Benign and Malignant Ovarian Tumors

ALEXANDER E. OMU. FRCOG

PROFESSOR AND SENIOR CONSULTANT
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
FACULTY OF MEDICINE
HEALTH SCIENCES CENTER
KUWAIT UNIVERSITY
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 Ovarian tumours can be divided into three main groups:

 Functional 24%
 Benign 70%
 Malignant 6%
Benign epithelial neoplastic cysts (60% of benign ovarian tumours)

1. Serous cystadenoma:
Develop papillary growths which may be so prolific that the cyst appears solid.
They are most common in women aged between 40-50 years.
About 15-25% are bilateral and about 20-25% are malignant.

2. Mucinous cystadenoma:
The most common large ovarian tumours which may become enormous.
They are filled with mucinous material and rupture may cause pseudomyxoma peritonei.
They may be multilocular.
They are most common in the 20-40 age group.
About 5-10% are bilateral and around 5% will be malignant.
Abdominal Masses
Pelvic Pain
3 Endometriod
4 Clear Cell (mesonephriod)
5 Brenner Tumor
 Germ Cell tumors

 Benign neoplastic cystic tumours of germ cell origin

 Benign cystic teratoma; rarely malignant. They arise from primitive germ cells.
 A benign mature teratoma (dermoid cyst) may contain well-differentiated tissue
- eg, hair, and teeth. 20% are bilateral.
 They are most common in young women.
 Poorly differentiated, malignant teratomas are rare.

 Stroma -Benign neoplastic solid tumours

 Fibroma (less than 1% are malignant); small, solid benign fibrous tissue tumours.
They are associated with Meigs' syndrome and ascites.
 Thecoma (less than 1% are malignant).
 Adenofibroma. Like Brenner's tumour:
 Rare ovarian tumours displaying benign, borderline or proliferative, and
malignant variants.
 Over 95% are benign and more than 90% are unilateral.
 They may be associated with mucinous cystadenoma and cystic teratoma.
Epemiology
Benign ovarian tumours occur in 30% of females with regular menses
(eg, luteal cysts as incidental findings on pelvic scans) and 50% of
females with irregular menses.
Predominantly they occur in premenopausal women; they may also
occur perinatally.
Benign ovarian tumours are uncommon in premenarchal and
postmenopausal women.
The likelihood of malignancy in women of childbearing age is low and
a large proportion of cysts are of functional origin, tending to resolve
over time.[1]
Benign neoplastic cystic tumours of germ cell origin are most
common in young women. They account for 15-20% of all ovarian
neoplasms.
 Risk factors
 Obesity.
 Tamoxifen therapy has been associated with an increase in persistent
ovarian cysts.
 Early menarche.
 Infertility.
 Dermoid cysts can run in families.
 Presentation

 Asymptomatic - chance finding (eg, on bimanual examination or ultrasound).

 Dull ache or pain in the lower abdomen, low back pain.
 Torsion or rupture may lead to severe abdominal pain and fever.
 Dyspareunia.
 Swollen abdomen, with palpable mass arising out of the pelvis, which is dull to percussion and does not disappear if the
bladder is emptied.
 Pressure effects - eg, on the bladder, causing urinary frequency, or on venous return, causing varicose veins and leg
oedema.
 Torsion, infarction or haemorrhage:
 Cause severe pain.
 Torsion may be intermittent, presenting with intermittent episodes of severe pain.
 Ovarian torsion is a complication for persistent masses in pregnancy.[2]
 Rupture:
 Rupture of a large cyst may cause peritonitis and shock.
 Rupture of mucinous cystadenomas may disseminate cells which continue to secrete mucin and cause death by binding
up the viscera (pseudomyxoma peritonei).
 Ascites - suggests malignancy or Meigs' syndrome.
 Endocrine - hormone-secreting tumours may cause virilisation, menstrual irregularities or postmenopausal bleeding. This is
uncommon though.
 Differential diagnosis

