1.DR. SRAVANTHI DR. CHINMOY DR. MINAKSHI

2. NORMAL OVARIES Normal size 5 x 3 x 3cm Variation in dimensions can result from Endogenous hormonal production(varies with age andmenstrual cycle) Exogenous substances, including OCs, GnRH agonists, orovulation-inducing medication, may affect size 3. Lifetime Risk of ovarian neoplasm A woman has 510% lifetime risk of undergoing surgery for a suspected ovarian neoplasm and 1321% of these will be found to be have an ovarian malignancy 4. DIFFERENTIAL DIAGNOSIS OF ADNEXAL MASSORGANCYSTIC SOLIDOVARY Functional cyst, Neoplastic cyst,NeoplasmBenign, Malignant, Endometriosis Benign MalignantFALLOPIAN Tubo-ovarian abscess Tubo-ovarian abscessTUBES Hydrosalpinx Ectopic pregnancyParaovarian cyst NeoplasmUTERUSIntrauterine pregnancy in a bicornuate Pedunculated oruterus inteligamentous myomaBOWEL Sigmoid or caecum distended with gas Diverticulitis, Ileitis,or feces Appendicitis, Colonic cancerMISCELLANEOUS Distended bladder, Pelvic kidney,Abdominal wall hematoma orUrachal cyst abscess, retroperitoneal 5. Differential diagnosis of the adnexal masses varies considerably withthe age of the patients. In pre-menarchal girls and post-menopausal women adnexal massshould be considered highly abnormal requires immediateinvestigation. In menstruating patients differential diagnosis is varied. 6. DIAGNOSTIC EVALUATION OF THE PATIENT WITH ANADNEXAL MASS Complete physical examination Pelvic ultrasound examination Computed tomography scan with contrast enhancement orintravenous pyelography Colonoscopy or barium enema study, if symptomatic Laparoscopy, laparotomy 7. OVARIANMASSES FUNCTIONAL INFLAMMATORYNEOPLASTICOTHERS ENDOMETRIOMAFOLLICULAR CYST TUBO OVARIAN ABSCESS BENIGN ENLARGED PCOCORPUS LUTEUMBORDERLINE PAROVARIAN CYSTCYST MALIGNANTTHECA LUTEIN 8. COMMON OVARIAN TUMOURS InfancyPre pubertal Adolescent Reproductive Peri Post Menopausal Menopausal1Functional Functional Functional Functional Epithelial Neoplastic cyst cyst cyst cyst ovarianovarian tumortumor2. Germ cellGerm cellGerm cellDermoidFunctional Functional tumortumortumor cyst cyst3. Epithelial EpithelialMets tumortumor 9. Functional ovarian cysts Follicular cysts Corpus luteum cysts Theca lutein cysts Luteomas of pregnancy By far the most common clinically detectable enlargementsof the ovary in the reproductive years. All are benign and usually asymptomatic. 10. Follicular cysts Cystic follicle is defined as Follicular cyst of diameter > 3cm Most common functional cysts. Rarely larger than 8cm. Lined by granulosa cells Found incidentally on pelvic examination Usually resolve within 4 8 weeks with expectant management May rupture or torse occasionally causing pain and peritonealsymptoms. 11. Follicular cysts 12. Corpus luteal cyst Less common than follicular cyst. May rupture leading to hemoperitoneum and requiring surgicalmanagement( more in patients taking anti coagulants or withbleeding diathesis) Unruptured cysts may cause pain because of bleeding intoenclosed ovarian cyst cavity. 13. Corpus luteal cyst 14. Theca lutein cysts Least common Usually bilateral Result from overstimulation of the ovary by - hCG Do not commonly occur in normal pregnancy Often associated with hydatidiform moles, choriocarcinoma,multiple gestations, use of clomiphene and GnRH analogues. May be quite large (up to 30 cm) , multicystic, and regressspontaneously. 15. Theca lutein cysts 16. Management of functional cysts Expectant Watchful waiting for two or three cycles is appropriate. Combined oral contraceptives appear to be of no benet. Should cysts persist, surgical management is oftenindicated.Oral contraceptives for functional ovarian cysts (Review) Cochrane Database of Systematic Reviews 2011 17. Endometriomas Most common site of involvement is the ovary. Endometriomas are pseudocysts formed by invagination of the ovariancortex, sealed off by adhesions. They may completely replace normal ovarian tissue. Cyst walls are usuallythick and fibrotic. USG: anechoic cysts to cysts with diffuse low-level echoes to solid-appearing masses. Fluidfluid or debrisfluid levels may also be seen. They may be unilocular or multilocular with thin or thick septations Malignant