1. Introduction:

Ovarian tumours may arise at any age, but are commonest between 30 and 60 and because of lack of any specific symptoms, ovarian tumours are often large by the time the patient presents to the doctor. Menstrual function is seldom upset and because there is abdominal swelling, the patients may think that she is pregnant if she has a period of amenorrhea.

2. Classification of ovarian tumours:

Ovarian tumours could be:

A-   Primary ovarian tumours

B-   Secondary ovarian tumours

3. Primary ovarian tumours

These could be benign or malignant:

1. Functional cysts (all are benign) these include:
   1. Surface inclusion cyst.
   2. Follicular cysts.
   3. Poly cystic ovarian disease.
   4. Theca-lutein cysts.
   5. Endometroid cysts.
2. Tumors originating from surface epithelium include:
   1. Serous.
   2. Mucinous.
   3. Endometroid.
   4. Mesonephroid.
   5. Brenner tumours (This type of tumours could be benign or malignant i.e mucinous cystadenoma or mucinous cystadenocarcinoma).
3. Germ cell tumours:
   1. Benign ones are:
      1. Cystotertaoma.
      2. Solid teratoma.
   2. Malignant ones are:
      1. Dysgerminoma.
      2. Teratoma.
      3. Gonadoblastoma.
      4. Yolk sac tumours.
      5. Carcinoid.
      6. Choriocarcinoma.
4. Hormone-producing tumours:
   1. Estrogen-producing:
      1. Granulosa cell tumour.
      2. Thecoma.
   2. Androgen-producing:
      1. Arrhenoblastoma.
      2. Hilar cell tumour.
      3. Lipoid cell tumour.
   3. Stromatus tumours: (Sarcoma).

3.1. Features suggestive of malignancy:

• Age:
  • Patient over 50 yrs, chance of malignancy is over 50%.
  • Tumours in childhood are usually malignant.
• Rapid growth.
• Ascites.
• Consistency (solid tumors ++ malignant).
• Multilocular cyst with solid areas are highly suggestive of malignancy.
• Pain: referred pain is a sign of malignancy.

3.2. Functional cysts (all benign):

• Follicular cysts:

A normal grafian follicle reaches 2-2.5cms before it ruptures. A follicular cyst is one who is more than 2.5cm and less 5cm. Uncomplicated follicular cysts do not cause any symptoms and are benign. They resolve spontaneously and any patient who is thought to have a follicular cyst should be re-examined after 4-6 weeks. Laparotomy should be performed only if the cyst persists or increase in size during this time.

• Corpus luteum cysts:

After ovulation there is little bleeding into the follicle and if this bleeding is increased the corpus luteum is distended and forms a corpus luteum cyst.

• Theca-Lutein and Granulosa-Lutein cysts:

Multiple bilateral ovarian cysts occur in association with hydatidiform moles or choriocarcinoma. They are caused by the high output of gonadotrophins, and may reach 10cm in diameter. After treatment or removal of the abnormal chorionic tissue the cysts resolve.

3.3. Tumours arising from the surface epithelium:

The modified peritoneal cells which cover the surface of the ovary are the most common source of ovarian tumours.

These include:

1. Mucinous tumours  either benign (mucinous cystadenoma) or malignant (mucinous cystadenocarcinoma) the tumours are multilocular and reach enormous sizes. All the cysts of the tumours contain mucin.
2. Serous cystadenoma (benign) or serous cystadenocarcinoma (malignant): This is a common type of ovarian tumours. The cysts contain thin serous fluid and can be of any size up to 40bcms in diameter. They are often bilateral. They occur most commonly during late reproductive life. With this type of malignant tumours ascites is common.
3. Endometroid tumours: this is a rare tumour arises when the ovary is already affected by endometriosis.
4. Mesonephroid tumours: These are uncommon tumours with variable histological pattern characterized by tubules and small cystic spaces with papillae projecting into them.
5. Brenner tumour: These are solid ovarian tumours with a white cut surface. Although they do not secrete hormones but occasional reports of associated endometrial hyperplasia (uterus) were found with such ovarian tumours.

3.4. Germ cell tumours:

Teratoma: (could be benign or malignant) this is a common cystic tumour accounting for about 25 percent of ovarian tumours. It contains a variety of tissues derived from 2 or more of the primary germ layers, endoderm, mesoderm and ectoderm. It usually contains sebaceous glands, teeth, hair, nervous tissue, cartilage, bone respiratory and intestinal epithelium and thyroid gland tissue. These tumours are believed to arise from the aberrant division of unfertilized oocytes. It may occur at any age but commonly found during reproductive life. Of the other germ cell tumours of the ovary the most important is the choriocarcinoma of the ovary. (chemotherapy).

