Adnexal masses ("adnexa" refers to structures next to the uterus, including the uterine tubes and ovaries).
Approximately 20% of women will develop at least one ovarian cyst in their lifetimes, and approximately 1 in 72 will develop ovarian cancer.
Ovarian cysts are sacs of fluid that form within or on the ovaries; they can be simple or complex.
"Functional" cysts, including follicular and corpus luteal cysts, are produced by normal events in the
menstrual cycle.
Ovarian cysts are usually asymptomatic, incidental findings, but they can cause pain and/or hemorrhaging in cases of rupture or torsion.
Malignancy is unusual, but is higher post-menopause.
Be aware children can also have ovarian cysts, which often spontaneously resolve.
Ovarian Cancer is a leading cause of cancer deaths, partly because it is often diagnosed in advanced stages with poorer prognosis.
Primary ovarian cancer can originate from cells in the ovaries, uterine tubes, or peritoneum.
Signs/Symptoms:
Signs and symptoms of ovarian cysts and tumors overlap, and include: abnormal uterine bleeding, pain or pressure in the pelvic area, back, and abdomen (often with pain during intercourse), nausea, bloating, and changes in urination or defecation. Larger adnexal masses can produce feelings of bloating and stomach fullness, which can lead to weight loss.
Diagnosis:
In diagnosing ovarian cysts and tumors, we can use ultrasound to determine size and location.
Also, rule out pregnancy, UTI, and PID.
In some ovarian cancers, tumor markers can be helpful (please scroll for "additional notes").
Risk factors:
Risk of cyst and tumor development increases with age, endometriosis, certain genetic mutations, and lifetime number of ovulatory cycles.
Lifetime number of ovulatory cycles is determined by age at menarche and menopause, parity, lactation, and use of hormonal contraceptives that block ovulation).
Thus, protective effects are conferred by factors that reduce the number of lifetime ovulations (later menarche, earlier menopause, higher parity, lactational amenorrhea, and use of hormonal contraceptives).
Follicular cysts
When the ovarian follicle doesn't rupture and release the egg, a follicular cyst forms around the trapped egg.
Corpus luteal cysts
When the corpus luteum doesn't dissolve after ovulation, it becomes a corpus luteal cyst.
Theca lutein cysts
The result of human chorionic gonadotropin (hCG) excess or hypersensitivity; they form most often during pregnancy or infertility treatments.
These cysts are also referred to as "hyperreactio luteinalis".
Recall that hCG is produced by the early placenta; when excess hCG stimulates the nearby ovaries, it triggers the formation of multiple, often bilateral, cysts. These cysts usually regress postpartum.
Gestational trophoblastic disease
Rare group of tumors that form during pregnancy.
Most tumors are noncancerous, but some are cancerous.
Signs/symptoms – bleeding, discharge, pain or mass in pelvic area, extreme nausea and vomiting.
Types include Hydatidiform moles (molar pregnancy) – excess production of trophoblast tissue, no viable fetus. - Remove with dilation and curettage.
Endometriomas
Estrogen-dependent ectopic endometrial stroma, glands, fibrous tissue, and blood.
The dark, tarry blood gives them the dark brownish color that lends them the nickname "chocolate cysts."
Be aware that endometriomas can also be found elsewhere in the body, and require yearly follow-ups.
Treatment/prevention of ovarian cysts:
To treat and prevent ovarian cysts, we can use hormonal contraceptives, which block ovulation.
However, cysts with the following characteristics warrant further evaluation: greater than 10 cm, complex architecture with solid components, thicker septa, ascites, and increased vascularity.
Removal of the ovary is recommended if malignancy is suspected, or if the mass is persistent, painful, or if there is risk of torsion (which can lead to ischemia and ovarian necrosis).
Ovarian tumors are classified according to their cell type of origin: epithelial cells on the surface of the
ovary, germ cells (oocytes), or stromal cells, which includes the ovarian stroma, thecal cells, and granulosa cells.
Each category has several subtypes.
EPITHELIAL TUMORS
Carcinomas
High grade serous carcinoma is the most lethal and most common form; more than 70% of ovarian cancers are high grade serous carcinoma.
High grade serous carcinoma often originates from epithelial cells in the uterine tubes; they are often bilateral, with both cystic and solid components.
Endometrioid carcinoma is the second most common ovarian cancer, accounting for approximately 10% of cases. - Usually low-grade with good prognosis. These tumors are thought to arise from transformed endometrial tissues, and are associated with endometriosis and Lynch Syndrome.
Mucinous carcinoma is often the result of metastasis from gastrointestinal tumors. Rare.
Clear cell carcinoma is associated with endometriosis. Rare.
Cystadenomas
Common, benign, and large.
Serous cystadenomas are lined by cells that resemble uterine tube epithelium.
Mucinous cystadenomas are lined by mucus-secreting cells that resemble gastrointestinal epithelium.
