BENIGN LESIONS OF OVARY

BY

DR.JASMINA BEGUM.

CONTENT- Non neoplastic cyst & benign neoplastic

tumours- Clinical features- Diagnosis- Differential diagnosis- Management- Complications

OVARYTHE HUMAN OVARY HAS A STRICKING PROPENSITY TO DEVELOP A WIDE VARITY OF TUMORS MOST OF WHICH ARE BENIGN.

80% OF ALL OVARIAN TUMORS ARE BENIGN,ALTHOUGH THIS VARIES WITH AGE.

BENIGN LESIONS OF OVARY

NON NEOPLASTIC NEOPLASTIC(BENIGN)

FUNCTIONAL PATHOLOGY

1.Follicular cyst 1.PCOS A. SURFACE EPITHELIUM 2.Corpus luteal cyst 2.endometrioma 1. Serous 3.Theca lutein & 3. T O mass 2. Mucinous granulosa lutein cyst 3. Endometroid 4. Brenner

B.GERM CELL TUMOUR (BENIGN) C. SEX CORD / STROMAL 1. thecoma/fibroma 2. androblastoma

FOLLICULAR CYST (commonest)

CORPUS LUTEUM CYST

THECA LUTEIN CYST

AGE GROUP Adolescent, reproductive age groups ,can occur in perimenopause

Reproductive age Reproductive age

CAUSE Hyperestronism Over activity of corpus luteum

Excess chorionic gonadotropin secreted in GTD, following to ovulation induction drugs

Size

Laterality

Grow ≥3 & ≤8 cm

B/L or U/L

3 – 10 cm

U/L

Large upto 30 cm

B/L

FOLLICULAR CYST CORPUS LUTEUM CYST

THECA LUTEIN CYST

GROSS Thin walled , unilocular , filled with straw coloured fluid

Pink or haemorrhagic cyst, cut section yellowish orange, filled with blood clots

Multicystic, greyish blue colour, filled with straw colour fluid or blood

Histology Lining epithelium Granulosa cells

Luteinised granulosa cell

Theca lutein cells,granulosa lutein cells

C/F Usually asymptomatic , diagnosis incidental

Dull with U/L pelvic pain Rupture with hemoperitoneum more common

Small are asymptomatic, large -discomfort , painRupture/torsion (more common)

Hemorrhagic cyst with unusual appearance simulating a neoplasm

Shows enlarged uterus in the centre and bilateral Theca lutein cysts. The cyst on the left shows a breach in the capsule and the

right cyst with thin hemorrhagic area suggestive of impending rupture

PCOS:-0.5-4%, infertile women, young reproductive age-excess androgen , chronic anovulation-Pathology: ovaries enlarged, stroma increased, capsule thickened, pearly white-c/s: multiple follicles in cortex -Histo: thickened tunica albuginea, stromal hyperthecosis-insulin resistance (acanthosis nigricans)-CF: amenorrhoea, hirsutism, obesity, enlarged PCO.-Investigations Management – Wt. reduction COCP Tt. Of hirsutism Tt. Of infertility

BENIGN OVARIAN TUMORS

Ovarian neoplasm may be divided generally by cell type of origin into three types:

1.epithelial2.stromal3.germ cell

BENIGN OVARIAN NEOPLASMSEPIDEMOLOGY:-Incidence: 1-3% among outpatient , 75% -benign-Racial factors: higher in white population, lowest in japan-Economic status: higher in industrialised countries-Environmental factors:

PATHOLOGY:-Origin: mesoepithelial cells on ovarian surface-Incidence: epithelial tumours—80% of all ovarian tumours serous cystadenoma– 50% of all epithelial tumoursmucinous cysts—12-15%endometroid—10%unspecified—25-27%