3.5. Hormone-producing tumours:

1. Estrogen-producing tumours: These include granulosa cell tumour and thecoma.The tumours are of average size, and they usually produce estrogen very rarely may produce progesterone. The endocrine effects depend on the age of the patient. If the tumour arises before puberty the estrogen causes the breast to grow and endometrial bleeding to occur (precocious puberty). During reproductive life the periods will remain regular provided the amount of estrogen produced is small but if the estrogen output is high there will be amenorrhea and cystic glandular hyperplasia of the uterus. If the tumour occurs after the menopause they cause post menopausal bleeding and enlargement of the breasts.
2. Androgen-producing tumours: These include:
   1. Arrhenoblastoma.
   2. Hilar cell tumour.
   3. Lipoid cell tumour.
3. They secrete androgens and cause:
   1. Amenorrhea.
   2. Atrophy of the breasts.
   3. Growth of body hair.
   4. Deeping of voice.

4. Secondary ovarian tumours:

• Cancer from other sites do metastasize to the ovaries and the primary site could be the uterus, the colon, the stomach and the breasts. The Krukenberg tumour is a tumour arising in the stomach. That metastasizes to the ovary (lymphatic spread).
• Cancer of the ovary is now the commonest cause of death from cancer of the female genital track and the number of woman who dies from cancer ovary exceeds the combined total of deaths from cancer of the cervix and the endometrium. The overall risk of developing cancer ovary is about 1%.
• Ovarian cancer spreads by local infiltration and can gain access to nearby structures such as the uterus, the broad ligament, the omentum and the intestine. Also lymphatic spread is encountered.

4.1. Staging of ovarian cancer:

• Determined at operation
• The FIGO (FEDERAL INTERNATIONAL GYN ORGANIZATION) staging is as follows:
  • Stage I: disease limited to one or both ovaries.
  • Stage II: growth beyond the ovaries but confined within the pelvis.
  • Stage III: growth with wide spread intra-peritoneal metastases.
  • Stage IV: distant metastasis.

4.2. Clinical features:

4.2.1. Symptoms:

1. No symptoms and usually discovered during examination (routine) for F.P. or cervical cytology or ANC.
2. Pressure symptoms.
3. Tight clothes (midline swelling).
4. Dull pain in lower abdomen.
5. Respiratory embarrassment.
6. Loss of wt. (cachexia) and malaise.
7. Ascites.
8. Pain only if the tumour is complicated by torsion, rupture or hemorrhage.
9. Endocrine effects if the tumour is hormone secreting.

4.2.2. Signs:

• Benign:
  • Feeling of adnexal mass on V/E & this mass is moving freely If the tumour distends the rectovaginal pouch retroversion of the uterus will be felt.
  • Medium sized tumours abd. mass and big tumours will be obvious and may cause respiratory embarrassment.
  • X-rays (teratoma-bone).
  • USS more useful & diagnostic.
  • EUA & laparoscopy.
• Malignant:
  • General examination if cancer is advanced signs are obvious.
  • V/E palpable ovaries in post menopausal woman is suggestive.
  • PR examination.
  • Percussion (shifting dullness).
  • Paracentesis (for cytological ex.).
  • If intestinal obstruction occurs due to spread of the cancer signs will be obvious.

4.3. Investigations:

• The routine (Hb, blood group, urine).
• Color Doppler USS.
• MRI.
• CXR.
• IVU.

4.4. Complications:

• Torsion.
• Rupture.
• Hemorrhage.
• Impaction.
• Infection.

4.5. Differential diagnosis:

• Full bladder.
• Pregnancy.
• Uterine fibroid.
• Chronic salpingitis.
• Pelvic kidney.
• Faeces.

4.6. Treatment:

• Surgery: ascetic fluid or peritoneal washings are taken for cytology.
• Staging of the cancer.
• Ex. of pelvic and para-aortic lymph nodes.
• Benign tumour (conservative surgery).
• Malignant ones (total hysterectomy + bilateral salping-oophorectomy + omentectomy).
• Inoperable big tumours (debulking).
• Chemotherapy.
• Radiotherapy.

4.7. Pregnancy with ovarian tumour:

Ovarian tumour detected with pregnancy should be removed as laparotomy may cause abortion so removal of the tumour is done after 16 weeks of pregnancy if the tumour is found after 16 weeks it should be removed immediately.