My Clinical Notes

• Ovary is attached to the broad ligament by the mesovarian, attached to the pelvic wall by the infundibulopelvic ligament and to the uterus by the ovarian ligament
• Outer cortex is covered in germinal epithelium (from which the most common carcinoma is derived)
• Inner medulla contains CT and vessels

Acute presentations

• Rupture of ovarian cyst – causes intense pain
• Haemorrhage of an ovarian cyst – may cause hypovolaemic shock
• Torsion of the pedicle cause infarction and pain

Disorders of ovarian function

• Polycystic ovary syndrome – cysts are small multiple poorly developed follicles
• Premature menopause – when the last period is reached before the age of 45

Ovarian Tumours

Primary neoplasms

• May be benign or malignant
• A benign cyst may undergo malignant change

Epithelial tumours

• Derived from the epithelium covering the ovary
• Most common in most menopausal women
• Histology may demonstrate borderline malignancy where histological features are present but invasion isn’t

Germ cell tumours

• Originate from undifferentiated primordial cells of the gonad
• Examples include teratomas, dysgerminoma (female equivalent of seminoma)

Sex cord tumours

• Originate from the stroma of the gonad
• Granulosa cell tumours are generally malignant but slow growing
• Rare, normally round in post menopausal women
• Secrete oestrogen, which stimulates the endometrium causing bleeding, endometrial hyperplasia and even malignancy
• Thecomas are very rare and usually benign, they also secrete oestrogen
• Fibromas are rare and benign. They can cause Meigs’ syndrome where ascites and a right pleural effusion accompany a small ovarian mass

Secondary malignancies

Ovary is a common site for metastic spread particularly from the breast and GI tract

Secondaries account for 10% of malignant ovarian masses

Carcinoma of the Ovary

• Presents late and therefore overall prognosis is poor
• Causes more deaths than cervical and uterine cancer together
• Most common between the ages of 60-70

• 90% are epithelial carcinomas
• In the rare event a women under 30 is affected it is likely to be a germ cell tumour

Aetiology

• Benign cysts can undergo malignant change but a premalignant phase is not normally recognised
• Risk factors related to the number of ovulations – early menarche, late menopause and nulliparity are risk factors
• Lactation, multiparity and the contraceptive pill are protective
• 5% are familial via the BRCA1 and 2 gene mutations

Clinical features

• Abdominal distension, pain or abnormal vaginal bleeding
• Ask about breast and GI symptoms because as mass could be metastic from these sites
• An ovarian mass is likely to be malignant if

Rapid growth

Ascites

Advanced age

Bilateral masses

Solid or septate nature on ultrasound

Increased vascularity

Spread/Staging

• Ovarian adenocarcinoma generally spreads directly with the pelvis and abdomen
• Lymphatic and blood born spread can occur
  • Stage 1 disease macroscopically confined to the ovaries
  • Stage 1a one ovary is affected, capsule is intact
  • Stage 1b both ovaries affected, capsule in intact
  • Stage 1c one/both ovaries affected, capsule not intact or malignant cells in the abdominal cavity
  • Stage 2 disease is beyond ovaries but confined to the pelvis
  • Stage 3 disease is beyond pelvis but confined to abdomen
  • Stage 4 disease is beyond abdomen

  Investigations

  • Ultrasound – features suggestive of malignancy are solid or septate tumour, high vascularity and ascites
  • CA125
  • Liver function tests
  • CXR

This entry was posted on Saturday, September 29th, 2007 at 4:30 pm and is filed under Gynaecology/Obstetrics. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.