Benign tumours of the ovary ppsx

C h a rj I e r 11 levels to prevent 1 w'th p'OQftogeiiB, BbBis is either minimally nque& or radical. Mth total Wsalpingn-nophorectomY Bui. pre&en^i ng v/rth pamftil •hlheirlalarhLrLiHor Benign tumours of the ovary Pathclagy 119 Investigation Aye dislr bulion of ovarian fumnurs 122 Mdnapemeni: Presentation 122 Treatment Differential diaanosiB 123 124 125 127 t^c (chocolate) cysts of the 73 •feOuB to menstrual SIB nito \T\e peritoneal cavily t?a-ey OVERVIEW Benign civanan cysts aie comnon, Itequenlty dsvrri|)tijrnatk" ami often resolve spnifEneous.y Tliey are fha fourth flu gynaecological cause of hospital Edmigs-oa By the aga of 65yE3r& 4 p&rcent ulall women '"ill luve been admired ID hpspiial af rpquira surgery. f3 pgrcenl in ptemenn|i5usal ^omg/i ^re malidnd^l dnd 45 per uenl in po&lrnsnapau?a '"omen are mjlignanl The main ab|cctive^ of manage merit art ID exclude malignancy T.nd to a™d t/Bl^ciOen^, ivllnoulcau&lna undue morbidity 01 impai ring future fertilify- in Vonii^ei^omen. DvEri^ntumniir^mavb'iphysiologlcjIorpdfhologifa.l and may jn^e from any lifsifeinirfEnvaF^.MDsi benign rj.>arlaFitiliT|D[jrs are cystlt Tiie finding cf solid ^lemflifs makes ifiahgiianoy mere likeh/. Ho'vever, flbronws. rhKLomi5, da^nmids *id Btenper tumours u I •• , .H .| .1 ><i inn Pathology Physiological cysts •*iii.h foini in (he ovary during the nornul ^v.iri.iri •Kle Mnsr A re ^svinplonulii incidental rlndnigs at pc^K examination or ultrasound scdrl. ^ mf itirtv mLur in any premenopausal woman, H ino&l common in voung w-omeii. They are an JIL commonly mulciple. They may al^o nccur in prernsliire fomalu trophnblastn: disease. and m women <:y$t Lined by ftfanulo^dcdU^ lliis is lliCLinvinionc!,ll>cnign ovarian tumour and [^ in oat often found incidenulh\ lr results fiom lilt non-rupliirc of ,i domiiwrt foflidt or the failure of atresia in j non-dominint foOidf. A fblliculai cy&t can pciiiit lor w tr.'l rncoilnul chides jntl mjyrfLhJL^LjdiamckTofijplO 10cm- Smaller o; J - are more likely to resnlve, but may require intervention !'i Benign tumours oflhE ovary if symptoms develop or if they do nol resolve W-16 weeks, Occasionally they may I'onlinsic (u pro- duce oestrogen, causing nienstru.il disturbances and tndometrial hvperplasia. common than tollicular cysts, these are more likely lo present with rntrapcritoneal bleeding. This, is more lommon on the right side> possibl]. as a result of increased intraluminal pressure secondary to ovarian vein .anatomy. They may also rupture. This usually happens on davs20-2fiof the cycle. Corpora hi tea are not called luce.il cys.fi iinlesfi they are mote than 3cm [n diametei. Benign germ tell tumours Germ cell tumours aie among the commonest ovarian (urtiours seen in ^vomen less than 30 yean* of age. Overall, only 2-3 per cent are malign-mi* bul in me undcr-twciitic; this proportion may me to a third. Malign JMI tumours are usually solid, although benign forms also commonly II.HC a solid element, 'llius the tradition?] classification into solid 01 cystic germ cell tumours* signifying malignant or benign respectively, may be misleading,. -\s the (Hint suggests, (hey urise tram totipotential gei m cell?,, and may therefore contain dementi of all three gcim laycis (onbryoirk ditferent- iaiion). Differentiation iiilo ies.ults.[n ovariancboriocarciiionij tumour. When neither embiyonic nor extra embryonic differentiation occurs^ n tlf^gemiinoma itsLilti. Dermold cyst (mmurt; cystic ceratnma) The benign dennoidcv^t [& (he only benign geim cell tumour lh;il ib common, ll re&ulti from difit:renti- atinn into embryonic tissues II account forsround 40 per cent of all ovarian neoplasms and is most eommon in young women. The median age of pw- nelttation is 30years (Comerci«aL, 1994), II is bilateral in about 11 per cent df cases. However, if the connralat- cral ovary is macroscopically normal, the chance of a concealed second dermoid is very low (1-2 percent), piiiticularly [t preoperative ultiasound is normal, A dermuiil is usually a miilocular cyst less Chan 13cm in diameter, in which eclodrnnd] structures are predominant. Thuii it is often lined with epithelium tiki: the epidermis and contains skin appendages teeth, sebaceous material, hair and nervous tissue. Liido'lerm^l derivatives include thyroid* bronchus and mEesline, and the nic^odcrni niavbe represented by bdne, cartilage and smooth muscle. Chciisionall; 1 onlv a single tissue- may be present* in which case the term moiiodennal teratoma is used. The classic examples are carcinoid and struma ovarii, which contains honnonally active ihyroid tissue. Primary Cdrcinoid lumo u rs, of the ovary rarely metastasire, hut 30 per cent may give rise to typical earcinoid symptoms -'Saundcrs et al., i960!. Thyroid tissue is found in 3-20 per ie.nl of cystic ler.itonias. Tlie term 'struma ovarii' should be leserved for tumours, composed predominant!; of thyroid tissue anil as such comprise only 1.4 percent of •.vslk lerrflo- mafi. Only 5-6 per cent of struma ovarii produce sufficient thyroid hormone to cause bypertbyioidi&m. Some 5-10 per cuit ol struma uvarii develop in(o cardnoma. 