quite often functional cystic spaces in the ovary.
But sometimes they could be endometriomas or if there are
solid areas present, may harbour malignancy.
Current management principles of ovarian cysts are outlined
unilateral cysts in the adolescent:
If the clinical and ultrasonographic pictures are indicative of a
simple ovarian cyst without any twist, it could be a functional cyst
(e.g: follicular or corpus
luteum cyst) and could be left alone for 3 months. In the
past, oral contraceptives were prescribed to reduce the size of the
cysts, but recent studies have
shown that they may disappear even without any treatment
beyond 3 months points towards a simple serous cystadenoma. Simple
serous cystadenoma is a
benign ovarian tumour. In a young unmarried girl a laparoscopic
ovarian cystectomy is the treatment of choice .
ovarian cysts in the adolesent with pain: If the patient
has persistent pain accompanied by autonomic symptoms like
vomiting, one has to think in terms of a twist in the ovarian cyst.
the twisted vascular pedicle through ultrasonography is suggestive
of ovarian torsion, and color Doppler sonography could be helpful in
predicting the viability
of adnexal structures by depicting blood flow within the twisted
vascular pedicle. A diagnosis of twisted ovarian cyst warrants
surgery. During surgery, a bluish colour in the cyst on initial
inspection is not confirmatory of gangrene in the ovary. In some
cases, untwisting of the cyst may bring back vascularity to the
ovary, which may then
regain its original colour (8).
A cystectomy may now be done. In case the ovary has undergone gangrene,
adnexectomy is the only option. Laparoscopic techniques if
available are kindest to the patient in these circumstances. If the patient has symptoms of endometriosis like congestive
dysmenorrhoea, an endometrioma
has to be suspected. In India, Ultrasonography in this age group is usually done with transabdominal probes, which may
be inadequate to distinguish a simple cyst from an endometrioma. Endometriomas should be managed by laparoscopic ovarian cystectomy and coagulation
of any other endometriotic implants.
unilocular simple ovarian cyst in the reproductive age group: In
this age group, a vaginal sonography is possible, and in expert
hands, a differentiation can be be made between a simple cyst and an
endometrioma, the latter showing internal echoes. A simple cyst
could be observed for 3 months. If it does not disappear, the diagnosis of a benign ovarian neoplasm like serous or
mucinous cystadenoma should be made.
If the patient has completed her family,
salpingo-oophorectomy could be done on the affected side, instead of
is a much more complicated procedure compared to ovarian cystectomy
and is not warranted for treatment of benign neoplastic cysts.
Endometriomas in this age group should be tackled taking in to
consideration the findings in the rest of the abdomen. If there is
extensive endometriosis in the pelvis, it may be prudent to do a
hysterectomy with bilateral oophorectomy if the patient has
completed her family. She should subsequently be put on hormone
replacement therapy to prevent symptoms of oestrogen deficiency.
cysts with solid areas
in the adolescent age group:
presence of solid areas in the cyst makes the mass a complex mass.
Complex masses should alert one to the possibility of
neoplasms, benign or malignant.
However, the mere presence of solid areas is not diagnostic
of neoplasm. Complex cysts could be corpus luteum cyst, hemorrhagic
cyst, ectopic pregnancy, ovarian torsion, tubo-ovarian abscess or
or either benign or malignant neoplasm. Assuming that pregnancy,
torsion, and infectious causes are excluded, a repeat sonogram
should be performed after the next menses. Patients with pain may
need to be scanned at a shorter interval. Hemorrhagic cysts can have
a variable sonographic appearance that commonly changes over a
period of days. If the mass decreases in size on ultrasound
follow-up, it can continued to be followed. If the cyst persists for
longer than two or three cycles, then neoplasm is more likely, and
surgical evaluation is indicated. As with simple cysts, increase in
size, pain, or mass effect should prompt earlier surgical
intervention. Malignancy should be suspected on ultrasonography in
some cases by observing the thickness of the capsule, shadowing,
echogenecity, etc. Even if the ovarian cyst is palpable over the
the author’s experience, if an ovarian cyst is palpable above the
umbilicus, unilocular and filled with clear fluid as shown on
Ultrasound, it is possible to select a site on the abdomen where the
cyst is looking tense and adjacent to the abdominal wall and put a
needle in and aspirate the fluid through suction. Now it becomes
easier to put in the laparoscope and salpingooophorectomy/cystectomy
becomes possible. In a large cyst, the thinner portion of the cyst is first
excised. This makes it easier to delineate the ovarian wall from the
cyst wall. A cystectomy can now be performed.