 Non-neoplastic functional cysts - eg, follicle cyst, corpus luteum cyst, theca
lutein cyst.
 Any other cause of pelvic pain.
 Polycystic ovary syndrome.
 Endometrioma.
 Ovarian malignant tumour.
 Bowel - colonic tumour, appendicitis/appendix mass, diverticulitis.
 Gynaecological - pelvic inflammatory disease, tubo-ovarian abscess, uterine
tumour (eg, fibroids), ectopic pregnancy, para-ovarian cyst.
 Pelvic malignancies - eg, retroperitoneal tumours, small intestine tumours and
mesothelial tumours.
Investigations
It is important that some types of adnexal cysts (such as endometrioma, mature
cystic teratoma, and paraovarian cysts) are diagnosed correctly as these may
affect patients’ fertility, may be associated with significant pelvic disease or put
the patient at risk for ovarian torsion.[3]

Pregnancy test (uterine or ectopic pregnancy).

FBC - infection, haemorrhage.
Urinalysis - if there are urinary symptoms.
Ultrasound - a pelvic ultrasound is the single most effective way of evaluating an
ovarian mass. Transvaginal ultrasonography is preferable due to its increased
sensitivity over transabdominal ultrasound.
CT or MRI scan - usually required only if ultrasound results are not definitive or if
intra-abdominal pathology is suspected.
A recent meta-analysis found that the sensitivity and specificity of MRI for correct
detection of malignancy may reach 92% and 88%, respectively.[4]
Diagnostic laparoscopy may be performed in some cases.
Fine-needle aspiration and cytology may be used to confirm the impression that
a cyst is benign.
Cancer antigen 125 (CA 125):
CA 125 does not need to be done in premenopausal women who have had an
ultrasound diagnosis of a simple ovarian cyst made.
CA 125 is unreliable in differentiating benign from malignant ovarian masses in
Cancer antigen 125 (CA 125):
premenopausal women because of the increased rate of false positives and
reduced specificity.
Diverticulitis, endometriosis, liver cirrhosis, uterine fibroids, menstruation,
pregnancy, benign ovarian neoplasms and other malignancies (pancreatic,
bladder, breast, liver, lung) can all result in an elevated CA 125 levels.[5]
CA 125 is primarily a marker for epithelial ovarian carcinoma and is only raised
in 50% of early-stage disease.
When serum CA 125 levels are raised, serial monitoring of CA 125 may be
helpful, as rapidly rising levels are more likely to be associated with
malignancy than high levels which remain static.
If serum CA 125 assay is more than 200 units/mL, discussion with a
gynaecological oncologist is recommended[6].
The main use of CA 125 is in assessing response over time to treatment for
malignancy.
Lactate dehydrogenase (LDH), alpha-fetoprotein (AFP) and human chorionic
gonadotrophin (hCG) should be measured in all women under the age of 40
with a complex ovarian mass because of the possibility of germ cell tumours.
NB: although pelvic ultrasound is highly sensitive in detecting adnexal masses,
its specificity in detecting malignancy is lower.[1]
Risk of Malignancy Index (RMI)
There are different risk of malignancy scores which can be used to assess an ovarian mass.[7]
The RMI I is the most effective for women with suspected ovarian cancer. This is also recommended
by the National Institute for Health and Care Excellence (NICE) guideline on ovarian cancer.[8] It
should not be used for premenopausal women though.
RMI I combines three pre-surgical features: serum CA 125 (CA 125); menopausal status (M); and
ultrasound score (U).
The RMI is a product of the ultrasound scan score, the menopausal status and the serum CA 125 level
(IU/mL) as follows:
RMI = U x M x CA 125.
The ultrasound result is scored 1 point for each of the following characteristics: multilocular cysts, solid
areas, metastases, ascites and bilateral lesions. U = 0 (for an ultrasound score of 0), U = 1 (for an
ultrasound score of 1), U = 3 (for an ultrasound score of 2-5).
The menopausal status is scored as 1 = premenopausal and 3 = postmenopausal.
Serum CA 125 is measured in IU/mL.
Recommendations are that those women suspected of having ovarian cancer who have an RIM
score greater than 200 should have a CT of the abdomen and pelvis performed in secondary care.
Management
Many patients with simple ovarian cysts based on ultrasound findings do not require treatment.