Benign ovarian tumors

MUCINOUSCYST ADENOMA

SEROUSCYST ADENOMA

BRENNER BENIGN CYSTIC TERATOMA

INCIDENCE 12-15 % of Epithelial tumors

20-25% of all OV.tumors

50 % of all Epithelial tumors

40% of all ovarian tumors

2 – 3 % of all Epithelial tumors

1 -2% of all ovarian tumors

95 % of Germ cell tumors

15 – 20% of all ovarian tumors

Bilateral

Malignant chance

10%

5 –10%

40%

40%

8 -10%

rare

15 -20%

1 -2%

20- 40 % of all ov. Tumors in pregnancy

TUMOR MUCINOUS SEROUS DERMOID

ORIGINTotipotent surface epithelium of ovary

Totipotent surface epithelium of ovary

germ cells arrested after 1st meoitic division

PATHOLOGYnaked eye : huge size & wt 5-10 kg pedunculated, largest. smooth, lobulated with whitish or bluish white , translucent tumor.

c/s: thick, visid mucin (glycoprotein) colourless multiloculated with papillary. honey combed appearance

naked eye:smooth, shiny, greyish white exuberant papillary projections .

c/s:multilobulated clear fluid (serum) proteins (albumin & globulin)

naked eye: moderate size, capsule tense & smooth

c/s: trabeculated appearance , sebaceous material with hair , clear rokitansky’s protruberance

-microscopy: lined by 1 layer of tall coloumnar epithelium with dark staining basal nuclei without any cilia. Epithelium resemble to those of endocervix.

-complication: rupture pseudomyxoma peritonei & shows adhesions with visera .

microscopy:- lined by cubical epithelium - papillary structures – dense fibrous stroma covered by single or multiple layers of columnar epithelium. ciliated secretory & peg cells. Epithelium resemble to those of endosalpingeal epithelium

micro: stratified squamous epithelium,granulation tissue, may be transitional/ columnar

.

MUCINOUS CYSTADENOMA

SEROUS CYSTADENOMA

SEROUS /MUCINOUS CYSTADENOMA

Gross appearance of a mucinous (A) and serous (B) cystadenoma of the ovary. The mucinous type is generally multiloculated and can be quite large.

BRENNER TUMOUR-U/l , small to moderate, seen after 50 years-Gross: resembles fibroma, smooth solid tumour-C/s: gritty, yellowish grey-Histology: fibrous tissue with transitional epithelium ( walthard cell nests)-Cf: pmb, pseudo meig

ENDOMETROID TUMOUR:-2% of all ovarian tumours-Lined by glandular epithelium-Moderate size, solid, with cystic areas with haemorrhagic fluid.

Gross appearance of a cut-open Brenner tumor.

2. SEX CORD STROMAL OVARIAN NEOPLASMS

Hormone secreting tumors of the ovary.

These tumors include fibromas, Sertoli-Leydig cell tumors (Arrheno–blastomas or androblastomas).

FIBROMA:-origin: stromal cells of ovarian cortex-small sessile nodule, long pedicle ,solid,smooth surfaced tumour-c/s: white -microscopy: interlacing bundles of spindle shaped cells-complication: torsion ,meig syndrome

ANDROBLASTOMA/SERTOLI-LEYDIG CELL TUMOR-testicular adenoma-androgen secreting tumour-seen in women less than 30 year-gynandroblastoma (granulosa + androblastoma cells)-cf: amennorhoea, atrophy of breasts, enlargement of clitoris, body hair growth, deepening of voice.

Gross appearance of an ovarian fibroma.

3. GERM CELL TUMORSTUMORS OF GERM CELL ORIGIN MAY REPLICATE STAGES RESEMBLING THE

EARLY EMBRYO

CAN OCCUR AT ANY AGE

12-15% OF OVARIAN NEOPLASM

60% OF GCTS OCCURS IN CHILDREN

MOST COMMON BENIGN TYPE IS ‘BENIGN CYSTIC TERATOMA’

DERMOID CYST

On clinical examination

Character 1. Age 2. Laterality3. Mobility4. Feel5. Surface6. Ascites7. Growth8. nodules

