Transcript Disease of the overy

Disease of the overy
Dr Alaa yousif mahmood
obstetric and gynecology department
MRCOG (LONDON)/DOG/M.B.ch.B
objective
• At end of this lecture the student should be able to
recognize
• Types of ovarian disease
• Approach for their proper:
• Diagnosis
• Management
• Follow up
Introduction
Disease of the ovary : a group of diseases affecting
the ovary and have a diverse spectrum of features
according to the particular tumour entity They include
non –neoplastic e.g (functinal,inflammatory)
& neoplastic( benign, borderline and malignant )
Benign ovarian cysts are common .frequently
asymptomatic and often resolve spontaneously. And
they are more common in young age group while
malignat more common in post menopause
Ovaries are organ that produce egg .
It lie in the pelvic cavity , they
are held in place by ligaments
attached to lateral pelvic site wall by
the infundibulopelvic lig, & to the
cornua of uterus By ovarian
ligament .
the Size of each ovary 3,2,1 cm in resting stage .
The ovary has central medulla cosisit of loose connective
tissue and outer cortex which is thick and dense .
the surface of the ovaries is covered by single layer of
cuboidal cells ,the germinal epithelium ,beneath this ill
defined layer of conensed connective tissue ‘tunica
albuginea’
Ovarian tumours
general, ovarian tumors are named
according to the kind of cells the
tumor started from and whether the
tumor is benign or cancerous.
There are 3 main types of ovarian tumors
 Epithelial tumors start from the cells that cover the
outer surface of the ovary .
 Germ cell tumors start from the cells that produce the
ova (eggs)
 Stromal tumors start from connective tissue cells that
hold the ovary together and produce the female
hormones estrogen and progesterone .
Non-neoplastic
functional cyst
1-folliculer cyst
2-corpus luteal cyst
Pathological
1-ovarian endometriotic cyst
2-polycystic ovarian syndrom
3-theca leutin cyst
Inflammatory
1-tubo-ovarian abscess
Benign neoplastic
Epithelial tumours
1- serous cystadenoma
2- mucinous cyst adenoma
3- brenner tumour
Germ cell tumours
1- benign teratoma
Sex cord stromal
tumours
1- fibroma
2- thecoma
3-sertoli-ledig cell tumour
Follicular cyst
Folliculer cyst is functional non
neoplastic Lined by granulosa cells,
and is most often found incidentally.
It results from the non-rupture of a dominant follicle,
or the failure of atresia in a non-dominant follicle. A
follicular cyst can persist for several menstrual cycles
and may achieve a diameter of up to 10 cm. Smaller cysts
are more likely to resolve, but may require intervention if
symptoms develop or if they do not resolve after
8-16 weeks. Occasionally, they may continue to produce
oestrogen, causing menstrual disturbances and
endometrial hyperplasia.
Luteal cyst
Less common than follicular cysts,
these are more likely to present
with intraperitoneal bleeding. This is
more common on the right side,
possibly as a result of increased
intraluminal pressure secondary
to ovarian vein anatomy. They may
also rupture. This usually happens on days 20-26 of the
cycle.and its size more than 3 cm in diameter.
Pathological cyst
Theca lutin cyst
multiple ovarian cyst occur in
condition with increase hcg level
e.g h.mole resolve if hcg level fall
Polycystic ovarian syndrom
genarally bulky overies with multiple
small follicle.fibrotic capsule and smooth surface
endometriotic cyst
usually filled with old altered blood
(chocolate cyst) These cysts can be
painful during sexual intercourse and
during menstruation
Benign epithelial tumours
Serous cyst adenoma
This is the most common benign
epithelial tumour and is bilateral
in about 20-30%. It is usually a
unilocular cyst with papilliferous
processes on the inner surface
.The epithelium on the inner surface is cuboidal or
columnar and may be ciliated. The cyst fluid is thin
and serous. They are seldom as large as mucinous
tumours.
Benign epithelial tumours
Mucinous cystadenoma
constitute 15-25 per cent of all ovarian
tumours and are the second most
common epithelial tumour.
They are typically large, unilateral,
multilocular cysts with a smooth inner surface.5% bilateral can get
extremly large up to 150 kg ,
The lining epithelium consists of columnar mucus secreting cells. The
cyst fluid is generally thick and glutinous.
A rare complication is pseudomyxoma peritonei,which is more often
present before the cyst is removed than following intraoperative
rupture. Pseudomyxoma peritonei is commonly associated with
mucinous tumours of the appendix.
Brener tumors
1-2% of ovarian tumor.unilateral and have solid grey
white or yellow appearance to cut surface fibrous
eliment &transitional epithelium the may Screate
estrogen
Germ cell tumour
Dermoid cyst (mature cystic teratoma)
It accounts for around 40 % of all
ovarian neoplasms most commonly
in young women. The median age of
presentation is 30 years .
It is bilateral in about 10 % of cases.
It results from differentiation into embryonic tissues.
Usually a unilocular cyst less than 15 cm in diameter, in
which ectodermal structures are predominant. Thus it is
often lined with epithelium like the epidermis and
contains skin appendages, teeth, sebaceous material,
hair and nervous tissue
It can cause chemical peritonitis if content spill.
(mature cystic teratoma)
. Occasinally only a single tissue may be present in which
case the term monodermal teratoma
is used.
