Benign ovarian masses include functional cysts and tumors; most are asymptomatic.Most functional cysts and benign tumors are asymptomatic. Sometimes they cause menstrual abnormalities. Hemorrhagic corpus luteum cysts may cause pain or signs of peritonitis, particularly when they rupture. Occasionally, severe abdominal pain results from adnexal torsion of a cyst or mass, usually > 4 cm. Treatment varies depending on the patient's reproductive status.
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Benign ovarian tumours
1. BENIGN OVARIAN TUMOURS
Dr. NIRANJAN CHAVAN
Professor & Unit Chief
LTMMC & LTMGH Hospital , Sion, Mumbai -22
Chairperson, FOGSI Oncology & TT Committee.(2012-2014)
Convener & Chair, FOGSI –Violence against Doctor Cell (2015-2016)
Member, Oncology Committee AOFOG (2013-2015)
Managing Committee Member ,AFG & IAGE
Editor-AFG Times Newsletter
Director, Chavan Maternity & Nursing hOME
J.P. Road, Andheri West, Mumbai 53
2. NORMAL OVARIES
Normal size 5 x 3 x 3cm
Variation in dimensions can result from
Endogenous hormonal production(varies with age
and menstrual cycle)
Exogenous substances, including OCs, GnRH
agonists, or ovulation-inducing medication, may
affect size.
3.
4. BENIGN OVARIAN TUMOURS
Epidemiology
Embryology
Etiology
Risk factors
WHO classification
Pathology of ovarian tumours
Management
(diagnosis & management)
Surgery
5. EMBRYOLOGY OF THE OVARY
Primitive gonads appear around the 5th week of IUL as the gonadal ridge from
the coelomic epithelium on the medial aspect of the urogenital ridge.
In the xx embryo , the cortex develop as the ovary and the medulla regress to a
small area.
The ovarian serosa is the direct descent of the coelomic epithelium and it give
rises to endocervical,endometrial,endosalphinx and the epithelium of the
urogenital system.
The undifferentiated serosal cells can undergo neoplastic changes and lead to
tumours of the above tissues.
9. OVARIAN TUMOUR SCREENING MULTI MODEL
Ca 125 and Ultrasound scanning
Ca 125 >30 uml is abnormal
Ca 125 is an antigen found in the foetal amniotic and coelomic epithelium.in adults it is
found in mesothelial cells of pleura
Pericardium and tubal, endometrial, endocervical and the ovary.
The surface epithelium of normal foetal and adult ovaries does not express the antigen ,
except in inclusion cysts, papillae or metaplasia
An elevated level is found in 50% of stage 1 and >90% in women with advanced disease.
Sensitivity is 97% Specificity is 96%
False positive in
ca endometrium ,ca colon, endometriosis, fibroid, PID, pregnancy and menstruation
10. CLASSIFICATION OF OVARIAN MASS
1. Simple cyst
2. Hemorrhagic cyst
3. Hyperstimulation in women who have undergone fertility treatment
4. Luteoma of Pregnancy
5. Endometrioma
6. Brenners tumour
7. Epithelial tumours
Serous and mucinous, endometroid and clear cell tumours.
8. Sex cord and Mesenchymal tumours
Fibrothecomas, granulosa cell , sclerosing stromal and sertoli-
leydig cell tumours.
9. Germ cell tumours
Mature and immature teratomas, dysgerminomas, endodermal
sinus tumours, embryonal carcinomas.
11. FUNCTIONAL OVARIAN CYSTS
Follicular cysts
Corpus luteum cysts
Theca lutein cysts
Luteomas of pregnancy
By far the most common clinically detectable enlargements of the ovary
in the reproductive years.
All are benign and usually asymptomatic.
12. FOLLICULAR CYSTS
Cystic follicle is defined as Follicular cyst of diameter > 3cm
Most common functional cysts.
Rarely larger than 8cm.
Lined by granulosa cells
Found incidentally on pelvic examination
Usually resolve within 4 – 8 weeks with expectant management
May rupture or torse occasionally causing pain and peritoneal
symptoms.
13.
14. CORPUS LUTEAL CYST
Less common than follicular cyst.
May rupture leading to hemoperitoneum and requiring
surgical management( more in patients taking anti
coagulants or with bleeding diathesis)
Unruptured cysts may cause pain because of bleeding
into enclosed ovarian cyst cavity.
