3. Urethral Caruncle
• A urethral caruncle is a small, fleshy outgrowth of
the distal edge of the urethra.
• The tissue of the caruncle is soft, smooth, friable,
and bright red and initially appears as an eversion
of the urethra
• They occur most frequently in postmenopausal
women and must be differentiated from urethral
carcinomas.
• Urethral caruncles are believed to arise from an
ectropion of the posterior urethral wall associated
with retraction and atrophy of the
postmenopausal vagina.
4. • The growth of the caruncle is secondary to
chronic irritation or infection.
• Histologically the caruncle is composed of
transitional and stratified squamous epithelium
with a loose connective tissue
• Frequently subdivided by their histologic
appearance into papillomatous, granulomatous,
and angiomatous varieties.
• Many women are asymptomatic, whereas others
experience dysuria, frequency, and urgency.
Sometimes the caruncle produces point
tenderness after contact with undergarments or
during intercourse. Ulcerative lesions usually
produce spotting on contact more commonly
than hematuria.
5. Urethral Caruncle
• Initial therapy is oral or
topical estrogen and
avoidance of irritation.
• If the caruncle does not
regress or is symptomatic, it
may be destroyed by
cryosurgery, laser therapy,
fulguration, or operative
excision.
• Following operative
destruction, a Foley catheter
should be left in place for 48
to 72 hours.
7. Cysts
• The most common large cyst of the vulva is a
cystic dilation of an obstructed Bartholin's duct.
• Approximately 2% of new gynecologic patients
present with an asymptomatic Bartholin's duct
cyst.
• Treatment is not necessary in women younger
than 40 unless the cyst becomes infected or
enlarges enough to produce symptoms.
8. Hydradenoma
• The hidradenoma is a rare, small, benign vulvar tumor that
originates from apocrine sweat glands of the inner surface of
the labia majora and nearby perineum. Occasionally, they
may originate from eccrine sweat glands.
• For unknown reasons, they are discovered exclusively in
white women between the ages of 30 and 70, most
commonly in the fourth decade of life. These tumors have
not been reported prior to puberty. Hidradenomas may be
cystic or solid. Approximately 50% of hidradenomas are less
than 1 cm in diameter.
• These tumors have well-defined capsules
• Treatment - surgical
9. Lipoma
• Lipomas are benign, slow-growing, circumscribed tumors
of fat cells arising from the subcutaneous tissue of the
vulva
• The largest vulvar lipoma reported in the literature
weighed 44 pounds.
• Lipomas are the second most frequent benign vulvar
mesenchymal tumor. Because of the fat distribution of
the vulva, most lipomas are discovered in the labia
majora and are superficial in location.
• They are slow growing, and their malignant potential is
extremely low.
10. Fibromas are the
most common benign solid
tumors of the vulva.
They are more frequent
than lipomas, the other common
benign tumors of mesenchymal
origin.
• Fibromas occur in all age groups and most commonly
are found in the labia majora.
• However, they actually arise from deeper connective
tissue. Thus they should be considered as
dermatofibromas.
• Smaller fibromas are asymptomatic; larger tumors may
produce chronic pressure symptoms or acute pain when
they degenerate. Treatment is operative removal if the
fibromas are symptomatic and/or continue to grow.
Occasionally they are removed for cosmetic reasons.
15. Dysontogenetic Cysts
• Dysontogenetic cysts of the vagina are thin-
walled, soft cysts of embryonic origin. Whether
the cysts arise from the mesonephros
(Gartner's duct cyst), the perimesonephrium
(müllerian cyst), or the urogenital sinus
(vestibular cyst) is predominantly of academic
rather than clinical importance. The cysts may
be differentiated histologically by the epithelial
lining
• Most of these benign cysts are asymptomatic,
sausage-shaped tumors that are discovered
only incidentally during pelvic examination.
Small asymptomatic Gartner's duct cysts may
be followed conservatively
16. Treatment
• Operative excision is indicated for chronic
symptoms.
• Rarely, one of these cysts becomes infected,
and if operated on during the acute phase,
marsupialization of the cyst is preferred.
• Excision of the vaginal cyst may be a much
more formidable operation than anticipated.
• The cystic structure may extend up into the
broad ligament and anatomically be in
proximity to the distal course of the ureter.