'Hie majority (611 per centi of dermoid o'ats arc asymptomatic. However 3.5-10 pei cent mayunderV (oi^sion. Less commonly {1—4 per cent), thev m^y rup- ture ipontaneousiy, either suddenly, causing an acute abdomen and a chemical peritonitis, or slowly, caus- ing chrome t^ranulomatous peritonitis. >Vs the latter may also jrisu following inlraoperative spillage, great care should he taken to avoid this event, and thor- ough peritoneal Livagc must be performed if it dots occur, During, pregiidiiev. rupture is more common due to external pressure from the expanding gravid uterus 01 to trauma during delivery. About 2 per cent are said to contain a malignant component, usually J squamous- carcinoma in women ovei 41) yeais. old. Poor prognosis is indicated bj non-squamoiis histologv and capaular rupture.; Amongst women ^ged under ZOywrs, up to Mil per of ovarian malignancies, a re due In germ cell luinm (see Chapter 13). Mature <olid terarawia These rare lumours lontain mature tissues iuit 111 the dermoid cvsr> but there ^ire fe\v cy&iic Jte^s. Th* must be differentiated trom immature teratoi which are malignant (see Chapter 13}. Benign epithelial lumours 'Che majorily of ovarian neopla^ia, both benign ai malignant, arise from the ovarian surface epitheln The) in? therefore e& dcnvijig horn the D the embronic result in development cvjtadenijmata:, endor serous) pathways Or respectively. Mthough 1 to occur ataslightlyyo i, the jrci Serous fystndeiwma This is the most comn and is bifateraf in abo a uniloculj r cyst with | •mer surface and occa Tilt epithelium on the inllimnarrtnd maybcci toncentric calcified bo* n these evsts, J>u( more ccxinterprtrtj. Hie cyst I « seldom as huge is m utnatu i' :se constitute 15-? und are the sec Th^i 1 are tyjiica. wirh a smooth Hammersmith Hospital, bf lining epithelium c cells. The cysl rare loin plica lion L Ikn following intraoperj •tntonei is commonly ••Hours, of the apptndi eoviiiyanil appendix ai ^differentiated careim VnhcimetaLl4<J4).T rfiieh continue lo secrr gether and consequent ne S-^-ear survival rule L thy 10 years js few as ! loid tysfadet emgn endoinetriuid cys ovarian lir and nervous tissue. pde thyroid, bronchus mn may he lepiebeiited • rksue may be pieseni, ooodcrmal teratoma is IT carcinoid and .struma nonally - active thyioid •ours of the ovary rarely nm fcive rise to lypical mci al., 19601. Thyroid cent ot cysiic teratomas. should be reserved for manlK' ot thvi\>id tissue I per cent of cystic teralo- f flmma ovarii produce o ca u HC hypei thy™ i idism. uma ovaiii develop inio nil of dermoid <_ysts arc -10 per Lent nav undeigo IpercentJ.iheymayrup- , causing an acute I, Ol blOWly, C3US- . peritonitis. A« the Li Her Inoperative spillage, great oid (his event, and thor- fl be performed if it due* •uptuie is more common am the expanding gravLd •faery d to contain a nialignani carcinoma in v*onieB is. indicted t" and cap^uldr lupdire. T 20 year>> up tn ^D per cer* •due lli germ cell Hi in nun in iiulurc tuples. iLibt li^a • are few cystic are,i5- Thq mn immature r I j). mrs icnplasia, both benign ovarian surface The.' aic therefore essentially niewthcJial in nature, deriving from ihe coelomic epithelium overlying the embryonic gonadal ndgc^ from which develop Miillenan and \\iil ffinn blniLturcb. Therefore, this may in develcipment along eiirfnoervi^jl (muanuiii ), cndometrral (endnmetrinid) or tulul pathways or uriiepfJhtlial 'Prcnnerl lines respectively. Although beniftii eplllielidl dimouri, tend to occur jl a blighdy younger age than their ntnligiianl counterparts, [bey are musl common in women over 10 ears. t cystadenomg Thi*, is (he must common benign epithelial lumour. and is bilateral in about 10 per cent. Ii is usually a uniloculjr cyst wi[ll papillilbroui processes on ihe inner surface and occasionally on the ouler surface. The epithelium on Ihe inner smface is. cuhnidil i>r columnar and may be cilidletl. Psammoma bodies are •Dcenlric calcified bodies which occur utca&ionallv in ihesc iy>li, but moie frequently in their ni^li^nant counterparts, Thecy&i fluid h thrn and .serous. I'hey tn- seldom as. large as mucinotis Uimouis. unous e^f: ixmstitule 15-25 per cent of all ovarian rnnurs jud dre the ii<:cund most common epithelial mour. Tliey are typkillv Urge, unilateral, multiloc r cy^li wild a smooth inner surface ^ specimen al innne rsmilh ilobpii^l, London, weighed over ]4 \fg'. ic lining epithelium coclbiitb of columnai mucus- cells. The cyst fluid ii generally thick and A rare complication is pM'iidomysoma pentonei, htthib more often presenr before (he iv^i ib R-moved «n Follow ing intiaoperatiye rupture, fseiidurnyxomj ntonei is commonly associated ivith inucinnus mouvs of the appendix. Svnchronous tumours of (ovary and appendix are common, nie&en re usually ril-differenlidled larcinomas or borderline tumours fttrthenuet j[., 1994). I'beyre&ull in ittxilmg groivtli^ 4ich continue to secrele mucin. Causing matting pellnjr and consequent nbslruction of bowel loops. W 5-year suryfrdlrafeib Approximately 5(1 pei cent, n by lOyeaisasfewas Ifi percent are alive. Brenner The«e account for only 1-2 per cent of all oranan tumours, and are bilateral in 10-15 per cent ufcabcs. The> r probably arise trorn Wolffian metaplasia of the Surface epilhelium. The lumour consists of islands of transitional epithelium (Wallhard nests] in a dense fibrotic stroma, giving a largely sol id appearance. The vast maiority are bcnign, but borderline or malignant specimens have been reported. Almost three-quarters occur in women over the age of 40dild aboul half are incidenlal findings, being recognised only by ihe pathologist All hough some can be large, the majority aie less than 2crn in diameter Some secret uestro- gens, and abnormal vaginal bleedinp