17. THECA LUTEIN CYSTS
Least common
Usually bilateral
Result from overstimulation of the ovary by β- hCG
Do not commonly occur in normal pregnancy
Often associated with hydatidiform moles, choriocarcinoma, multiple
gestations, use of clomiphene and GnRH analogues.
May be quite large (up to 30 cm) , multicystic, and regress
spontaneously.
19. MANAGEMENT OF FUNCTIONAL CYSTS
Expectant
Watchful waiting for two or three cycles is appropriate.
Combined oral contraceptives appear to be of no benefit.
Should cysts persist, surgical management is often indicated.
Oral contraceptives for functional ovarian cysts (Review)
Cochrane Database of Systematic Reviews 2011
20. ASYMPTOMATIC SIMPLE CYSTS
<5cms Likely physiological
(do not require follow up)
5-7 cms Yearly USG
>7cm Require further
imaging/surgical
intervention.
RCOG 2011
22. (A) INFLAMMATORY
OVARIAN CYSTS TUBO-
OVARIAN ABSCESS
Are present in 14-38% of patients
hospitalized with pelvic inflammatory
disease (PID) .
Commonly seen in patients with poor access
to routine gynecologic care.
23. The traditional criteria for the diagnosis of PID include
subjective bilateral abdominal pain per patient report and
positive physical examination findings for bilateral adnexal
tenderness at palpation and cervical motion tenderness.
A hydrosalpinx is generally anechoic, whereas a pyosalpinx
may have increased echoes within the fluid.
25. (A) ENDOMETRIOMA OF OVARY
Most common site of involvement is the ovary.
Endometriomas are pseudocysts formed by invagination of
the ovarian cortex, sealed off by adhesions.
They may completely replace normal ovarian tissue. Cyst
walls are usually thick and fibrotic.
26. • USG: anechoic cysts to cysts with diffuse low-level
echoes to solid-appearing masses.
Fluid–fluid or debris–fluid levels may also be
seen.
• They may be unilocular or multilocular with thin or
thick septations
• Malignant transformation: 0.3% to 0.8%
• Management: medical and/ or surgical
32. On MRI Serous Cystadenoma
On USG
Serous
Cystad
enoma
33. (B) MUCINOUS CYSTADENOMA
Have tendency to become huge masses
Gross : Round to ovoid masses with smooth capsules
that are usually translucent or bluish to whitish gray.
Interior divided by discrete septa into loculi
containing clear , viscid fluid.
Microscopy : Epithelium – tall, pale staining,
secretary with basal nuclei and goblet cells
5 – 10% are malignant
36. DERMOID CYST/ BENIGN CYSTIC TERATOMA
Often bilateral (15 -25%)
GROSS: thick, opaque , whitish wall.
CONTENTS: hair, bone, cartilage, and a large amount of greasy sebaceous material.
MICROSCOPICALLY : all the three germ layers (ectoderm, mesoderm and endoderm)
Malignant change occurs in 1-3%. Usually of a squamous type.
Risk of torsion is 15%
An ovarian cystectomy is almost always possible, even if it appears that only a small amount
of ovarian tissue remains
40. FIBROMA
Most common benign, solid neoplasms of the ovary.
Compose approx 5% of benign ovarian neoplasms and 20% of all solid tumors of the
ovary.
Frequently seen in middle-aged women.
Characterized by their firmness and resemblance to myomas
Misdiagnosed as exophytic fibroids or primary ovarian malignancy
Not hormonally active
Fibromas may be associated with ascites or hydrothorax as a result of increased
capillary permeability thought to be a result of VEGF
Mieg’s syndrome (ovarian fibromas, ascites and hydrothorax) is uncommon and usually
resolves after surgical excision.
43. THECOMA
Solid fibromatous lesions that show varying degrees of yellow or orange
discoloration
Almost always confined to one ovary
Usually >40 years, 65% after menopause
May be hormonally active and hence associated with estrogenic or occasionally
androgenic effects.
Luetinised thecoma – younger, sclerosing peritonitis and ascites
Leydeig cell thecoma – associated with Reinke crystals
Rarely malignant
44. BRENNER TUMOR
It is named for Fritz Brenner, who characterized it in 1907. The term "Brenner
tumor" was first used by Robert Meyer, in 1932.
Uncommon tumor grossly identical to fibroma.
Arise from Walthard cell rests ,also from surface epithelium, rete ovarii and
ovarian stroma.
