BENIGN OVARIAN TUMORS

A.KIRAN
ROLL NO 3
IX term
• INCIDENCE
The incidence of ovarian tumor amongst
gynaeological admission varies from 1-3%.
About 75% of these are benign

The principal ovarian tissue components are-

– Epithelial cells (from coelomic epithelium)
– Oocytes (primitive germ cells)
– Mesenchymal elements (gonadal stroma)
CLASSIFICATION
I. Epithelial tumor(60-70%)
• Serous cyst adenoma
• Mucinous cyst adenoma
• Endometroid tumors
• Mesonephroid/clear cell tumors
• Transitional cell: Brenner tumor
• Squamous cell tumors
II. Sex cord stromal tumors(6-10%)
• Granulosa cell tumors
• Thecoma-fibroma group tumors
o Thecoma
o Fibroma
o Unclassified
• Androblastoma
o Sertoli cell tumor
o Sertoli-leydig cell tumor
o Hilus cell tumor
• Gynandroblastoma
III. Lipid cell tumor
IV. Germ cell tumours (20-25%)
• Dysgerminoma
• Endometrial sinus tumor(yolk sac tumor)
• Embryonal cell carcinoma
• Polyembryoma
• Choriocarcinoma
• Teratoma
 Mature (dermoid cyst)
 Immature
 Monodermal - Struma ovarii, Carcinoid
Mucinous cyst adenoma
• Origin- totipotent surface epithelium
• 20-25% of all ovarian tumours (common)
• Bilateral in 10% cases
• Risk of malignancy: 5-10%
• Gross appearance
Largest benign ovarian tumor
Wall-smooth, lobulated, whitish/translucent (thin)
 Cut section- Cyst: multiloculated with papillary
growth arising from septum.
-cyst fluid- thick, viscid, colorless mucin.
• Microscopy
Single layer of tall columnar cells with basal nuclei.
Serous cyst adenoma
• Origin: totipotent surface epithelium of ovary
• 40% of ovarian tumors
• 40% cases bilateral
• 40% risk of malignancy
• Smaller cysts, not so abundant secretion. So,
more chance of epithelial proliferation to form
papillary projections.
• Intracystic hemorrhage more likely.
• Gross appearance
 Wall-smooth, shiny, grayish white,Papillary
projections.
 Cut section-unilocular/multilocular.
 Fluid-clear,rich in albumin and globulin.
• Microscopy
 Single layer cubical epithelium
 Papillae-dense fibrous stroma covered by
columnar epithelium.
 Psammoma bodies-spherical, laminated, calcified
(cellular degeneration)
Endometroid tumors
• Rare (5%)
• epithelial cells resembling those of
endometrium.
• Endometroid carcinomas (malignant variety)
may occur.
Clear cell Tumor
• Mesonephroid tumor
• Highly aggressive
• 40-70 years.
• Hobnail cells-
– Abundant glycogen
– Nuclei protrude into glandular lumen.
Brenner tumor
• 1-2% of all ovarian tumors
• Bilateral- 8-10%
• Age>40 years
• Gross-similar of fibroma, solid, <2cm
• Histology-
– In compact fibrous stroma, islands of transitional
epithelium (Walthard nests).
– Nuclei-longitudinal groove (coffee bean appearance)
• c/f- abnormal vaginal bleeding due to
estrogen secretion by tumor
• Treatment-
– Young women-unilateral oophorectomy
– Elderly women-total hysterectomy and bilateral
salpingo-oophorectomy
Dermoid cyst
• Origin-from Germ cells arrested after First
meiotic division.
• 30-40% of all ovarian tumors.
• Bilateral in 15-20 %
• Risk of malignancy-low(1-2%) –SCC
• Complications -most common torsion(15-20%)
• Gross appearance
• Cyst-moderate size ; capsule- tense, smooth.
• Cut section-
– Predominantly sebaceous material w/ hair.
– Maybe clear fluid (CSF)
– Rokitansky’s protuberance
• Area of solid projection
• Covered by skin w/ sweat, sebaceous glands
• Teeth and bone are formed here.
• Microscopy
– wall- lined by stratified squamous epithelium,
granulation tissue.
– Epithelium maybe transitional or columnar.
– Tissue components-
• Ectodermal: skin,hair,teeth,nerve tissue.
• Mesodermal: bone, cartilage, muscle
• Endodermal: thyroid, salivary glands, intestine,
bronchus.
Struma Ovarii and Strumal Carcinoids
• Struma ovarii
– thyroid tissue-hyperthyroidism.
– <3% of mature teratomas.
