer.  Cancer J 2002;  8 (Suppl1);  S22- S30.

Randall T C.  Rubin S C.  Cytoreductive surgery for ovarian cancer.  Surg Clin North Am 2001:  81:  871-883.

Shwartz P E.  Current diagnosis and treatment modalities for ovarian cancer.  Cancer Treat Res 2002;  107:  99-118

 

 
 

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