Brenner tumors are usually found incidentally at pathologic evaluation, often in
conjunction with a mucinous cystadenoma or dermoid cyst. They are relatively
rare tumors and are most common in the fifth to sixth decades of life.
45. On microscopy – markedly hyperplastic fibromatous matrix interspersed with
nests of epitheloid cells showing coffee bean pattern
Considered uniformly benign. But scattered reports of malignant Brenner’s
available
Endocrinologically inert, but could be ass. with virilization and endometrial
hyperplasia
Cut section
Microscopy
47. Found in all age groups and associated with the pseudo
precocious puberty.
Early breast development , menstrual disorders,
postmenopausal vaginal bleeding make up the
characteristic symptom.
Laboratories studies demonstrate an increase in the number of mature
epithelial cells in the vaginal cytologic specimen, elevated urinary and serum
estrogen levels and varirant degree of endometrial proliferation.
Microscopy :
The characteristic cell is the round or slightly ovoid granulosa cell with its dark
nucleus.
Mitosis are common and the ovumlike “Call Exner bodies “ are classic.
Granulosa stromal Sex cord tumours
48. Sertoli Leydig cell Tumours
Also called as Androblastoma
Often affect females beneath the ages of 40yrs
Usually be luteinised, simulating the classic pattern of the testes and
producing steroids
Generally benign, may produce the masculinisation.
49. TREATMENT OF NEOPLASTIC TUMOURS
In most instances, simple excision of the solid tumors is adequate
therapy, particularly for women of reproductive age.
50. CLINICAL PRESENTATION
Asymptomatic – accidentally discovered on USG
Chronic pattern of pain, increasing abdominal girth over months or weeks.
Associated with secondary symptoms of anorexia, nausea, vomiting,
urinary frequency.
Could be associated with primary or secondary amenorrhea, menstrual
irregularities, virilization, precocious puberty
Become acutely symptomatic if undergoes torsion, rupture or
haemorrhage.
Benign ovarian neoplasms are indistinguishable clinically from malignant
counterparts
51. Age : late child bearing age
dermoid , mucinous adenoma common in reproductive age
dermoid common in pregnancy
Symptoms
Asymptomatic , detected accidently during routine abdominal or gynecological
examinations
or during laporoscopic or laparotomy.
Nonspecific symptoms like
Feeling of abdominal distension and vague discomfort.
Features of dyspepsia such as flatulence and eructations.
Gradually more pronounced symptoms appear like
Abdominal swelling which may be rapid
Dull abdominal pain
Respiratory distress which may be mechanical due to ascites/pleural effusion.
Menstrual abnormalities in functioning ovarian tumours.
For other ovarian tumours symptoms may differ eg .Androblastoma - Hirsutism.
Signs
General condition usually remains unaffected.
The patient may be cachectic due to protein loss in huge mucinous cyst adenoma.
CLINICAL PRESENTATION
52. On abdominal examination
Inspection
Bulge of lower abdomen over which abdominal wall moves freely with respiration.
The mass may fill the entire abdominal cavity everting the umbilicus with visible veins
under the skin.the flanks remain flat. Mass is cystic or solid.
Palpation
Surface is smooth ,non tender and freely mobile from side to side but restricted from
above downwards unless pedicle is long.
upper and latearal borders are well defined bt the lower pole is difficult to reach.
Percussion
dull in centre and resonants in the flanks.
A fluid thrill may be elicited
when the wall are thin and the content is watery. A
friction rub may be present over the tumour.
Bimanual Pelvic examination
Uterus seperate from the mass
groove present between uterus and the mass
movement of the mass p/a fails to move the cervix
lower pole of the cyst felt through the fornix
absence of pulsation of uterine vessels through the fornix
53. COMPLICATIONS OF BENIGN OVARIAN TUMOURS
Torsion : Commonly seen in Dermoid cyst, serous cystadenoma.
Intracystic hemorrhage : serous Cystadenoma, venous congestion.
Infection : Following torsion.
Rupture : Big and tense type,following trauma.
Pseudomyxoma peritonei : Seen in Mucinous Cystadenoma
Intestinal Obstruction
Malignancy : Rare .
57. TRANSVAGINAL ULTRASOUND
Pattern recognition is superior to all other scores.
Subjective evaluation of ovarian masses based on pattern
recognition can achieve sensitivity of 88% to 100% and specificity of
62% to 96%.
Adding doppler does not seem to yield much improvement in the
diagnostic precision, but increases the confidence with which a
correct diagnosis of benignity or malignancy is made.