• Strumal carcinoids
– <5% of ovarian teratomas.
– Hormonally active- serotonin, bradykinin, other
peptide hormones from agrentaffin cells as in
GIT/bronchial tissues.
– Carcinoid syndrome-
• episodic facial flushing, abdominal pain,diarrhea,
bronchospasm.
• more common in metastatic carcinoid tumors
than ovarian primaries.
CLINICAL FEATURES
Symptoms
• Mostly asymptomatic
• Heaviness in lower abdomen
• Mass- gradually increasing
• Pain- dull aching
• Large tumor-cardiorespiratory/GI
symptoms(nausea,indigestion).
• Menstrual pattern- unaffected unless in
hormone producing tumor-
– Granulosa cell tumor(feminizing)- menorrhagia,
postmenopausal bleed.
– Sertoli-Leydig cell tumor(masculinizing)-
amenorrhea.
Signs
• Pitting edema (tumor presses on great veins)
• Abdominal examination
o Inspection- bulging abd. wall, moves freely with
repsiration
-mass fills entire abdomen: umbilicus everted w/
visible veins; flanks remain flat.
o Palpation
– Feel: cystic/tense cystic (solid tumors-rare)
– Mobility: side to side- freely mobile, above down-
restricted unless pedicle is long.
– Borders: lower pole-difficult to reach(pelvic origin)
– Surface: smooth/grooved in lobulated tumor
– Tenderness: not tender.
o Percussion
– Dull in center, resonant in flanks
– Wall-thin and content-watery = fluid thrill
– Ascites + Rt side hydrothorax associated with
fibroma, thecoma, Brenner or granulosa cell
tumor = Meigs’ Syndrome.
o Auscultation
– Friction rub over a tumor maybe present
• Pelvic examination
• Bimanual examination
– Uterus separated from mass
– Groove between uterus and mass
– Movement of mass per abd. fails to move cervix
– On elevation of mass per abd.,cervix remains in
stationary position
– Lower pole of cyst can be felt through the fornix
– Absence of pulsation of uterine vessels through
fornices.
SPECIAL INVESTIGATIONS
• Sonography-
– TVS w/ color flow Doppler study-tumour
volume,wall,septa,vascularity.
– high risk malignancy: multilocular cyst, solid areas,
metastasis, ascites, bilateral tumors, high blood
flow.
• CT- adnexal mass w/ mixed attenuation (due to large
amount of fat calcification and tooth)
• MRI-benign/malignant
• Serum CA 125, AFP, beta-hCG
• X-ray of abdomen-dermoid cyst(teeth/bones)
• Laparoscopy-differentiate painful cystic mass
with disturbed ectopic pregnancy.
• Cytology-aspiration from ascites/pleural
effusion for malignant cells.
COMPLICATIONS
• Torsion of pedicle (dermoid/serous cyst)
• Intracystic haemorrhage(serous cystadenoma)
• Infection (following torsion)
• Rupture (big tense cyst w/ wall degeneration)
• Malignancy (serous cyst adenoma-common)
Torsion
• Common in dermoid, serous cyst adenoma.
• Symptom- acute hypogastric pain w/ lump.
• Abd. Examination-tense, tender cystic mass in
hypogastrium arising from pelvis.
• Pelvic examination- mass separate from uterus
• Treatment- laparotomy/laparoscopy and
detorsion/ovariotomy
MANAGEMENT
• Once tumor is diagnosed, admit for operation.
Guidelines for surgery.
• Incision- vertical paramedian sufficiently big
enough to deliver the cyst intact.
• Inspect- peritoneal fluid(clear,straw
color,infective, hemorrhagic), sample sent for
cytology.
• Deliver the tumor intact.
• Cyst aspiration not preferred
• Inspect and palpate other ovary, pelvic organs,
liver, omentum, under surface of diaphragm
,Para-aortic LN.
• To proceed for Definitive Surgery.
• To cut the tumor and inspect for malignancy.
o DEFINITIVE SURGERY.
• Young patients desirous of fertility.
 Ovarian cystectomy
 Ovariotomy (salpingo-oophorectomy)
 Both ovaries involved- ovarian cystectomy in at
least one.
 Preservation of uterus for possible ART when
bilateral ovariotomy is done.

• Parous women >40

 Total hysterectomy w/ bilateral salpingo-
oophorectomy.
THANK YOU.