17. Inclusion cysts
• Usually result from birth trauma or
gynecologic surgery. Often they are
discovered in the site of a previous
episiotomy or at the apex of the vagina
following hysterectomy.
• Histologically, inclusion cysts are lined by
stratified squamous epithelium. These
cysts contain a thick, pale-yellow
substance that is oily and formed by
degenerating epithelial cells.
18. Inclusion cysts
• Often these cysts are erroneously called
sebaceous cysts in the misbelieve that the
central material is sebaceous.
• Similar to vulvar inclusion cysts, the etiology
is either a small tag of vaginal epithelium
buried beneath the surface following a
gynecologic or obstetric procedure or a
misplaced island of embryonic remnant that
was destined to form epithelium.
• The majority of inclusion cysts are
asymptomatic. If the cyst produces
dyspareunia or pain, the treatment is
excisional biopsy.
19. Vaginal Polyp
• This is a rare tumor which can be seen in
infants or in adults. The origin from
the vaginal
mucosa has to
be demonstrated
to differentiate
from much more
common urethral
caruncles,
cervical and
uterus polyps.
20. Vaginal fibroma
• Fibroma of the vagina is a very rare
tumor. It may be pedunculated and
appear at the
introitus.
Clinically it is a
firm benign
noninfiltrating
growth.
23. • Intraepithelial neoplasia is a spectrum of
premalignant changes in the epithelium of the
cervix that histologically show varying degrees
of cellular atypia. Numerous terms are used to
describe the severity of the atypias, but there is
no clearly defined boundary between them.
• During reproductive life the squamocolumnar
junction is usually on the portio of the cervix
near the external os. It may be found farther
away from the os during and after pregnancy
and usually recedes into the endocervical canal
after menopause.
24. • Many cases of cervical intraepithelial neoplasia (CIN)
do not progress. Some particularly low-grade lesions
spontaneously regress, but all have the potential for
progression to malignancy.
• The risk of progression for CIN I (mild dysplasia—
LGSIL) to a higher grade lesion is approximately
16%.
• High-grade lesions (carcinoma in situ [CIN III]—
HGSIL) are at greater risk for malignant progression
and usually are found in larger abnormal
transformation zones.
• Malignant progression risk is greatest for CIN III,
least for CIN I, and intermediate for CIN II.
• Carcinoma in situ with gland involvement is treated
the same as carcinoma in situ without gland
involvement.
25. • The precise cause of CIN is not known but
appears to be associated with sexual activity
and HPV infection.
• Females with multiple sex partners are at
increased risk for CIN, and males with multiple
sex partners increase the risk of neoplasia for a
female sex partner.
• Cigarette smoking increases the risk of CIN.
Increased levels of vitamins A and E may
decrease the risk.
• Prolonged oral contraceptive use (more than 5
years) is associated with an increased
frequency of cervical neoplasia.
26. Diagram of cervical epithelium showing various
terminologies used to characterize progressive
degrees of cervical neoplasia
27. Potential Risk Factors for Cervical Neoplasia
Epidemiologic Characteristics Other Potential Factors
• Early intercourse • Oral contraceptives
• Multiple sex partners • Cigarette smoking
• Early marriage • Vitamin C
• Early childbearing • Prior radiation
• Prostitution • Intrauterine DES
• Male factors — "high-risk" exposure
consort • Lupus erythematosus
• Socioeconomic status, • Vitamins A and E,
race folates
• STD infection Viral Relations
• Immune status, including • Papillomavirus
HIV infection • Herpesvirus
• Cytomegalovirus
29. • The false negative rate for properly performed cytology
smears is approximately 5% to 20%.
• "Rapidly progressing" cervical carcinoma appears
primarily due to false-negative smears rather than to a
true rapid progression from normal to malignant
epithelium.
• Abnormal cells on Pap smears occur with increasing
frequency in those receiving chemotherapy and in
patients with lupus erythematosus.
• The colposcope is used to evaluate the cervix if an
abnormal Pap smear is present. Usually multiple biopsy
specimens of an abnormal transformation zone are
needed for an adequate evaluation.
• Colposcopic and cytologic findings do not establish a
diagnosis; biopsy is necessary.
35. Antibody-mediated viral
neutralization.
Neutralizing,
conformational isotopes
are expressed on the
surface of human
papillomavirus (HPV)
virions.
