cysts

Question 1

types of benign ovarian cysts

Answer 1

1. physiological / functional cysts
2. benign germ cell tumors
3. benign epithelial tumors

Question 2

types of physiological/functional cysts

Answer 2

1. follicular cysts

2. corpus luteum cysts

Question 3

follicular cysts

Answer 3

1. commonest type of ovarian cyst
2. due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
3. commonly regress after several menstrual cycle

Question 4

corpus luteum cysts

Answer 4

1. during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. 2. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
2. more likely to present with intraperitoneal bleeding than follicular cysts

Question 5

types of benign germ cell tumors

Answer 5

1. Dermoid cyst

Question 6

Dermoid cyst

Answer 6

1. also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
2. most common benign ovarian tumour in woman under the age of 30 years
3. median age of diagnosis is 30 years old
4. bilateral in 10-20%
5. usually asymptomatic. Torsion is more likely than with other ovarian tumours

Question 7

Benign epithelial tumors

Answer 7

arise from ovarian surface epithelium

1. Serous cyst adenoma
2. Mucinous cysts adenoma
3. brenner’s tumor - unilateral with solid yellow or grey appearance

Question 8

serous cyst adenoma

Answer 8

1. the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
2. bilateral in around 20%

Question 9

mucinous cyst adenoma

Answer 9

1. second most common benign epithelial tumour
2. they are typically large and may become massive
3. if ruptures may cause pseudomyxoma peritonei

Question 10

sex chord stromal tumors

Answer 10

1. Fibroma

Question 11

Fibroma

Answer 11

1. most common sex chord stromal tumor
2. Important to know about as up to 40% present with Meig’s syndrome which is the association between these tumours and ascites/pleural effusion.

Question 12

Benign neoplastic cysts (ability to turn malignant)

Answer 12

1. Epithelial tumors
2. Benign germ cell tumors
3. Sex chord stromal tumors

Question 13

Non neoplastic cysts

Answer 13

1. Functional - follicular / non neoplastic
2. Pathological :
   - Endometrioma : chocolate cysts that appear in those with endometriosis
   - Polycystic ovaries : ultrasound shows more than 12 antral follicles ( ring of pearls sign on ultrasound )
   - Theca lutein cyst - consequence of markedly raised HCG e.g. molar pregnancy

Question 14

management

Answer 14

1. Premenopausal women:

• CA125 does not need to be undertaken when the diagnosis of a simple ovarian cyst has been made ultrasonographically.
• The CA125 can be raised by anything that irritates the peritoneum, so in premenopause there are numerous benign triggers for an increase.
• Lactate dehydrogenase, alphafetoprotein and hCG should be measured in all women under 40 due to the possibility of germ cell tumours.
• Rescan a cyst in 6 weeks. If it is persistent then monitor with ultrasound an CA125 3-6 monthly and calculate RMI.
• If persistent or over 5cm consider laparoscopic cystectomy or oophorectomy.

2. Postmenopausal women:
   - Low RMI (less than 25): follow up for 1 year with ultrasound and CA125 if less than 5cm.
   - Moderate RMI (25-250): bilateral oophorectomy and if malignancy found then staging is required (with completion surgery of hysterectomy, omentectomy +/- lymphadenectomy).
   - High RMI (over 250): referral for staging laparotomy

Question 15

ovarian cancer

Answer 15

The clinical features of ovarian cancer are non-specific, and most patients present with late-stage disease.

They are most often of the epithelial subtype:

1. Serous cystadenocarcinoma – characterised by Psammoma bodies.
2. Mucinous cystadenocarcinoma – characterised by mucin vacuoles.

Question 16

management of ovarian cancer

Answer 16

Management
1. Surgery – staging laparotomy for those with a high RMI with attempt to debulk the tumour.

2. Adjuvant chemotherapy – recommended for all patients apart from those with early, low grade disease and uses platinum based compounds.
3. Follow up – involves clinical examination and monitoring of CA125 level for 5 years with intervals between visits becoming further apart according to risk of recurrence.

Question 17

investigations for ovarian cancer

Answer 17

All patients with suspected ovarian cancer should have basic blood tests included

• FBC,
• U&E,
• LFT and albumin.

In the UK, NICE recommends

-abdominal and pelvic ultrasound for pelvic masses, from which the RMI can be calculated.

In cases of confirmed cancer, chest x-ray and CT abdomen/pelvis should be undertaken for staging and pre-operative purposes.

Question 18

clinical features of ovarian cysts and tumors

Answer 18

1. Accidental and asymptomatic – found on scanning for other reasons e.g. pregnancy.
2. Chronic pain – may develop secondary to pressure on the bladder or bowel also causing frequency or constipation.
   - It may also manifest as dyspareunia or cyclical pain in those patients with endometriosis who have developed chocolate cysts.
3. Acute pain – these patients may have bleeding into the cyst, rupture or torsion.

3, Bleeding per vagina.

Therefore, never ignore a postmenopausal patient with nonspecific gynaecological or gastrointestinal symptoms. Enquire specifically about:

4. Bloating
5. Change in bowel habit
6. Change in urinary frequency
7. Weight loss
8. Irritable bowel syndrome
9. Bleeding per vagina

Question 19

risk factors for ovarian cancer

Answer 19

1. Nulliparity
2. Early menarche
3. Late menopause
4. Hormone replacement therapy containing oestrogen only
5. Smoking
6. Obesity
7. BRCA1 & 2 – these mutations increase the risk of breast and ovarian cancers. Ovarian cancer risk is as much as 46% at age 70 in BRCA1 positive families and 12% in BRCA2.
8. Hereditary nonpolyposis colorectal cancer (Lynch II Syndrome) – this is a rare syndrome with an associated increased risk of developing colorectal and endometrial cancers. It also confers a lifetime risk of developing ovarian cancer quoted at around 12%