Project-1

A Study based on Ovarian teratomas: A clinical condition associated with ovaries its Clinical Management and Surgical treatment

Overview:

• Ovarian teratomas also known as Ovarian cyst are the common gynaecological problems encountered by gynaecologist in their daily practice. They can occur in any age group in females. They are broadly divided into two types, i.e., physiological or pathological (Fig-0).
• Physiological cysts are mainly follicular and luteal cysts and need no treatment unless the cysts are complicated.
• Pathological cysts can be benign or malignant. Benign tumours are more common in young females, while malignant ones are common in elderly females.
• Benign tumours generally are not harmful and will not lead to cancer, while the malignant tumour is harmful and will become cancerous in the future; hence should be treated immediately.
• Ovarian cysts don’t show any symptoms until they become large up to a harmful size; thus, diagnosis is required to detect them.
• The number of diagnosed cases of ovarian cysts has improved with the widespread carrying out of regular physical examinations by gynaecologist’s and ultrasonographic technology

(Fig-0): A 56-year-old woman with right ovarian mature cystic teratoma. Numerous small floating balls are seen in the gravity independent side of the cyst. A larger floating ball is seen in the gravity-dependent side. These balls were composed of pale yellow keratinoid material in macroscopy images (1)

Anatomy of Ovaries:

• The female gonads are called the
• In both the males and females, the gonads develop within the mesonephric ridge and descend through the abdomen. However, unlike the testes, the ovaries stop in the pelvis.
• The ovaries are paired, oval organs attached to the posterior surface of the broad ligament (Fig-1)of the uterus by the mesovarium (a fold of peritoneum, continuous with the outer surface of the ovaries).
• The main functions of the ovaries are:
• To produce oocytes(female gametes) in preparation for fertilisation.
• To produce the sex steroid hormones oestrogenand progesterone, in response to pituitary gonadotrophins (LH and FSH) (2).

Fig-1.

Components of the Ovaries:

• The ovary has three main histological features Fig-2

• Surface – formed by simple cuboidal epithelium (known as germinal epithelium). Underlying this layer is a dense connective tissue capsule.

• Cortex – comprised of a connective tissue stroma and numerous ovarian follicles. Each follicle contains an oocyte, surrounded by a single layer of follicular cells.

• Medulla – formed by loose connective tissue and a rich neurovascular network, which enters via the hilum of the ovary.

Hilum

Fig-2

Ligaments:

• Two peritoneal ligaments attach to the ovary (Fig-3).

• Suspensory ligament of ovary – fold of peritoneum extending from the mesovarium to the pelvic wall. Contains neurovascular structures.

• Ligament of ovary – extends from the ovary to the fundus of the uterus. It then continues from the uterus to the connective tissue of the labium majus, as the round ligament of uterus.

Fig-3

Blood supply to ovaries:

• The main arterial supply to the ovary is via the paired ovarian arteries. These arise directly from the abdominal aorta (inferior the renal arteries). There is also a contribution from the uterine arteries (Fig-4).
• Venous drainage is achieved by paired ovarian veins. The left ovarian vein drains into the left renal vein, and the right ovarian vein drains directly into the inferior vena cava.
• The ovaries receive sympathetic and parasympathetic innervation from the ovarian and uterine (pelvic) plexuses, respectively. The nerves reach the ovaries via the suspensory ligament of the ovary, to enter the ovary at the hilum.

Fig-4

Ovarian teratomas Signs and Symptoms:

• Most patients with ovarian cysts are asymptomatic; the ovarian cyst remains undiscovered as no identifying symptoms are observed until ultrasonography or routine pelvic examination is done by a gynaecologist.
• Some cysts, however, may be associated with a range of symptoms, which are sometimes severe, while malignant ovarian cysts frequently do not cause symptoms until they reach an advanced stage.
• Pain or anxiety may arise in the lower abdomen. Torsion (twisting) or rupture may lead to more severe pain.
• In cyst rupturing, there is sudden, unilateral, s pelvic pain. This can be allied with trauma, exercise, or coitus. Furthermore, cyst rupture can lead to peritoneal signs; abdominal distention and bleeding occur that are commonly self-limited harp
• Other symptoms include the following: -
• Patients may experience discomfort with intercourse, particularly deep penetration.
• Difficulty in bowel movement or pressure may develop, leading to a desire to defecate.
• Some patients may experience tenesmus.
• Abdominal fullness and bloating.
• Young children may present with precocious puberty and early onset of menarche.
• Indigestion, heartburn, or early satiety.
• Micturition due to pressure on the bladder.
• Hirsutism, infertility, oligomenorrhea, obesity, and acne.
• Irregularity of the menstrual cycle and abnormal vaginal bleeding, the menstrual interval may be prolonged, followed by menorrhagia.
• Theca-lutein cysts are normally bilateral and, therefore, can cause bilateral and dull pelvic pain.