The epitopes (antigens)
are recognized by
lymphocytes, and specific
neutralizing antibodies are
generated. These
neutralizing antibodies
bind specifically to surface
epitopes and inhibit viral
infection.
36. Therapy of Intraepithelial Neoplasia
Ablative Treatment
• Cryotherapy
Three varieties of
cryotherapy probes.
37. Therapy of Intraepithelial Neoplasia
Ablative Treatment
Laser Therapy
• The laser has been widely used in conjunction with
the colposcope.
• The energy from the laser beam is absorbed by
water with resultant vaporization of the target tissue.
• The laser beam is controlled by a small "joystick,"
and the spot size of the laser can be varied but is
usually less than 1 mm.
• Usually therapy is carried to a depth of 5 to 7 mm
and a power density of over 600 W/cm2
• the complications of pain and bleeding are also
related to the power density and depth of treatment.
38. Cautery
• Electrocautery was the mainstay of outpatient
therapy of CIN before the advent of
cryosurgery, laser therapy, and the LEEP
procedure.
• The treatment can be accomplished with a hot
wire unit generating heat to the cervix or an
electrodiathermy unit, which requires current to
be passed through the tissues and electrical
grounding of the patient.
• The treatment is carried out with sufficient
depth to destroy cervical glands.
• An electrocautery unit is less expensive than the
laser and appears able to yield comparable
therapy results to cryosurgery but is infrequently
used today.
39. Excisional Therapy
• Conization
• if the colposcopic examination is unsatisfactory,
• if there is uncertainty regarding the presence of
invasive disease,
• if there is neoplasm in the endocervix,
• if the cells seen on cytologic examination are not
adequately explained by the biopsy specimens
• if the biopsy suggests the possibility of microinvasion
• if invasion is suspected but cannot be confirmed,
conization is mandatory because the proper diagnosis
of microinvasion cannot be made from a biopsy
specimen.
• excisional therapy is also carried out when childbearing
function is to be maintained or when a patient prefers
therapy less extensive than hysterectomy and is willing
to adhere to a strict protocol for follow-up.
40. TECHNIQUE
• COLD KNIFE CON
• LASER CONIZATION.
• LOOP ELECTROEXCISION PROCEDURE
(LEEP)
Examples of electrodes
used for a LEEP procedure.
41. A, Cone biopsy for CIN of exocervix. Limits of
lesion were identified colposcopically.
B, Cone biopsy for endocervical disease. Limits of
lesions were not seen colposcopically.
42. • The goal of treatment in CIN is eradication of all
abnormal tissue.
• Laser therapy, cryotherapy, and electrocautery have
been reported to have equivalent results and lead to
eradication of the lesions in about 90% of the patients
with carcinoma in situ after initial therapy.
• Cervical stenosis, infertility, and premature birth may
result from excisional therapy of CIN if large areas of
the endocervix are destroyed. Limiting the cone or LEEP
height to less than 1.5 to 2.0 cm decreases this risk.
• Conization for the therapy of CIN is as effective as
hysterectomy, especially if the margins are free of
disease.
43. • Evaluation of the abnormal Pap smear in pregnancy is
conducted primarily to rule out the presence of invasive
carcinoma. CIN is evaluated and treated in the
postpartum period.
• Some CIN lesions discovered during pregnancy
spontaneously regress postpartum.
• The risk of long-term development (up to 10 years) of
intraepithelial neoplasia following initial therapy is about
3%.
• Most short-term recurrences of intraepithelial neoplasia
occur within 1 to 2 years after initial treatment.
• Patients treated for CIN should have annual cytology
indefinitely.
44. Ulcer of the cervix
• A true ulcer
with loss of
epithelial
covering is
seen in the
anterior lip
of cervix
45. Lacerations
• Cervical lacerations frequently occur with both
normal and abnormal deliveries.
• Lacerations may occur in non-pregnant women with
mechanical dilation of the cervix.
• Obstetric lacerations vary from minor superficial tears
to extensive full-thickness lacerations at 3 and 9
o'clock, respectively, which may extend into the
broad ligament. In gynecology the atrophic cervix of
the postmenopausal woman predisposes to the
complication of cervical laceration when the cervix is
mechanically dilated for a diagnostic dilation and
curettage.
• Acute cervical lacerations bleed and should be
sutured.
