Benign ovarian tBenign ovarian tumoursumours By By

Dr.Dr. Khattab KAEO Khattab KAEO

Prof. Prof. and Head of Obstetrics & and Head of Obstetrics & GynaeGynaecologycology Department Department

FacFaculty of Medicine, Al-Azhar ulty of Medicine, Al-Azhar UnivUniversity, ersity, DamiettaDamietta

Functional (Hormone-dependent) cystsFunctional (Hormone-dependent) cysts

-Follicular cyst: It occurs due to failure of ovulation. Usually regresses within 8 w

- Corpus luteum cyst: <4 cm fluctuant and may cause haemo-peritoneum when ruptures. Usually regresses within 8 weeks.

-Stein – Leventhal syndrome.

- Chocolate cyst.

- OHSS.

- Theca Lutein cyst. Occurs in 30% of hydatidiform moles & in 5-10% of choriocarcin-oma. Almost always bilateral, >15 cm.

- Ovarian hyperthecosis.

Luteoma of pregnancy: Benign, solid, uni-/bi-lateral, may be as large as 20 cm.

Hyperreactio luteinalis: Similar, cystic, hCG.

Complications of ovarian cyst:Complications of ovarian cyst:

Torsion: The cyst uses the adjacent Torsion: The cyst uses the adjacent tube & broad ligament as a tube & broad ligament as a pediclepedicle

Rupture This may occur Rupture This may occur spontaneouslyspontaneously or after examination, trauma, etc. or after examination, trauma, etc.

Infection. Infection.

Haemorrhage. Haemorrhage.

Malignant transformation in some Malignant transformation in some benign tumours and spread of benign tumours and spread of malignant ones. malignant ones.

Benign tumours Benign tumours

ThecomaThecoma occurs at all age groups but occurs at all age groups but more common in the 50s and 60s. It is more common in the 50s and 60s. It is

a a gonadal stromalgonadal stromal tumour. tumour.

Benign cystic teratomas (Dermoid cyst):Benign cystic teratomas (Dermoid cyst):These are the most common ovarian tumours These are the most common ovarian tumours at the age of 20s and account for nearly 20% at the age of 20s and account for nearly 20%

of the ovarian neoplasms. They occur at an of the ovarian neoplasms. They occur at an earlier age, often in childhood. earlier age, often in childhood.

They are frequently bilateral, ovoid and uni-They are frequently bilateral, ovoid and uni-locular. They are particularly liable to have a locular. They are particularly liable to have a long pedicle and easily undergone torsion or long pedicle and easily undergone torsion or interfere with the movement of the pregnant interfere with the movement of the pregnant

uterus. The wall consists of dense fibrous uterus. The wall consists of dense fibrous tissue lined by stratified squamous tissue lined by stratified squamous

epithelium The cyst is filled with thick yellow epithelium The cyst is filled with thick yellow sebaceous material. Teeth are found in 33% sebaceous material. Teeth are found in 33%

and hair in 20% of cases. and hair in 20% of cases. 1-2% are potentially malignant (immature 1-2% are potentially malignant (immature

teratoma).teratoma).

Struma ovarii:Struma ovarii:

= 5-10% of benign cystic = 5-10% of benign cystic teratomas (germ cell teratomas (germ cell tumour). tumour).

5% are thyrotoxic. 50% will 5% are thyrotoxic. 50% will have a disappearance of have a disappearance of symptoms after excision.symptoms after excision.

5% 5% carcinoma. carcinoma.

Brenner tumour:Brenner tumour:

It is most common in the It is most common in the 6th decade. 6th decade.

It forms 2% of all ovarian It forms 2% of all ovarian solid tumours.solid tumours.

It is mainly It is mainly solidsolid and and resembles fibroma, but resembles fibroma, but composed of fibrous and composed of fibrous and epithelial elements. epithelial elements.

Fibroma:Fibroma: = 3-5% of ovarian tumours. It is = 3-5% of ovarian tumours. It is a a gonadal stromalgonadal stromal tumour and may be tumour and may be

impossible to differentiate from impossible to differentiate from thecoma. Average diameter is 6 cm. thecoma. Average diameter is 6 cm.

