Ovarian Tumors (Prof.

Bassaws Class)
Background
Some of these are benign others have malignant form.

Cysts in Young Women

Usually affects women in their 20's. These include the following three cysts:

Simple Cysts or Follicular Cysts

Corpus Luteal Cysts
Theca Luteal Cysts
Endometrioma

SIMPLE CYST/ FOLLICULAR CYST CORPUS LUTEAL CYSTS

Description This is a follicle with usually clear fluid.

Character This is as follows: This cyst tends to have blood in it.

Size Some can grow usually small

Surface Smooth surface
Bilateral Unilateral
Loculations Unilocular

Presentation This as follows: This can present as:

Asymptomatic- Majority will also regress Ruptured Ectopic- However it just

themselves mimics a ruptured ectopic

AUB- Due to the production of estrogens

from these cysts can present with bleeds

Lower Abdominal Pain

Management Medical If the patient is pregnant then fix the opposing

ends as the Progesterone that the Corpus Luteum
If 4cm or Less and Symptomatic- Low Dose makes is needed to maintain the pregnancy.
OCPs for 3 cycles and they will most likely
regress
 Repeat the Clinical Exam and USS in 3
months

Surgical

If no response from above then offer

surgical excision
Other Specifics

THECA LUTEAL CYSTS ENDOMETRIOMA/ CHOCOLATE CYSTS

Description It is formed due to high levels of HCG in the Serum This is due to endometriosis on the Ovary.
usually associated with a Mole or Multiple Pregnancy.

MCQ. Complete mole has the chance of becoming MCQ. The most common site of Endometriosis is
Gestational Trophoblastic Disease. on the Posterior Ovary Surface as a Chocolate
Cyst.
Character This is as follows:

Size Large usually

Surface Smooth Surface
Bilateral Bilateral
Loculations Multiloculated
Extensive Adhesions- This is the main
cause for Infertility as it can obstruct the
Fallopian Tubes or compress them.

Presentation This as follows: This is as follows:

Ovarian Mass on Pelvic Exam usually in Usually Ovarian Masses become Central
conjunction with someone who has had a and are easily confused with the
Molar Pregnancy Bladder but the adhesions keep the
chocolate cyst in the RIF as a mass.

MCQ. The Chocolate cyst when Large does not

become Central compared to most other cysts. It
stays in the RIF due to Adhesions.

MCQ. CA 125 is elevated mildly is Endometriosis.

Also is elevated in Pregnancy, Fibroids and PID.

Management Treat the underlying cause and it will regress once no

longer under the effects of HCG.

If no regression after 6 weeks then the patient was

not treated properly.

Monitor with Serial USS and HCG.

Other Specifics
Ovarian Tumors
Epithelial Origin Sex Cord or Stromal Origin Germ Cell Origin Secondary Cancer to the
Ovaries
ENDOCRINE TUMORS
Serous Granulosa Cell Teratoma Breast
Cystadenoma/ Granulosa Theca Cell Teratocarcinoma Secondary
Cystadenocarcinoma Thecoma Dysgerminoma Endometrial
Mucinous Fibroma Choriocarcinoma Secondary
Cystadenoma/ Androblastoma- Yolk Sac Tumor Krukenburg
Cystadenocarcinoma Leydig and Sertoli Tumor
Brenner Tumor Cell Tumors
Endometrioid Tumor
Clear Cell Tumor
Papillary Tumor

Operative Guide with Unexpected Tumor Finding

One option is to use Frozen Section while patient on the table.
Contemplate doing a Total Abdominal Hysterectomy, Bilateral Salpingo-oophorectomy,
Omentectomy.
Chemotherapy is Post-Op and is called Adjuvant Treatment.

The Characteristics of Malignant Cysts

Larger- More Malignant Chance
Bilateral
Multiloculated
Peri Ovarian Adhesions
Solid with Cystic Components
Ascites- Straw Colored
Obvious Peritoneal Deposits - on Omentum feels Hard and like Cake

Epithelial Origin Tumors

 Serous Adenoma or Adenocarcinoma Mucinous Adenoma or Adenocarcinoma

Description Most common Ovarian Cancer.

s

Character Benign Malignant Benign Malignant

Cystic Cystic and Solid Cystic Cystic and Solid

Smooth Rough Surface Very Large Very Large
Surface Large Multiloculated Multiloculated
Small Multilocular Thick Walls Thick Walls
Unilocular Mucoid Material Mucoid Material
Clear Fluid

Other Tumor Marker is CA 125. Tumor Marker is CA 125.

Specifics
MCQ. Can also contain Psamomma Bodies. MCQ. This Mucinous Tumor is associated with Peritoneal
deposits called Pseudomyxoma Peritonei. These are
mucoid deposits in the peritoneum producing a mucoid
Ascites. The most common cause is Primary Appendiceal
Cancer but also is caused by Mucinous Ovarian Cancer.
The Mucoid material causes severe Fibrosis in the
peritoneum.