However, in a huge ovarian cyst, the functional ovarian
tissue left behind after such a procedure is very less.
cysts in the menopausal woman: If
the cyst is only 3-5cm, she should have a serum CA-125 level done
and a color doppler sonography done.
If CA–125 levels are less than 65IU and colour doppler is
suggestive of a nonmalignant lesion, she could be followed up at
2,3,6,9, and 12 months and annually there after. In cysts larger than this a unilateral salpingo-oophorectomy
should be done, provided the CA125 levels and color doppler is
suggestive of a nonmalignant lesion. An international multicenter
study found that postmenopausal patients with an asymptomatic simple
ovarian cyst 3-5 cm in diameter and a normal CA125 had a 0% risk of
(6). CA125 is an
antigenic determinant that is elevated in 80% of all patients with
serous cystadenocarcinoma of the ovary but in only 50% of the
patients with stage I disease. As a diagnostic aid, measurement of
CA125 is most useful in postmenopausal patients with an
ultrasonographically suspicious mass. In this setting, a level
greater than 65 U/mL has been shown to have a positive predictive
value of 97%. Color flow Doppler has been reported to be helpful in
identifying malignancy. Computerized tomography (CT) does not have
as good resolution of ovarian masses as ultrasound but does tell you
a lot about the rest of the abdomen. Magnetic resonance imaging (MRI)
is a little better at describing ovarian masses and, like CT, gives
a good view of the entire abdomen; however, MRI is more costly.
In summary, simple
unilocular cysts are likely to be benign but should always be
followed up with Ca- 125 levels. If it is greater than 65 U/ml, to
be on the safe side the patient should be treated as ovarian
malignancy. When CA125 levels are normal, the patients should be
cysts as opposed to simple cysts need careful evaluation. Cysts
>6cm should alert one to the possibility of malignancy.
The differential diagnosis of such a cyst in this age group
should include an inflammatory tubo-ovarian mass, an endometrioma, a
benign Teratoma (Dermoid) or even a hemorrhagic corpus luteum cyst.. In all these conditions a laparoscopic cystectomy/salpingo-oophorectomy
is all that is needed. Here, it is useful to remember that CA-125 is
elevated (>35mIU) in endometriomas, Pelvic infections, pregnancy
and assossiated liver disease. A markedly elevated Ca-125 (>200mIU) may make one strongly
suspect malignancy and take a decision straight away in favour of a
hysterectomy with bilateral salpingo-oophorectomy. A normal CA-125
level alone is not enough to rule out malignancy.
Quite often the diagnosis of borderline malignant ovarian
tumour is made presumptively at the time of surgery on seeing the
excrescences on the tumour, adhesions etc, confirmation being made
only after histopathology. Thus in a patient with multilocular
cysts, a colour doppler scanning and testing of serum for tumour
markers might help in preoperatively detecting malignancy, but even
if preoperative evaluation does not indicate malignancy a careful
histopathology is mandatory postoperatively.
cyst in pregnancy: Traditionally,
asymptomatic ovarian cysts >8cm should be removed only after 16
weeks as till then there is a possibility that the cyst is a corpus
luteum cyst. Asymptomatic corpus luteal cysts disappear in second
symptomatic cysts (Torsion, haemmorrhage, rupture) should be removed
even in first trimester.Ultrasonographic cyst aspiration could be
tried in selected cases.(20)
In cases where cystectomy is done before 10 weeks, progesterone
support should be given as the corpus luteum may have been
removed.Progesterone suppositories are available in strengths of
100mg and 200mg. These could be given twice daily orally or
route is known to give better absorption rates.