Expectant management
Women with small (less than 50 mm in diameter) simple ovarian cysts generally do not require follow-up, as
these cysts are very likely to be physiological and almost always resolve within three menstrual cycles.[6]
Women with simple ovarian cysts of 50-70 mm in diameter should have yearly ultrasound follow-up and
those with larger simple cysts should be considered for either further imaging (MRI) or surgical
intervention.[10]
Even in postmenopausal women, as many as 80% of incidental adnexal masses will resolve over a period o
several months. For those that are persistent, unchanged, less than 10 cm, and with normal CA 125 values,
the likelihood of an invasive cancer is sufficiently low that observation should usually be offered.[11]
However, ovarian cysts that persist or increase in size are unlikely to be functional and may need surgical
managem
 Management
 Many patients with simple ovarian cysts based on ultrasound findings do not require treatment.

 Expectant management
 Women with small (less than 50 mm in diameter) simple ovarian cysts generally do not require follow-up, as these cysts are
very likely to be physiological and almost always resolve within three menstrual cycles.[6]
 Women with simple ovarian cysts of 50-70 mm in diameter should have yearly ultrasound follow-up and those with larger
simple cysts should be considered for either further imaging (MRI) or surgical intervention.[10]
 Even in postmenopausal women, as many as 80% of incidental adnexal masses will resolve over a period of several
months. For those that are persistent, unchanged, less than 10 cm, and with normal CA 125 values, the likelihood of an
invasive cancer is sufficiently low that observation should usually be offered.[11]
 However, ovarian cysts that persist or increase in size are unlikely to be functional and may need surgical managem
Oral contraceptives
The oral contraceptive pill is not recommended, as its use has not been shown to promote the resolution of
functional ovarian cysts.[12]Watchful waiting for two or three cycles is appropriate and if cysts persist then
surgical management is often indicated.
Surgery
If conservative measures fail or criteria for surgery are met, surgical therapy for benign ovarian tumours is
generally very effective and provides a cure with minimal effect on reproductive capacity.
Persistent simple ovarian cysts larger than 5-10 cm, especially if symptomatic, and complex ovarian cysts
should be considered for surgical removal.
In children and younger women (wishing to preserve maximum fertility), cystectomy may be preferable to
oophorectomy.[13]
Laparoscopic surgery for benign ovarian tumours is usually preferable to open surgery.
Although most adnexal masses are benign in pregnancy, when surgical management is chosen,
laparoscopy can be safely performed.[2]
Ovarian torsion:
Usually initially treated by laparoscopy with uncoiling of the affected ovary and possible oophoropexy.
Salpingo-oophorectomy may be indicated if there is severe vascular compromise, peritonitis or tissue
necrosis.
Immediate surgical intervention is indicated for a haemorrhagic cyst.
Laparoscopy will need to be upgraded to laparotomy when malignancies are discovered.
Pseudomyxoma peritonei is treated by surgical debulking.
Complications
Torsion of an ovarian cyst can occur.
Haemorrhage is more common for tumours of the right ovary.
Rupture of an ovarian cyst can occur.
Infertility can occur as a result of ovarian tumours or their treatment. However, the role of cysts in infertility
is controversial and the effects of surgical treatment are often more harmful than the cyst itself to the
ovarian reserve. Surgery does not seem to improve pregnancy rates.[14]

Prognosis
This is variable and depends on the type and size of tumour, associated complications and the patient's
age.
Most small ovarian cysts in premenopausal women will resolve spontaneously.
Ovarian torsion: if operated within six hours of onset of symptoms, tissue will usually remain viable.
Prognosis of surgically removed cysts ultimately depends on the histology.
•References

An ovarian cyst is a sac filled with liquid or semiliquid material that arises in an o
Risk factors for ovarian cancer

The exact cause of ovarian cancer is unknown.

•a family history of ovarian cancer

•genetic mutations of genes associated with ovarian cancer, such as BRCA1 or BRCA2

•a personal history of breast, uterine, or colon cancer

•Obesity

•the use of certain fertility drugs or hormone therapies

•no history of pregnancy
•endometriosis

Older age is another risk factor. Most cases of ovarian cancer develop after menopause.
It’s possible to have ovarian cancer without having any of these risk factors.

