Ovarian tumours in pregnancy: a literature review

Ovarian tumours in pregnancy are a diagnostic and management challenge that is increasingly being faced by the clinician. While most masses are benign and resolve spontaneously, there are others that persist and indicate the need for surgical management. Ultrasound not only detects asymptomatic masses but also helps to guide their management based on presence or absence of features suspicious of malignancy. The role of tumour markers in pregnancy is limited due to their non-specific nature. Most masses treated in pregnancy are benign (most commonly dermoids), and most malignancies are either of low malignant potential or germ cell tumours, usually early stage disease. Surgical management is indicated for symptomatic masses or those with increasing size or complexity indicating possible malignancy. Both laparoscopy and laparotomy have similar results with regard to obstetric outcome. Conservative management is preferred in the remainder. MRI may help in better characterization of doubtful masses. National tumour registries can help to establish guidelines.     

Guidelines for the management of ovarian cancer during pregnancy

Adnexal masses may be detected during prenatal ultrasound, and ovarian cancer may be suspected during pregnancy. Even though such masses are rarely malignant (1/10,000 to 1/50,000 pregnancies), the possibility of borderline tumour or cancer must be considered. It is a common assumption by both patients and physicians that if an ovarian cancer is diagnosed during pregnancy, treatment necessitates sacrificing the well-being of the fetus. However, in most cases, it is possible to offer appropriate treatment to the mother without placing the fetus at serious risk.     

Breast cancer during pregnancy

Breast cancer in pregnancy is an uncommon situation but poses dilemmas for patients and their physicians. There is a paucity of prospective studies regarding diagnosis and treatment of breast cancer during pregnancy. Women diagnosed with breast cancer during pregnancy have similar disease characteristics to age-matched controls. Current evidence suggests that diagnosis may be carried out with limitations regarding staging. Surgical treatment may be performed as for non-pregnant women. Radiotherapy and endocrine or antibody treatment should be postponed until after delivery. Chemotherapy is allowed after the first trimester. Physicians should be aggressive in the workup of breast symptoms in the pregnant population to expedite diagnosis and allow multidisciplinary treatment without delay.     

gastric cancer during early pregnancy two case reports

We report two cases of advanced gastric carcinoma in pregnancy. Received: 10 July 1995 / Accepted: 21 December 1995     

Ovarian pregnancy torsion

Introduction Ovarian-cyst torsion is often seen in early pregnancy due to progesterone stimulation. It is the fifth-most-common gynecological emergency, with a reported incidence of 3%. An ectopic pregnancy implanted in the ovary is rare, occurring in only 0.5–1% of such pregnancies.Case report We presented a case of ovarian pregnancy with concomitant ipsilateral side tubal torsion managed by laparoscopy.Discussion and conclusions Varying density distribution in the ovary can predispose to ovarian torsion. Emergency surgery may offer the possibility of avoiding the ablation of functional ovarian tissue. Early detection and prompt management can preserve fertility and ovarian function. The etiology, presenting syndrome and management are discussed.     

Breast cancer during pregnancy: epidemiology,phenotypes, presentation during pregnancy and therapeutic modalities

Although it is uncommon in general, breast cancer is the most commonly diagnosed cancer during pregnancy. While treatment for pregnant patients should adhere to treatment guidelines for non-pregnant patients, there exist specific considerations concerning diagnosis, staging, oncological treatment, and obstetrical care. Imaging and staging are preferably performed using breast ultrasound and mammography. Other ionizing radiation imaging modalities, including computed tomography (CT) and Positron Emission Tomography/ Computed Tomography (PET/CT), can be selectively performed when the estimated benefit for the mother outweighs the risks to the foetus, e.g., when the results will change clinical management. MRI is appropriate to stage for distant disease on the indication. Breast cancer during pregnancy is less often hormone receptor-positive and more frequently triple-negative breast cancer compared to age-matched controls. The basic principle is that women should receive state-of-the-art oncological treatment without delay if possible and that the pregnancy should be maintained as long as possible. Treatment strategy should be multidisciplinary defined, carefully weighing the selection, sequence, and timing of treatment modalities depending on patient-, tumour-, and pregnancy-related characteristics, as well as patient preferences. Initiating cancer treatment during pregnancy often decreases the risks of early delivery and prematurity. Breast cancer surgery is possible during all trimesters. Radiotherapy is possible during pregnancy in the first half of pregnancy. Chemotherapy can be safely administered starting from 12 weeks of gestational age, but endocrine and HER2 targeted therapy are contraindicated throughout the whole pregnancy. Importantly, foetal growth should be monitored and long-term follow-up of the children is encouraged in dedicated centres.     