One study has reported 6 cases of laparoscopic cystectomy for
adnexal torsion without miscarriages, proving that in skilled hands
laparoscopy is safe in 1st
trimester(17). The author also has done 2 laparoscopic ovarian cystectomies
in first trimester of pregnancy with good maternal and fetal
cysts getting impacted in the pouch of Douglas causing obstruction
to labour in second stage could also be aspirated.
Q: If a perimenopausal woman complains of mild
abdominal pain and she is found to have an
ovarian cyst of 4 cm, in one ovary, on
ultrasonography, what should be the management?
A large number of ovarian cysts are now being
discovered on ultrasound and there is only a low
risk of malignancy in these cysts and therefore,
not all need be managed surgically. A cyst
could be functional or organic. Functional
cysts regress on their own.
Mild abdominal pain with a simple ovarian cyst
of size 3-5cm, which are unilocular, could be
managed conservatively without any intervention,
on the assumption that it is a functional cyst.
Other causes of abdominal pain like pelvic
infection, urinary tract infection, abdominal
colic, acid peptic disease, etc should be looked
for and managed. This management is rational
women with an ovarian cyst, but with no
symptoms, family or personal history of cancer
(e.g., ovarian, breast, colorectal),
physical or laboratory evidence suggestive of
infection, pregnancy, or systemic illness, are
considered at low risk of ovarian cancer and
may be followed with serial ultrasonography.
If the cyst persists, and if it is not
increasing in size, it could still be followed
up without intervention1, The
patient should be reassured.
Q: What should be management of a unilocular
simple 3-5 cm cyst in a menopausal woman?
A: The possibility of malignancy has to be kept
in mind, more in the postmenopausal woman. The
protocol of management should be the same. An
international multicenter study found that
postmenopausal patients with an asymptomatic
simple ovarian cyst 3-5 cm in diameter and a
normal CA125 had a 0% risk of malignancy3.
CA125 is an antigenic determinant that is
elevated in 80% of all patients with serous
cystadenocarcinoma of the ovary but in only 50%
of the patients with stage I disease. As a
diagnostic aid, measurement of CA125 is most
useful in postmenopausal patients with an
ultrasonographically suspicious mass. In this
setting, a level greater than 65 U/mL has been
shown to have a positive predictive value of
97%. In RCOG guidelines2,
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.
Q: What should be the management of a
multilocular cyst in the post menopausal woman”
A: : Multilocular cysts as opposed to
simple cysts need careful evaluation. Cysts >6cm
should alert one to the possibility of
malignancy. The differential diagnosis of such
a cyst in this age group should include an
inflammatory tubo-ovarian mass, an endometrioma,
a benign Teratoma (Dermoid) or even a
hemorrhagic corpus luteum cyst.. In all these
conditions a laparoscopic cystectomy/salpingo-oophorectomy
is all that is needed. Here, it is useful to
remember that CA-125 is elevated (>35mIU) in
endometriomas, Pelvic infections, pregnancy and
assossiated liver disease. A markedly elevated
Ca-125 (>200mIU) may make one strongly suspect
malignancy and take a decision straight away in
favour of a hysterectomy with bilateral
salpingo-oophorectomy. A normal CA-125 level
alone is not enough to rule out malignancy.