Likewise, having any of these risk factors doesn’t necessarily mean you’ll get ovarian cance
Risk factors for ovarian cancer
According to the Centers for Disease Control and Prevention (CDC), about 20,000 American women
get ovarian cancer each year. The risk of ovarian cancer rises with age. You’re more likely to get it when you’re middle-aged or older.
Other risk factors include:
•having a close family member who had it, such as your mother, grandmother, sister, or aunt
•carrying the BRCA1 or BRCA2 gene mutation
•having had breast, cervical, uterine, or colorectal cancer
•a previous diagnosis of melanoma or endometriosis
•having an Eastern European or Ashkenazi Jewish background
•never giving birth or having fertility problems
•hormonal therapy — specifically, taking estrogen without progesterone for 10 years or more
See your doctor right away if you have some of these risk factors and experience any symptoms of ovarian cancer.

Treatment may involve

surgery,
chemotherapy,
radiation,
or a combination of therapies.
The earlier ovarian cancer is diagnosed
and treated, the better the prognosis
Diagnosis of Ovarian Cancer
.Incidental
Symptoms
If your doctor is concerned that you have ovarian cancer, they’ll likely recommend a pelvic exam. Performing
a pelvic exam can help your doctor discover irregularities, but small ovarian tumors are very difficult to feel.
As the tumor grows, it presses against the bladder and rectum. Your doctor may be able to detect
irregularities during a rectovaginal pelvic examination.
the following tests:
•Transvaginal ultrasound (TVUS): This is a type of imaging test that uses sound waves to detect tumors in
the reproductive organs, including the ovaries. However, TVUS can’t help your doctor determine whether
tumors are cancerous.
•Abdominal and pelvic CT scan: If you’re allergic to dye, they may order an MRI.
•Blood test to measure cancer antigen 125 (CA-125) levels: This is a biomarker that is used to assess
treatment response for ovarian cancer and other reproductive organ cancers. However, menstruation,
uterine fibroids, and uterine cancer can also affect levels of CA-125 in the blood.
•Biopsy: This involves removing a small sample of tissue from the ovary and analyzing the sample under a
microscope. A biopsy is the only way your doctor can confirm whether you have ovarian cancer.
Stages of ovarian cancer?
based on how far the cancer has spread. There are four stages, and each stage has sub-stages:

Stage 1
Stage 1 ovarian cancer has three sub-stages:
•The cancer is limited, or localized, to one ovary in stage 1A.
•The cancer is in both ovaries in stage 1B.
•In stage 1C, there are also cancer cells on the outside of the ovary.

Stage 2: The tumor has spread to other pelvic structures. In stage 2A, the cancer has spread to the uterus or fallopian tubes.
In stage 2B, it has spread to the bladder or rectum.

Stage 3
Stage 3 ovarian cancer has three sub-stages:
•In stage 3A, the cancer has spread beyond the pelvis to the lining of the abdomen and the lymph nodes in the abdomen.
•In stage 3B, the cancer cells are outside of the spleen or liver.
•In stage 3C, deposits of cancer at least 3/4 of an inch are seen on the abdomen or outside the spleen or liver. However, the
cancer isn’t inside the spleen or liver.
Stage
4
the tutumor has metastasized, or spread, beyond the pelvis, abdomen, and lymph nodes to the liver or lungs. In stage 4A, the
cancerous cells are in the fluid around the lungs. Stage 4B is the most advanced stage. In stage 4B, the cells have reached
the inside of the spleen or liver or even other distant organs like the skin or brain.
TREATMENT

TREATMENT of ovarian cancer

The treatment depends on how far the cancer has spready

•radiation
•surgery to stage the cancer and remove the tumor
•targeted therapy
•hormone therapy

Surgery
Surgery is the main treatment for ovarian cancer. The goal of surgery is to remove the tumor, but a hysterectomy, or complete remov
al of the uterus, is often necessary. Your doctor may also recommend removing both ovaries and fallopian tubes, nearby lymph nodes,
and other pelvic tissue. Identifying all tumor locations is difficult. In one study, researchers investigated ways to enhance the surgical process
so that it’s easier to remove all of the cancerous tissue.