The value of ultrasound visualization of the ovaries during the routine 11-14 weeks nuchal translucency scan

OBJECTIVE: To investigate the feasibility and possible value of routine screening for ovarian pathology in asymptomatic pregnant women at 11-14 weeks' gestation. STUDY DESIGN: A policy of routine ovarian visualization was implemented in 2925 pregnant women attending for a nuchal translucency scan at 11-14 weeks' gestation. In all cases, an attempt was made to visualize the ovaries on transabdominal ultrasound scan. Simple cysts were defined as unilocular cysts with regular internal walls and no solid components, which contained clear anechoic fluid. All other cysts were classified as complex. Simple cysts<5 cm in diameter were all managed expectantly with no further follow-up. All women with large simple cysts>or=5 cm in diameter or complex cysts had further detailed follow-up scans. Surgical intervention during pregnancy was offered to women with clinical symptoms suggestive of cyst complications or those with ultrasound features suggestive of malignancy. All other women were managed expectantly until after delivery. RESULTS: Adnexal cysts were found in 728/2925 (24.9%) pregnant women. 400/728 (55%) women had simple cysts<5 cm in diameter, whilst 328/728 (45%) women had large simple or complex cysts requiring follow-up. On subsequent scans, cysts resolved spontaneously in 278/328 (84.8%) women. A total of 33/728 (4.5%) women with ultrasound evidence of adnexal cyst underwent surgery. In one woman the intervention was required because of pain, one woman had suspected cancer on ultrasound scan and the remaining 31/33 (94%) of operations were performed at patients' requests. All the cysts were found to be benign on histological examination. The overall intervention rate was 1.1/100 screened pregnant women or 4.5/100 cysts detected on ultrasound scan. CONCLUSION: Asymptomatic adnexal cysts detected in the first trimester of pregnancy are unlikely to be malignant or to cause clinical symptoms antenatally. The policy of routine ultrasound visualization of the ovaries in pregnancy cannot be justified.     

Ovarian cancer screening: Current status and future directions

Ovarian cancer is the third most common gynaecological malignancy and the most lethal worldwide. Most patients are diagnosed with advanced disease which carries significant mortality. Improvements in treatment have only resulted in modest increases in survival. This has driven efforts to reduce mortality through screening. Multimodal ovarian cancer screening using a longitudinal CA125 algorithm has resulted in diagnosis at an earlier stage, both in average and high risk women in two large UK trials. However, no randomised controlled trial has demonstrated a definitive mortality benefit. Extended follow up is underway in the largest trial to date, UKCTOCS, to explore the delayed reduction in mortality that was noted. Meanwhile, screening is not currently recommended in the general population Some countries offer surveillance of high risk women. Novel screening modalities and longitudinal biomarker algorithms offer potential improvements to future screening strategies as does the development of better risk stratification tools.     

Ovarian endometrioma--risks factors of ovarian cancer development

OBJECTIVE: Our prospective studies in Japan have found an increased ovarian cancer incidence in women with ovarian endometrioma (standardized incidence ratio, 8.95; 95% confidence intervals, 4.12-5.3). The risk increased with increasing age at ovarian endometrioma diagnosis. The goal of this study was to define the risk factor(s) of ovarian cancer development in a Japanese population with ovarian endometrioma. We also analyzed whether the predisposition toward ovarian cancer is limited to endometrioid and clear cell carcinoma. STUDY DESIGN: A total of 6398 participants at 212 participating hospitals in Shizuoka, Japan, were enrolled in the Shizuoka Cohort Study on Endometriosis and Ovarian Cancer (SCSEOC) Trial, which had prospective and retrospective components. The follow-up period was up to 17 years (median, 12.8 years). The risks of development of ovarian cancer were assessed in 6398 women with ultrasonographically diagnosed ovarian endometriomas. Cox proportional-hazards regression function was used to estimate impact in terms of risk factors and possible development of ovarian cancer. RESULTS: The prospective study demonstrated that 46 (0.72%) of 6398 women developed histologically proven ovarian cancer and were operated upon during follow-up. Clear cell carcinoma (39%) and endometrioid adenocarcinoma (35%) were commonly observed among women with ovarian cancer. By multivariate analysis, tumor size > or =9 cm in diameter and postmenopausal women were independent predictive factors of patients with development of ovarian cancer. CONCLUSIONS: Some endometriosis lesions may predispose to clear cell and endometrioid ovarian cancers. Advancing age and the size of endometriomas were independent predictors of development of ovarian cancer among women with ovarian endometrioma.     

Thyroid cancer in pregnancy.

