1. ‫بسم ال الرحمن الرحيم‬
Ovarian tumours
By Dr. Sallama kamel

2. :The classification of ovarian cysts and tumours
:A.Non-neoplastic functional cysts
.Follicular cysts-
.Leuteal cysts-
.Theca- lutein and granulosa lutein cysts-
.Endometriotic cysts-
:B.Primary ovarian neoplasms
:(Epithelial tumours ( benign, borderline or malignant .1
.Serous tumour-
.Mucinous tumour-
-.Endometrioid tumour-
.Clear cell ( mesonephroid ( tumour-
.(Brenner tumour (benign-
.Undifferentiated carcinoma-

3. :Sex cord stromal tumours.2
.(Granulosa cell tumour (malignant-
.(Theca cell tumour (benign-
.(Fibroma (benign-
.Androblastoma: sertoli-leydig cell tumour-
Germ cell.3:tumour
:a. Benign
cystic Teratoma (dermoid cyst( and-
.solid teratoma-
:b.Malignant
.Dysgerminoma-
.Malignant change in cystic teratoma-
.Malignant solid teratoma-
.Non-gestational choriocarcinoma-
.(Yolk sac tumour (endodermal sinus tumour-
:C. Metastatic tumours

4. Physiological cyst
They are simply large versions of the cysts that-
forms in the ovary during the normal ovarian
.cycle
Most are asymptomatic and found incidentally on-
.pelvic examination or ultrasound
.They are most common in young women-
.They may be a complication of ovarian induction-
They also occur in women with trophoblastic-
.disease

5. :Follicular cysts.1
it result from the non-rupture of a dominant follicle or the failure of atresia in
.a non-dominant follicle
.2 :Luteal cysts
 .Less common than follicular cyst
 .Are more likely to present with intra-peritoneal bleeding
 .They may also rupture
 .This is usually happens on day 20-26 of the cycle
.Theca-lutein and granulosa lutein cysts.3
These occurs in association with Hydatidiform moles or-
.choriocarcinoma
Similar cysts may formed if excessive doses of gonadotrophins or of-
clomiphines are given to induce ovulation causing hyperstimulation
.syndrome

6. Simple follicular cyst

7. :Epithelial tumours
.These tumours arise from the ovarian surface epithelium-
So they arise from the Coelomic epithelium overlying the-
.embryonic gonadal ridge
Since the epithelial covering of the ovary and the mullerian
duct ( from which the tubal, endometrial and cervical
, epithelium are derived ( are both from coelomic epithelium
comparable metaplastic transformation into different types of
.epithelium is possible
So the cells may differentiate to endocervical cells giving rise-
. tomucinous cystadenoma
Differentiation into endometrial cells give rise to-
.Endometrioid tumour
serous Differentiation to tubal epithelium give rise to-
.cystadenoma
Brenner Differentiation along uro-epithelium give rise to-
.tumour
.They are most common in women over 40 years old

8. :Serous cystadenoma.1
These are the most common epithelial tumours-
with a range from benign to the highly
. malignant
.benign serous cyst The benign form are called-
It is unilocular cyst with papilliferous processes on-
the inner surface and occasionally on the outer
.surface
The lining epithelium is cuboidal or columnar and-
.may be ciliated
.The cyst contain thin serous fluid-
They are usually smaller than the mucinous-
.tumour
They are often bilateral-
They occur most commonly in late reproductive-
.and early postmenopausal life

9. The malignant form called Serous
:papilliferous carcinoma
.This is the commonest primary ovarian carcinoma-
.It is bilateral in 50%-
-The growth often penetrates the capsule and project on
the external surface with dissemination of the cells into
the peritoneal cavity giving multiple seedling metastases
and ascites.
-The cyst contains many papillary processes which have
proliferated so much that they almost fill the cavity and
there may be exophytic papillary growth on the surface.
-The lining cells are multilayer and may invade normal
tissues.

