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
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 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
- Currently no evidence for CA-125 or ultrasound screening of general population
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
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
- Platinum-based chemotherapy regimens are the most effective
- The role of a second-look laparotomy and further debulking is controversial
Bibliography
Cannistra S A. Cancer of the ovary. N Engl J Med 2004; 351: 2519-2529.
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 |