transformation: 0.3% to 0.8% Management: medical and/ or surgical 18. Benign ovarian tumors Serous cystadenoma Mucinous cystadenoma Dermoid cyst Fibroma Thecoma Brenners tumor 19. SEROUS CYSTADENOMA Generally benign Bilateral 10% Risk of malignancy : 5 10 % borderline malignant20 -25% malignant GROSS : multilocular with papillary components. MICRO : low columnar epithelium with cilia. Characteristic psammoma bodies (end products of degenerationof papillary implants)are found. Associated fibrosis may lead to cystadenofibroma 20. MUCINOUS CYSTADENOMA Have tendency to become huge masses Round to ovoid masses with smooth capsules that areusually translucent or bluish to whitish gray. Interior divided by discrete septa into loculi containingclear , viscid fluid. Epithelium tall, pale staining, secretary with basal nucleiand goblet cells 5 10% are malignant 21. DERMOID CYST Often bilateral (15 -25%) GROSS: thick, opaque , whitish wall. CONTENTS: hair, bone, cartilage, and a large amount of greasy sebaceousmaterial. MICROSCOPICALLY : all the three germ layers (ectoderm, mesoderm andendoderm) Malignant change occurs in 1-3%. Usually of a squamous type. Risk of torsion is 15% An ovarian cystectomy is almost always possible, even if it appears thatonly a small amount of ovarian tissue remains 22. FIBROMA Most common benign, solid neoplasms of the ovary. Compose approx 5% of benign ovarian neoplasms and 20% of all solidtumors of the ovary. Frequently seen in middle-aged women. Characterized by their firmness and resemblance to myomas Misdiagnosed as exophytic fibroids or primary ovarian malignancy Not hormonally active Fibromas may be associated with ascites or hydrothorax as a result ofincreased capillary permeability thought to be a result of VEGF Miegs syndrome (ovarian fibromas, ascites and hydrothorax) is uncommonand usually resolves after surgical excision. 23. THECOMA Solid fibromatous lesions that show varying degrees of yellow ororange discoloration Almost always confined to one ovary Usually >40 years, 65% after menopause May be hormonally active and hence associated with estrogenic oroccasionally androgenic effects. Luetinised thecoma younger, sclerosing peritonitis and ascites Leydeig cell thecoma ass. with Reinke crystals Rarely malignant 24. BRENNER TUMOR Uncommon tumor grossly identical to fibroma Arise from Walthard cell rests ,also from surface epithelium, reteovarii and ovarian stroma On microscopy markedly hyperplastic fibromatous matrixinterspersed with nests of epitheloid cells showing coffee beanpattern Considered uniformly benign. But scattered reports of malignantBrenners available Endocrinologically inert, but could be ass. with virilization andendometrial hyperplasia 25. GONADOBLASTOMAS Gonadoblastoma is a rare benign tumor that has the potential for malignanttransformation and affects a subset of patients with an intersex disorder ordisorder of sex development (DSD). Contain both germ cells and sex cord stromal cells. Arise in patients with dysgenetic gonads - 46 XY f/b 45XO/ 46 XY mosaic. Presents usually as phenotypic female 10cm in diameter Palpable adnexal mass in a premenarchal orpostmenopausal women Torsion or rupture suspected 37. Ovarian mass in reproductive age group /= 5 cms USG USGcysticComplex,observation solid,suspiciousPersistence or progression surgery 38. Asymptomatic simple cysts7cmRequire further imaging/surgicalintervention. RCOG 2011 39. CYST ASPIRATION Diagnostic cytology has poor sensitivity to detectmalignancy, ranging from 25% to 82% Not therapeutic, even when a benign mass is aspirated Approx. 