Benign and Malignant Ovarian Disease


Inflammatory Conditions

  1. Pelvic Inflammatory Disease (PID)
    1. Pathophysiology
      • ascending infection of the upper female genital tract
      • involves the uterus, fallopian tubes, and ovaries
      • sexually transmitted disease caused by N. gonorrhoeae or C. trachomatis
      • long-term sequelae includes infertility, chronic pelvic pain, and increased risk of ectopic pregnancy

    2. Clinical Presentation
      • fever > 102° is common
      • pelvic and lower abdominal pain is usually bilateral, but may also be limited to one side
      • physical exam typically demonstrates cervical motion or adnexal tenderness
      • pus may be seen at the cervical os
      • in unclear cases, transvaginal ultrasound may reveal thickened fluid-filled tubes

    3. Management
      • antibiotics active against N. gonorrhoeae or C. trachomatis (cefoxitin + doxycycline e.g.)
      • laparoscopy occasionally will be necessary to rule out appendicitis or other abdominal pathology
      • laparoscopic findings consistent with PID include swollen erythematous tubes with exudates

      Pelvic Inflammatory Disease - Laparoscopy
  2. Tubo-Ovarian Abscess (TOA)
    1. Etiology
      • inflammatory mass involving the fallopian tube and ovary
      • may also involve adjacent structures such as the bladder or bowel
      • occurs as a complication of pelvic inflammatory disease

    2. Clinical Presentation
      • fever, elevated WBC, lower abdominal pain, and an adnexal mass are the classic symptoms
      • may also present with sepsis and peritonitis if the abscess ruptures

    3. Diagnosis
      • transvaginal ultrasound, CT, or MRI can all identify a TOA

      Tubo-Ovarian Abscess - CT Scan
    4. Management
      1. Premenopausal Patients
        • most hemodynamically stable premenopausal patients with unruptured abscesses < 7 cm in diameter can be successfully managed with antibiotics alone
        • abscesses ≥ 7 cm will require an image-guided drainage procedure or surgical incision + drainage

      2. Postmenopausal Patients
        • there is a high rate of malignancy in this patient group
        • most will require surgical exploration with the possibility of a full staging procedure
        • a frozen section of the adnexal mass should be performed

      3. Ruptured TOA
        • requires emergency exploration
        • a salpingo-oophorectomy is the standard approach for unilateral disease
        • for postmenopausal women, a complete TAH-BSO is the procedure of choice

Ovarian Masses

  1. Benign Lesions
    • may be found incidentally at the time of laparotomy or laparoscopy

    1. Ovarian Cysts
      1. Simple Cysts
        • if the cyst is > 5 cm or symptomatic, aspiration or fenestration is easily performed open or laparoscopically
        • fluid and cyst wall should be sent to pathology
        • in the postmenopausal age group, oophorectomy should be considered

        Simple Ovarian Cyst
      2. Cystadenomas
        • have both cystic and solid components
        • serous cystadenomas and mucinous cystadenomas are the most common pathologies
        • benign lesions with an excellent prognosis
        • peak incidence is between ages 50 - 60
        • may be asymptomatic or cause mass-effect symptoms
        • average size is 10 cm
        • cystectomy should be considered in premenopausal women
        • salpingo-oophorectomy is preferred in postmenopausal women

        Ovarian Mucinous Cystadenoma
        Mucinous Cystadenoma

    2. Endometrioma
      • dark fluid-filled cavity originating within the ovary (‘chocolate’ cyst)
      • may be a source of chronic pelvic pain, infertility, decreased ovarian function, and increased risk of ovarian cancer
      • observation and medical management are usually ineffective
      • oophorectomy should be reserved for postmenopausal women
      • premenopausal women should have an ovarian-sparing endometrioma excision by a specialist

      Endometrioma - Laparoscopy
    3. Brenner Tumors
      • also known as a transitional cell tumor since histologically it resembles urothelium
      • often found incidentally at laparotomy
      • peak incidence is between ages 60 - 70
      • most tumors are < 2 cm in size and are benign
      • treatment is salpingo-oophorectomy, primarily for histologic confirmation