Bilateral in 10% of case. Occasionally Bilateral in 10% of case. Occasionally multiple. Feels hard and homogeneous; multiple. Feels hard and homogeneous; occasionally cystic because of marked occasionally cystic because of marked

oedema. <5% of them is associated oedema. <5% of them is associated with Meigwith Meig’’s s syndromesyndrome (= any benign (= any benign

solid ovarian tumour associated with solid ovarian tumour associated with ascites, right hydrothorax, pyrexia &, ascites, right hydrothorax, pyrexia &,

more importantly, cure of fluid after more importantly, cure of fluid after removal of the tumour). Although it is removal of the tumour). Although it is hormonally inert, oestrogenic activity hormonally inert, oestrogenic activity

may associate (resulting from stimula-may associate (resulting from stimula-tion & luteinisation of non-neoplastic tion & luteinisation of non-neoplastic theca cells). The median age is 48 y, theca cells). The median age is 48 y, so, the usual treatment is TAH BSO. so, the usual treatment is TAH BSO.

Serous cystadenomaSerous cystadenoma: with : with psammomapsammoma bodies and proliferative papillae. bodies and proliferative papillae. Histologically, broad papillae are Histologically, broad papillae are covered by a single layer of columnar covered by a single layer of columnar epithelium. The latter resembles that of epithelium. The latter resembles that of the endosalpinx i.e. composed of cilia-the endosalpinx i.e. composed of cilia-ted cells, secretory cells and peg cells. ted cells, secretory cells and peg cells. Mucinous cystadenoma :Mucinous cystadenoma : The lining The lining columnar cells resemble the secretory columnar cells resemble the secretory cells of the endo-cervix. The intracyto-cells of the endo-cervix. The intracyto-plasmic mucin and basal location of the plasmic mucin and basal location of the nuclei are characteristic.nuclei are characteristic. Pseudomyxoma peritoneiPseudomyxoma peritonei may be of may be of intestinal origin or from mucinous cyst intestinal origin or from mucinous cyst adenoma. adenoma.

B

TreatmentTreatment

Benign tumours >10 cm must be removed. Benign tumours >10 cm must be removed.

If <10 cm in <35 years old women, the If <10 cm in <35 years old women, the case may be reviewed in a few months if case may be reviewed in a few months if there is no suspicion of malignancy. A there is no suspicion of malignancy. A follicular or luteal cyst may resolve follicular or luteal cyst may resolve spontaneously. spontaneously.

Indications for surgery in adnexal mass :

TreatmentTreatment

CystectomyCystectomy is enucleation of is enucleation of the tumour from its capsule. the tumour from its capsule. This is not feasible in very This is not feasible in very large tumors or in those with large tumors or in those with previous inflammation. previous inflammation. OvariotomyOvariotomy is removal of an is removal of an ovary containing a tumour. ovary containing a tumour.

Ovarian Mass Ovarian Mass

90% of ovarian masses are fun- 90% of ovarian masses are fun- ctional cysts that disappear spon ctional cysts that disappear spon taneously within 2-6 months.taneously within 2-6 months. Otherwise, aspiration can be Otherwise, aspiration can be applied. applied.

Ovarian cyst is present in 6% of Ovarian cyst is present in 6% of asymptomatic women. asymptomatic women. They develop as luteinized un-They develop as luteinized un-ruptured follicles which occur in ruptured follicles which occur in 10% of cycles of infertile couples 10% of cycles of infertile couples

Ovarian cysts in postmenopausal womenOvarian cysts in postmenopausal women

Prevalence:Prevalence: ±22% (common). ±22% (common).

Diagnosis:Diagnosis: Clinical & US. Doppler Clinical & US. Doppler examination, CT and MRI do not examination, CT and MRI do not improve the diagnostic capability improve the diagnostic capability of differentiating benign from mali-of differentiating benign from mali-gnant tumors. gnant tumors.

Complications:Complications: A torted cyst will A torted cyst will be purple black. Rupture be purple black. Rupture shock shock or peritonitis. or peritonitis.

ManagementManagement The low risk of malignancy of many of these cysts The low risk of malignancy of many of these cysts

suggests that not all of them need sur-gery. The suggests that not all of them need sur-gery. The risk of malignancy can be assessed using risk of malignancy can be assessed using CA125 (>30 u/ml) & TVS. Larger cysts may CA125 (>30 u/ml) & TVS. Larger cysts may need to be assessed by TAS. Color-flow Doppler need to be assessed by TAS. Color-flow Doppler sonography may be of benefit. Ultrasound scan sonography may be of benefit. Ultrasound scan looks for multi locularity; evidence of solid looks for multi locularity; evidence of solid areas; evidence of metasta-ses; ascites & areas; evidence of metasta-ses; ascites & bilaterality. Simple, unilateral, unilocular bilaterality. Simple, unilateral, unilocular ovarian cysts, <5 cm have a low risk of ovarian cysts, <5 cm have a low risk of malignancy (<1%). In addition >50% of these malignancy (<1%). In addition >50% of these cysts will resolve spontaneously within 3 cysts will resolve spontaneously within 3 months. Such cysts in the presence of normal months. Such cysts in the presence of normal levels of serum CA125 can be managed levels of serum CA125 can be managed conservatively with a follow-up TVS after 4 conservatively with a follow-up TVS after 4 months. This, of course, depends upon months. This, of course, depends upon symptoms and clinical assessment. symptoms and clinical assessment.