25% of cysts will recur within 1 year Aspiration of a malignant mass may induce spillage andseeding of cancer cells into the peritoneal cavity 40. INDICATIONS OF FNAC Predominantly benign masses based on clinical, USG findings andCA125 levels, but a few findings are causing diagnostic dilemma then FNAC helps to confirm the nature and aid in pre-op planningand counseling. Patients who have clinical and radiographic evidence of advancedovarian cancer and who are medically unfit to undergo surgery-Malignant cytology will establish a cancer diagnosis, therebypermitting initiation of neo-adjuvant chemotherapy ACOG, 2007 41. OPERATIVE MODALITIES Laparoscopy vs laparotomy decision based on suspicion ofmalignancy and technical expertise No RCTs comparing recurrence rates following laparoscopy orlaparotomy. The objective is to try cystectomy if possible. Laparoscopic surgery for benign ovarian tumours is associated withless pain, shorter hospital stay, and fewer adverse events than withlaparotomy. Cochrane Database of Systematic Reviews 2009 42. The standards for laparoscopy in benign tumours1. careful examination of the external surface of the tumour and sampling of the peritoneal cavity2. avoidance of any tumoral rupture3. protection of the ovarian tumour with an endoscopic bag before removal 43. ROLE OF FROZEN SECTION The diagnostic accuracy of frozen section analysis is high for malignant and benign ovarian tumours, but accuracy is poor in the case of borderline ovarian tumors. Medeiros 2005 44. Ovarian mass in childhood: History and physical examination Appr. Imaging studies Simple cyst Solid or solid cystic - Observe and reassessMRI and tumor markersHigh suspicionLow suspicionof malignancy of malignancy LaparotomylaparoscopyFrozen sectionMalignant oophorectomy Benign - cystectomyand staging 45. Post op surveillance in children No specific lit. regarding recurrence rate esp. Hence recommendations are at best empirical. Should be followed up with annual USG. In adults follow up with biannual USG is sufficient Tumor markers are not regularly used 46. Post menopausal gonad atrophies to a size of 1.5 X 1 X 0.5cm on average Shouldnt be palpable on pelvic examination. Presence of palpable ovary must alert the physician to the possibility of an underlying malignancy. 47. Incidence in asymptomatic post menopausal women 1.5% by pelvic examination3.3% to 14.5% by USG. obstet gynecol survey, 2002 Causes -10% functional 90% neoplastic (either benign or malignant) 48. ASSESSMENT It is recommended that ovarian cysts in postmenopausal women shouldbe assessed using CA125 and transvaginal grey scale sonography. There is no routine role yet for Doppler, MRI, CT or PET.SENSITIVITYSPECIFICITYTVS 89%73% CA 125 81%75%RCOG 2010 49. Calculation of RMI (Risk malignancyindex): It is an effective way of triaging patients into low ,moderate, high risk for malignancy, according to whichthe referral to a higher centre and management protocolwill differ. RCOG 2010 50. It is recommended that a risk of malignancy index shouldbe used to select those women who require primarysurgery in a cancer centre by a gynecological oncologist. RCOG Guideline No. 34 October 2003 Using a cut off point of 250, a sensitivity of 70% andspecificity of 90% can be achieved. 51. RCOG Simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have alow risk of malignancy. It is recommended that, in the presence of a normalserum CA125 levels, they be managed conservatively. Aspiration is not recommended for the management of ovarian cysts inpostmenopausal women. It is recommended that a risk of malignancy index should be used to selectwomen for laparoscopic surgery, to be undertaken by a suitably qualifiedsurgeon. 52. It is recommended that laparoscopic management of ovarian cysts in postmenopausal women should involve oophorectomy (usually bilateral) rather than cystectomy. 53. They were not separately classified by the FIGO and the WHO until the early 1970s. Borderline tumors make up approximately 15% of all epithelial ovarian tumors. The mean age of occurrence is approximately 10 years younger than that of women with frankly malignant ovarian cancer. 54. Tumour subtypes 2 major histological tumor subtypes Serous(50%) (bilateral in 30%) Could be associated with extraovarian lesion : implants(35%) Mucinous (46%) Mucinous tumors do not have a clearly defined origin. Substantial information indicates that many tumors may actually originate from the appendix; thus, this organ should be removed at the time of surgery. 