is a common pcesenliiikm. Clear cell (mesonephroid) Those aiibcrromserosal cells showing little differenti- alioti, and are onlv rarely benign. The typical histn- lopical appearance is of clear or 'hobnail' cells arranged in mixed patterns Benign sex cord sirornal tumours Sex cord stromal tuinnur', represenl only 4 per cent ol benign o.'anan tumours. They occur at an, 1 aye, from I'repuberUl fblldren toelderly>postmenopausa] vi'omen. Many secrete hnrmones and |ire-bent 'vith the results ot inappropriate norirmne effects. Granulosti ceil tumours These are all mahgnant tumours but are mentioned here because they are generally confined to the ovary when they present and so have a good prognosis. However, ihey do grow very slowfy and recurrences are oflen si'en 10-20 ye;us latei. They are largely solid in nuifit cases Call-Liner bodies aiepathognomonic but are seen in less than half of granules*! cell tumours. Some produce oe^trogens and most appear to secrete mhibin endoineiriuml cvsts aic difficult to diffecenti- cell rumour* Alniosl fill are benign, solid and unilateral, t presenting in the sixth decade. Manyprodnorotflro- •' •n. in sufficient quantity to have SVHCTBIC cficcts such as piviodoub puberty, poMrnenopiuHl bleed- ing, endometrial hy|serplasia and endomdrial cancer They rarely cause asciles or a plcunl !•"• Benign lumoursol the ovary Pibtoma These unusual tumours, are tiii>sl frcqatnl around 50 years of age. Most are derived frnm stromal eel Is and are .similar to thecomas. The) 1 are bird, mobile and lobule Led -*ith H gliiU-nmg while burfacc. Less lhan 10 per cent aie bil.iler.il. While as^ites occurs manyol ihe largci fibromas, Meigs syndrome - and pleura! effusion in association mth a fibroma of tlie ovary - is seen in only I per oenl of Z3SCS. Presenlation ^ cdl tumours These are usually of low-grade- malignancy. Most are found around H) vents of age They are rare, com- prising Icib than 0.2 per cent ol ovarian tumours. They are often difficult to diblinguibh from oilier avarian tumours because nf the variety of cells ami sirtnilccturc seen. Many produce androgens, and signs of virih^tion art jeen in three -quarleis of paiieutfi. Some secrete estrogens, I'Liey JTO usually small and umlaleral. Ape distribution of ovarian tumours In younger women, the moit common benipi ovar lan neoplafiin is the germ cell tumour, artiongil older women, itiitlie epithelial eel I tumour (Fig, 1 LI), The [lerccnirfgc- of ovarian ni'oplaima rhal arc benign also changes with the age of the woman [Fig. 11.2 J. The presentation of benign ovarian tumours Is 35 follows. • Asymptomatic • Pain • Abdominal • Press ura • Men^lrual dislurlninces • HDrmonal effects • Abnormal cervical linear Asymptomatic Mady benign ovarian lumaurs are found inditcnlally in fhe course of investigating another unrelated prob- lem or during a routine examination while perform- ing 3 cervical imeai or at an antenalal clinic. As pelvic ultrasound, and particularly Iramva^inal iidnning, is now used more frequently, physiological cysts detected more alien, \\lieie ultrasound was used in Lriala of JirLcnin^ for ovarian cancer, the maiority nimoursdetecred were benign, Aboul SO j>cr cejilnf simple o'sts less than 6cm in diameler will lesolve sponlancuuily rf ob&erved over a period of t> monlhs- A furiher 25 per cent regre-ss in the following 2 Use of an oral contraceptive pill does not encourage the resolution of physiological cysts. 100- 90- 60- 40 Sex cord Germ cell Epithelial 11 1 "isK-l:-g csl d stnbution :%: ul t Treaigd surgicgily by age. P-ge 'years) ? The proportion of surgically Teated ovarian lumours thai arfl ijemgn falls with increasing age until iheflighth decade [Modified from Koonings etal .19391 Pain r>.iiTi ym an cr i, rupture, haci us-u.ill; gives rise to . b) r iscliaertua ol rhe cy Haemorrhage into ih pp&ulcLs '.tretchedr Jn ing ectnpK pregnancy lumour Ihii happen* (ysT. Chronic lower results from Jhe pressu bulls irinn-wrnmon i present Abdominal swell -i Parienli beldom note Tumour n .iiy large. ocw&iouallv JT11 (he enti Big of which women c loan ov.irinn lumour. Miscellaneous Gastrointestinal or ui from pressure effects, Ii e veins 31 times uterine piv ui awonianwilh ly paiient • bill ihis nia UC lo the tuinuur. Rar !nl with oCilroeci ', menorrhagia >t enfar^emenr 01 L Lion of and rumens ill), prugressiiiji lo or ihe voice 01 difo :d, thyrniu^icosis n of thvroid hormoo !\}\ a patient with found to have an whidi ia lolfowed bv i' L Surprfsin; Differential diagnosis . ; Pain is as follows arc found incidentally another unrelated prob- mnation .vbile perform- intenaial dime. :\fi pelvic f trail waginal rearming, y, pbysiolojital cysls are ' ultrasound v,a\> used in • canter, the majority of pi r Abcmt 50 per c^nl of in diameter will resolve vera period of 6 months, sin tbe following 2 years, c pill docs not entourage cal cslir tr & f (years) surgically heated Acute pjin fiom an ovarian tumour may result from lorsion, ruptiirt 1 , haemorrhage or infection. Torsion usually gives rise 10 a sharp, consiam pain caused byischaemijnf lheq-st Areas may become in farcied BjKrnrjnhagr into the cyit may tauit: pain a& tht tosule is stretched. Intraperiloticdl bleed ing mimick- bg ectopic pregnancy may result from rupture nftbe tumour. This, happens most frequently with a luteal cysl. Chronic lo^cr abdominal pain bomciimt-i result from the pressure of a benign ovarian tumour, but is more common if endomeli