• Cervical lacerations that are not repaired may give
the external os of the cervix a fish-mouthed
appearance; however, they are usually
asymptomatic.
46. Lacerations
• The use of laminaria tents to slowly soften and dilate
the cervix before mechanical instrumentation of the
endometrial cavity has reduced the magnitude of
iatrogenic cervical lacerations.
• Furthermore, the practice of routine inspection of the
cervix, stabilized with one or more ring forceps,
following every second- or third-trimester delivery
has enabled physicians to discover and repair
extensive cervical lacerations.
• Lacerations should be palpated to determine the
extent of cephalad extension of the tear.
• Extensive cervical lacerations especially those
involving the endocervical stroma may lead to
incompetence of the cervix during a subsequent
pregnancy.
48. Cervical polyp
• Endocervical and cervical polyps are the most common
benign neoplastic growths of the cervix.
• Cervical polyps usually present as a single polyp, but
multiple polyps do occur occasionally. The majority are
smooth, soft, reddish-purple to cherry red, and fragile.
They readily bleed when touched. Endocervical polyps may
be single or multiple and are a few millimeters to 4 cm in
diameter.
• The classic symptom of an endocervical polyp is
intermenstrual bleeding, especially following contact such
as coitus or a pelvic examination. Sometimes an associated
leukorrhea emanates from the infected cervix. Many
endocervical polyps are asymptomatic and recognized for
the first time during a routine speculum examination. Often
the polyp seen on inspection is difficult to palpate because
of its soft consistency.
• Histologically the surface epithelium of the polyp is
columnar or squamous epithelium, depending on the site of
origin and the degree of squamous metaplasia
50. Cervical Myomas
• Cervical myomas are smooth, firm masses that
are similar to myomas of the fundus.
• A cervical myoma is usually a solitary growth in
contrast to uterine myomas, which in general,
are multiple.
• Depending on the series, 3% to 8% of myomas
are categorized as cervical myomas.
• Because of the relative paucity of smooth
muscle fibers in the cervical stroma, the
majority of myomas that appear to be cervical
actually arise from the isthmus of the uterus.
52. Cervical Myomas
• Most cervical myomas are small and asymptomatic.
When symptoms do occur, they are dependent on the
direction in which the enlarging myoma expands. The
expanding myoma produces symptoms secondary to
mechanical pressure on adjacent organs. Cervical
myomas may produce dysuria, urgency, urethral or
ureteral obstruction, dyspareunia, or obstruction of the
cervix.
• Occasionally a cervical myoma may become
pedunculated and protrude through the external os of
the cervix. These prolapsed myomas are often
ulcerated and infected. A very large cervical myoma
may produce distortion of the cervical canal and upper
vagina. Rarely, a cervical myoma causes dystocia
during childbirth.
• The diagnosis of a cervical myoma is by inspection and
palpation.
55. Endometrial Polyp
• Endometrial polyps are localized overgrowths of
endometrial glands and stroma that project beyond the
surface of the endometrium.
• They are soft, pliable, and may be single or multiple.
Most polyps arise from the fundus of the uterus.
• Polypoid hyperplasia is a benign condition in which
numerous small polyps are discovered throughout the
endometrial cavity.
• Endometrial polyps vary from a few millimeters to
several centimeters in diameter, and it is possible for a
single large polyp to fill the endometrial cavity.
• Endometrial polyps may have a broad base (sessile) or
be attached by a slender pedicle (pedunculated).
56. Endometrial Polyp
• The majority of endometrial polyps are asymptomatic.
Those that are symptomatic are associated with a wide
range of abnormal bleeding patterns. No single
abnormal bleeding pattern is diagnostic for polyps;
however, menorrhagia, premenstrual and postmenstrual
staining, and scanty postmenstrual spotting are the
most common. Occasionally a pedunculated endometrial
polyp with a long pedicle may protrude from the
external cervical os. Sometimes large endometrial
polyps may contribute to infertility.
• Polyps are succulent and velvety, with a large central
vascular core. The color is usually gray or tan but may
occasionally be red or brown. Histologically an
endometrial polyp has three components: endometrial
glands, endometrial stroma, and central vascular
channels
57. Endometrial Polyp
• Malignant change, when found in an endometrial polyp,
is usually curable, and the endometrial carcinoma is most
often of a low stage and grade.