10. Ovarian carcinoma

11. :Mucinous cystadenoma.2
nd
. most common epithelial tumourThe 2-
They are large, unilateral , multilocular cysts with smooth inner-
.surface
.The lining epithelium is columnar mucous-secreting cells-
.The cyst contain thick glutinous fluid-
:(Malignant mucinous cyst (Mucinous carcinoma
.Constitute 10% of ovarian cancers
On histological examination, 5% of mucinous cysts found to be-
.malignant
:Epithelial tumours of borderline malignancy
mean that the tumour carry some of the features of malignancy) e.g. -
.)multilayering of cells and nuclear atypia
.But there is no stromal invasion-

12. Mucinous cystadenoma

13. :Endometrioid cystadenoma.3
.These are very similar to ovarian endometriosis-
They may be associated with pelvic pain and-
dyspareunia
.due to adhesions
Brenner tumour
Macroscopically:a Brenner tumour resembles a
fibroma, being a solid tumour with a white cut
.surface
Histologically:-It consists of islands of round
transitional-like epithelium in a dense fibrotic
stroma giving a solid

14. :Germ cell tumours
It is among the commonest ovarian tumours seen in• •
.women of less than 30years old
Amongst women under 20 years ,up to 80% of ovarian●
.malignancies are due to germ cell tumours
. Overall only 2-3 percent are malignant•
These tumours arise from a totipotential germ cell•
Thus they contain element of all three germ layer( embryonic•
.(differentiation
Differentiation into embryonic tissues result in teratoma
.(dermoid cyst(
Differentiation intoextra-embryonic tissues results in•
.ovarian choriocharcinoma or endodermal sinus tumour
When neither embryonic nor extra-embryonic differentiation•
. occurs,dysgerminoma results

15. (Dermoid cyst (mature cystic teratoma
.This is the commonest germ cell tumour and it is benign-
.It results from differentiation into embryonic tissues-
.It account for about 40% of all ovarian neoplasm-
It is most common in young women and the median age of-
.presentation is 30 years old
it contain a variety of tissues derived from the two or more of the-
..primary germ layers
.The dermoid cyst is usually unillocular cyst-
Less than 15cm in diameter-
It is often lined by epithelium like the epidermis and contain skin-
appendages, teeth , sebaceous material , hair and nervous tissues,
.cartilage bone and thyroid tissues
.The cavity of the cyst contain yellow greasy material-

16. Dermoid cysts

17. The majority of dermoid cysts (60%( are-
.asymptomatic
.However it may undergo torsion-
Less commonly it may rupture-
spontaneously, either suddenly causing an
acute abdomen and chemical peritonitis,
or slowly causing chronic granulomatous
.peritonitis
During pregnancy, rupture is more common-
due to external pressure from expanding
.gravid uterus or to trauma during delivery

18. :Malignant germ cell tumours
These are rare tumours accounting for only 3% of
.ovarian cancers
:Dysgerminoma.1
Yolk sac tumour ( endodermal sinus tumour(..2
Secret alpha feto protein
:Immature Solid teratoma.3
.Non gestational choriocarcinoma: secret HCG.4

19. :sex cord stromal tumours
.These account for only 4% of benign ovarian tumours-
They occur at any age from prepubertal children to elderly,-
.postmenopausal women
They secrete hormones and present with the results of-
.inappropriate hormone effects
.Granulosa cell tumours: secret estrogen.1
.Theca cell tumours: also secret estrogen.2
- :Fibroma.3
Meig‘s syndrome ) ascites , pleural effusion in association with a
.fibroma of the ovary( is seen in only 1% of cases
Sertoli- leydig cell tumours: secret androgens.4

20. Clinical presentation of ovarian
tumours
.Asymptomatic-
.Pain-
.Abdominal swelling-
.Pressure effects-
.Menstrual disturbances-
.Hormonal effects-

21. :Asymptomatic.1
Many benign ovarian tumours are found incidentally in the course of
investigating another unrelated problem or during a routine
.examination
:Pain.2
Acute pain from an ovarian tumour may result from-
.complication e.g. torsion, rupture, haemorrhage or infection
give rise to a sharp, constant pain caused byTorsion-
.ischaemia of the cyst and areas may become infarcted
Haemorrhage into the cyst may cause pain as the capsule is-
.stretched
Rupture of the cyst causes intraperitoneal bleeding mimicking-
.( ectopic pregnancy (this happens mostly with a luteal cyst

22. Twisted ovarian cyst

23. :Abdominal swelling.3
Patients seldom note abdominal swelling until the tumour is-
. very large
A benign mucinous cyst may occasionally fill the entire-
.abdominal cavity
.pressure effects .4
Gastro-intestinal or urinary symptoms may result from-
.pressure of large tumour
In extreme cases, oedema of the legs, varicose veins and-
.haemorrhoids may result
:menstrual disturbances.5 -
Occasionally the patient will complain of menstrual -
disturbances but this may coincidence rather than due to
.the tumour

24. : hormonal effects.6
rarely Sex cord tumours may present with-
oestrogens effects such as precocious puberty,
menorrhagia and glandular hyperplasia, breast
.enlargement and postmenopausal bleeding
Secretion of androgens may cause hirsuitism and-
acne initially progressing to frank virilism with
.deepening of the voice or clitoral hypertrophy

