OVARIAN TUMORS

INTRODUCTION

Dr Anusha Rao P
PGY2
(OBG)
CAIMS

NORMAL OVARIES
Normal size 5 x 3 x 3cm
Variation in dimensions can result
from
Endogenous hormonal production(varies
with age and menstrual cycle)
Exogenous substances, including OCs,
GnRH agonists, or ovulation-inducing
medication, may affect size

DIFFERENTIAL DIAGNOSIS OF ADNEXAL

MASS
ORGAN
OVARY

CYSTIC

SOLID

Functional cyst, Neoplastic

Neoplasm

cyst, Benign, Malignant,

Benign

Endometriosis

Malignant

FALLOPIAN

Tubo-ovarian abscess

Tubo-ovarian abscess

TUBES

Hydrosalpinx

Ectopic pregnancy

Paraovarian cyst

Neoplasm

Intrauterine pregnancy in a

Pedunculated or

bicornuate uterus

inteligamentous myoma

Sigmoid or caecum distended

Diverticulitis, Ileitis,

with gas or feces

Appendicitis, Colonic

UTERUS
BOWEL

cancer
MISCELLANEOU

Distended bladder, Pelvic

Abdominal wall

kidney, Urachal cyst

hematoma or abscess,
retroperitoneal

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

OVARIAN
MASSES

FUNCTIONAL

INFLAMMATO
RY

NEOPLASTIC

FOLLICULAR CYST

TUBO OVARIAN ABSCESS

BENIGN

CORPUS LUTEUM

BORDERLINE

CYST

MALIGNANT

THECA LUTEIN

OTHERS
ENDOMETRIOMA
ENLARGED PCO
PAROVARIAN CYST

COMMON OVARIAN TUMOURS

Infancy

Pre
pubertal

Adolesc
ent

Reproduc
tive

Peri
menopau
sal

Post
Menopau
sal

Functional
cyst

Functional
cyst

Functional
cyst

Functional
cyst

Epithelial
ovarian
tumor

Neoplastic
ovarian
tumor

2.

Germ cell
tumor

Germ cell
tumor

Germ cell
tumor

Dermoid

Functional
cyst

Functional
cyst

Epithelial
tumor

Epithelial
tumor

3.

Mets

Functional ovarian cysts

Follicular cysts
Corpus luteum cysts
Theca lutein cysts
Luteomas of pregnancy
By far the most common clinically detectable
enlargements of the ovary in the reproductive
years.
All are benign and usually asymptomatic.

WHO CLASSIFICATION

I. Common Epithelial Tumors:

. Serous tumors
. Mucinous tumors
. Endometrioid tumors
. Clear cell tumors
. Brenner tumors
. Mixed epithelial tumors
. Undifferentiated ca.
. Unclassified epithelial tumors

II. Sex cord tumors:

Granulosa-stromal cell tumors, theca
cell tumors
Androblastomas
Gynandroblastomas
Unclassified

III. Lipid cell tumors

IV. Germ cell tumors:
Dysgerminoma
Endodermal sinus tumor
Embryonal ca.
Polyembryoma
Choriocarcinoma
Teratoma
Mixed

V. Gonadoblastomas:
Pure
Mixed
VI. Soft tissue tumors (not specific to
ovary)
VII. Unclassified tumors
VIII. Secondary tumors
IX. Tumor-like conditions

Simple ultrasound-based rules for the

diagnosis of ovarian cancer.
Ultrasound Obstet Gynecol2008
RCOG 2011

CLINICAL PRESENTATION

Asymptomatic accidentally discovered on USG

Chronic pattern of pain, increasing abdominal girth over

months or weeks.

Associated with secondary symptoms of anorexia, nausea,

vomiting, urinary frequency.

Could be associated with primary or secondary

amenorrhea, menstrual irregularities, virilization,
precocious puberty

Become acutely symptomatic if undergoes torsion, rupture

or haemorrhage.

COMPLICATIONS
Torsion
Intracystic hemorrhage
Infection
Rupture
Pseudomyxoma peritonei
Malignancy

PHYSICAL EXAMINATION
Abdominal and vaginal examination
and the presence or absence of local
lymphadenopathy
Assess

Laterality
Cystic Vs solid
Mobile Vs fixed
Smooth Vs irregular
Ascites
Cul-de-sac nodules
Rapid growth rate

TVS

Pattern recognition is superior to all other scores.

Subjective evaluation of ovarian masses based on

pattern recognition can achieve sensitivity of 88% to
100% and specificity of 62% to 96%.

Adding doppler does not seem to yield much

improvement in the diagnostic precision, but increases
the confidence with which a correct diagnosis of
benignity or malignancy is made.

