Benign ovarian Tumors Dr. Fayez Khatib Department of Obstetric & Gynecology SZMC.

Benign ovarian TumorsDr. Fayez Khatib

Department of Obstetric & Gynecology

SZMC

Normal adult ovary

Ovaries are normally not palpable in pre-menarche, and after the menopause

In the reproductive age group ovaries are palpable in the lean pts.

Ovarian size of different age groups

Premenopause - 3.5 x 2 x 1.5 cm

Early menopause 1 – 2 yrs- 2 x 1.5x0.5cm

Late menopause 2-5yrs- 1.5x0.75x0.5cm

Normal adult ovary

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

Normal adult ovary

Lifetime Risk of ovarian neoplasm

A woman has 5–10% lifetime risk of undergoing surgery for a suspected ovarian neoplasm– 13–21% of these will be found to be have an ovarian malignancy

Differential diagnosis of the adnexal masses varies considerably with the age of the patients.

In pre-menarchal girls and post-menopausal women adnexal mass should be considered highly abnormal – requires immediate investigation.

In menstruating patients differential diagnosis is varied.

Normal adult ovary

Classification

• Neoplasms derived from the surface epithelium- 65-80% • Neoplasms derived from germ cells-10-15%

• Neoplasms derived from specialized gonadal stroma- 5-10%

• Neoplasms metastatic to the ovary-5%

Type

Epithelial

Germ cell

Specialized gonadal stromal

Metastatic

Ovarian Neoplasm By Age

Type <20y

Epithelial 29%

Germ cell 59%

Specialized gonadal stromal 8%

Metastatic 4%


Type 20-50y

Epithelial 71%

Germ cell 14%


Metastatic 10%


Type >50y

Epithelial 81%

Germ cell 6%


Metastatic 9%


OVARIAN MASSES

FUNCTIONAL INFLAMMATORY NEOPLASTIC OTHERS

FOLLICULAR CYST

CORPUS LUTEUM CYST

THECA LUTEIN

TUBO OVARIAN ABSCESSBENIGN

BORDERLINE

MALIGNANT

ENDOMETRIOMAENLARGED PCOPAROVARIAN CYST

Types of Ovarian Tumors

FUNCTIONAL OVARIAN CYSTSa. Follicular cystsb. Corpus luteum cystsc. Theca luten cysts

BENIGN OVARIAN NEOPLASM1. Serous cystadenoma2. Mucinous cystadenoma3. Brener tumor4. Dermoid cysts 5. Fibroma

6. Endometrioma

Benign ovarian Tumors

These are cysts related to ovarian function i.e. the

process of ovulation

By far the most common clinically detectable

enlargements of the ovary in the reproductive years.

Can be reach up to 10 cm in diameter

All are benign and usually asymptomatic

Resolve spontaneously.

Functional cysts

• Follicular cysts

• Corpus luteum cysts

• Theca lutein cysts

Functional cysts

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.

Follicular cysts

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.

Corpus luteal cyst

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.

Theca lutein cysts

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

Benign ovarian neoplasm

Classification

• Neoplasms derived from the surface epithelium• Neoplasms derived from germ cells

• Neoplasms derived from specialized gonadal stroma

• Neoplasms metaplastic to the ovary

• 30% of epithelial ovarian tumors in postmenopausal women are malignant

• 7% of epithelial ovarian tumors in premenopausal women are malignant

Serrous cystadenoma

Mucinous cystadenoma

Brenner tumor

Benign epithelial ovarian tumors

Borderline Epithelial Tumors

Atypical proliferating tumors

• Greater epithelial proliferation

• Noninvasive

• 15% of epithelial ovarian cancer

• Mean age at diagnosis: 40y

• Usually asymptomatic

• Can cause pain/pressure

• Diagnosed as ovarian mass/cyst

• CA-125 usually not elevated

Risk factors:

– Infertility

– Infertility drugs

– Hereditary?

• Protective:

– Multiple births

– Breast feeding

– Oral contraceptives


Treatment

– Surgery

• Cystectomy;USO – 12% recurrence (?)

• TAH + BSO – 2.5% recurrence (?)