60. DOPPLER EVALUATION
Hypoxic tissue in tumors recruit low-resistance, high-flow blood
vessels
Role in evaluating ovarian mass is controversial – as the ranges of
values of RI,PI,MSV between benign and malignant masses overlap.
PI<1, RI<0.4
To overcome this, vascular sampling of suspicious areas (papillary
projections, solid areas, thick septations) using both 3D USG and
power doppler both has been evaluated and found effective.
61. OTHER IMAGING MODALITIES
CT, MRI, PET not recommended in the initial evaluation
CT scan: evaluating
LN involvement,
Omental mets, peritoneal deposits, hepatic mets,
obstructive uropathy
or a probable alternate primary site when cancer is suspected based upon TVS
MRI : differentiating non adnexal pelvic masses (like leiomyomata), expensive and inconvenient.
ACOG GUIDELINES 2007
63. SENSITIVITY SPECIFICITY PPV NPV
61-90% 71-93% 35-91% 67-90%
CA125
Most useful when non-mucinous epithelial cancers are
present
Elevated in 80% of patients with epithelial ovarian Ca but
only in 50% of patients with stage I disease
Increased sensitivity in post menopausal women esp. when
associated with relevant clinical and USG findings
Cut-off of 30 u/ml, sensitivity of 81% and specificity of 75%
64. Levels higher than 5 mg/Lare seen in 85-90% of mucinous
tumours but only in 30% of other epithelial cancers.
CEA
It is elevated in mucinous ovarian malignancy.
CA 19.9
65. HE4
HE4 is a precursor to the epididymal secretory protein E4 and in normal ovarian tissue,
there is minimal gene expression and production of HE4.
HE4 when studied in the premenopausal group of patients was able to discriminate
benign tumors from malignancies
As a single tumor marker, HE4 had the highest sensitivity for detecting ovarian cancer,
especially Stage I disease.
Combined CA125 and HE4 is a more accurate predictor of malignancy than either
alone or to any other dual combination of markers
HE4 levels(>70 pM) were found to be elevated in over half of the patients with ovarian
cancer with normal serum CA125 levels (>35 U/ml)
Moore et al. / Gynecologic Oncology, 2008
66. Benign Ovarian tumour Malignant Ovarian tumour
Common in middle age group
Painless unless compicated
No edema
No varicosities
Generally unilateral
Unilocular
Thin walled
Thin septae if present
No papillae or solid contents
Normal or decreased vascularity on
doppler
No metastasis
Slow growing
Smooth, cystic
Freely mobile
No ascites or if present clear fluid on
paracentesis
Seen at extremes of ages
May be painful
Edema maybe present
Varicosities may be present
May be bilateral
Multilocular
Thick walled
Thick septae
Mixed echogenicity
High vascularity, low pulsatility index and
low resistance index
Metastasis in advanced disease
Rapidly growing
Solid, nodular, irregularly shaped
Fixed
Ascites present and on paracentesis the
fluid may be blood stained.
68. INDICATIONS FOR SURGERY
Any solid ovarian lesion
Any ovarian lesion with papillary vegetation on the cyst wall
Any adnexal mass >10cm in diameter
Palpable adnexal mass in a premenarchal or postmenopausal
women
Torsion or rupture suspected
69. Ovarian mass in reproductive age group
<5 cms. >/= 5 cms
USG USG
cystic
observation
Complex,
solid,
suspiciou
s
Persistence or progression
surgery
70. CYST ASPIRATION
Diagnostic cytology has poor sensitivity to detect malignancy,
ranging from 25% to 82%
Not therapeutic, even when a benign mass is aspirated
Approx. 25% of cysts will recur within 1 year
Aspiration of a malignant mass may induce spillage and seeding
of cancer cells into the peritoneal cavity.
71. OPERATIVE MODALITIES
Laparoscopy vs laparotomy – decision based on suspicion of
malignancy and technical expertise
No RCTs comparing recurrence rates following laparoscopy or
laparotomy.
The objective is to try cystectomy if possible.
Laparoscopic surgery for benign ovarian tumours is associated with less
pain, shorter hospital stay, and fewer adverse events than with
laparotomy.
