Benign Gynecologic Lesions

MARLA A. LLANTO, MD
VULVA
 Urethral Caruncle

 small, fleshy outgrowth

of the distal edge of the
urethra.
 soft, smooth, friable,
and bright red
 initially appears as an
eversion of the urethra
 Urethral Caruncle

 Generally:
 Small single,sessile, may be pedunculated grow to be 1 to 2 cm in
diameter.

 occur most frequently in postmenopausal women

 believed to arise from an ectropion of the posterior

urethral wall associated with retraction and atrophy of
the postmenopausal vagina.

 growth secondary to chronic irritation or infection

 Urethral Caruncle

Histologically :

 transitional and stratified squamous epithelium with

a loose connective tissue
 Urethral Caruncle

 Symptoms
 Many:asymptomatic

 Others:
 dysuria, frequency, and urgency.
 spotting

 Diagnosis :
 Biopsy under local anesthesia.
 Urethral Caruncle

 Initial therapy :
 oral or topical estrogen and avoidance of
irritation.
 does not regress or is symptomatic
cryosurgery, laser therapy, fulguration, or
operative excision
 Urethral Caruncle

 Following operative destruction

 a Foley catheter should be left in place for 48 to 72 hours.

 Follow-up is necessary to ensure that the patient does not
develop urethral stenosis.

 Small, asymptomatic urethral caruncles do not

need treatment.
 Cyst

 The most common large cyst of the vulva is a

cystic dilation of an obstructed Bartholin’s duct.
 Cyst

 Treatment

 not necessary in women younger than 40 unless the cyst

becomes infected or enlarges enough to produce symptoms

 Asymptomatic cysts in premenopausal women :

 may be managed conservatively

 Treatment :
 excision with careful dissection to avoid urethral injury
 Cyst

 Epidermal inclusion cyst

 Sebaceous cyst
 Most common vulvar cyst

 Epithelial cyst
 located immediately beneath the epidermis
 on the anterior half of the labia majora
 usually multiple, freely movable, round, slow growing, and
nontender
 firm to shotty in consistency, and their contents are usually
under pressure
 Grossly, they are white or yellow, and the
contents are caseous, like a thick cheese.
 Cyst

 Inclusion cyst
 may develop following trauma when an infolding of
squamous epithelium has occurred beneath the epidermis in
the site of an episiotomy or obstetric laceration.
 Cyst

 Most require no treatment

 If infected: treatment consists of heat applied locally

and incision and drainage.

 If recurrently infected or produce pain

 excised when the acute inflammation has subsided
 Nevus

 “mole”
 localized nest or cluster of melanocytes
 undifferentiated cells arise from the embryonic
neural crest and are present from birth

 Vulvar nevi : one of the most common benign

neoplasms in females
 Nevus

 ranges from a few millimeters to 2 cm.

 Grossly: flat, elevated, or pedunculated.

 generally asymptomatic.
 Nevus

INTRADERMAL
Histologically:
lesions are subdivided
into three major groups:
•Junctional
•Compound COMPOUND
• intradermal

JUNCTIONAL
 Nevus

 vulvar area
 contains approximately 1% of the skin surface of the body
 5% to 10% of all malignant melanomas in women arise from this
region.

 It is estimated that 50% of malignant melanomas

arise from a preexisting nevus

 majority of women who develop melanomas :

 AGE: 50s
 Nevus

 Ideally, all vulvar nevi

DYSPLASTIC
should be excised and
examined histologically

 Special emphasis
should be directed
toward the flat
junctional nevus and CHARACTERISTICS:
more than 5 mm in
the dysplastic nevus diameter
 greatest potential for
malignant transformation irregular borders and
patches of variegated
pigment.
 Nevus

 Removal
 local anesthesia or coincidentally with obstetric delivery or
gynecologic surgery.

 Proper excisional biopsy

 should be three-dimensional and adequate in width and depth
 Approximately 5 to 10 mm of normal skin surrounding the nevus
should be included
 should include the underlying dermis
 Nevus

 Recent changes in growth or color,

ulceration,bleeding, pain, or the development of
satellite lesions  BIOPSY!

ABCD of an early malignant Melanoma :

Asymmetry,
Border irregularity
Color variegation
Diameter usually greater than 6 mm.
 Hemangioma

 rare malformations of blood vessels rather than true

neoplasms

 Vulvar hemangiomas

 frequently are discovered initially during childhood

 usually single, 1 to 2 cm in diameter,flat, and soft,
 range in color from brown to red or purple
 Hemangioma

 Histologically

 the multiple channels of hemangiomas are predominantly

thin-walled capillaries arranged randomly and separated by
thin connective tissue septa
 Hemangioma

 Most are asymptomatic

 occasionally they may become ulcerated and bleed
 Hemangioma

TYPES OF VULVAR HEMANGIOMAS

 Strawberry
 bright red to dark red, elevated
 rarely increases in size after age 2

 cavernous hemangiomas
 appear during the first few months of life and may increase in size until
age 2
 spontaneous resolution generally occurs before age 6

 Senile or cherry angiomas

 arise on the labia majora
 Postmenopausal women
 Hemangioma

 Pyogenic granulomas
 are an overgrowth of inflamed granulation tissue

 grow under the hormonal influence of pregnancy

 with similarities to lesions in the oral cavity

 usually approximately 1 cm in diameter

 Treatment
 wide and deep excision to prevent recurrence
 Hemangioma

 The diagnosis :gross inspection of the vascular lesion.