      Ovarian Brenner Tumor
  2. Ovarian Cancer
    1. Incidence
      • median age at diagnosis is 63
      • 85% of cases are sporadic; 15% are hereditary
      • BRCA1 carriers have a lifetime risk of 40% - 60%
      • BRCA2 carriers have a lifetime risk of 15% - 45%
      • HNPCC carriers have a 7% lifetime risk

    2. Pathology
      • ovarian cancers may originate from epithelial cells, germ cells or stromal cells
      • majority originate from epithelial cells
      • primary peritoneal cancers are classified and treated as epithelial ovarian cancers
      • epithelial cell tumors spread along peritoneal surfaces and through the lymphatics; visceral metastases are uncommon

    3. Clinical Manifestations and Diagnosis
      • early tumors are asymptomatic
      • advanced tumors produce non-specific symptoms: early satiety, increasing abdominal distention, vague abdominal pain
      • physical exam may reveal a pelvic mass or ascites
      • US will characterize the pelvic mass
      • CT scan may detect ascites or metastatic disease
      • CA-125 is usually, but not always, elevated

      Ovarian Carcinomatosis
      Ovarian Carcinomatosis

    4. Surgery
      • 3 primary objectives: make a histologic diagnosis, complete staging, optimal debulking
      • also used to palliate complications, particularly bowel obstructions

      1. Operative Staging
        • performed through a long midline incision
        • visceral and parietal surfaces are inspected for metastases
        • total omentectomy is performed, including the gastrocolic omentum
        • ascites is collected and sent for cytology
        • if no ascites is present, peritoneal washings are obtained from the pelvis, paracolic gutters, and subdiaphragmatic areas
        • hysterectomy and bilateral salpingo-oophorectomy
        • retroperitoneal and pelvic lymph node dissections
        • random peritoneal biopsies of uninvolved areas (diaphragm, paracolic gutters)

      2. Cytoreduction (or Debulking)
        • surgical goal is complete removal of all disease
        • if complete removal is not possible, there is a survival advantage if the tumor can be optimally debulked (no residual lesions > 1 cm)
        • bowel resection, splenectomy are indicated if they lead to optimal debulking
        • for mucinous tumors, an appendectomy is performed to rule out metastases from an appendiceal cancer
        • if the tumor cannot be optimally debulked, it is reasonable to close, treat with systemic chemotherapy, and then perform an ‘interval’ cytoreduction
        • secondary cytoreduction can also be considered for recurrent disease

    5. Adjuvant Chemotherapy
      • platinum and taxane-based systemic chemotherapy is standard for advanced stage disease
      • if the patient has been optimally debulked, then intraperitoneal chemotherapy provides a significant survival advantage

  3. Metastatic Lesions
    • common site of metastasis from other primary tumors
    • colon, stomach, and breast are the most common primary sites
    • most are detected on surveillance imaging
    • both ovaries are involved in more than 50% of cases
    • oophorectomy should be offered if the ovaries are the only site of metastatic disease

    Ovarian Metastasis - Krukenberg Tumor
    Ovarian Metastasis - Krukenberg Tumor

Ovarian Anatomy

  1. Blood Supply
    • uterine artery and veins are contained in the infundibulopelvic (suspensory) ligament
    • the ureter is also contained in this ligament

    Ovarian Blood Supply
  2. Salpingo-Oophorectomy
    • the tube and ovary are lifted up to expose the infundibulopelvic ligament
    • a window is made in the peritoneum, and the ovarian vessels are isolated, clamped, and suture ligated, carefully visualizing and protecting the ureter
    • the broad ligament is divided up to the insertion of the ovarian ligament and fallopian tube
    • the ovarian ligament and tube are then ligated and divided

    Ovarian Ligaments






References

  1. Schwartz, 10th ed., pgs pgs 1698 – 1704
  2. Sabiston, 20th ed., pgs pgs 2043 – 2047
  3. UpToDate. Management and Complications of Tubo-ovarian Abscess. Richard H. Beigi. May 22, 2020. Pgs 1 – 24