Quite often the diagnosis of borderline
malignant ovarian tumour is made presumptively
at the time of surgery on seeing the
excrescences on the tumour, adhesions etc,
confirmation being made only after
histopathology. Thus in a patient with
multilocular cysts, a colour doppler scanning
and testing of serum for tumour markers might
help in preoperatively detecting malignancy, but
even if preoperative evaluation does not
indicate malignancy a careful histopathology is
Q. What should be the management of a menopausal
woman with an simple ovarian cyst of larger than
A:In a woman with an ovarian cyst larger than 5
cm differentiation should be made between
organic and functional cysts. Normally formed
follicles or corpus luteum in the ovary may
sometimes undergo cystic transformation, leading
to formation of follicular cysts or corpus
leuteal cysts, which are functional cysts. .
The majority of follicular cysts disappear
spontaneously by either reabsorption of the cyst
fluid or silent rupture within 4 to 8 weeks of
initial diagnosis 4. Unless
ultrasound features definitely indicate organic
cyst, a presumptive diagnosis of functional
ovarian cyst could be made and the patient
watched over for 6 months. However, persistence
of the cyst over 6 months means there is
likelihood that the cyst is not functional, and
that it needs surgical intervention. If the
patient has acute or chronic pelvic pain, which
could be attributable to the cyst, surgical
treatment is warranted, even if the cyst appears
to be functional.
Organic cysts are formed due to some benign or
malignant pathology in the ovary resulting in
formation of ovarian cysts which do not regress.
In case of suspected organic cysts, immediate
surgery is indicated.
The criteria that that the cyst is organic, are
that, the cyst is more than 5 cm and persisting
, there are thick septa within the cyst, there
are intra or extracystic vegetations, or if
there is heterogenous content within the cyst.
Colour Doppler USG should be done in these
cases. Low resistance index (less than 0.5) and
high CA 125 levels are suggestive of
In younger women, if there is no suspicion of
malignancy, ovarian cystectomy with conservation
of ovary could have been done. But in a post
menopausal woman, unilateral
salpingooophorectomy with removal of the tissue
without possible spillage into the abdomen would
be the ideal treatment of choice. Laparoscopic
surgery being a less morbid procedure, for the
patient, should be preferred if the centre has
facilities for laparoscopy. In case of
suspected malignancy, although there are many
reports of laparoscopic surgery in advanced
centres, by and large, laparotomy is considered
to be the gold standard.
Q: What are the ultrasound criteria to know if a
cyst harbours malignancy?
A: Morphologic indexing of a cyst is helpful to
know if the cyst is malignant. Morphologic
index developed by De priest is given below.
Cyst wall structure and wall thickness
Thin septa <3mm
Thick septa 3-10mm
A point scale (0 to 4) was developed within each
category, with the total points per evaluation
varying from 0 to 12.
An ultrasound morphology index score <5 in a
pre-menopausal woman is in keeping with a benign
In post-menopausal patients, a morphology index
score ≥5 has a positive predictive value for
malignancy of 0.45.
Malignancy indexing can also be helpful in
diagnosing malignancy in a post menopausal woman
Risk of Malignancy Index(RMI) = U ×M ×CA 125.
M=3, a constant for menopausal women.
CA 125=value of CA 125.
Low-risk RMI = <25; Risk
of cancer is <3%
Moderate-risk RMI = 25 to 250; Risk of
cancer is 20%;
High-risk RMI = >250 Risk of
cancer is 75%;
Q: What are the risk factors for ovarian cancer?
A: Family history of ovarian cancer is
associated with increased risk of ovarian
cancer. Family history of epithelial cancers are
specially associated with increased risk of
ovarian cancer. There are genetic markers,
which can predict whether such an individual is
at an increased risk of developing ovarian
cancer. The most studied gene associated with
ovarian cancer is the BRCA1 gene. If relatives
of patients who develop ovarian cancer are found
to have this gene, they could undergo frequent
surveillance for development of ovarian cancer.
If such individuals have to undergo
hysterectomy, they should undergo a prophylactic
bilateral oophorectomy as well. Similarly there
are quite a few other genes also which have been
found to be present in increased frequency in
women with ovarian cancer. But, without further
studies to confirm their usefuleness, it has not
been found necessary to genetically screen the
population as a whole to see who is at increased
risk of ovarian cancer. These studies are
available in India,but are prohibitively costly.