TREATMENT
 CHILDREN:
 Asymptomatic hemangiomas
 rarely require therapy

 ADULTS
 initial treatment :
 subtotal resectionLarge symptomatic hemangiomas that are bleeding or
infected

 differential diagnosis is questionable?  excisional biopsy

 cryosurgery or use of an argon laser

 associated with troublesome bleeding
 Fibroma

 most common benign

solid tumors of the
vulva

 occur in all age groups

 most commonly are

found in the labia
majora
 Fibroma

 grow slowly
 Size: vary from a few centimeters to one gigantic
vulvar fibroma reported to weigh more than 250
pounds.
 majority : between 1 and 10 cm in diameter
 have a smooth surface and a distinct contour
 Fibroma

 have a low-grade potential for becoming malignant.

 Smaller fibromas: asymptomatic

 larger ones: may produce chronic pressure
symptoms or acute pain (degeneration)
 Fibroma

Treatment
 operative removal if symptomatic or continue to grow

Occasionally they are removed for cosmetic reasons.

 Lipoma

 arebenign, slow-
growing,
circumscribed tumors
of fat cells arising from
the subcutaneous
tissue of the vulva
 Lipoma

 majority of lipomas in the vulvar region: <3 cm.

 The largest vulvar lipoma reported in the literature weighed 44
pounds

 second most frequent benign vulvar mesenchymal tumor

 most are discovered in the labia majora and are

superficial in location

 slow growing

 Low malignant potential

 Lipoma

 Excision
 performed to establish the diagnosis, although smaller tumors
may be followed conservatively
 Endometriosis

 Vulvar Endometriosis : rare

 Only 1 in 500 women with endometriosis

 few millimeters to several centimeters in diameter

 The subcutaneous lesions are blue, red, or purple,

depending on their size, activity, and closeness to the
surface of the skin.
 Endometriosis

 usually found at the site of an old, healed obstetric

laceration, episiotomy site, an area of operative
removal of a Bartholin’s duct cyst, or along the canal
of Nuck.
 Endometriosis

 The most common symptoms: pain and introital

dyspareunia.

 The classic history is cyclic discomfort and an

enlargement of the mass associated with menstrual
periods.
 Endometriosis

Treatment
 wide excision or laser vaporization depending on the
size of the Mass

 Recurrences are common following inadequate

operative removal of all the involved area.
VAGINA
 Urethral Diverticulum

 a permanent, epithelialized, saclike projection that

arises from the posterior urethra

 Often present as a mass of the anterior vaginal wall.

 Common problem, being discovered in

approximately 1% to 3% of women.
 Urethral Diverticulum

 majority of cases :initially diagnosed in reproductive-

age females,
 peak incidence in the fourth decade of life

 symptoms
 nonspecific

 identical to the symptoms of a lower urinary tract infection.

 Urethral Diverticulum

 Diagnos1s:
chronic or recurrent lower urinary tract symptoms

 Histologically :
 lined by epithelium; however, there is a lack of muscle in the
saclike pocket

 may be congenital or acquired

 Urethral Diverticulum

 Ginsburg and Genadry

 discovered that 90% : (+) symptoms of chronic lower urinary
tract infection as the presenting complaint
 Approximately 15% : (+)hematuria.

 Three Ds associated with a diverticulum:

 Dysuria

 Dyspareunia

 Dribbling of the urine

 Urethral Diverticulum

Diagnosis:
 most common methods
 voiding cystourethrography
 cystourethroscopy
 Others
 urethral pressure profile recordings

 transvaginal ultrasound

 computed tomography (CT) scans

 magnetic resonance imaging (MRI)

 positive-pressure urethrography
 Urethral Diverticulum

 Excisional surgery
 should be scheduled when the diverticulum is not acutely
infected

 Diverticula of the distal one third may be treated by simple

marsupialization
 Urethral Diverticulum

 The recurrence rate :10% and 20%

 many failures are due to incomplete surgical

resection.
 Inclusion Cyst

 most common cystic structures of the vagina

 Usually discovered in the posterior or lateral walls of

the lower third of the vagina

 Inclusion cysts vary from 1 mm to 3 cm in diameter

 Inclusion Cyst

 more common in parous women.

 Usually result from birth trauma or gynecologic

surgery.

 Often in the site of a previous episiotomy or at the

apex of the vagina following hysterectomy.
 Inclusion Cyst

Histologically

 lining: stratified squamous epithelium

 contain a thick, pale yellow substance that is oily and

formed by degenerating epithelial cells
 Inclusion Cyst

 majority of inclusion cysts are asymptomatic

 If the cyst produces dyspareunia or pain, the

treatment is excisional biopsy.
 Dysontogenetic Cysts

 thin-walled, soft cysts of embryonic origin.

 mesonephros (Gartner’s duct cyst)

 perimesonephrium (müllerian cyst)
 urogenital sinus (vestibular cyst)
 The cysts may be differentiated histologically by the
epithelial
 Most mesonephric cysts have cuboidal, nonciliated epithelium.
 Most perimesonephric cysts have columnar, endocervical-like
epithelium.
 Dysontogenetic Cysts

 The cysts may be differentiated histologically by the

epithelial lining

 Most mesonephric cysts have cuboidal, nonciliated

epithelium.