• It is interesting that benign polyps have been found in
approximately 20% of uteri removed for endometrial
carcinoma. Recently, unusual polyps have been described
in association with chronic administration of the
nonsteroidal anti-estrogen tamoxifen.
• The incidence of endometrial abnormalities associated
with chronic tamoxifen therapy is polyps 20% to 35%,
endometrial hyperplasia 2% to 4%, and endometrial
carcinoma 1% to 2%.
• The management of endometrial polyps is removal by
curettage or via the hysteroscope.
• Because of the frequent association of endometrial polyps
and other endometrial pathology, it is important to
examine histologically both the polyp and the associated
endometrial lining. Polyps, because of their mobility, often
tend to elude the curette.
58. Tiny hysteroscopic scissors,
about as big around as the
ink tube on a standard writing
pen, are used to cut the stalk.
Photo taken during
Hysteroscopy of a small
endometrial polyp.
Notice the stalk.
59. Leiomyomas
• Leiomyomas, also called myomas, are benign tumors of
muscle cell origin.
• These tumors are often referred to by their popular
names, fibroids or fibromyomas, but both terms are
semantic misnomers if one is referring to the cell of
origin.
• Most leiomyomas contain varying amounts of fibrous
tissue, which is believed to be secondary to
degeneration of some of the smooth muscle cells.
• Leiomyomas are the most frequent pelvic tumors, with
the highest prevalence occurring during the fifth decade
of a woman's life.
• Although leiomyomas arise throughout the body in any
structure containing smooth muscle, in the pelvis the
majority are found in the corpus of the uterus.
60. • Occasionally, leiomyomas may be found in the fallopian
tube or the round ligament, and approximately 5% of
uterine myomas originate from the cervix.
• Myomas may be single but most often are multiple.
Myomas are discovered in one of four white women and
one of two black women.
• They vary greatly in size from microscopic to
multinodular uterine tumors that may weigh more than
50 pounds and literally fill the patient's abdomen.
• Myomas are more prone to grow and become
symptomatic in nulliparous women. The question as to
why some women develop myomas while others do not
is unanswered. However, genetic determinants definitely
contribute to their development. Symptomatic uterine
leiomyomas are the primary indication for approximately
30% of all hysterectomies.
• Initially most myomas develop from the myometrium,
beginning as intramural myomas. As they grow, they
remain attached to the myometrium with a pedicle of
varying width and thickness.
61. • Myomas are classed into subgroups by their relative
anatomic relationship and position to the layers of the
uterus.
• The three most common types of myomas are
intramural, subserous, and submucous, with special
nomenclature for broad ligament and parasitic myomas.
• Continued growth in one direction determines which
myomas will be located just below the endometrium
(submucosal) and which will be found just beneath the
serosa (subserosal)
• The most common symptoms related to myomas are
pressure from an enlarging pelvic mass, pain including
dysmenorrhea, and abnormal uterine bleeding. The
severity of symptoms is usually related to the number,
location, and size of the myomas. However, the
majority of women with uterine myomas are
asymptomatic.
62.
63. • Laparoscopic view of a uterus with a
pedunculated posterior myoma
• A fibroid in this location should not affect
chances for pregnancy or miscarriage
• However, if it were pushing into the cavity of
the uterus, it might cause problems
64. Diagnosis
• The majority of uterine myomas may be
diagnosed by pelvic examination, difficult cases
will benefit from ultrasound examination or a
search for concentric calcifications on an
abdominal x-ray film.
• There are several recent reports of computed
tomography (CT) and magnetic resonance
imaging (MRI) studies of uterine myomas.
• However, these imaging techniques are more
expensive than ultrasound.
• Until CT and MRI can distinguish between benign
and malignant myomas, they will rarely be
ordered in routine clinical management of
myomas.
65. Treatment
• The management of a woman with small,
asymptomatic myomas is judicious observation. When
the tumor is first discovered, it is appropriate to
perform a pelvic examination at 6-month intervals to
determine the rate of growth. The majority of women
will not need an operation, especially those women in
the perimenopausal period, where the condition
usually improves with diminishing levels of circulating
estrogens.
• Women with abnormal bleeding and leiomyomas
should be investigated thoroughly for concurrent
problems such as endometrial hyperplasia. If their
symptoms do not improve with conservative
management, operative therapy may be considered.