• > 50% diagnosed at stage Ia

• Invasive / noninvasive implants:

Invasive implants are the most important predictor of recurrence

• Further therapy: not useful- Does not respond to chemotherapy

• 5 & 10-year survival > 90%, 20 year survival of 70%


Epithelial Ovarian Tumors - Serous Tumors

May occur on the ovarian surface, occasionally arises in extraovarian peritoneumUnilocular or multilocular containing clear serous fluid Endosalpingeal cell-type 60% BENIGN - bilaterality in 25%:Smooth glistening cyst

wall, no epithelial thickening or papillae, single layer of columnar cells line cyst

15% BORDERLINE - bilaterality in 34%:Epithelial atypia in cyst lining, with stratification and formation of papillae; No stromal invasion

25% MALIGNANT - bilaterality in 67%: Epithelial atypia often greater, complex architecture of papillae, multinodular. Stromal invasion present

Serous cystadenoma

Generally benign

Bilateral – 10-25 %

Risk of malignancy : 5 – 15 % borderline malignant

20 -25% malignant

Size ranges from 5-40cm

GROSS : multilocular with papillary components.

MICRO : low columnar epithelium with cilia.

Characteristic psammoma bodies (end products of degeneration of

papillary implants)are found.

Associated fibrosis may lead to “cystadenofibroma”


Serous Cystadenoma

Serous cystadenoma


Bilateral cystadenoma

Epithelial Ovarian Tumors - Mucinous Tumors

Mucinous tumors are much less likely to be bilateral and to be malignant than Serous tumors! 80% BENIGN - only 5% bilateral 10% BORDERLINE 10% MALIGNANT - only 20% bilateral

• Cystic, mucin producing , usually multilocular• Mostly intestinal-type cell, can also resemble endocervical cells• May reach enormous size•• 5% Pseudomyxoma peritonei: peritoneal cavity becomes filled with gelatinous mucinous fluid (similar to cyst contents), which mats together the abdominal viscera; Rx is surgical, and repeated operations are required.


Have tendency to become huge masses

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.

Epithelium – tall, pale staining, secretary with basal nuclei and

goblet cells

5 – 10% are malignant


Benign Mucinous Tumor of Ovary


Benign Mucinous Tumor of Ovary


Brenner tumor( Transitional cell ):Fibroepithelial tumors derived from the surface epithelium of the ovary

which undergoes metaplasia to form urothelial-like components.

Mean age at presentation: 50 years

Rare- Constitute 1 - 2 % of all ovarian neoplasms

Usually benign ; But scattered reports of malignant Brenner’s available

Solid , grossly identical to fibroma,

Unilateral- 7 % are bilateral, left side predominance

Endocrinologically inert, but could be ass. with virilization and

endometrial hyperplasia - PMB- In postmenopausal women

On microscopy – markedly hyperplastic fibromatous matrix interspersed with nests of epitheloid cells showing “coffee beans” pattern

Brenner tumor( Transitional cell )

Brenner tumor



Brenner tumor: “coffee beans”


Classification

• Neoplasms derived from the surface epithelium

• Neoplasms derived from germ cells• Neoplasms derived from specialized gonadal stroma


Germ Cell Tumors

10-15 % of ovarian tumors are germ cells, 3% of them are malignant Rapidly growing Produce symptoms:

Abdominal pain Distension Torsion Rupture

Pelvic pressure Menstrual disorders Virilism

Germ Cell Tumors

Classification of germ cell neoplasms • Teratoma

• Mature cystic teratoma • Monodermal teratoma (e.g. struma ovarii)• Immature teratoma

• Dysgerminoma• Yolk sac tumor (endodermal sinus tumor) • Embryonal carcinoma• Choriocarcinoma

Germ Cell Tumors- Teratoma

Mature cystic teratoma(Dermoid): - Benign neoplasm Most common ovarian teratoma and most common ovarian germ

cell tumor Typically occurs during reproductive years Cystic tumor with firm capsule, filled with sebaceous material and

hair (occasionally teeth can be found) Thickened area from which hair and teeth arise is called

"Rokitansky's protuberance" Composed of mature elements derived from all three germ layers

(ectodermal elements such as skin, hair, sebaceous glands, and mature neural tissue predominate; cartilage, bone, respiratory and intestinal epithelium are common)

Often bilateral (15 -25%)

Malignant change occurs in 1-3%. Usually of a squamous type.

Complications include torsion-(Risk of torsion is 15%), rupture,

infection, hemolytic anemia

An ovarian cystectomy is almost always possible, even if it appears

that only a small amount of ovarian tissue remains

Mature cystic teratoma(Dermoid):



Dermoid Cyst

mamillae or Rokitansky's protuberances


Dermoid Cyst


Dermoid Cyst


Dermoid Cyst


Monodermal teratoma A teratoma composed predominantly of one tissue element Most common type is "struma ovarii", which is mature

thyroid tissue

Classification


• Neoplasms derived from germ cells



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.

Fibroma

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.