25. :Diagnosis
:Full history.1
Details of the presenting symptoms and a full gynaecological history-
should be obtained with particular reference to the date of the last
menstrual period , the regularity of the cycle, any previous
pregnancies , contraception, medication and family history
.( particularly of ovarian, breast and bowel cancer (
:(Examination ( abdominal and pelvic examination.2
If the patient presented with acute abdomen look for evidence of-
.hypovolaemia
The neck , axilla and groins should be examined for-
.lymphadenopathy
.A malignant ovarian tumour may cause a pleural effusion-
.This is much less commonly found with benign tumour-
.Also some patient may have ankle oedema-
The abdomen should be inspected for distension by fluid (ascites( or-
.by the tumour itself
A male distribution of hair may suggest a rare androgen-producing-

26. :Bimanual examination
.This is an essential part of assessment-
.To palpate the mass , its mobility, consistency-
Presence of nodules in the pouch of Douglas and-
.the degree of tenderness
,A cystic mobile mass is mostly benign-
while a hard, irregular fixed mass is likely to be
.malignant

27. :Investigations
Ultrasound.1
Trans-abdominal and trans-vaginal ultrasound can-
demonstrate the presence of an ovarian mass with
.reasonable sensitivity and specificity
However it can not distinguish reliably between benign and-
malignant tumours but solid masses are more likely to be
.malignant than the purely cystic mass
The use of colour- flow Doppler may increase the reliability of-
.ultrasound
. can be used but are more expensiveCT scan and MRI-

28. :Radiological investigations.2
A chest X- ray is essential to detect metastatic disease in the-
. lungs or a pleural effusion
Occasionally an abdominal X-ray may show calcification,-
.suggesting the possibility of a benign teratoma
A barium enema is indicated only if the mass is irregular or-
.fixed, or if there are bowel symptoms
:Blood test and serum markers.3
Elevated WBC. count may indicate infection-
Ca 125-
Raised serum Ca125 is strongly suggestive of ovarian
.carcinoma, especially in postmenopausal women

29. level is elevated in women withB-HCG -
.choriocarcinoma
levels may be elevated in some womenOestradiol-
with physiological follicular cysts and sex cord
.stromal tumours
are increased with Sertoli-lydigAndrogens-
.tumours
Raised alpha-fetoprotein levels suggest a yolk sac-
.tumour

30. :Management of benign ovarian tumours
This will depend upon the
.Severity of the symptoms-
. Age of the patient-
.The risk of malignancy-
.Her desire for future pregnancy-
:The asymptomatic women
:The older women
Women over 50 years of age are more likely-
to have a malignancy so surgery is usually
.indicated

31. :In pre-menopausal women
Young women of less than 35 years are-
both more likely to wish to have further
children and are less likely to have
.malignant epithelial tumour
A clear unilocular cyst of 3-10 cm identified-
by ultrasound should be re- examined after
. weeks for evidence of diminution in size 12

32. If the cysts persists, such women may be followed with a -
.six-monthly ultrasound and Ca125 estimations
If the cyst does enlarge , laparoscopy or laparotomy may be-
.indicated for removal
A cyst of more than 10 cm is unlikely to be physiological or to.
.resolve spontaneously and operation indicated
The use of combined oral contraceptive pills is unlikely to-
.accelerate the resolution of a functional cyst
:The patient with symptoms
If the patient present with severe acute pain or signs of
intraperitoneal bleeding an emergency laparoscopy or
.laparotomy will be required

33. :The pregnant patient
An ovarian cyst in pregnant women may undergo torsion or may-
.bleed
The pregnant women with an ovarian cyst is a special case because of-
.the risk of surgery to the fetus
Thus if the patient present with acute pain due to torsion or-
haemorrhage into an ovarian cyst or if appendicitis is a possibility,
the correct course is to undertakea laparotomy regardless the
.stage of the pregnancy
The operation should be covered with by tocolytic drugs and-
.performed in a center with intensive neonatal care
st
trimester, itIf asymptomatic cyst is discovered during the 1-
is prudent to wait until after 14 weeks‘. gestation before removing it

34. This avoids the risk of removing a corpus luteal cyst upon-
.which the pregnancy might still be dependent
nd
and 3rd trimesters , the management of anIn the 2-
asymptomatic ovarian cyst may be either conservative or
.surgical
Cysts > 10cm , which have simple appearance on U/S , are-
unlikely to be malignant or to result in cyst accident and
.may therefore be followed by U/S
. Many may resolve spontaneously-
If the cyst unresolved 6 weeks postpartum , surgery-
.indicated