Targeted therapy
Targeted therapies, such as chemotherapy and radiation treatments, attack the cancer cells while doing little damage to normal cells in
the body. Newer targeted therapies to treat advanced epithelial ovarian cancer include bevacizumab (Avastin) and olaparib (Lynparza).
Doctors only use olaparib in people with mutations in the BRCA genes
Fertility preservation
Cancer treatments, including chemotherapy, radiation, and surgery, can damage
the reproductive organs, making it difficult to become pregnant.
Possible fertility preservation options include:

•Embryo freezing: This involves freezing a fertilized egg.

•Oocyte freezing: This procedure involves freezing an unfertilized egg.

Surgery to preserve fertility: In some cases, surgery that only removes one
ovary and keeps the healthy ovary can be done. This is usually only possible in
early stage ovarian cancer.

•Ovarian tissue preservation: This involves removing and freezing ovarian

tissue for future use.

•Ovarian suppression: This involves taking hormones to suppress ovarian

function temporarily.
Ovarian cancer research and studies
New treatments for ovarian cancer are studied each year.
Researchers are also exploring new ways to treat platinum-resistant ovarian cancer.
When platinum resistance occurs, standard first-line chemotherapy drugs like carboplatin and cisplatin are
ineffective.
Certain drugs are also studied for their potential benefits in ovarian cancer.
A 2014 study examined targeted treatments for those with more advanced stages of this cancer.

Ovarian cancer treatment primarily focuses on surgery to remove the ovaries and uterus, and
chemotherapy. As a result, some women will experience menopause symptoms. A recent studyexamined
how hormone therapy (HT) affects quality of life after ovarian cancer treatment.
This study found that HT is safe for menopause treatments in women with ovarian cancer. People in the
study maintained a high quality of life while receiving HT after being treated for ovarian cancer.

A 2015 article looked at intraperitoneal (IP) chemotherapy. This study found that those who received IP
therapy had a median survival rate of 61.8 months.

This was an improvement as compared to 51.4 months for those who received standard chemotherapy
PREVENTION OF OVARIAN CANCER
There are no proven ways to totally eliminate the risk of
developing ovarian cancer.

Lowering your risk of developing ovarian cancer include:

•taking oral birth control pills
•breastfeeding
•pregnancy
•surgical procedures on your reproductive organs like
a tubal ligation or hysterectomy
SEX & RELATIONSHIPS
LIFESTYLE
DIET
NUTRITION
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9 Dirtiest
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SSURVIVAL RATEThe survival rate is the percentage of women who survive a certain number of years at a given stage of diagnosis. For
example
, the five-year survival rate is the percentage of patients who received a diagnosis at a particular stage and live at least five years
after their doctor diagnosed them. The relative survival rate also takes into account the expected rate of death for people without
cancer.
Epithelial ovarian cancer is the most common type of ovarian cancer. The American Cancer Society estimates the relative survival
rate for this type of ovarian cancer as:
•Stage 1: 90 percent
•1A: 94 percent
•1B: 92 percent
•1C: 85 percent
•Stage 2: 70 percent
•2A: 78 percent
•2B: 73 percent
•Stage 3: 39 percent
•3A: 59 percent
•3B: 52 percent
•3C: 39 percent
•Stage 4: 17 percent
The survival rate is higher than 90 percent when the cancer is found early and treated right away.
About 15 percent of ovarian cancers are detected at the earliest stages.
Scientists are currently researching more improved and reliable ways to detect Ovarian Cancer
 Ronice Goforth

Ovarian cancer

Once a year, CTCA has their Celebrate Life for five-year survivors. At this

event, the survivors are honored and recognized and plant a ‘Tree of Life.’

When] I arrived at CTCA, the driver made a point to show me the trees of life

planted to honor previous cancer survivors. That was the first ray of hope for

me, and I determined that I too would plant my tree. In 2008, I had my

‘Celebrate Life’ and I got to plant my tree.