Rarely malignant

Gonadoblastomas

Gonadoblastoma is a rare benign tumor that has the potential for

malignant transformation and affects a subset of patients with an

intersex disorder or disorder of sex development (DSD).

Arise in patients with dysgenetic gonads - 46 XY f/b 45XO/ 46 XY mosaic.

Contain both germ cells and sex cord stromal cells.

Presents usually as phenotypic female <30 years with primary amenorrhea

and virilization.

Treatment – laparoscopy or laparotomy with removal of b/l dysgenetic

gonads.

Further treatment depends on malignant germ cell component

Classification


• Neoplasms derived from germ cells



Endometriomas

Most common site of involvement is the ovary. Large hemorrhagic cyst (chocolate cyst), Cyst walls are

usually thick and fibrotic. They may completely replace normal ovarian tissue. USG: anechoic cysts to cysts with diffuse low-level echoes

to solid-appearing masses. They may be unilocular or multilocular with thin or thick

septations Malignant transformation: 0.3% to 0.8% Management: medical and/ or surgical

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

hemorrhage. Benign ovarian neoplasms are indistinguishable clinically from

malignant counterparts

Complications

Torsion

Intracystic hemorrhage

Infection

Rupture

Pseudomyxoma peritonei

Malignancy

Diagnostic evaluation of the patient with an adnexal mass

Complete physical examination

Pelvic ultrasound examination, Doppler?

Computed tomography scan with contrast enhancement

Tumor markers-( ca-125)

Laparoscopy, laparotomy

Evaluation

Abdominal and vaginal examinationAssess

– Laterality – Cystic Vs solid– Mobile Vs fixed– Smooth Vs irregular– Ascites– Cul-de-sac nodules

Unilateral

Cystic

Mobile

No ascites

No cul de-sac nodules

Slow or no growth

Clinical features of benign ovarian masses

TVS

Pattern recognition is superior to all other scores.

Simple ultrasound-based rules for the diagnosis of ovarian cancer. Ultrasound Obstet Gynecol2008, RCOG 2011

TVS

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 between benign and malignant masses overlap.

PI<1, RI<0.4

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..

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

– 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

1. Unilocular

2. Smooth surface

3. No solid elements

4. No external or internal outgrowth

5. No ascites

6. Unilateral

7. Normal Doppler flow

Radiological features of benign ovarian masses

Tumor markers

CA-125HE4BHCGLDHAFP

Calculation of RMI (Risk malignancy index):

RMI=MxUxCA-125

Calculation of RMI (Risk malignancy index):

It is an effective way of triaging patients into low , moderate, high risk for malignancy, according to which the referral to a higher centre and management protocol will differ.

It is recommended that a ‘risk of malignancy index’ should be used to select those women who require primary surgery in a cancer centre by a gynecological oncologist.

RCOG Guideline No. 34 October 2003

Operative intervention

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

Ovarian mass in childhood:History and physical examination

Appr. Imaging studies

Simple cyst- Observe and reassess

Solid or solid cystic

MRI and tumor markers

High suspicion of malignancy

Low suspicion of malignancy

Laparotomy laparoscopy

Frozen section Malignant – oophorectomy and staging

Benign - cystectomy

Ovarian mass in reproductive age group

<5 cms. >/= 5 cms

USG USG

cystic

observationComplex,

solid, suspicious

Persistence or progression

surgery

Asymptomatic simple cysts

<5cms Likely physiological

(do not require follow up)

5-7 cms Yearly USG

>7cm Require further

imaging/surgical intervention.

RCOG 2011

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

Ovarian mass In Postmenopausal women

Ovaries atrophic and shouldn’t be palpable on pelvic

examination.

Presence of palpable ovary must alert the physician to the possibility

of an underlying malignancy.

Incidence in asymptomatic post menopausal women –

1.5% by pelvic examination

3.3% to 14.5% by USG

Causes -10% functional

90% neoplastic (either benign or malignant). Obstet gynecol survey, 2002


Simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a low

risk of malignancy. It is recommended that, in the presence of a normal serum

CA125 levels, they be managed conservatively.

Aspiration is not recommended for the management of ovarian cysts in

postmenopausal women.

It is recommended that a ‘risk of malignancy index’ should be used to select

women for laparoscopic surgery, to be undertaken by a suitably qualified surgeon.

It is recommended that laparoscopic management of ovarian cysts in

postmenopausal women should involve oophorectomy (usually bilateral) rather

than cystectomy.


Operative intervention

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

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

Operative Modalities

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Benign ovarian Tumors Dr. Fayez Khatib Department of Obstetric & Gynecology SZMC.

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