OBJECTIVE: To compare stage at diagnosis, treatment and survival among pregnant women with thyroid cancer to non-pregnant women with thyroid cancer, and to assess the impact of treatment on maternal and perinatal outcomes. METHODS: A database containing maternal and newborn discharge records linked to the California Cancer Registry was queried to obtain information on all thyroid cancers from 1991-1999. Women with thyroid cancer occurring during pregnancy were compared to age-matched non-pregnant women with thyroid cancer. RESULTS: 595 cases of thyroid cancers were identified (129 antepartum and 466 postpartum). About 64% of thyroid cancers were diagnosed at stage 2 among pregnant women versus 58% among non-pregnant controls. The odds of thyroid cancer were 1.5 times higher among Asian/Pacific Islanders than among Non-Hispanic White women. Pregnancy had no significant effect on mortality after diagnosis of thyroid cancer. Thyroidectomy during pregnancy was not associated with adverse maternal or neonatal outcomes. CONCLUSIONS: Thyroid cancer discovered during or after pregnancy does not appear to have a significant impact on the prognosis of the disease.     

Ovarian cancer and late onset paraneoplastic cerebellar degeneration

Paraneoplastic cerebellar syndrome (PCD) is a rare, neurological disorder that primarily emerges before the detection of malignancy. We present a case involving a 52-year-old woman who was diagnosed and treated for primary ovarian cancer in 2005. In 2007, the patient exhibited ataxia, dysarthria and peripheral neuropathy. Following neurological assessment and immunologic testing, the diagnosis of PCD was made. The disease typically precedes the detection of malignancy by a year or more and has been documented in only a few cases following the treatment for ovarian cancer.     

妊娠合并卵巢肿瘤的临床分析

目的 探讨妊娠合并卵巢肿瘤的处理时机及方式对妊娠的影响。方法 回顾性分析我院1992年1月～2003年12月间收治的妊娠合并卵巢肿瘤患者117例，对比其处理方式与并发症发生情况及妊娠结局的关系。结果 妊娠合并卵巢肿瘤的急腹症并发症发生率较高，孕期采取非手术治疗者晚孕期并发症发生率显著高于孕28周前采取手术治疗者(P=0．044)，晚孕期手术治疗者早产发生率显著高于早、中孕期手术治疗者(P=0．048)。结论 本组资料显示妊娠合并卵巢肿瘤的手术最佳时机为早、中孕期，非手术治疗有增加妊娠期间急腹症并发症的风险，晚孕期手术治疗增加早产风险。     

Ovarian cancer screening—Current status,future directions

Evidence of a mortality benefit continues to elude ovarian cancer (OC) screening. Data from the US Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial which used a screening strategy incorporating CA125 cut-off and transvaginal ultrasound has not shown mortality benefit. The United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) is using the Risk of Ovarian Cancer (ROC) time series algorithm to interpret CA125, which has shown an encouraging sensitivity and specificity however the mortality data will only be available in 2015. The article explores the impact of growing insights into disease aetiology and evolution and biomarker discovery on future screening strategies. A better understanding of the target lesion, improved design of biomarker discovery studies, a focus on detecting low volume disease using cancer specific markers, novel biospecimens such as cervical cytology and targeted imaging and use of time series algorithms for interpreting markers profile suggests that a new era in screening is underway.     

Ovarian cancer patient surveillance after curative-intent initial treatment

Objective

Patient surveillance after potentially curative treatment of ovarian carcinoma has important clinical and financial implications for patients and society. The optimal intensity of surveillance for these patients is unknown. We aimed to document the current follow-up practice patterns of gynecologic oncologists.

Methods

We created four idealized vignettes describing patients with stages I-III ovarian cancer. We mailed a custom-designed survey instrument based on the vignettes to the members of the Society of Gynecologic Oncologists (SGO). SGO members were asked, via this instrument, how often they requested 11 discrete follow-up evaluations for their patients for the first 10 postoperative years after treatment with curative intent.

Results

We received 283 evaluable responses (30%) from the 943 SGO members and candidate members. The most frequently performed items for each year were office visit, pelvic examination, and serum CA-125 level. Imaging studies such as chest X-ray, abdominal-pelvic CT, chest CT, abdominal-pelvic MRI, and transvaginal ultrasound were rarely recommended. There was marked variation in the frequency of use of most tests. There was a decrease in the frequency of testing over time for all modalities.

Conclusion

This dataset provides detailed documentation of the self-reported surveillance practices of highly credentialed experts who manage patients with ovarian cancer in the 21st century. The optimal follow-up strategy remains unknown and controversial. Our survey showed marked variation in surveillance intensity. Identifying the sources of this variation warrants further research.