losis or [nfecliou is prtscnl. Abdominal swelling Patient*, seldoin nnte abdoiniuji] ^veiling until <he tumour is very large A benign mucinous cyst nuy «casionalli fill the entire abdominal cavity. The bloat- ing of which women eompldin so often is rarely due lo an ovarian lumour. Ditterential diagnosis lrom " i i| or urinary symptoms may mi pressure efi^ts. In iinreme cases, osdema of the t£s, varicose veins and liaemorrhoid^ may result- Sornetimea uterine prolapse u the presenting com- ^4in[ in j ^'onirfn wilh an o'anan cyst. Occasionally patienu coni]>Uin of menstrual dis- L _rbance^, but this, may be coincidence rather than d-JL lo lh>: lumuur. Rarely, so.corJ blrom^l lumourb prebccu wilh oestro^cn elfctU i,uch <\* pretotious ubertv; metmrrbagii and glJikdular hyper pi as ia, rast cnlargemenl or poitmcnopau&al bleeding, fcictionofjndrogcns may cause hksutism and dene •lilially, progressing to frank virili&m with deepen- of the voice or clitoial hypertrophy. Very rarely :fd, thyrotoncosia may rc&dt from cctopic &ccr:- >n of Ihyroid hormone. Rarely, a patient with an abuoimal cervical smear I be found lo havt an ovarian lumour, (ht removal which is followed by resolution of [he cyfological litA Surprisingly, these are nften benign Tht diffcrenlial di^nosis of benign ovarian tumours is broads reflecting the vide range ol presenting symptoms. 1 Differential diagnosis of benign ovarian lum ours Pain Sponlarieou 5 abortion Append icitis Meckel's Abdominal swelling Pregnanl uterus Fibroid iiTe-us I n 1 1 1, d. er Distended sov-el Ovarian Coloreclal PraEEura Eflecls Urinarj 1 Iract Conslipalion Hormonal All othef nanses of rn?n^lru^l irregul3iilie&, puberty and pD&tmRnopau^l bleeding A lull bladder ihuLiid l>t i-On^idered in iliedifferen- lial dia^iiosis uf any pelvic nia^5- In nremenopausai women, a gravid uterus must il^-ays be consldcrcdi- Fibroidi can be irnpijs&ibh 1 to tUilin^uijll from ovarian lunionrs. Rarely, a Umbrijl cv*!t nijy gi\nv sufficicndy tn cause anxiety. Ectopic prcgnaimj ma.' pristnl d^ i pelvic mass and lower abdominal pain, ^peddlly if there has been chronic imraperilnneal bleeding. Oricn a ruptured, bleeding corpus lute urn i* ill bt: nmlaken IbranecUppic gustation, ll m^\ be difficult to differentiate between appendicitisund an ovarun CVSL Cooperaiic»n bctvMTfn gj-naecologisi jnd ^uigctm is tiscnial lo avoid unneces- sary iLirgt.iv on simple ovarian cysts in younj- women 24 Benign lu incurs of I he ouaty and the effetlithiimav have upon subsequent fertility. Pelvic ijjllaniflifltolydiwas* may give fise lo a nus-s ot adherent bowd, a hydros !]pin* or pjoialpin.v IT the tumom is ovarian, maligning 1 musl be excluded. In the v^sl majority of cases this can only be done b} 1 a laparotomy. h\en iben, careful histological examination inaj be necessary Ho exclude invjiion. Fvo/en sectiojl will only rarely be of value. \ pelvic mass may also be caused by H ret,lal Humour 01 diver- liculilii llodgkm's. disease in ay present jj. -A pelvic afenlargw pclvjclyinph node*,. Investigation The invest i^ilioni required w[l I depend upon ihetir- cumstances. of ibe prr&entation. Patients presentiDg widi acute .symptoms will usually require emcigency surgery, nhenJdi a&j mptomatic patients or v,omen with chronic problem^ rrw.y benefit from move detailed preliminary as-ses^inent. Gynaecological history of Ibe presenting symptoms and ,1 full gynae- cological his lory should be obtained with particular reference to the dj[e of Ihc l;iii menilrual period, the regularity of the menitiual cycle, any previous prcg- nancie*,, con[r.iccplion, medication and family his- toiy fpariiculjrlyofiivrfrirfn, breaa or bowel cancer) General history and examination tric cancer meiasLa&iiingto the peJvis. Similarly, a bia- tory of altered bowul habil 01 itclal bJeeding would iiiggtit diverticulitLs or ret(Hl ^drcfnoma. Howerei, ovarian laruntfrna ma} r al.so present with these frdliircs. If the palieiil has presented a& an acute emergency; look for evidence ol hypovoUerniii. I lyptmniion 15 a relatively InLtiign of blood lt>s.s, as. the blond prtiMirc will be maintujisd for some tune by peripheral arlcnolarand cenrr.il vtiiiuiLi .'fljoconitriction. When decompensdUi>n occurs, H often does >,o very rapidly, It is vHal lo recogni/i.' ibe carlv ^[3113 tacbycardid and cold peripheries. The bTCJ$(i should be palpated .ind ihe neck, axillae and groim tx.imined lor lymphadenopalhy. A malignant oyarian tumour may caufle a pleural effusion. This ii much less commonly found with a benign tumour. Soil]<jp;iLii:n(b rrwA'ha'eankJc- oedema. Very occasionally, foot drop nw\ br noted at. a reiiilt ol\umprii&ion ol pelvic nerve roots TTiis would not occur with A benign liimour, but suggests a malig- nanq-with lymphatic involvement, Abdominal examinalion The abdomen should he inspected for signs, of disten- sion by fluid or by the tumom itself. Dfljted veins may he seen ml ihe lover abdominal wall. Gentle pal- pation will reveal areas of lendcTiicwf, ,md pcritoniiin may be elicited by asking the patient to cough or sudt in dud bluw out her abdominal ivall. Male hair di.slrf bution niays-u^esrarare^iLtrogcn-prod^ininglumoiir The best way of detecting a nus^s that arises, from ihe pelvii jj ti> palpatt gently with the radial bolder of the left hand, starting in the upper abdomen and woiking caudilly. This is [he reverse of Ihe protcw (fluent Lo OUT)' medical sludent for feeling the liver edge Using only the right