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Flashcards in Benign Tumours Deck (27):

What are fibroids?

Fibroids are extremely common benign monoclonal tumours of the smooth muscle cells of the uterine myometrium, containing a large amount of extracellular matrix with disordered collagen. They start as multiple, single-cell seedlings distributed throughout the uterine wall. These then increase in size very slowly over many years, stimulated by oestrogens and progestogens. As the fibroid grows, the central areas may not receive an adequate blood supply and undergo benign degeneration often followed by calcification


What causes fibroids?

The cause of fibroids is debated but it is thought to be a combination of acquired genetic change plus the effects of hormones and growth factors, possibly related to a response to ischaemic injury at the time of menses.


Name the types of fibroids:

Intramural (the majority).

Submucosal: growing into the uterine cavity. They may be pedunculated and may protrude through the cervical os.

Subserosal: growing outwards from the uterus - can be:
-Pedunculated subserous (abdominal)


Name some symptoms of fibroids:

Most uterine fibroids are asymptomatic (up to half).

But they can cause;
-Prolonged or heavy menstrual bleeding (can lead to anaemia- fatigue etc).
-Pelvic pressure or pain
-Fibroids may present with recurrent miscarriage or infertility. However, only submucous fibroids decrease fertility but their removal restores fertility to baseline rates.
-Pedunculated submucosal fibroids may cause inter menstrual bleeding
-5% of pregnant women noted to have fibroids experience acute pain during the pregnancy, due to fibroid degeneration.
-Pressure on the bowel may cause constipation and pressure on the bladder may cause urinary

Fibroids don't undergo malignant change to a sarcoma except in very rare circumstances but tumours assumed to be benign fibroids may occasionally later be identified as uterine sarcomas. Most women with sarcoma have symptoms of a suspected gynaecological malignancy: abdominal pain and abnormal bleeding.


How common are fibroids?

-Uterine fibroids are the most common non-cancerous tumours in women of childbearing age, occurring in 77% of women. They are clinically apparent in 25%.

-Fibroids are three times more common in African-American women than in white Americans. Black women tend to be younger at the time of diagnosis and have more numerous, larger and more symptomatic fibroids.


What age do fibroids tend to present?

Although they have been reported occasionally in adolescents, most women are in their 30s or 40s when the myomas become symptomatic. The incidence increases with age up to the menopause.


Examination required when suspecting fibroids:

Palpable abdominal mass arising from the pelvis.
Enlarged, often irregular, firm, non-tender uterus palpable on bimanual pelvic examination.
Signs of anaemia due to menorrhagia.


Ddx for fibroids?

-Dysfunctional uterine bleeding.
-Endometrial polyps, endometrial cancer.
-Chronic pelvic inflammatory disease.
-Tubo-ovarian abscess.
-Uterine sarcoma.
-Ovarian tumour.
-Pelvic masses (other causes of a pelvic mass include t-tumour of the large bowel, appendix abscess, and diverticular abscess).


Investigations needed in suspected fibroids:

-Pregnancy test if chance of pregnancy
-FBC (anaemia), iron studies.
-Pelvic ultrasound may be indicated to exclude other causes of a pelvic mass, to confirm the presence and size of a fibroid and to exclude possible complications such as urinary tract obstruction causing hydronephrosis. Transvaginal ultrasound (TVUS) is more accurate.

-MRI is highly sensitive and specific and is occasionally required if ultrasound is not definitive in assessing the fibroid(s) when myomectomy is being considered.

-Endometrial sampling (Pipelle®): for histology in the assessment of abnormal uterine bleeding.

-Hysteroscopy: with biopsies.

-The combination of lactic acid dehydrogenase (LDH), LDH isoenzyme 3 and gadolinium-enhanced MRI is highly accurate in diagnosing leiomyosarcoma pre-operatively, if sarcoma is suspected clinically.


Management of fibroids:

Only required if symptomatic. Symptoms will usually reduce/ stop post-menopause.

-Non-steroidal anti-inflammatory agents (eg, ibuprofen) may be tried. They reduce menstrual blood loss when the cause is unknown due to reducing prostaglandins.
Antifibrinolytic agents (eg, tranexamic acid) may also also reduce menorrhagia.