35. Malignancy is uncommon in pregnancy occurring in less than-
.3% of the cysts
However a cyst with a features suggestive of malignancy on-
.U/S , or one that is growing, should be removed surgically
The tumour marker C 125 is not useful in pregnancy since it-
.may be elevated in normal pregnancies
:Prepupertal girl
.Ovarian cysts are uncommon and often benign-
.Teratoma and follicular cysts are the most common-
Presentation may be abdominal pain, distension or precocious-
.puberty
:Management depends on-
.relief of symptoms-
exclusion of malignancy and-
conservation of maximum ovarian tissue without depressing-
.fertility

36. Types of surgery for apparently benign ovarian
:tumours
:For young women less than 35 years
.(Cystectomy ( removal of the cyst only.1
Oophorectomy( removal of the ovary with the.2
cyst( in case of complicated cyst like torsion with
gangrenous ovary or very large cyst with no
.remaining ovarian tissues
For woman more than 45 years with ovarian cyst
more than 6cm in diameter it is advisable to do
total abdominal hysterectomy and bilateral
.salpingo-oophorectomy

37. Malignant ovarian tumours
:Introduction
nd
most commonOvarian cancer is the 2-
gynecological malignancy and the major
.cause of death from a gynecological cancer
Unfortunately survival from ovarian cancer-
remains poor, due in part to the late
.presentation of the disease

38. .Most ovarian tumours are of epithelial origin-
They are rare before the age of 35 years, but the-
incidence increases with age to a peak in the
.(50-70 years (mean age is 64years
Most epithelial tumours are not discovered until-
.they have spread widely
Surgery and chemotherapy forms the main stay of-
.treatment
.The 5 year survival is less than 25%-
Only 3 % of ovarian cancers are seen in women-
younger than 35 years and most are non-
.epithelial cancers such as germ cell tumours

39. :Incidence
The lifetime risk of developing ovarian cancer on-
.(the general population is 1.4 % (one in 70
Ovarian cancers are more prevalent in developed-
.nations
There are variations in incidence with ethnicity,-
Caucasian women have the highest incidence (14
per 100 000( whereas Asian women have a lower
.(incidence (10 per 100 000
There is a significant genetic aspect to ovarian-
.cancer with earlier presentation at 54 years

40. :Aetiology and risk factors
Epithelial ovarian cancer(EOC( is due to malignant
.transformation of the ovarian epithelium
There are two main theories regarding this
:malignant transformation
.1Incessant ovulation theory:
Continuous ovulation causing repeated trauma to the ovarian
epithelium leading to genetic mutation and development of
.cancer
This theory is supported by an increased incidence of EOC in-
nulliparous women, women with early menarche or late
menopause and
reduced incidence in multiparous women and women used-
oral contraceptive pills

41. .(Etiology and risk factors(cont
:Excess gonadotrophin secretion.2
This promotes higher levels of oestrogen which in
turn leads to epithelial proliferation and malignant
.transformation of the ovarian epithelium

42. :(Aetiology and risk factors (summery
Increased risk
.Nulliparity.1
Early menarche and Late menopause , both of these are.2
associated
.with long estimated numbers of years of ovulation
.increasing age at first birth.3
.The prolonged use of drugs for induction of ovulation.4
Obesity, endometriosis and the use of IUCD .5
:reduced risk
.Multiparity.1
.Breast feeding reduce the risk.2
Oral contraceptive use reduces the risk by 20% after.3 -
.5years of use
Tubal ligation and hysterectomy.4 -

43. Genetic factors in ovarian cancer
It is estimated that at least 10-15% of ovarian cancer have a-
.genetic link
There are now at least 3 forms of hereditary EOC(BRCA1,
.(BRCA2 and Lynch syndrome
A woman with one affected close relative has risk of 5%-
..With two affected close relatives the risk increase to 40-50%
Hereditary cancers usually occur around 10 years before-
.sporadic cancers and are associated with other cancers
The most common hereditary cancer is the breast ovarian-
cancer syndrome (BRCA( which are two types BRCA1 (80%(
.(% and BRCA2 (15
And lynch syndrome which is colorectal cancer, endometrial-
.cancer and 10% risk of ovarian cancer