hand, is the commonest reason for tailing rn detetl peM-a bduminal maiucs. Shifting dullness is probably me e^sies^t way of demonstrating abcittb, but it remains a very inaensi' tive technique- It is aiwa}'5 worth listening for bowel bounds in any patient with an acute ahdnmcTi. Ilieir complete abicntc in the presence ol peritonism is ominous sign. Bimannai examination This, is an esi-^ntial component ol the assessment because, even in evperi hsinili, ullr^&ound examin- ation is not infallible. By palpating the m-iss between bold ihe I'rfginaf and abdominal hands, its mobility texture and co nsisl em. y, the presence of nodules in the pouch ol Douglas and the degree of lend OTKM can he determined (Fig. lL3j. \Miile it is ini|>o&s.ibfc to make a firm didgnoiis iMihbimanual examination a hai-d, irreguljii, fixed m.jss is likely tu be Ultrasound diological invest transvaginal ultrasound demon strate |he presence of an ovarian mass reasonable sen%itivity,md fair spivifial' and>altn< Ma nay erne nl 125 oncnl of Ihe assessment Luds ultrasound eAiimin- Jpating the niabs between minal handb, LLJ mobility proence of nodules in ihc kgree of tenderness can all |- While il ib impossible ithbirnanii.]! examination, la be invasiu 1 . nvaginai ultra &ound can of an Ov.irijn mas.! nr specificity and. Figure 11 3 Bimanual examination involves palpating ths pelvis organs between both hands. il can !i tn ilisiinguish rclubK between benign dnd rnalignanl tumouis. solid ovarian masses are more liki'ly lu be malignant than their cystic counterpart. The use i>f colour- flow ttiippler nwy increase the reli- ability of uHr^ininil. Neither Lom^uicri'cd tom- ographic scanning nor magnetic resonance imaging lias iip.nilii.dnl advantages om ullrnsound in Ihii situation, and borli are innre expensive. Ultrasound-guided diagnostic ovarian :yst aspiration This inv r estigat[on has been introduced giadually into piactice from the subspecially of ivproduilkm, VH\KK ullriib^o mid-guided cg^ tr.lleciion is now cnniinojipl^ce r This hd5 happened without the benefit of appiopriace dial^to indicate its pulcnlial cfficaci 1 . Unforr.iinicely, thisfechniqueh^s tiptoa?! percent •he-negative rate and ? 1 per tent false-positive late forme cytalagical diagno-jis of malignancy !Diemiit n i. tt j]., 19&7J. Thcrt ib 4 rib-k of dLbJumindlin^ mali^- nanl cells along the needle track or in to ihe peritoneal cavity, bal the size of thai risk is noE established. The kysl often fills d^din with fluid, Overall, ullrasound-guided js.pir,ition nf ovarian tysts. cannot he recommended as a diagnostic tool Radiological investigations AchtatX-rnv ib ci&^nlut to detecl L&oQflatic disease in ibe lungs or -• [>leur^l effuiiiin ihjii mnv be loo small to detecl clinically. Occaiioiiiillv an ii niai show (.alcitkalion, &u^^c^(ing ihe possibilil! of a benign teratoma. An intravenous uvogram i.s often performed but is seldom useful. A barium enema is indicated only it' the- miisi ii irregular or liAcd, or if there arc buwel byiiiploms. A ^omputerired toniog- rafihy scan i.s seldom indicated. Blond test and serum markers It is always sensible to mcabiire lh<: hmmo'globin, -uld an domed while cell count would .surest infection. Pktelel count and clotting screen maybe uselul intlic rare case ola large ultra -abdominal blevtl. Blood mfty be cro S3- matched if ncn&bary. iei-um miirkeri have venoe^'ablish a rnle in the rou- tine management of moil ovarian tumours. HOWOLT, a raised scrum CA 12!> is strongly suggtstive ul nvar- iiin L;irtineim^, cipeci.ilK in postmenopausal women. Women with extensive endnmetnosi.s may al.sn elevated levels, but the concentration h iibu-jllynol gonadotrophin (p-hCCi) concentration might be nicaMirtd to exdiule an L'ctopie pr<:gniincv, but taophoblabtic tumour:, anil bonnjgernne-11 tumours bctrttt thii [jwrker Oe^tradiol levels maybe el^ated in some women with physiological folhcular cysts and &c.\ coid&tiomal tumours. Andiogen conccntrationb nu> bi: increased bv!>ertoli-l eyd ig tumours. KaLsed alpha - feloprotein levels siiflge.jt a yolk sac tumour. Management 'Ihe management will depend upon the .severity of the symptoms, the age of the patient and therefore UK rid of malignancy, and her desire fur further children. The asymptomatic patient The ttliier woman Women ovci 50 years of agt arc far rnurclikeiv t' 1 have a nijligmncy and have linfle to gam from the conser- vative management ot a pelvic maw more ihan 5<;m in diameter (Rulm & Pits[on h 19R7). Mhy.siological cys(s are, \w definition, unlikely However, the cap- acity ot the postmtnopausal ovary to gcneiiiLc: benign cysts is greater thiin pruvjuusly Ihoughl, occurring id 2ri Benign in incurs ol Ihe ovary may bi L u&enil to confirm Lhrtl (hi 1 ultr^- iound legion isiivrfrirfn, but the open approach is slill tobc-rcmoved. Aye (years} Figure 11 4 TN incidence of ovarian cancer In Enyland and Wiles fOfficeof Populallon Censuses and 1 Surveys. 19S5). Note how uncommon ovarian cancer is befirp Ihe age of 35 years up lo 17 pci ceni of asymptomatic women ', Irvine et al., 1992;., Mure than 5(1 per ^nl oi smalL simple cysts will resi.iK'e:>pontanenuslv. hut almost 30 per cent is ill remain static ^Levme et aL, 1992). hVen in this age £riiu[>, ojilv 2y-!>0 per cent of ,.11 ovarian cysts will be mdignanl (Fig. 11.4). Therefore, efforts haw bean made to defino-erilciia that would enable unnecessary Mir.gi.Ti- in he avoided in this older age group. Evaluation of Int cyst with tumour markeis^ ultrasound and colour flowDopplet studies, and ^-aieful follow-up ^u^^at that simple, uniUlcr^l ^ r st3 leqs th,if) 6 tmin diameter williCA 125 leas than 35rjiU'mT, and norm^d .