Infertility and nulliparity is associated with
increased risk of ovarian cancer. The use of
infertility drugs was suspected to increase the
risk, but it has been found that it is
infertility per se and not the use of ovulation
inducing drugs that increases the risk of
The use of oral contraceptive pills,
sterilization and gynaecological surgeries like
hysterectomy has been found to be associated
with a decreased risk of ovarian cancer.
Can all ovarian cysts be managed by the
A: Ovarian cysts which appear to be advanced in
staging are best handled by oncology surgeons,
as they are better equipped to do
lymphadenectomy, difficult dissections in the
highly vascular tumour, etc. ACOG guidelines
recommend the following cases to be referred to
the oncology surgeon;
Post-menopausal women with suspicious pelvic
Elevated CA-125 level (>35 U/mL)
A nodular or fixed pelvic mass
Evidence of abdominal or distant metastasis
A family history of 1 or more first-degree
relatives with ovarian or breast cancer.
Pre-menopausal women with a suspicious pelvic
Greatly elevated CA-125 level (> 200 U/mL)
Evidence of abdominal or distant metastasis
A family history of 1 or more first-degree
relatives with ovarian or breast cancer.
factors for ovarian cancer: Family
history of ovarian cancer is associated with increased risk of
ovarian cancer.Family history of epithelial cancers are specially
associated with increased risk of ovarian cancer.
There are genetic markers, which can predict whether such an
individual is at an increased risk of developing ovarian cancer. The
most studied gene associated with ovarian cancer is the BRCA1 gene.
If relatives of patients who develop ovarian cancer are found
to have this gene, they could undergo frequent surveillance for
development of ovarian cancer.
If such individuals have to undergo hysterectomy, they should
undergo a prophylactic bilateral oophorectomy as well. Similarly
there are quite a few other genes also which have been found to be
present in increased frequency in women with ovarian cancer. But,
without further studies to confirm their usefuleness, it has not
been found necessary to genetically screen the population as a whole
to see who is at increased risk of ovarian cancer. These studies are
as yet not available in India.
Infertility and nulliparity is associated with increased risk
of ovarian cancer. The
use of infertility drugs was suspected to increase the risk, but it
has been found that it is infertility per se and not the use of
ovulation inducing drugs that increases the risk of ovarian cancer.
use of oral contraceptive pills, sterilization and gynaecological
surgeries like hysterectomy has been found to be associated with a
decreased risk of ovarian cancer.
of Ovarian Cancer:
Knowledge about the stages is necessary to make a decision on
whether the surgical modality adopted for a particular tumour is
adequate or if it is to be followed up with further treatment.
I Growth limited to the ovaries
IA Growth limited to one ovary; no ascites,No tumor on the external
IB Growth limited to both ovaries; noascites. No tumor on the
external surfaces;capsules intact.
IC Tumor either stage IA or IB, but with tumor on surface of one or
both ovaries;or with capsule ruptured; or with ascitescontaining
malignant cells; or with positive peritoneal washings.
II Growth involving one or both
ovaries,with pelvic extension.
IIA Extension or metastases to the uterus or tubes.
IIB Extension to other pelvic tissues.
IIC * Tumor either IIA or IIB but on thesurface of one or both
ovaries; or with capsule(s) ruptured;
with ascitescontaining malignant cells; or withpositive peritoneal
III Tumor involving one or both ovaries with peritoneal implants
outside the pelvis or
retroperitoneal or inguinal nodes;
superficial liver metastasis equals stageIII;
is limited to the true pelvis, but there is histologically proven
malignant extension to small bowel or omentum
IIIA Tumor grossly limited to the true pelviswith negative nodes but
with Histologically confirmed microscopicseeding of abdominal
IIIB Tumor involving one or both ovaries with histologically
confined implants of abdominal peritoneal surfaces, none exceeding 2
cm in diameter; nodes are negative
IIIC Abdominal implants larger than 2 cm indiameter or positive
retroperitoneal or inguinal nodes
IV Growth involving one or both ovaries with distant metastases; if
pleural effusion is present, there must be positive cytology to
categorize as stage IV.