Diagnostic technique:

• Differential diagnosis of an adnexal mass should include gynaecologic and non-gynaecologic sources for the evaluation.
• When evaluating an ovarian cyst, the differential diagnosis includes both benign and malignant lesions; it is mainly done to distinguish a benign tumour from a malignant tumour or other serious conditions with a similar occurrence and symptoms.
• At an early age group, the vast majority of ovarian masses are benign; however, due to suspicion of malignancy and some other conditions like the presence of pregnancy, leucocytosis, anaemia, and haemorrhage, differential diagnosis is required to separate ovarian cyst from other conditions.
• The physical examination should include an abdominal and pelvic region examination along with a bimanual pelvic region examination.
• One should look for alerting signs such as an irregular, solid, fixed, and nodular mass accumulated in the area around ovaries that might feel physically or a bilateral finding may be present.
• The presence of fluids in the peritoneal cavity should warn us about the possibility of malignancy.
• The physician should remember that physical examination has poor sensitivity for detecting ovarian masses (15% - 51%), and it will not provide reliable information about the presence of a cyst in the ovaries.
• Most common technique used to detect ovarian cyst is Transvaginal Ultrasonographic.

Transvaginal Ultrasonographic:

• Transvaginal sonography (TVS) is an integral part of virtually every ovarian cancer screening algorithm, whether it is used as the initial screening test or as a secondary test in women with an elevated biomarker profile.
• TVS, performed with a 5–7.5 MHz vaginal probe (Fig-5), generates accurate ovarian images that can be used to detect early changes in ovarian morphology and volume not appreciated on clinical examination.
• Ovarian volume is calculated using the prolate ellipsoid formula (length × width × height × 0.523). Criteria for ovarian abnormality vary according to each screening trial, but usually involve both volume and morphology.
• Ovarian volumes >20 cm3 in premenopausal women and >10 cm3 in postmenopausal women are defined as abnormal (Fig-6), because these values are more than two standard deviations above the published mean ovarian volumes for normal women in these two groups.
• This screening can be done in two ways:

1. External ultrasound scans
2. Vaginal ultrasound scan

Fig-5: Philips V9-4v 4D Transvaginal Probe

Fig-6: Sonographic images of benign and malignant ovarian morphology. Numeric representation of increasing morphologic complexity is noted in the first column (3).

• External ultrasound scans:

• You lie on the couch next to the ultrasound machine. You might be able to sit up depending on which part of your body is being scanned (Fig-7).
• The sonographer will spread a clear gel onto your skin over the area they are checking. The gel feels cold. It helps to transmit the sound waves to the probe. The scan appears on a screen next to you.
• You might feel a little pressure as the sonographer presses the probe against your skin and moves it around the area they are scanning. Tell them if this is uncomfortable.
• An ultrasound scan can take up to 45 minutes depending on what's being scanned.

Fig-7

• Vaginal ultrasound scan:

• The doctor inserts a small thin ultrasound probe into your vagina. This looks like the same shape and size as a tampon (Fig-8).
• The probe is covered with a protective sheath like a condom and has some lubricating gel on it.
• The test may be uncomfortable and a little cool from the gel, but shouldn't hurt. This type of scan does not take long.
• The sonographer will gently move the probe to get the pictures they need. At times the sonographer may place their hand on your tummy and press to move some of your organs to get a clear view on the screen.

Fig-8: Transvaginal ultrasound. An ultrasound probe connected to a computer is inserted into the vagina and is gently moved to show different organs. The probe bounces sound waves off internal organs and tissues to make echoes that form a sonogram (computer picture)

Surgical procedure for ovarian cyst:

• In the surgical treatment of benign ovarian cysts in young women, independently of its size, one of the main goals that all surgeons need keep in mind is to preserve the reproductive and hormonal functions of the ovaries and prevent recurrence.
• However, relatively frequent, this cannot be achieved because the cysts have strong adhesions with the ovary.
• The laparoscopic approach for the removal of cysts with a diameter greater than 10 cm presents different difficulties; the most important are as follows:
• First, the rupture of the cysts with spillage of its contents during the introduction of a trocar or Veress needle.
• The authors prefer an open technique with the use of a Hasson trocar near the umbilicus.
• They did not aspirate the cyst prior to the operation.
• Some surgeons prefer cyst size reduction prior to laparoscopy and it may be obtained using different techniques such as ultrasound-guided aspiration or with the use of the Bohannon catheter (4).
• Second, there is a limited visualization and work space that causes difficulties in identifying important structures such as the ureters.
• Third, the extraction of the cyst is not simple and in the presence of potential malignancy, spillage of the cyst contents could lead to dissemination and seeking where the trocars were placed.
• The significance of spillage in cases of malignancy is controversial. The concern about spillage of tumour cells and its possible worsening of prognosis arose from early studies of tumour rupture.
• The only factors that influence tumour relapse were tumour grade, the presence of dense adhesions or the presence of large volume ascites.
• Therefore, the intra-operative rupture of tumour did not influence the prognosis.

Research sources:

1. Utility of the “floating ball sign” in diagnosis of ovarian cystic teratoma

http://dx.doi.org/10.4274/tjod.galenos.2019.67209

2. AN OVERVIEW OF OVARIAN CYSTS

10.13040/IJPSR.0975-8232.11(11).5434-40

3. Transvaginal ultrasonography in ovarian cancer screening: current perspectives

https://doi.org/10.2147%2FIJWH.S38347

4. Laparoscopic approach for very large benign ovarian cyst in young woman

https://doi.org/10.4103%2F0972-9941.58502