•ajcular resi stance piiLEiTns aie likely to bebsnigD and nidv safely be uuiuged c vatively |Go3d3(ein, l99,=Jj Haikyctal., IWSj.In cases, if t\n-^- h no change in the tybt at the second uflr.i&ound at i months, follow-up with fi-nionthly ultrasound iind CA 1ZS eslinidlion is sate. Most will resolve in 1 v^-ns, but some dn |>ersiM fur up to 7 years The lole of laparos^opic Mirgevy in |Jic si&sc«ment arid Irc^tmeiU of ^|lpar^Jntly benign cysts in ihis age group is conlruvcraial (Fnwler & Curler, 1995; Parker, 1995^ UHiilfll iht imalJ q^sts described abo\c may be niJMjgod witliuut surgery, (here may be a small minor role for lht kparo&copic ,iss:c^ms:nt and treatment of larger (perhaps up to U>cm) hut olhcrvvi&c apparently benign cysts Nonetheless, this .should only bi' in the hands of Ihojie who are Ixnh Uparoscopically experi- enced and prepared to perform definil ivc siirg^ci' tor ail nmpecled ovarian carcinoma under me sjrni'jmacs- efk. Com pick- and mtacr rcnujval of the cvst should adbcvrd. For ihc more general gynaecologist. Prensftsi>j>ui/s{>! women Young i onien aged Icsi than 3^ years are both innre likuly to wish to haw [he oplion of furthei children and less likdv tu hitve a mall^njint epithelial lumour. Howe\ r er. ovarian tvjis moic (han UJcni in dfaineler. AIC unlikely to lie physiological or to resolve spon- tanwiisK. A noimalfofliculnir c;^l up lo 3 cm in diam- eter requires nu fiirlhiT investigation Aclearunilocidar Cyst of 3^ 10 cm identified by ultiiiiound should he re-c\amiin'd 12 ^>eeks later for evident c of diminution in si7£. I fthf 171! persists, such women nmyliefolloivLd with ivmoiulily ullr^sound and CA 1Z5 estin],i|iiirii,i$ diiiribcd above. Tlie use of a combined oral contra- ceptive is unlikely to accelerate tlie resolution of 9 functional cyst (l>(einLimpli Hammond, 19yi|;> jrul hormonal treatment ofundumrtriosis does not usu- ally bi'ndil an endonietrioinA, If die LVbtdota en laige, laparoscopy Or lap jrutomy may he i Crileria for observation of an asymptomatic ovarian tumour Uni'ateral lumour without solid elements men - lumour 3-1Qcra n 1 wo men -turn pur ?-<j cm IP diameter 125 * Nulreetluid or massss suggesting Dmentalrstacr mattsd bo^-'el loops The patient with symptoms if (fit pjhcnt presents willi si^crc, acute pain or signs of hiitvaperilluieal bleeding, an emergent] 1 kipaioicopy or laparotomy will be rcquinxi. More thrnnic iymp- toms of p,iin or pressure may pus.lhy pcd.'ic ultrasound it no mas?, C^ii be felt, butultrasouni] \$ unlikely to con- tribute to the invest igation of a woman in whom both can be clearly fell lo be of 3 nomial sire. The piegftarss patient An Ovarian cyst in a pnjgiwnl woman may undergo toision or m,n bleed. There LS said \<? bu sin increased incidence of these complications ill pri-gnancy; the female fetus Fnal ovarian j 12 irecks', andoe.stradic . Thus small of an asymptomatic Q mental rake cr i although the evidence tor tins is poor. Very occasion- ally, a cvsl tail prevent the presenting fetal part from engaging. Adermoid cyst nwv rupture or leak slowly, lausmg peritonitis However, an ovarian cyst is usu- ally discovered incidentally at the antenatal clinic or on ultrasound, and Occasionally at Caesarean section. Thepregnanl woman with an ovarian cvst is a spe- cial Usi 1 because ot the dangers to the fetus of surgery, These have probably been eiaggcialed in the past, and no urgent operation should IK postponed solely because of a pregnancy. Thus, if the paiierH preicms will] acule pain due to torsion 01 haemorrhage into an ovarian tumour or if appendicitis is j possibility, the correct course is to undertake a faparotoiny regardless of ibes la ge of the pregnancy. The likelihood of labour ensuing i« small, llo^uver, the operation should be covered by tocolytic drills and performed in a centre with intensive neonatal care when possible Tf an asymptomatic cyst is discovered, it is prudent to wait uniil after 14 weeks* yeslaiion before remov- ing it. This avoids the risk of removing a corpus hiRal CY'I upon which the pregnancy might slill be depend- ent. Tn the second and lliird trimester, the manage- ment of an asymptomatic ovarian cysl rnay be eilher Cnnsen'aiiie 01 suigical. The risks to the mother and fetus of .in elective procedure need to be balanced •gainst the chances of a cyst dttident, an unexpected malignancy or spontaneous resolution. Cyslsle&s thjn 1C cm in diameter that have a simple appearance on ultrasound are unlikely in be malignant or to result in cyst accident, and may therefore be followed ultra- o^raphically; many will resolve spontaneously (Thomion & Wtlls> L987.J. If the cyst is umesolved 4 weeks postpartum, surgery m,iy be undertaken itcn. The role for cyst aspiration in pregnancy, eillifr Ifc^nnstkall] 1 or Iherapeulically, is small. Ovarian cancer is ujicommun in pregnancj, occur- •Mig in less than 3 per cent of c>-gts r However, a cyst h features suggestive otmaligiianq'oii ullrasound, one thai is growing, should be removed surgically, tumour marker CA 1Z5 is not useful in the preg- I «vman> since elevated le^'els occur frequently as apparently phyiiologkal change. Management may wed to include a Caessirean hysterectomy, bilateral go-oophorectoinyand oinentectonii. ovarian andropen