-Combined hormonal contraception pill (CHC). This is helpful if the patient requires contraception, although it is not as effective as a levonorgestrel-releasing intrauterine system LNG-IUS (Mirena®)

-Gonadotrophin-releasing hormone (GnRH) agonists:
Produce reduction in the size of fibroids, in the region of 50% within three months but, once discontinued, fibroids regrow to their former size within about two months; therefore, they are mainly useful pre-hysterectomy.

-Mifepristone is a progesterone receptor inhibitor which is effective at reducing fibroid-related bleeding but, as it results in exposure of the endometrium to unopposed oestrogen, it may cause endometrial hyperplasia. It does not reduce uterine volume and hence has no role pre-surgery.

-Ulipristal acetate: A selective progesterone receptor modulator (SPRM), with predominantly inhibitory action. It acts by inhibiting cell proliferation and inducing apoptosis. It has been shown to be superior to placebo and non-inferior to GnRH agonists. Like mifepristone however, long term endometrial safety data are still required before SPRMs can be used other than pre-surgery. The licensed indication is for pre-operative treatment and duration of treatment should not exceed two three-month courses. Measure LFTs once monthly for patients on this.


Risk factors for fibroids:

Fibroids are more common in obese women and women with an early menarche - factors which increase lifetime exposure to oestrogen.


Protective factors against fibroids:

Exercise and increased parity are protective factors.


Surgical indications for fibroids:

-There is excessively enlarged uterine size.
-Pressure symptoms are present.
-Medical management is not sufficient to control symptoms.
-The fibroid is submucous and fertility is reduced.


Surgical options for fibroids:

Myomectomy - this is used in patients who wish to maintain their reproductive potential or keep their uterus. Abdominal myomectomy is a safe alternative to a hysterectomy. However, there is a risk of excessive bleeding and a risk of requiring hysterectomy at the time of the operation. Therefore, blood should be cross-matched pre-operatively and the patient needs to give their consent to hysterectomy should the need arise. Lapascopically is associated with lower risks.

Hysteroscopic endometrial ablation - for women presenting with menorrhagia.

Total hysterectomy: This has been the mainstay of treatment for many years, eliminating both symptoms and the possibility of recurrence. It is also indicated when there are many fibroids. If these are small then the vaginal route is appropriate but if they are large (especially if intraligamentous) then laparotomy is indicated with preservation of ovaries if possible. Blood loss may be reduced by preceding use of GnRHas.

Uterine artery embolisation (UAE): This procedure has been shown to be both effective (for short- and medium-term symptom relief) and safe for women who wish to keep their uterus, although the effects on fertility and pregnancy are uncertain. Ensuring the tumour is a benign fibroid and not a malignant sarcoma is essential prior to UAE.

MRI-guided transcutaneous focused ultrasound.


Name the three types of ovarian tumours:

-Functional 24%
-Benign 70%
-Malignant 6%


Name the two types of benign epithelial neoplastic cysts:

Benign epithelial neoplastic cysts (60% of benign ovarian tumours):

Serous cystadenoma:
-Develop papillary growths which may be so prolific that the cyst appears solid.
-They are most common in women aged between 40-50 years.
-About 15-25% are bilateral and about 20-25% are malignant.

Mucinous cystadenoma:
-The most common large ovarian tumours which may become enormous.
-They are filled with mucinous material and rupture may cause pseudomyxoma peritonei. They may be multilocular.
-They are most common in the 20-40 age group. About 5-10% are bilateral and around 5% will be malignant.


Name a benign neoplastic cystic tumours of germ cell origin and some features:

Benign cystic teratoma; rarely malignant.
They arise from primitive germ cells.
A benign mature teratoma (dermoid cyst) may contain well-differentiated tissue - eg, hair, and teeth.
20% are bilateral.
They are most common in young women.
Poorly differentiated, malignant teratomas are rare.


Name some benign neoplastic solid tumours and features:

-Fibroma (less than 1% are malignant); small, solid benign fibrous tissue tumours. They are associated with Meigs' syndrome and ascites.
-Thecoma (less than 1% are malignant).
-Brenner's tumour:
-Over 95% are benign and more than 90% are unilateral.
They may be associated with mucinous cystadenoma and cystic teratoma.


Risk factors for ovarian cysts:

Tamoxifen therapy has been associated with an increase in persistent ovarian cysts.
Early menarche.
Dermoid cysts can run in families.