The choice between a myomectomy and hysterectomy
is usually determined by the patient's age, parity, and
most important, future reproductive plans.
66. • Classic indications for a myomectomy
include:
– a rapidly expanding pelvic mass,
– persistent abnormal bleeding,
– pain or pressure,
– enlargement of an asymptomatic myoma
to more than 8 cm in a woman who has
not completed childbearing.
67. • Two associated but rare diseases should be noted:
intravenous leiomyomatosis and leiomyomatosis
peritonealis disseminata. Intravenous leiomyomatosis is a
rare condition in which benign smooth muscle fibers
invade and slowly grow into the venous channels of the
pelvis. The tumor grows by direct extension and grossly
appears like a "spaghetti" tumor. Only 25% of tumors
extend beyond the broad ligament; however, case reports
exist of tumor growth into the vena cava and right heart.
• Leiomyomatosis peritonealis disseminata (LPD) is a benign
disease with multiple small nodules over the surface of the
pelvis and abdominal peritoneum. Grossly, LPD mimics
disseminated carcinoma. However, histologic examination
demonstrates benign-appearing myomas. This disorder is
usually associated with a recent pregnancy.
69. Adenomatoid Tumors
• The most prevalent benign tumor of the oviduct is the
angiomyoma or adenomatoid tumor.
• They are small, gray-white, circumscribed nodules, 1 to
2 cm in diameter.
• These tumors are usually unilateral and present as
small nodules just under the tubal serosa.
• These small nodules do not produce pelvic symptoms
or signs.
• These benign tumors also are found below the serosa
of the fundus of the uterus and the broad ligament.
• Microscopically they are composed of small tubules
lined by a low cuboidal or flat epithelium. Histologic
studies have established that the thin-walled channels
that comprise these tumors are of mesothelial origin.
• These tumors do not become malignant; however, they
may be mistaken for a low-grade neoplasm when
initially viewed during a frozen-section evaluation.
70. Follicular Cysts
• Follicular cysts are by far the most frequent
cystic structures in normal ovaries.
• The cysts are frequently multiple and may
vary from a few millimeters to as large as 15
cm in diameter.
• However, a normal follicle may physiologically
become cystic, and therefore it is important
to have a minimal diameter for a follicular
cyst.
• This diameter is generally considered to be
between 2.5 and 3 cm. Follicular cysts are not
neoplastic and are believed to be dependent
on gonadotrophins for growth.
71. • Enlarged polycystic
ovary following
laparoscopic
cauterization
Follicular cysts are translucent, thin walled, and are filled with a watery,
clear to straw-colored fluid. If a small opening in the capsule of the cyst
suddenly develops, the cyst fluid under pressure will squirt out. These
cysts are situated in the ovarian cortex, and sometimes they appear as
translucent domes on the surface of the ovary.
72. Corpus Luteum Cysts
• Corpus luteum cysts are less common than follicular
cysts, but clinically they are more important.
• Corpus luteum cysts may be associated with either
normal endocrine function or prolonged secretion of
progesterone. The associated menstrual pattern may be
normal, delayed menstruation, or amenorrhea.
• Most corpus luteum cysts are small, the average
diameter being 4 cm.
• Corpus luteum cysts vary from being asymptomatic
masses to those causing catastrophic and massive
intraperitoneal bleeding associated with rupture.
• Many corpus luteum cysts produce dull, unilateral, lower
abdominal and pelvic pain. The enlarged ovary is
moderately tender on pelvic examination. Depending on
the amount of progesterone secretion associated with
cysts, the menstrual bleeding may be normal or delayed
several days to weeks with subsequent menorrhagia.
73. • Corpus luteum cyst with thickened cyst
wall and definite lutein cell lining
recognized by its color. Cyst is filled
with hemorrhagic gelatinous material.
74. Benign Cystic Teratoma (Dermoid Cyst,
Mature Teratoma)
• Benign ovarian teratomas are usually cystic structures
that on histologic examination contain elements from
all three germ cell layers.
• The word teratoma was first advanced by Virchow and
translated literally means "monstrous growth."
• Teratomas of the ovary may be benign or malignant.
Although dermoid is a misnomer, it is the most
common term used to describe the benign cystic tumor,
composed of mature cells, whereas the malignant
variety is composed of immature cells (immature
teratoma).