tumours in adolescents: Breen
and Maxson combined four series to demonstrate the shifting
distribution of ovarian neoplasms by patient age. In young
adolescents 10 to 14 years old, 72% of
ovarian neoplasms were germ cell; 8%, sex cord stromal; and
16%,epithelial tumours. Among the older adolescents 15 to 17 years
old, 49% were germ cell; 16%,sex cord stromal, and 28%, epithelial.
Cystic teratomas (Dermoids) are the most common benign tumour in
this age group. Dermoids are benign germ cell tumours. They usually
contain skin, teeth, bones, hair, and extremities. . On sonography,
dermoid cysts often appear as complex cystic masses that contain
solid elements that cause shadowing.
Laparoscopy or laparotomy can be used to remove
dermoids by cystectomy in most patients or by oophorectomy when
necessary. If the dermoid is larger than 6 cm or the patient has
undergone multiple surgical procedures with adhesions, laparotomy is
the preferred treatment approach..
Careful attention should be given to the other ovary because
of the 12% rate for bilateral occurrence.
There is a 1-2% chance of malignant change in Dermoids, but
this is unusual in this age group, being an occurence seen usually
in the post-menopausal age group.
Cell Malignancy :Germ cell tumors are the most common type of
ovarian malignancy in adolescents. The median age at diagnosis for
these tumors is 18 to 20 years. Unilateral salpingo-oophorectomy
followed by platinum chemotherapy gives very good results, retaining
the reproductive potential of the patient.
It is the commonest germcell malignancy.In early cases unilateral
salingo-oophorectomy followed by surveillance is all that is
necessary. In advanced
cases, combination chemotherapy has to be added.
germ cell tumours: Other germ cell malignancies found in adolescents
include immature teratoma, embryonal carcinoma, endodermal sinus
tumor, gonadoblastoma, choriocarcinoma, and mixed germ cell tumors.
Many of these tumors produce markers, as previously discussed, that
may be useful for following response to therapy. Most patients
should receive postoperative chemotherapy with bleomycin, etoposide,
and cisplatin, with the exception of those with stage I, grade I
immature teratoma, who can be followed with surveillance. The
survival rate for these patients is not as good as those with
dysgerminoma but is still excellent, especially for those with early
stage disease with appropriate adjuvant chemotherapy.
markers in ovarian Ca in adolescent age group: Whenever
a patient is suspected to have an ovarian malignancy, she should
have the levels of tumour markers checked, both for diagnostic
purposes and for following up the patient after surgery. The tumor
marker, Cancer antigen 125(CA-125) is not as useful in adolescents
as in menopausal patients. Elevation can be caused by a variety of
processes that result in peritoneal irritation, such as
endometriosis or PID, making the test nonspecific in this age group.
Germ cell tumours are more common in this age group and the tumour
markers specific to these tumours will be more useful in this age
can be made by endodermal sinus tumors, embryonal cell cancer, mixed
germ cell malignancies, and rarely by immature teratomas. Serum
beta-hCG can be found in nonpregnant patients with embryonal cell
carcinoma and choriocarcinoma. Patients with dysgerminoma may have
elevated lactate dehydrogenase levels. Tumor markers are most useful
for following treatment response in patients diagnosed with ovarian
caner in the adult woman:
epithelial tumors: Conservative surgery with the preservation of
some ovarian tissue is enough in young women with benign epithelial
tumors. This usually includes ovarian cystectomy or oophorectomy. In
postmenopausal women a TAH/BSO can be considered to avoid future
epithelial tumours: Almost 85% of all ovarian malignancies are
derived from ovarian epithelium, making epithelial malignancies the
most commonly encountered ovarian cancer.