synthesis commences jt wicks', andoestradiol andprogesierorieai 20 weeks', Llion r Thus iimall tolhculai cysts up lo 7 mm in diameter may oicunn up to a third ol'newborn girls However, larger cvsls ire rare and> usujllv, findings Most are follicular cysis* although cibts, q^tic teratomata and panulo^a cell lumours also oocur, 'iTiey rruy undergo torsion or haemor- rhage, and occasionally necrosis of the pedicle may result in the 'disappearance' of the ovary. Rarely, small- bowel lompression may cause polyhvdiamnios, but diaphragmatic splinting and consequenl pulmonary hypoplasia does not seem lo occur Most re.solvespon- laneously, either antcnataily or, more commonly, post- naially. Consideration may need lo be given to the anlenatal aspiration of a vei y large cyst if il is fell lhat it may obstruct laboui or be ruptured dui ing vagina] delivery, dlthoug.il Ihis is reported rarck Therefore, delivery by Caesarean section is not indicalcd, Cysls thai have not lesolved by 6 months of age should be explored surgically. The pieptibertal girl Ovarian cysts are uncommon and often benign 'IcnHOrtUlsi ,md follicular cysts are the most common. Theca and granulnsa cell tumours may secrete hor- mone*. Priientrftion mai r be with abdominal pain or dislension. or precocious puberlv, LIUILI isosexiuil or heterosexual. Management depends upon ihe relief ot symptoms, exclusion of malignancy and conser- vation of maximum ovarian tissue without leopaidiz- ing fertility. Treat rneril K HUH ni is mostly surgical, allhough there may he •i few women in ivhom cyst aspiration is indicated. Therapeutic ultrasound-guided cyst aspiration The theoretical advantages ol this technique are that jurgeri 1 is avoided and c^bt accidents arc reduced. However, ii assumes thai the cyst fluid, is unable lo re-accumulate, and thai bolli physiological (lifcely to icsolve spontaneously) and malignant cysts can be reliably excluded beforehand, Cytological JiStismenl of the aspiraled fluid is performed routinely but can- not be relied upon !o exclude malignancy lseeabo\ r e| L The rok of this iedinigue ihercforc remains con- troversial. The hesi candidate is a voting woman ;: i Benign tumours al (lie ovary a unilateral, unNWilrir., anechom, thin-walled k&b than 10cm in dijrnetcr. The recurrence rate is 27 per rani if the lluid is clear ami Is3 per cent il'it is bloodstained (De Ciespigny et al , 1989). A tumour ma young wo nun lhal appears to be largely solid on ultrasound is likely to he .3 germ rail tumour and requires removal. An acutely painful ovary may be due to torsion, ami burgm is essential. There may be a small pljce for cyit aspiration in women in whom surgery is conflidfrtd lo be high risk, either beta UK of coexisting medical prnbkm&or because dense pelvit;]illusions envelop the ovaries. Examination under anaesthesia Prior lo any lapaioscopy or laparolomy for a sus- peeled ovarian lumour, il is prudent to perform a biinamial examination under aiiat&thcsia Co confirm the pro^no; of the mass. Lapamscopic procedures Lapaioscopy may be of value if there is uneertjinlv about the natiue of ihe pelvic m^ji r ThuiH may be pos- sible to a^oiJ a laparoto my when there ib no pathology However, il can be difficult Co exclude nvarijn dibtab^ in ihc presence of marked pelvk inflammatory disease 'Ihe second indication for laparoswpy Is it' Ihe patient hap a cj/SL builable for laparoscopic Surgery iNfihat el al. W&y;. 'ihii decision should be tnj.de afier a full history and careful bimanual examination, ultrasound ,is!rt&bineni and a thorough appraisal ol the whole abdominal cavit}-, ihe contralafpraJ ovary The parieiil should be aware ol ihe possibility,, and consented for, d laparulomy In case rnalignjiicy ib found 01 unexpected Lit^rOic complications are encountered. Indications for laparoscopy Uncertainty aboul Ihe nature ol the mass Tumour suitable lor laparnacopLC surgery - aga 1*55 than 35 years - ulTrasound sJiun'E nc solid - simple ovarian cy&f The advantages are lho>e of inpaiobcopic surgery in general: less posioperarive pain, shurlcr hospital slay and qukket rcium lo normal activiries. Jt may also result in Icsi adhcaion formation than an open procedure, although ihe cvidtnte i& not ccm.mcmg. However, the consequences of spillage ft cy$< i m- tents, incomplrn; t-xciiion of ihe q-st ^all and an unexpected histologicril disgnyib of malignanq are considerable disad\ r anijjie'i- Up (o 8^ ptr tent of malignant ovarian tumours found by chance al a laparoscopic operrilion for a *cyst* are treated inad- equately ^Mainian et al , 1491). [Hirnoid cv^fb are heller removed bylaparolomy because of the serious con sequences of ledkdg,*; of the cy-it contents. Laparoscopic surgery is bebl rebv:rved for young women, undei 35 >-ears of age, in whom ihe likdi- hood of macgnaDf disease is small and in wJiom inn- icrvation of ovarian tissue ti more important. These operalionb require considerable expertise in scopic numpulalion and should not he with out ap prupriak-training. Laparotorny A ilinkal diagnosis may no[ l>e po^bible without a Ittpoiotomy and c\cn then liistologiu-il ev.irnin^iion is essential for a conndtntconclusion. Fiozen section is seldom of value m thiisitoadon, asa tliorou^h exam- ination of ihe liimour is required to exdude inv.isKe disease. If there is any possibilily ofinvasive disease, a longi- tudinal skin incision should be used loalkm adequate exposure in (he upper abdomen. Tf wider exposure U