Surgical management may be achie-Surgical management may be achie-ved by aspiration, laparoscopy or ved by aspiration, laparoscopy or laparotomy.laparotomy. Aspiration is not recom- Aspiration is not recom-mended in postmenopausal women mended in postmenopausal women This is because cytological exam of This is because cytological exam of ovarian cyst fluid is poor at disting ovarian cyst fluid is poor at disting uishing between benign and malig-uishing between benign and malig-nant tumours. In addition, there is a nant tumours. In addition, there is a risk of cyst rupture, and if malig-risk of cyst rupture, and if malig-nant, this would have an unfavour-nant, this would have an unfavour-able impact on disease free able impact on disease free survivalsurvival

Laparotomy: Staging laparotomy may Laparotomy: Staging laparotomy may include bilateral selective pelvic and include bilateral selective pelvic and para-aortic lymphadenectomy. para-aortic lymphadenectomy.

Laparoscopy: Functional cysts are treated by Laparoscopy: Functional cysts are treated by laparoscopic fenestration & coagulation of laparoscopic fenestration & coagulation of thethe cavity, while benign tumours are best cavity, while benign tumours are best treatedtreated by by striping of the capsule. The main reason for striping of the capsule. The main reason for operating upon postmenopausal women with operating upon postmenopausal women with ovarian cysts is to exclude malignancy. This is ovarian cysts is to exclude malignancy. This is best achieved by a staging laparotomy.best achieved by a staging laparotomy. Laparoscopy, therefore, should be reserved for Laparoscopy, therefore, should be reserved for those women who are not eligible for conserva-those women who are not eligible for conserva-tive management, but still have a relatively low tive management, but still have a relatively low risk of malignancy. It is recommended that risk of malignancy. It is recommended that laparoscopy should include oophorectomy laparoscopy should include oophorectomy (usually bilateral)(usually bilateral) rather than cystectomy. Uni or rather than cystectomy. Uni or bilateral oophorectomy this will be partially deter bilateral oophorectomy this will be partially deter mined by the wishes of the woman. If a woman mined by the wishes of the woman. If a woman with intermediate risk is going to be managed by with intermediate risk is going to be managed by laparoscopic oophorectomy, they should be laparoscopic oophorectomy, they should be counseled preoperatively that a full-staging counseled preoperatively that a full-staging laparotomy would be required if evidence of laparotomy would be required if evidence of malignancy is revealed. malignancy is revealed.

work-up work-up

Premenopausal Postmenopausal Premenopausal Postmenopausal

Simple on US, <6cm Simple on US, <3cmSimple on US, <6cm Simple on US, <3cm

& normal CA-125 & normal CA-125 & normal CA-125 & normal CA-125

(the risk of being malign. is 2%) (the risk of being malign. is 2%)

Observe for 6-8 w + OCP Observe + FU Observe for 6-8 w + OCP Observe + FU

Persistent on US, Solid/complex, Solid/complex on US, Persistent on US, Solid/complex, Solid/complex on US,

>6cm or >6cm or CA-125 >3cm or CA-125 >3cm or CA-125 CA-125

Surgical Evaluation Surgical Evaluation

Borderline tumours (WHO)Borderline tumours (WHO)10-15% of all ovarian malignancies are 10-15% of all ovarian malignancies are

semimalignant (hyperplastic ovarian semimalignant (hyperplastic ovarian tumours without histologic stromal tumours without histologic stromal invasion but with peritoneal implants). invasion but with peritoneal implants). Carcinoma of low malignant potential Carcinoma of low malignant potential ((FIGO ). They are characterized by LACK FIGO ). They are characterized by LACK OF STROMAL INVASION and tendency to OF STROMAL INVASION and tendency to spread locally. They are frequently diag-spread locally. They are frequently diag-nosed in the reproductive age womennosed in the reproductive age women, , 10 years younger than that of frank 10 years younger than that of frank malignancymalignancy. Borderline tumours are of . Borderline tumours are of EPITHELIAL origin. EPITHELIAL origin.

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