Malignant• older• Bilateral• Fixed• Solid• Irregular• Present• Rapid• Present

Benign younger unilateral Mobile Cystic Smooth Absent Slow Absent

Criteria on USG

BENIGN• U/L ,uni/multi locular

Cystic areas with regular thin wall thin septa and nonechogenic cavity

• TVS(doppler) shows regular vascular branching

MALIGNANT• B/L, thick wall, thick

septa, echogenic areas in cavity Irregular heterogenous parts

• TVS neovascularisation• Low RI & PI

USG:

• Benign • Malignant

CLINICAL FEATURESAGE:- late child bearing age -dermoid, mucinous adenoma common in reproductive -dermoid common in pregnancysymptoms: -asymptomatic - detected accidently -heaviness in lower abdomen, mass - dull aching pain, - cardiorespiratory & gastrointestinal upset

(nausea, indigestion) -menstrual pattern unaffected except in hormone

producing tumours signs: cachetic , pitting edema legs

ABD EXAMINATION

Inspection -- bulging of lower abdomen mass – central/ one side/ whole abdomen visible veins , flanks – flat Palpation -- cystic / tense cystic freely mobile from side to side with restricted in above down, smooth surface , nontender Percussion -- dull in center resonant in flanks fluid thrill + Auscultation -- friction rub +

Bimanual pelvic examination -- uterus separated from mass groove + between uterus & mass movement of mass p/a fails to move cx lower pole of cyst felt through fornix absence of pulsation of ut vessels thro fornix

D.D

1.Full bladder

2. Pregnancy 3. Pregnancy with fibroid 4. Ascites 5. Fibroid uterus 6. Encysted peritonitis

INVESTIGATION

To confirm diagnosisUSG Tumor markersStraight x-ray abdomenParacentesisLaproscopy

COMPLICATIONS1. Torsion2. Intracystic hge3. Infection4. Rupture5. Malignancy6. Pseudomyxoma peritonei

Torsion: (axial rotation)• 10 – 15%• moderate size & wt• free mobility & long pedicle• common in dermoid or serous cystadenomaCauses:-Trauma, violent physical movement, contraction of preg uterus, intestinal peristalsis.

• Hemodynamic theory• Symptoms- acute pain + lump, vomiting, fever, shock ,

tachycardia. P/A: tense, tender, cystic mass with

restricted mobility P/v: mass abd separate from uterusDD: 1. Disturbed ectopic preg 2. Acute hydramnios 3. Perforating h mole 4. Torsion of subserous pedunculated fibroidRx: Pain– morphine Laparotomy ( cystectomy/ salpingoophorectomy)

INTRACYSTIC HGE: -serous cystadenoma, malignancy.-venous congestion.

INFECTION:-following torsion-organisms – from intestine, uterine tubes.

RUPTURE:-big & tense cyst-trauma, malignancy, papillary type.

PSEUDOMYXOMA PERTONEI:-mucinous ascites-asso with mucinous cyst adenoma ovary, mucocele appendix & gall bladder, intestinal malignancy.-spontaneous perforation -recurrence high, prognosis poor ( infection, intestinal obstr)-Rx: hystrectomy, BSO with removal of mucin, peritoneal implants with appendix.

OVARIAN CYST premenopause women

Cystic teratoma Simple cyst size 5-8 cm

Benign morphologyCA-125 ≤35IU/L

All other cyst

Laproscopic surgery Follow up 3-6 month or COCP

Laproscopy / laparotomy

Increase in sizesymptomatic

Yes No

Laproscopic cystectomy Follow up

Ovarian cyst postmenapause

Simple cyst size 3-5 cm, Benign morphologyCA-125≤ 35IU/L Doppler RI ≥0.4

Size ≥ 5 cmMorphology suspiciousCA-125 ≥35IU/L

Follow up 6 weeks

Increase in sizeCA-125 Rising

Laparotomy

Yes No

Laparotomy Follow up

SURGERY: young women- ovarian cystectomy Oophorectomy (salpingoophorectomy)parous women- TAH+BSOothers- individualisation.laparoscopic cystectomy / ovariotomylaparoscopy/ USG guided aspiration of cyst.

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