55. Histology and Cytology According to Dietel and Hauptmann, the histology of borderlinetumors is characterized by the following features: Epithelial multi-layering of more than 4 cell layers Not more than 4 mitoses per 10 high-power field (HPF) Mild nuclear atypia Increase in nuclear/cytoplasmic ratio Slight to complex branching of epithelial papillae and pseudopapillae Epithelial budding and cell detachment into the lumen No destructive stromal invasion - A major component in differentiating malignant from borderline tumors 56. TUMOR STAGING Comprehensive staging : of significant prognostic valueand is performed surgically Borderline ovarian tumors are staged according to theFIGO classification of ovarian cancer. 57. INACCURATE STAGING Pathologic diagnosis is difficult to confirm by frozensection. The diagnosis of borderline ovarian cancer is based onsurgical staging. There is no accurate way to predict the final pathology ofovarian tumors from laboratory or imaging studies alone. 58. PROGNOSIS Excellent overall prognosis 60% chance of having stage I disease when diagnosed. 95% of borderline ovarian tumors have diploid deoxyribonucleicacid (DNA) If the tumor is aneuploid, the recurrence rate is high Although TP 53 positivity and HER2 over expression in invasivecancer have been associated with a worse prognosis, the same geneprofile has conferred a survival advantage in borderline tumors. Invasive implants 59. Recurrence and Survival Stage I disease confirmed by comprehensive staging havea recurrence rate of approximately 15%. The 5-yearsurvival rate for such patients approaches 100%. With stage II-IV disease, the prognosis is different; anincreased stage is associated with a worse prognosis andonly age at diagnosis and the presence of invasiveimplants are shown to influence prognosis. 60. IMAGING - USG Intratumoral blood flow in borderline tumors (90%) issimilar to that of malignant neoplasms (92%). Theresistance and pulsatility indexes are also significantlyreduce 61. IMAGING - CT Preoperatively to identify possible foci of metastasis. CTscanning can For follow up of the patient in the future. However,no distinguishing characteristics that clearly identifya borderline ovarian tumor. 62. IMAGING - MRI In a retrospective study looking at MRI characteristics ofknown borderline tumors, Bent et al the investigators werenot able to identify any key imaging characteristics thatwould distinguish borderline tumors from other ovariantumors. MRI appearances of borderline ovarian tumours. Clin Radiol. Apr 2009;64(4):430-8. 63. BIOMARKERS CA-125 levels are not shown to aid in the diagnosis orfollow-up care In mucinous borderline ovarian tumors serum CA 19-9probably is a more accurate marker than CA 125 for theearly detection of recurrence 64. TREATMENT 65. Treatment Most important factors in deciding treatment options isstage of the disease. Proper staging consists of a thorough exploration of the entire abdominal cavity with peritoneal washings, infracolic omentectomy, removal of all macroscopic suspicious peritoneal lesions, and multiple peritoneal biopsies. 66. No consensus concerning treatment of patients with stage II-IVdisease The postoperative management protocol is far from clear. To date,no medical therapy has been shown to clearly improve outcomes An increased stage is associated with a worse prognosis Stage (II vs III vs IV), type of surgery, postoperative treatment,postoperative platinum-based chemotherapy, and even the number ofnoninvasive implants have no effect on progression-free survival. Only age at diagnosis and the presence of invasive implants areshown to influence prognosis. 67. Owing to the high association between surface proliferationsand peritoneal implants, exploration of the peritoneum shouldbe extensive and thorough. If possible, carefully evaluate and remove the implants. The type of implant (ie, invasive, noninvasive) should benoted by pathology, as it has significant prognostic value. Lymphadenectomy can be omitted for BOTs, even for theadvanced disease, because there is no difference inrecurrence or survival rate.Gynecol Oncol 98:390-395, 2005 68. * No further chemotherapy (in all stages.) 69. CHEMOTHERAPY Evidence is insufficient to determine exactly whichtherapy is indicated for borderline ovarian tumors. Platinum-based agents used, but with varying results Borderline tumors with noninvasive implants do notrequire any further therapy and should be observed.