• Dermoid is a descriptive term in that it emphasizes the
preponderance of ectodermal tissue with some
mesodermal and rare endodermal derivatives.
• Malignant teratomas that are immature are usually solid
with some cystic areas and histologically contain
immature or embryonic-appearing tissue.
75. • From 50% to 60% of dermoids are asymptomatic and
are discovered during a routine pelvic examination,
coincidentally visualized by an abdominal x-ray or
ultrasound examination, or found incidentally at
laparotomy.
• Presenting symptoms of dermoids include pain, and the
sensation of pelvic pressure.
• Specific complications of dermoid cysts include torsion,
rupture, infection, hemorrhage, and malignant
degeneration.
• Three medical diseases also may be associated with
dermoid cysts: thyrotoxicosis, carcinoid syndrome, and
autoimmune hemolytic anemia. Torsion of a dermoid is
the most frequent complication
76. • Benign cystic teratoma. This section
from the tumor demonstrates areas of
hair (dark arrows) and solid sebaceous
material (S).
77. Fibroma
• Fibromas are the most common benign, solid neoplasms
of the ovary. Their malignant potential is low, less than
1%. These tumors comprise approximately 5% of benign
ovarian neoplasms and approximately 20% of all solid
tumors of the ovary.
• The pelvic symptoms that develop with growth of
fibromas include pressure and abdominal enlargement,
which may be secondary to both the size of the tumor
and ascites.
• Smaller tumors are asymptomatic because these tumors
do not elaborate hormones. Thus there is no change in
the pattern of menstrual flow.
• Fibromas may be pedunculated and therefore easily
palpable during one examination yet difficult to palpate
during a subsequent pelvic examination.
• Sometimes on pelvic examination the fibromas appear to
be softer than a solid ovarian tumor because of the
edema and/or occasional cystic degeneration.
78. Meigs' syndrome
• Meigs' syndrome is the association of an
ovarian fibroma, ascites, and
hydrothorax. Both the ascites and the
hydrothorax resolve after removal of
the ovarian tumor. The ascites is
caused by transudation of fluid from the
ovarian fibroma.
79. • Fibroma of ovary. Cut surface shows
somewhat edematous, interlacing
bundles of connective tissue.
80. Transitional Cell Tumors—Brenner Tumors
• Brenner tumors are rare, small, smooth, solid,
fibroepithelial ovarian tumors that are generally
asymptomatic. The semantic classification of
neoplasms changes and the current preferred term for
benign Brenner tumor is transitional cell tumor. The
benign, proliferative (low malignant potential), and
malignant forms together comprise approximately 2%
of ovarian tumors.
• These tumors usually occur in women aged 40 to 60
years.
• Grossly, Brenner tumors are smooth, firm, gray-white,
solid tumors that grossly resemble fibromas. Similar to
fibromas, transitional cell tumors are slow growing
• Management of Brenner tumors is operative, with
simple excision being the procedure of choice.
81. Adenofibroma and Cystadenofibroma
• Adenofibromas and cystadenofibromas are closely
related. Both of these benign firm tumors consist of
fibrous and epithelial components.
• The epithelial element is most commonly serous, but
histologically may be mucinous and endometrioid or
clear cell.
• They differ from benign epithelial cystadenomas in that
there is a preponderance of connective tissue.
• Most pathologists emphasize that at least 25% of the
tumor consists of fibrous connective tissue. Obviously,
cystadenofibromas have microscopic or occasional
macroscopic areas that are cystic.
• The varying degree of fibrous stroma and epithelial
elements produces a spectrum of tumors, which have
resulted in a confusing nomenclature with terms such as
papillomas, fibropapillomas, and fibroadenomas.
82. Adenofibroma and Cystadenofibroma
• Smaller tumors are asymptomatic and are
only discovered incidentally during abdominal
or pelvic operations. Large tumors may cause
pressure symptoms or, rarely, undergo
adnexal torsion.
• Because adenofibromas are usually
discovered in postmenopausal women, the
treatment of choice is bilateral salpingo-
oophorectomy and total abdominal
hysterectomy. Because these tumors are
benign and because malignant transformation
is rare, simple excision of the tumor and
inspection of the contralateral ovary is
appropriate in younger women.