lequired after making ^ Iranb^-erie masion, the ends of the wound can be extended crjnMly L O fashion a flap from iht 1 uppci cdyeof the wound, A wmple-of ascitic fluid or ptrilonoal washings should he sent for cycolopcal examination nil ihe beginning of the oper- ation, ll ij csb^nlial to explore ihe .vbnlu abdomen thoroughly and lo inspect both ovaries. In a young woman less than 35 ytari oi age, an ovar- ian I umourib. very unlikely to lie malignant. Even iilhc mass is a primary ovarian malignancy, H ifilikuly to be a germ eel I tumour tha I is responsive to chemotherapi Thus, ovariao cystenomy or ujiilaieral ouphorectoJ is a sensible and safe treatment tor unila'era] civdriafl ma ses in this age yroup -'Bianchi et al., 19fl9). It HI sonittimcs said that the conliiilateral o.'arvshould t-e hisecled and a sample sent for histology in taw; Ihc [...]... will complain of a profuse, offensive vagiiul discharge, which may be bloodstained Other symptoms, iiuhjipaiiL are unturnmoii until n ver late Itti Malignant disease of Hie uterus and cervix epithelium nf the ectoiervk, Prebumiibli both the adenijenranoma and the squflmous carcinoma uribeliom the sjinc precursor cells and, intere.'itingly^ the bioIngical behayiour of buth common tvpes of carcinnma is... is called the «qu^moculurnrwr junction fSCjV The position of the JiC] •xiries ibnmghoLittheiepro ductive life (Fig 12.1) During infancy it lies just at the extern,il os>bul ^j ibo cervix mcieases in volume during puberty and al&opreg,niirn.y, iht SCI is said to roll out onto the ectocervix The delicate coluranar epithelium exposed tu the acid environment of tbe vagina undergoes a [irutush of raetapJabia... squamous epithelium Dysplasias are now usually referred lo M ccrvital mtracpithehal neoplasu [CIN] The} 1 are graded a& mild, moder^le or bevcie, depending on the degree of eytological atypia and al&o tbe tliicknes.5 of the epithelium involved CIN 1 affects only tbe deepest thirdof Ihc epithelium from the basal layer upwards, with maturation seen inure buperCard lo dmt CIX II affects two -thirds nf the thickness... evaluate their efficacy, acceptability jnd effect upnn Lhe prevdkncc of other Palhophysiofogy Transformation zone The ectocervix is covered by squamous epithelium, a btratiJled epithelium very simiUr lo bkin, but lacking kernilin, ihc protein that makes skin waterproof The canal of the cervk> however, ib lined by columnar upithchum, only one cell lliick, and ihc point where iliib': Iwo cpitheha meet... children, as with many other forma of mal^iHD» disease, ihe prognosis with conventional [rearmcnt hai been very poor The modern use of a combina(ion of e.\le.rnal irradialion and diejnothciapr lu& altered the outlook and allowed -• less radical torpta approach to be taken Esenieration is uowrarch/indicated in the ti-edlment of these tumours 142 Maliqnant disease of Ihe uterus and cemi The cause dcemcakancer... two -thirds nf the thickness of the epitheli u« while CIX 111 shows no maturation throughout the iull thickness A simpler iljibification (the Dethesda bystem) of these abnormalities has been proposed ivhcrc HFV infection alone and CIN I are grouped together ds 'low-grade squamous intraepithefial lesion-s (ISTL)' and ClN II and III as 'high-gwdc SIL (HSILJl Naitsrtt! history of CIN It has been known for... cell type, resembling the epithelium of (he ectoceivix The other principal lypeis adenocarcinoma wilh cdLs rcii'mbling tlie epithelium lining me endocervii.rtl CUlL JSecause cervical i,-pe h^s become more common in recent yeais and ntm accourm> for 15-20 percedl ofcBscs Both of these carcinomas ans* dost lo the SCJ, ivliere ihu... sulii^it-ntlv fit Ttatment ry confined to the cervix, ciherapv may be offered involving the vagina (but nul third) jnd/orinliltrnlingl [but not reiichin^ the pel' it side wall) Lla Carcinoma has involved the vagina lib Carcinoma has infiltrated thepaiarnetuum III Carcinoma involving the lower third of the vagina arul/ur extending lo the pelvic side iviill |therc: Is nu free bpiice tn'lweun iho lumcuir... not the waging Both forms of treatment an: probably equally c&CClive, although Ibi premenopausid w^mcn in parlitular, &Lirgcry is thuught to offer lower morbidity Once ibv ilise-jse liiis spread onrside the cervix, chemoradiorherapy is usually the mainstay Surgery The sl;][i[j,ird surgical procedure toi carcinoma of tht tcrvi is a Wertheim hvsterectomv, which involvBa removiiloftheuterub anil the pa... affecting the uteius is endnmdrial caicmoma, which arises from ihe lining oithe uterus, llowevei, sarcomas aim ,irisc from the ^Iruma of the endoniclrium or from thf myoinetvium, jnd fhese are discussed later in the chapter ihe baine lu'gh rate the deneeota tumourthi should nbeso rrtpidJv of oeitrogc:ns ai e fall! Aetiology The i-juse til" tndom aldiough a number c (tfendometriaJ canca of the Jac(ors . the .severity of the symptoms, the age of the patient and therefore UK rid of malignancy, and her desire fur further children. The asymptomatic patient The ttliier woman Women ovci 50 years of. itiitlie epithelial eel I tumour (Fig, 1 LI), The [lerccnirfgc- of ovarian ni'oplaima rhal arc benign also changes with the age of the woman [Fig. 11.2 J. The presentation of benign ovarian tumours. Chapter 13}. Benign epithelial lumours 'Che majorily of ovarian neopla^ia, both benign ai malignant, arise from the ovarian surface epitheln The) in? therefore e& dcnvijig horn the D the embronic result