PGI CLARICE VILLANUEVA

MODULE 6 – BENIGN TUMORS

GUIDE QUESTIONS:

1. What are your differential diagnosis?

SALIENT FEATURES:

Pertinent positives Pertinent negatives

32 years old No urinary symptoms
HISTORY OF PRESENT ILLNESS
RLQ mass No change in bowel habits
PAST MEDICAL HISTORY No history of malignancy
PERSONAL AND SOCIAL Non-smoker
HISTORY Non-alcoholic beverage drinker
MENSTRUAL HISTORY Regular menstrual cycle
No use of OCPs
No STIs
SEXUAL HISTORY
No dyspareunia
No PCB
OB HISTORY G1P1 (1-0-0-1)
No weight loss
REVIEW OF SYSTEMS
No anorexia
Grossly normal looking external
palpable, nontender,
genitalia
movable, cystic mass at the
PHYSICAL EXAMINATION No cervical motion tenderness
right adnexa measuring 12 x
No mass or tenderness on the
12 cm
left adnexa

a. Functional cyst particularly Follicular cyst since it is the most common type.
o Seen in normally menstruating women and is usually an incidental finding
o Functional because it follows the function of ovaries
o almost always benign
o Characteristics:
 Simple/one cyst
 No septations
 Has thin or thick smooth muscle
 Has no solid areas
 Fluid-filled (anechoic)
 Formed because of certain hormones
 May regress spontaneously
 o Types:
 Follicular cyst (most common)
o Size:2.5 or 3cm to 15cm
o May be solitary or multiple
o Fetus or neonate – secondary to maternal estrogen
o Mostly seen in young, menstruating women
o Associated with elevated levels of gonadotropins
o Gross: translucent, thin-walled, and are filled with a watery, clear to straw-
colored fluid
o Thin-walled, unilocular, anechoic
o Asymptomatic
o Result from:
o Dominant follicle failing to rupture
o Immature follicle failing to undergo atresia
 Corpus luteum cyst – less likely since patient have regular menstrual periods and is
asymptomatic
o Adnexal tenderness
o (+) “ring of fire” on color flow mapping during TVS
o Halban’s triad
 Delay in normal period
 Unilateral pelvic pain
 Tender adnexal mass
o Thin-walled, unilocular, mixed-echoes
 Theca lutein cyst (least common) – patient is primigravid so this is less likely
o Largest among the three
o Arise from prolonged stimulation of gonadotropins or HCG stimulation
 Large placenta, twins, diabetes, ovulation induction drugs,
hypothyroidism
o Thin walled, multilocular, anechoic

b. Endometrioma - aka chocolate cyst; less likely due to lack of symptoms and it is usually
bilateral.
o One of the most common causes of ovarian enlargement
o Usually bilateral
o Size: from small, superficial blue-black implants 1-5 mm in size to large, multiloculated
hemorrhagic cysts – 5-10 cm
o Dark brown, syrup-like
o Signs and symptoms:
 Asymptomatic
 Pelvic pain – most common (dysmenorrhea)
 Dyspareunia
  Infertility
o Tender, immobile ovaries secondary to dense adhesions

c. Ovarian neoplasms – mainly benign because of cystic characteristic

o Germ Cell Tumors – Most common: Dermoid cysts/Mature cystic teratoma and
Fibroma
d. Tubo-ovarian abscess – although this is easily ruled out since patient is asymptomatic
e. Paratubal cysts – highly likely due to its location

2. What laboratory and ancillary procedures will you request and rationale for each?
a. Transvaginal ultrasound – recommended imaging for a suspected or incidental finding of
adnexal mass, also for pattern recognition since some of the cysts and tumors have
characteristic ultrasound features
b. Color doppler – to evaluate vascular characteristics
o Improves specificity of ultrasound
c. Abdominal ultrasound
d. Pregnancy test
e. CBC – infectious in etiology, anemia can also be assessed and would matter for future
surgical management
f. Urinalysis – to rule out other non-gynecologic etiologies
g. Fecal blood testing – to rule out non-gynecologic etiologies
h. CA 125 – marker used for most ovarian tumors
i. Other serum biomarkers (AFP, LDH etc) and tumor markers such as CEA, HE4, CA 19-9,
etc – to further rule out malignancy or if other etiologies are highly considered and
assess need for referral to a gyne-oncologist
 3. Transvaginal ultrasound was done. What is your proposed management for the case?

ULTRASOUND
CERVIX 2.17 x 2.78 x 2.44 cm
UTERUS 5.83 x 4.82 x 5.01 cm
ENDOMETRIUM 1.4 cm; hyperechoic
RIGHT OVARY Not visualized
LEFT OVARY 3.3 x 2.69 x 3.08 cm.
OTHERS Within the right adnexa is a unilocular, cystic mass measuring 13.2 x 12.8
x 12.1 cm, with hyperechoic lines and dots within. Capsule is smooth
measures 0.2 cm.
IMPRESSION Average sized anteverted uterus,
Secretory phase endometrium.
Right adnexal mass probably ovarian, probably benign.
Normal sized left ovary.

MANAGEMENT:
o Surgical management: Cystectomy via laparotomy via midline vertical incision due to the
large dimension of the tumor
o If not surgically removed, annual transvaginal ultrasound is required.
4. Intraoperatively, cut section of the specimen is as follows. What is your diagnosis?

Mature Cystic Teratoma

o Contains components from the three germ layers

o Usually unilateral
o Asymptomatic
o Gross Features:
o Smooth and yellowish or pearly gray, doughly consistency, with both
cystic and solid component (tubercle of Rokitansky)
o Thick sebaceous fluid with tangled masses of hair, cartilage, bone, and
teeth
5. How will you differentiate benign from malignant tumors according to:
a. History

BENIGN
 Slow and progressive growth
rate
 May stop in growth or regress
 No constitutional symptoms
such as anorexia, weight loss
and cachexia
MALIGNANT
 Constitutional symptoms are
noted such as anorexia, weight
loss and cachexia
 Persistent bloating, generalized
abdominal pain, early satiety
 Unexplained weight loss
 Rapid growth rate
 Age in extremes are likely

b. Physical examination

BENIGN MALIGNANT
 Movable  Fixed due to adhesions
 Cystic  Lymphadenopathies are present
 Nontender – but not all the  Large size (more than 8mm
time would give you a suspicion that it
 Unilateral usually is malignant)
 No ascites  Solid
 Nodular
 Bilateral

Exceptions: Endometriomas and

tubo-ovarian abscesses are benign
lesions that may be fixed and
irregular

c. Laboratory
o Tumor markers would help in differentiang a benign from malignant such as the
following:
1. CA 125 – low specificity for detection of ovarian cancer; low specificity
since it is also elevated in many nonmalignant conditions specificity and
positive predictive value higher in postmenopausal women
2. Human epididymis protein 4 (HE4)
3. Carcinoembryonic antigen (CEA)
d. Ultrasound
INTERNATIONAL OVARIAN TUMOR ANALYSIS
e. Intraoperatively
BENIGN
 Well-circumscribed
 Encapsulated
 Thin capsule
MALIGNANT
 Poorly circumscribed due to
adhesions and invasion of
surrounding normal tissue
 Thick capsule
 Complex mass with both solid
and cystic components
f. Histologically

BENIGN MALIGNANT
 Usually well-differentiated  Exhibit morphologic alterations
components  Little to none differentiation
 Invasion to adjacent tissues
 Ability to metastasize
 Pleiomorphism and mitoses are
evident
 Large nuclear to cytoplasm ratio
approaching 1:1 instead of 1:3 or 1:4
 Loss of polarity
 Ischemic necrosis