The classic examples are
1- struma ovarii, which contains hormonally
active thyroid tissue. Only 5- 6 per cent of struma ovarii
produce sufficient thyroid hormone to cause
hyperthyroidism
2- Primary carcinoid tumours of the ovary 30 % may
give rise to typical carcinoid symptoms .
Benign sex cord stromal tumours
represent only 4 per cent of benign ovarian tumours. They
occur at any age,from prepubertal children to elderly,
postmenopausal women. Many secrete hormones and
present with the results of inappropriate hormone effects.
Fibroma
These unusual tumours are most frequent around 50 years
of age. Most are derived from stromal cells and are similar
to thecomas. They are hard, mobile and lobulated with a
glistening white surface. Less than 10 per cent are bilateral.
While ascites occurs with many of the larger fibromas,
Meig's syndrome -ascites and pleural effusion in
association with a fibroma of the ovary –up to 40% of cases
Benign sex cord stromal tumour
Theca cell tumours :almost all are benign, solid and
unilateral, typically in the sixth decade. Many produce
oestrogens in sufficient quantity to have systemic effects
such as precocious puberty, postmenopausal
bleeding,endometrial hyperplasia and endometrial
cancer.They rarely cause ascites or a pleural effusion.
Sertoli-Leydig cell tumours: Most are found around
30 years of age. They are rare, less than 0.2 % of ovarian
tumours. Many produce androgens, and signs of
virilization are seen in three-quarters of patients. Some
secrete oestrogens. They are usually small and unilateral.
Presentation of benign ovarian tumor
 Asymptomatic
 Chronic Pain:
dull ache
Pressure on organ urinary frequency.
bowel disturbance
dyspareunia {endometrioma}
 Cyclical pain {endometrioma}
 Acute pain
bleeding in the cyst
torsion
rupture
 Abdominal swelling
 Menstrual disturbances( Hormonal effects )
Differential diagnosis of benign ovarian tumours
 Pain
Ectopic pregnancy ,spontaneous miscarriages ,pelvic
inflammatory disease ,appendicitis,meckel‘
diverticulum,Diverticulitis
 Abdominal swelling
Pregnant uterus, Fibroid uterus, Full bladder, Distended
bowel, Ovarian malignancy, Colorectal carcinoma
 Pressure effects
Urinary tract infection, Constipation
 Hormonal effects
All other causes of menstrual irregularities, precocious
puberty and postmenopausal bleeding.
Approach to the patient
History : Menstrual history (L.M.P .cycle length
..irregular bleeding)
Pain ..site .duration.nature radiation down leg, precipitate
factor
Bowel, bladder function ..abdominal distention
Medical &family history (particularly of ovarian, breast or
bowel cancer)
 Examination systemic :pulse ..Bp..tempt
Abdomen :- mass arising from the pelvis..tenderness sign
of peritonism
Pelvic :-discharge ..bleeding. Adnexal mass
tenderness..mobile fixed ..smooth or nodular
investigation
Blood tests
Full blood count.
Tumour markers—CA125, consider other tumor
marker espeially in young woman with solid mass
AFP.HCG.LDH ,Inhibin & oestradiol
imiging: abdominal ultrasound presence and
appearance of abdominal mass and ascitis
Management
 Most cyst presenting with lower abdominal pain but
without sign of peritonism or systemic upset
management conservatively with analgesia as most will
resolve spontaneously
 however if woman present with acute abdomin and sign of
systemic upset due to ovarian torsion.rupture
.heamorrhge urgent diagnostic laparoscopy or laparotomy
may be required in this case blood should be send for
tumor marker at time of surgery if cyst is not benign for
follow up ……
Management
 in young age group germ cell tumor are more common up to 20% and
those presenting with ovarian torsion aim for conservative surgery
{cystectomy} if possible to preserve fertility
Premeno pausal women
malignant tumour are rare in this age group aim to exclude malignancy and
preserve fertility..
Calculate RMI in {low risk cyst} and less than 5cm treatment conservative
rescan in 6 weeks
If the cyst persist or more than 5cm then consider laprosopic cystectomy
if suspitious finding at time of laproscopy.abundon procedure..take peritoneal
biopsy for diagnosis &refer to cancer center for full stage laprotomy
Mangment of ovarian cyst in post menopausal woman
Calculate the risk of malignancy
low risk of malignancy simple cyst less than 5cm
&normal CA 125 follow up for one year with u/s &CA125
every 4 month if no change then discontiue monitoring
if any changes &RMI is still low or woman request
removal laparoscopic oophorectomy usually bilateral is
appropriate ..
moderate RMI oophorectomy usually bilateral is
appropriate in cancer center if malignancy is found then
full staging laparotomy will be needed
High RMI more than 250 refer to cancer center for full
staging laparotomy
Risk of malignancy index (RMI I)
 RMI= (U x M x CA125 ,)
 ultrasound score (U). menopausal status (M).and serum CA125
The ultrasound result is scored 1 point for each of the following characteristics:
{ a-multilocular cysts,
b- solid areas,
c-metastases,
d- ascites ,
e-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 is scored as 1 = pre-menopausal and 3 = post menopause
The definition of 'post-menopausal' is a woman who has had no period for
more than 1 year or a woman over 50 who has had a hysterectomy
• Serum CA125 is measured in IU/ml and can vary between 0 and hundreds
or even thousands of units.
Risk of malignancy index &ovarian cancer
Risk
RMI score
Risk of cancer
Low
less than 25
less than 3%
Modrate
25-250
20%
High
more than 250
75%
The end