It could be borderline, or frankly malignant.
They include, Serous, mucinous, endometrioid, clear cell,
Brenner-transitional cell, mixed mesodermal, and undifferentiated
ovarian tumors of low malignant potential (borderline tumors):
In these tumours, there are atypical cells seen, but there is
no stromal invasion. In
women who have completed their childbearing, a TAH/BSO/omentectomy
epithelial ovarian tumour: Frank malignancy is suspecte
the tumour is bilateral, adherent to adjacent organs has surface
implants,haemmorrhage and necrosis,solid areas or intracystic
tumours have to beremoved by cytoreductive surgery.
Cytoreductive surgery is the removal of as much of the tumor
and its metastases as possible. It includes TAH, BSO, and complete
omentectomy with resection of any metastatic lesions. In some
patients, bowel resection and retroperitoneal lymphadenopathy are
optimal cytoreduction. Optimal cytoreduction is achieved when the
largest residual tumor mass measures less than 1.5 cm. This has to
be followed up with chemotherapy. Sometimes the tumour
appears inoperable at first laparotomy.
These patients are first given chemotherapy and when the
tumour is more amenable to surgery, cytoreductive surgery should be
cell tumours: Germ
cell tumours include: dysgerminoma, endodermal sinus tumor,
embryonal carcinoma, polyembryoma, choriocarcinoma, teratoma, mixed
forms, and gonadoblastoma.
Gonadoblastoma, Mature teratoma (Dermoid), & Struma ovarii.
These include dysgerminoma, endodermal sinus tumor, embryonal carcinoma,
polyembryoma, choriocarcinoma, teratoma, mixed forms, and
all these tumours, unilateral salpingo-oophorectomy and surgical
exploration is all that is necessary in early stages.
Usually the tumour does not go beyond Stage sugery and I can be
stopped at unilateral salpingo-oophorectomy.
But if the stage has gone beyond Stage I, a cytoreductive
surgery has to be done,with additional therapy.
malignancies: Unilateral tumors are the rule in nondysgerminomatous
germ cell malignancies. Because of this, unilateral oophorectomy
should be performed. This would preserve the contralateral ovary, as
long as it appears normal, for hormone production and future
childbearing potential. . Cytoreductive
surgery for advanced disease should be undertaken when possible. In
patients needing to preserve childbearing function, unilateral
salpingo-oophorectomy should be done followed by chemotherapy.
Normal menstruation is known to resume on stopping
chemotherapy. There is
hardly any role for second look laparotomy for follow up of germcell
tumour markers may be enough for follow up.
cell tumours: These include Granulosa stromal cell tumor, Sertoli
stromal cell tumor, sex cord tumor with annular tubules, Leydig cell
tumor, lipid cell tumor, and gynandroblastoma.
I and IA : If unilatateral salpingo-oophorectomy has been done at
first surgery, that may be all that need be done.
It should be followed up with surveillance. Granulosa tumours are usually indolent and if limited to the
ovary, do not usually relapse.
IB onwards: If the patient has completed child bearing, TAH with BSO
may be done. Data are
limited on treating patients with advanced or recurrent stromal
tumors because of the rarity, multihistologic patterns, and indolent
behavior of these tumors. Even less information is available
regarding which patients should receive adjuvant therapy. However,
use of chemotherapy and even radiotherapy has been described in a
few studies for recurrent tumours.
and bilateral salpingo-oophorectomy followed by adjuvant
chemotherapy should be considered in the following cases:
Patients with stage I or II Epithelial tumours if any of the
following are present:
differentiated disease (grade 3), tumor excrescences on the surface
of the ovary, ascites, positive peritoneal cytology, or extraovarian
may be enough for patients with with the following tumours:
I, stage 1A Invasive epithelial tumors.
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Address for Correspondence;
Medical Centre, (Unit of Trichur Heart hospital),
Thrissur, Kerala, India.