Symptoms associated with ovarian cysts:

-Asymptomatic - chance finding (eg, on bimanual examination or ultrasound).
-Dull ache or pain in the lower abdomen, low back pain.
-Torsion or rupture may lead to severe abdominal pain and fever.
-Swollen abdomen, with palpable mass arising out of the pelvis, which is dull to percussion and does not disappear if the bladder is emptied.
-Pressure effects - eg, on the bladder, causing urinary frequency, or on venous return, causing varicose veins and leg oedema.
-Torsion, infarction or haemorrhage. Torsion may be intermittent, presenting with intermittent episodes of severe pain.Ovarian torsion is a complication for persistent masses in pregnancy.
-Rupture of a large cyst may cause peritonitis and shock.
Rupture of mucinous cystadenomas may disseminate cells which continue to secrete mucin and cause death by binding up the viscera (pseudomyxoma peritonei).
Ascites - suggests malignancy or Meigs' syndrome.
Endocrine - hormone-secreting tumours may cause virilisation, menstrual irregularities or postmenopausal bleeding. This is uncommon.


Ddx for ovarian cysts:

Non-neoplastic functional cysts - eg, follicle cyst, corpus luteum cyst, theca lutein cyst.

And other causes of symptoms experienced.


Investigations to do in pelvic masses:

-Pregnancy test (uterine or ectopic pregnancy).
-FBC - infection, haemorrhage.
Urinalysis - if there are urinary symptoms.
-Ultrasound - a pelvic ultrasound is the single most effective way of evaluating an ovarian mass. Transvaginal ultrasonography is preferable due to its increased sensitivity over transabdominal ultrasound.
-CT or MRI scan - usually required only if ultrasound results are not definitive or if intra-abdominal pathology is suspected.
-Diagnostic laparoscopy may be performed in some cases. Fine-needle aspiration and cytology may be used to confirm the impression that a cyst is benign.
Cancer antigen 125 (CA 125).

CA 125 does not need to be done in premenopausal women who have had an ultrasound diagnosis of a simple ovarian cyst made. CA 125 is primarily a marker for epithelial ovarian carcinoma and is only raised in 50% of early-stage disease.

Lactate dehydrogenase (LDH), alpha-fetoprotein (AFP) and human chorionic gonadotrophin (hCG) should be measured in all women under the age of 40 with a complex ovarian mass because of the possibility of germ cell tumours.


Name the expectant management of an ovarian cyst:

-Women with small (less than 50 mm in diameter) simple ovarian cysts generally do not require follow-up, as these cysts are very likely to be physiological and almost always resolve within three menstrual cycles.

-Women with simple ovarian cysts of 50-70 mm in diameter should have yearly ultrasound follow-up and those with larger simple cysts should be considered for either further imaging (MRI) or surgical intervention.
For those that are persistent, unchanged, less than 10 cm, and with normal CA 125 values, the likelihood of an invasive cancer is sufficiently low that observation should usually be offered.

However, ovarian cysts that persist or increase in size are unlikely to be functional and may need surgical management.


Surgical options for ovarian cysts:

If conservative measures fail or criteria for surgery are met, surgical therapy for benign ovarian tumours is generally very effective and provides a cure with minimal effect on reproductive capacity.

-Persistent simple ovarian cysts larger than 5-10 cm, especially if symptomatic, and complex ovarian cysts should be considered for surgical removal. In children and younger women (wishing to preserve maximum fertility), cystectomy may be preferable to oophorectomy. Laparoscopic surgery for benign ovarian tumours is usually preferable to open surgery.

Ovarian torsion: Usually initially treated by laparoscopy with uncoiling of the affected ovary and possible oophoropexy.Salpingo-oophorectomy may be indicated if there is severe vascular compromise, peritonitis or tissue necrosis.


Complications of ovarian cysts:

-Torsion of an ovarian cyst can occur.
-Haemorrhage is more common for tumours of the right ovary.
-Rupture of an ovarian cyst can occur.
-Infertility can occur as a result of ovarian tumours or their treatment. However, the role of cysts in infertility is controversial and the effects of surgical treatment are often more harmful than the cyst itself to the ovarian reserve. Surgery does not seem to improve pregnancy rates.


Name and explain 2 types of functional ovarian cysts:

Follicular cysts
commonest type of ovarian cyst
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
commonly regress after several menstrual cycles

Corpus luteum cyst
during the menstrual cycle if pregnancy doesn't occur the corpus luteum usually breaks down and disappears. If this doesn't occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
more likely to present with intraperitoneal bleeding than follicular cysts


The three features of Meig's syndrome are:

a benign ovarian tumour
pleural effusion