MCQ. Can have Psamomma bodies which are Calcium

Deposits in the Tumor.

Endometrioid Brenner

Description

Character The cells resembles the cells of These are tumors which are usually
Endometrial Cancer. They can co exist. benign.
All of these are essentially malignant.
They are:

Solid
Small

It can progress to a Transitional Cell

Cancer.
Other Specifics MCQ. This can progress to Transitional
Cell Cancer.

Clear Cell Tumor

Description

Character Large with Clear Cytoplasm. Nuclei are

deep staining called Hob Nail Nuclei.

Other Specifics MCQ. For both the Clear Cell and

Papillary Tumors they have poor
prognosis and usually arise from the
Fallopian Tubes.

MCQ. Clear Cell Tumors have HOB NAIL

nuclei which are deep staining.
Sex Cord Origin Tumors
Granulosa Thecoma

Description Sometime has both Granulosa Theca This is a solid tumor.

Cell components.

Character Large
Rubbery
Hard

Other Specifics These are very slow growing but

Malignant.

Produce Estrogens. Presents as: Produce Estrogens.

Precocious Puberty- AUB Post Menopausal Bleed

Post Menopause Bleed

MCQ. Contains Call Exner Bodies. MCQ. Usually Benign.

Eosinophilic fluid spaces between the
Granulosa Cells.

MCQ. Tumor Marker for these are

Inhibin.

Fibroma Androblastoma- Leydig and Sertoli Cell

Description These are Benign. Tumors are Solid. The Leydig Cell are Benign and the
Leydig- Sertoli mix can be Malignant.
Character

Other Specifics MCQ. Associated with Meig's Syndrome. MCQ. Causes Virilisation. Produces
Triad of Ascites, Pleural Effusion and Androgens. Check the Adrenal and
Benign Ovarian Tumor. These resolve Ovaries when facing Virilisation.
with Tumor Resection.
Germ Cell Origin
Dermoid Cyst or Teratoma Dysgerminoma

Description Commonest cell type is ectodermal so In young females from 10- 30 years.
Hair and Sebum very common. Behaves like a seminoma.

Common in 2nd and 3rd Decade.

Rule of 10's

10% of Ovary Tumor

10% Bilateral
10% Malignant
10% Recur
10 cm Diameter
Character As follows: As follows:

Unilocular with Protuberance Solid

into Lumen called Rokitansky Large
Tubercle that carries its blood
supply
Cystic
Clinical Presentation They are as follows:

Asymptomatic
Torsion/ Rupture
Pelvic Hyperthyroidism- due to
presence of thyroid tissue

Other Specifics Treatment is with Cystectomy and MCQ. Only one that is Radiosensitive.
Dissection of other side because 10%
are Bilateral.

MCQ. Know the Protuberance called

Rokitansky Tubercle.

MCQ. It can present with

hyperthyroidism.

MCQ. The Teratocarcinoma is a from

Skin Cell origin so is Squamous Cell
Cancer.

MCQ. Tumor Marker is FP.

Choriocarcinoma Yolk Sac or Endodermal Sinus Tumor

Description No relation to pregnancy and arises In very young girls before 5 years. Highly
Primary in the Ovary. aggressive. Poor Prognosis.

No response to Chemotherapy.
Other Specifics Tumor Marker is HCG. Tumor Marker is FP.
Secondary Ovarian Tumors
The spread usually comes from the following:

Breast
Endometrial
Fallopian Tube
Stomach

NB. MCQ. Krukenburg Tumor or Secondaries from the Stomach contain Signet Cells which have eccentric
nuclei.

Workup of Malignancy
The patient who is suspected of Cancer is Investigated with CA 125 and TV USS Findings and this is used
to Calculate a Score to Determine if she needs a Staging done in a Cancer Centre for Gyneoncology.

RMI or Risk of Malignancy Index = US Findings x CA 125 x Pre or Post Menopause Score

FIGO Staging
Stage I Confined to the ovaries.

It can have Ovarian Rupture, Surface Tumor or

Ascites.
Stage II Involves one or both Ovaries with Pelvic Extension.

Can extend to other pelvic structures such as

Uterus or Fallopian tubes.

Stage III Involves one or Both Ovaries with spread to

peritoneum outside the pelvis or retroperitoneal
lymph node involvement.

Stage IV Distant metastasis excludes peritoneal metastasis.

Includes the Liver and Spleen and Lungs.

It is staged SURGICALLY. This is done with Staging Laparotomy. This patient would have undergone the
RMI index and taken to a Gyneoncologist who would have done this Laparotomy.

This consists of the following:

Debulking
TAH + BSO
Omentectomy
Removal of Adhesions
Cytologic Washings

Post Surgical Follow Up

The patient can be for Palliative or Curative Intent Chemotherapy.

Carboplatin- MCQ. Better than Cisplatin due to Less Nephrotoxicity and Ototoxicity
Cisplatin
Taxanes such as Paclitaxel