Others
Brenner tumors are rare, but can be malignant; they comprise transitional cells (sometimes called urothelial cells).
GERM CELL TUMORS
Teratomas: Mature teratomas (formerly called dermatoid cysts) are generally benign and comprise mature tissues from multiple germ cell layers; we show a tumor with hair, teeth, and other tissues.
Immature teratomas are very rare, but malignant; they comprise immature tissues, and are more commonly found in patients under 20 years old.
Dysgerminomas are malignant, primitive germ cell tumors with variable histological patterns. They are most commonly found in children and young women; tumor markers include elevated lactate dehydrogenase (LDH).
Yolk sac tumors, aka, endodermal sinus tumors, are malignant and usually found in patients younger than 30 years old. They are soft, solid masses with a mucoid appearance; in histological samples, we may see
Shiller-Duval bodies, which comprise central vessels surrounded by fibroid tissue and tumor cells. Patients may also have elevated alpha fetoprotein (AFP).
SEX CORD-STROMAL TUMORS
Fibromas are benign tumors comprised of fibroblasts.
Thecomas are benign tumors comprised of theca cells. They are often estrogenic.
Most commonly diagnosed in peri- or postmenopausal patients who present with uterine bleeding.
Sertoli-Leydig cell tumors are usually benign tumors with sex cord and stromal components that secrete androgens.
Granulosa cell tumors are malignant tumors that often present with hyperestrogenism in adults, or early puberty in children.
Treatment of ovarian cancer:
Ovarian cancer is treated surgically and with chemotherapy; unfortunately, recurrence is common in patients with advanced stage cancer.
Anatomy review:
Ovaries are suspended by the utero-ovarian ligament, lateral to uterus, at ends of uterine tubes.
Covered by mesovarium (part of broad ligament), connected to pelvic wall via infundibulopelvic ligament (aka suspensory ligament of ovary).
Receive blood from ovarian artery, which branches off aorta.
Ovarian Tumor markers:
High grade serous carcinoma is often associated with TP53 mutations, BRCA1 or BRCA2 (tumor suppressor genes).
CA-125 (cancer antigen 125) is elevated in ovarian cancer, but not effective as part of screening tests. Can be used to check progress of cancer treatments.
Select Germ Cell Tumors with elevated hormone profiles:
Dysgerminoma – hCG, E2
Immature teratoma – AFP, LDH, 2=E2
Yolk sac tumor – AFP, LDH
Select Sex Cord-Stromal Tumors with elevated hormone profiles:
Thecoma – E2
Granulosa cell – E2
Sertoli-Leydig – AFP, E2, T, A4, DHEA
For references and more information, please see the full tutorial.
Immature teratomas are very rare, but malignant; they comprise immature tissues, and are more commonly found in patients under 20 years old.
Dysgerminomas are malignant, primitive germ cell tumors with variable histological patterns. They are most commonly found in children and young women; tumor markers include elevated lactate dehydrogenase (LDH).
Yolk sac tumors, aka, endodermal sinus tumors, are malignant and usually found in patients younger than 30 years old. They are soft, solid masses with a mucoid appearance; in histological samples, we may see Shiller-Duval bodies, which comprise central vessels surrounded by fibroid tissue and tumor cells. Patients may also have elevated alpha fetoprotein (AFP).
SEX CORD-STROMAL TUMORS
Fibromas are benign tumors comprised of fibroblasts.
Thecomas are benign tumors comprised of theca cells. They are often estrogenic.
Most commonly diagnosed in peri- or postmenopausal patients who present with uterine bleeding.
Sertoli-Leydig cell tumors are usually benign tumors with sex cord and stromal components that secrete androgens.
Granulosa cell tumors are malignant tumors that often present with hyperestrogenism in adults, or early puberty in children.
Treatment of ovarian cancer:
Ovarian cancer is treated surgically and with chemotherapy; unfortunately, recurrence is common in patients with advanced stage cancer.
Anatomy review:
Ovaries are suspended by the utero-ovarian ligament, lateral to uterus, at ends of uterine tubes.
Covered by mesovarium (part of broad ligament), connected to pelvic wall via infundibulopelvic ligament (aka suspensory ligament of ovary).
Receive blood from ovarian artery, which branches off aorta.
Ovarian Tumor markers:
High grade serous carcinoma is often associated with TP53 mutations, BRCA1 or BRCA2 (tumor suppressor genes).
CA-125 (cancer antigen 125) is elevated in ovarian cancer, but not effective as part of screening tests. Can be used to check progress of cancer treatments.
Select Germ Cell Tumors with elevated hormone profiles:
Dysgerminoma – hCG, E2
Immature teratoma – AFP, LDH, 2=E2
Yolk sac tumor – AFP, LDH
Select Sex Cord-Stromal Tumors with elevated hormone profiles:
Thecoma – E2
Granulosa cell – E2
Sertoli-Leydig – AFP, E2, T, A4, DHEA