DOPPLER EVALUATION
Hypoxic tissue in tumors recruit low-resistance, high-flow
blood vessels
Role in evaluating ovarian mass is controversial as
the ranges of values of RI,PI,MSV between benign and
malignant masses overlap. PI<1, RI<0.4
To overcome this, vascular sampling of suspicious areas
(papillary projections, solid areas, thick septations) using
both 3D USG and power doppler both has been evaluated
and found effective.
Chaotic vascular pattern in malignancy

OTHER IMAGING MODALITIES

CT, MRI, PET not recommended in the initial evaluation
CT scan: evaluating
LN involvement,
Omental mets, peritoneal deposits, hepatic mets,
obstructive uropathy
or a probable alternate primary site when cancer is

suspected based upon TVS

MRI : differentiating non adnexal pelvic masses (like

leiomyomata), expensive and inconvenient.

ACOG GUIDELINES 2007

TUMOR MARKERS

SENSITIVITY

61-90%

CA125
SPECIFICITY
71-93%

PPV

NPV

35-91%

67-90%

Most useful when non-mucinous epithelial cancers are present

Elevated in 80% of patients with epithelial ovarian Ca but only in
50% of patients with stage I disease
Increased sensitivity in post menopausal women esp. when
associated with relevant clinical and USG findings
Cut-off of 30 u/ml, sensitivity of 81% and specificity of 75%

HE4
HE4 is a precursor to the epididymal secretory protein E4 and in normal
ovarian tissue, there is minimal gene expression and production of HE4.
As a single tumor marker, HE4 had the highest sensitivity for detecting
ovarian cancer, especially Stage I disease.
Combined CA125 and HE4 is a more accurate predictor of
malignancy than either alone or to any other dual combination of
markers
HE4 levels(>70 pM) were found to be elevated in over half of the patients
with ovarian cancer with normal serum CA125 levels (>35 U/ml)
HE4 when studied in the premenopausal group of patients was able to
discriminate benign tumors from malignancies
Moore et al. / Gynecologic Oncology, 2008

NEW SCORES
ROMA: Risk of Ovarian Malignancy Algorithm
The dual marker algorithm utilizing HE4 and CA125 to calculate a
ROMA value
In patients with stage I and II disease, ROMA achieved a sensitivity of
85.3% compared with 64.7% for RMI
MOORE ET AL, AJOG 2010
OVA 1:
FDA approved. Combination of 5 immunoassays
CA 125, transthyrettin, apo lipoprotein A1, transferrin, B2 microglobulin
Sensitivity : 93%, specificity: 43% PPV 42% NPV 93%
COMMUN ONCOL, 2010

Asymptomatic simple cysts

<5cms

Likely physiological
(do not require follow up)

5-7 cms

Yearly USG

>7cm

Require further
imaging/surgical
intervention.
RCOG 2011

Ovarian mass in reproductive age group

<5 cms.

>/= 5 cms

USG

USG

cystic
Complex
, solid,
suspicio
us

observation

Persistence or progression
surger
y

Ovarian mass in childhood:

History and physical examination
Appr. Imaging studies
Solid or solid cystic

Simple cyst
- Observe and reasses

MRI and tumor markers

High suspicion
of malignancy

Low suspicion
of malignancy

Laparotomy

laparoscopy

Frozen section
Malignant
oophorecto
Benign - cystectomy
my and
staging

Ovarian cysts in postmenopausal women:

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
possibility of an underlying malignancy.

 Incidence in asymptomatic post menopausal

women
1.5% by pelvic examination
3.3% to 14.5% by USG.
obstet gynecol survey, 2002

Causes -10% functional

90% neoplastic (either benign or
malignant)

ASSESSMENT
It is recommended that ovarian cysts in
postmenopausal women should be assessed using
CA125 and transvaginal grey scale sonography.
There is no routine role yet for Doppler, MRI, CT or PET.
SENSITIVITY

SPECIFICITY

TVS

89%

73%

CA 125

81%

75%

RCOG 2010

RCOG
Simple, unilateral, unilocular ovarian cysts, less than 5cm in diameter,
have a low risk of malignancy. It is recommended that, in the presence
of a normal serum CA125 levels, they be managed conservatively.
Aspiration is not recommended for the management of ovarian cysts in
postmenopausal women.
It is recommended that a risk of malignancy index should be used to
select women for laparoscopic surgery, to be undertaken by a suitably
qualified surgeon.
It is recommended that laparoscopic management of ovarian cysts in
postmenopausal women should involve oophorectomy (usually
bilateral) rather than cystectomy.

BORDERLINE OVARIAN
TUMORS

They were not separately classified by theFIGO

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.

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.

Histology and Cytology

According to Dietel and Hauptmann, the histology of
borderline tumors 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

TUMOR STAGING
Comprehensive staging : of
significant prognostic value and is
performed surgically

Borderline ovarian tumors are staged

according to the FIGO classification
of ovarian cancer.

International Federation Of Obstetrics

And Gynecology (FIGO) staging
FIGO stage

Definition

Tumor confined to the ovary

II

Peritoneal implants within the

pelvis

III

Peritoneal implants beyond the

pelvis, Positive lymph nodes, or
both

IV

Liver parenchyma involvement,

or tumor beyond the peritoneal
cavity

TREATMENT

* No further chemotherapy (in all stages.)