Cochrane Database of Systematic Reviews 2009
72. SURGERY
Young women : Ovarian cystectomy
Oophorectomy ( salpingo ophorectomy)
Parous women : Total Abdominal Hysterectomy with Bilateral ophorectomy
Others : Individualisation
73. The standards for laparoscopy in benign tumours
1. careful examination of the external surface of the
tumour and sampling of the peritoneal cavity
2. avoidance of any tumoral rupture
3. protection of the ovarian tumour with an endoscopic
bag before removal
74. ROLE OF FROZEN SECTION
The diagnostic accuracy of frozen section analysis
is high for malignant and benign ovarian tumours,
but accuracy is poor in the case of borderline
ovarian tumors.
Medeiros 2005
75.
76. Conclusion
Ovarian masses are very commomly seen in general population.Most
of the times these are simple functional tumours which resolve
spontaneously within six to eight weeks.However an indepth
understanding of the ovarian masses is needed as th the grave
consequences that may follow if there is a wrong diagnosis.Imaging
studies especially ultrasound is a prime tool in diagnosing ovarian
tumours. Careful consideration to woman’s need should be addresses
before selecting any method of treatment.
Notas del editor
If ovulation does not occur, a clear fluid filled follicular cyst lined by granulosa cell may result.
When ovulation occurs , corpus luteum is formed that may become abnormally enlarged through internal hemorrhage or cyst formation
Variable delay in onset of menses and confusion regarding possibility of ectopic pregnancy: acute abdomen
Ovary with hemorrhagic corpus luteum cyst
Hemorrhagic corpus luteum with spider web like contents
Hemorrhagic cyst with blood clot.
Hemorrhagic cyst with unusual appearance simulating a neoplasm.
Sonogram from a patient with bilateral theca lutein cysts. The typical multilocular appearance is noted in the left ovary.
Ovarian Endometriomas demonstrating hypoechoic cystic structures with low amplitude uniformly distributed echotexture in the cavity of the cyst.
1. Benign epithelial tumors of the ovary can reach massive proportions. The serous cystadenoma seen here fills a surgical pan and dwarfs the 4 cm ruler
2.Here is a benign serous cystadenoma that demonstrates multiloculation. Note that the inner surface is, for the most part, smooth, with only a solitary papillation at the upper right.
3. Ultrasound imaging
4. Histopathological section: With few papillary projections from the surface
1.Cut open section of mucinous cystadenoma..
2. Histological section showing tall epithelial lining with pale staining nuclei at the basal pole.
3. Variable echogenicity in the contents of an adnexal multilocular cyst
The photo below shows a well-developed tooth arising from the right side of the mural nodule ("Rokitansky nodule") that contains most of the solid teratomatous elements. The central portion of the nodule contains mostly cutaneous tissues (skin, sweat glands, and hair follicles), while the neural tissues extend into the wall toward the left.
Cut section
Microscopically – stellate or spindle shaped cells arranged in fusiform pattern. Hyalinisation is frequent. The elongated fibroblastic tumor cells have spindle-shaped nuclei and may contain small amounts of lipid in their cytoplasm
Benign lesions can be managed by simple excision.
t/t of malignant brenner tumours is unsettled, various forms of chemotherapy have been used with little success.
Walthard cell rests are a benign cluster of epithelial cells most commonly found in the connective tissue of the Fallopian tubes, but also seen in the mesovarium, mesosalpinx and ovarian hilus. solid, sharply circumscribed and pale yellow-tan in colour. 90% are unilateral (arising in one ovary, the other is unaffected). The tumours can vary in size from less than 1 centimetre (0.39 in) to 30 centimetres (12 in). Borderline and malignant Brenner tumours are possible but each are rare.
Using these rules the reported sensitivity was 95%, specificity 91%, positive
likelihood ratio of 10.37 and negative likelihood ratio of 0.06.
The morphology index (MI) presently used in the University of Kentucky Ovarian Cancer Screening Trial was published initially by Ueland and colleagues and is illustrated in Figure 49.3. Both morphologic complexity and tumor volume, as calculated by the prolate ellipsoid formula, were related directly to the risk of malignancy
Morphologic abnormalities were easy to categorize, and interobserver variation was minimal. Risk of malignancy varied from 0.3% in ovarian tumors with a MI of <5 to 84% in tumors with a MI >=8. Using a MI >=5 as indicative of malignancy, the following statistical parameters were observed: sensitivity 0.981, specificity 0.808, PPV 0.409, and NPV 0.997. Therefore, morphologic indexing is a relatively accurate and cost-effective method to predict risk of malignancy in an ovarian tumor.