44. Management of women with family history
of ovarian cancer
This depend on the women‘s age, reproductive plane and-
.individual risk
Women with strong family history should be referred to-
.clinical genetics for assessment of the family tree
If this suggest a hereditary cancer , testing for BRCA1 and-
.BRCA2 may be offered
Screening with yearly TVUS and CA 125 is offered to women-
.aged 35 and over
Prophylactic bilateral salpingo-oophorectomy has a role in-
patient who are found to be carrying a gene mutation and
.have completed her family

45. :( Staging of ovarian cancer (FIGO staging
The staging of ovarian cancer is a clinical staging
Stage 1 .growth limited to the ovaries
Ia .growth limited to one ovary
.No ascites, no tumour on external surfaces ; capsule intact
.Ib tumour limited to both ovaries
.No ascites, no tumour on external surfaces; capsule intact
Ic either stage 1a or 1b with ascites contain malignant cells or
.tumour on the surface of one or both ovaries
Stage II.: growth involving one or both ovaries with pelvic extension
Stage III: growth involving one or both ovaries with peritoneal
implants outside the pelvis or positive retroperitoneal or inguinal
lymph nodes or superficial liver metastasis
Stage IV : growth involving one or both ovaries with distant
.metastasis, parenchymal liver metastasis equal stage 1V

46. Stage III OVARIAN CANCER
:Stage III a
Tumours grossly limited to pelvis with negative nodes but
.histologically confirmed peritoneal implants
:Stage III b
. Abdominal implants ˂ 2cm. In
:Stage III c
Abdominal implant
retroperitoneal or inguinal lymph nodes

47. :Spread of ovarian malignancies
usually to the pelvic peritoneum and otherdirect spread: -
.( pelvic organs ( uterus and broad ligament
commonly involves the pelvic and the para-Lymphatic spread-
.aortic nodes
Spread may also involves the nodes of the neck or inguinal
.region
Haematogenous spread-
.usually occurs late and involves mainly the liver, and lung-
.Bone and brain metastasis sometimes seen-

48. :Presentation and diagnosis
Vague abdominal pain or discomfort is the commonest presenting -
.complaint
.Distension or feeling a lump is the next most frequent-
:The patient may complain of-
.Indigestion*
.Urinary frequency*
.Weight loss*
.Or rarely abnormal menses or postmenopausal bleeding-
A hard abdominal mass arising from the pelvis is highly suggestive
.especially with ascites
A fixed, hard, irregular pelvic mass is usually felt best by combined-
.vaginal and rectal examination
.The neck and groin should also be examined for enlarged nodes

49. :Investigations
.full blood count.1
.Urea, electrolyte and liver function test.2
.Chest x-ray.3
Sometimes, barium enema and colonoscopy is needed to.4
differentiate between an ovarian and a colonic tumour or to assess
.bowel involvement
.(IVP (intravenous urography.5
Ultrasonography may help to confirm the presence of a pelvic .mass.6
.and detect ascites
.Tumour markers e.g. Ca 125.7
In most women the diagnosis is uncertain before laparotomy is.8
.undertaken

50. :Surgery
Surgery is the mainstay of both the diagnosis and the treatment of-
.ovarian cancer
A vertical incision is required for an adequate exploration of the-
.upper abdomen
A sample of ascitic fluid or peritoneal washings with normal saline-
.should be taken for cytology
The pelvis and upper abdomen are explored carefully to identify-
.metastatic disease
The therapeutic objective of surgery for ovarian cancer is the-
.removal of all tumour tissues
This is usually possible in the majority of stage I and stage II, but-
.impossible in advanced cases

51. To resect all visible tumour requires a total
hysterectomy, bilateral salpingo-oophorectomy and
.infra-colic omentectomy
However , in a young , nulliparous woman with unilateral-
tumour and no ascites ( stage Ia (, unilateral salpingo-
oophorectomy may be done after careful exploration to
exclude metastatic disease , and curettage of the uterine
.cavity to exclude a synchronous endometrial tumour
If the is subsequently found to be poorly differentiated or if-
the washings are positive, a second operation to clear the
.pelvis will be necessary

52. For older women who complete her family a total-
hysterectomy and bilateral salpingo-
.oophorectomy is usually done
:Chemotherapy
Women with stage Ia or Ib and well or moderately-
differentiated tumours will not require further
.treatment
All other patient with invasive ovarian carcinoma-
require chemotherapy (stage II-IV–possibly
.( stage Ic
.Drugs used are Carboplatin, cisplatin and taxol-

53. :Prognosis
:Borderline tumour
.Long term prognosis excellent in most cases
.Invasive tumours- 5 year survival rates
for Stage Ia and 1b ) well or moderately 90%- -
.) differentiated
.for stage III % 30-
.overall 25%-

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