 Most perimesonephric cysts have columnar,

endocervical-like epithelium
 Dysontogenetic Cysts

 Size: approx. 1 to 5 cm in diameter and are usually

discovered in the upper half of the vagina

 Incidence: 1 in 200 females

 Dysontogenetic Cysts

 Gartner’s duct cysts may be followed conservatively.

 Operative excision is indicated for chronic
symptoms.
 marsupialization of the cyst is preferred – if infected
Cervix
 Endocervical and Cervical Polyps

 are the most common benign neoplastic growths of

the cervix.

 Polyps may arise from

 endocervical canal (endocervical polyp)

 ectocervix(cervical polyp)

Endocervical polyps are more common than are cervical polyps.

 Endocervical polyps

 Endocervical polyps :most common in multiparous

women in their 40s and 50s.
 may be single or multiple
 a few millimeters to 4 cm in diameter.
 The stalk of the polyp is of variable length and width
 Endocervical and Cervical Polyps

 Cervical polyps usually

present as a single polyp,
but multiple polyps do occur
 have a short, broad base and
usually occur in
postmenopausal women.

 Occasionally. The majority are

smooth, soft, reddish purple to
cherry red, and fragile. They
readily bleed when touched.
 Endocervical and Cervical Polyps

 origin: they are usually secondary to inflammation or

abnormal focal responsiveness to hormonal
stimulation.

 The classic symptom

 intermenstrual bleeding, especially following contact such as
coitus or a pelvic examination.
 Leucorrhea (Sometimes)
 Endocervical and Cervical Polyps

 Six different histologic subtypes have been

described:
 Adenomatous- >80%
 Cystic
 Fibrous
 Vascular
 Inflammatory
 fibromyomatous.
 Endocervical and Cervical Polyps

 Most endocervical polyps may be managed in the

office by grasping the base of the polyp by clamp

 The polyp is avulsed with a twisting motion and sent

to the pathology laboratory for microscopic
evaluation.
 Endocervical and Cervical Polyps

 If the base is broad or bleeding ensues, the base may

be treated with chemical cautery, electrocautery, or
cryocautery.
 Nabothian Cysts

 retention cysts of endocervical columnar cells

occurring where a tunnel or cleft has been covered by
squamous metaplasia.
 Grossly: cysts may be translucent or opaque whitish
or yellow in color.
 Microscopic to macroscopic size
 majority between3 mm and 3 cm in diameter
 asymptomatic
 no treatment is necessary
 Cervical Myomas

 Cervical myomas are smooth, firm masses that are

similar to myomas of the uterine fundus
 A cervical usually a solitary growth
 3% to 8% of myomas
 Cervical Myomas

 majority of myomas that appear to be cervical

actually arise from the isthmus of the uterus.
 Cervical Myomas

 small and asymptomatic

 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.

 prolapsed myomas are often ulcerated and infected.

 Cervical Myomas

 diagnosis
 inspection and palpation
 Cervical Myomas

 Management :
 asymptomatic: small myomas  observed for rate of
growth
 Gonadotropin-releasing hormone (GnRH) agonists
 myomectomy
 hysterectomy
 radiologic catheter embolization
Uterus
 Endometrial Polyps

 localized overgrowths of endometrial glands and

stroma that project beyond the surface of the
endometrium.
 soft, pliable and may be single or multiple.
 Most arise from the fundus of the uterus

 Sessile: have a broad base

 Pedunculated: attached by a slender pedicle
 Endometrial Polyps

 Polypoid hyperplasia
 benign condition in which numerous small polyps are
discovered throughout the endometrial cavity
 Endometrial Polyps

Novak and Woodruff’s

 review of 1100 women with polyps
 the growths were discovered in all age groups
 peak incidence: between the ages of 40 and 49
 prevalence of endometrial polyps in reproductive-age women
is 20% to 25%
 approximately 10% of women has endometrial polyp when the
uterus is examined at autopsy.
 Endometrial Polyps

 cause : unknown
 unopposed estrogen may be one cause

 majority are asymptomatic

 (+) 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.
 Endometrial Polyps

Grossly:
 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.
 Endometrial Polyps

 Histologically,
 three components:
endometrial glands,
endometrial stroma, and
central vascular channels
 Endometrial Polyps

 Malignant transformation - 0.5%.

 Endometrial Polyps

 Optimal management of endometrial polyps is

removal by hysteroscopy with D&C
 Leiomyoma

 A.K.A myomas
 are benign tumors of muscle cell origin
 Most contain varying amounts of fibrous tissue
 believed to be secondary to degeneration of some of the
smooth muscle cells
 Leiomyoma

 Leiomyomas are the most frequent pelvic tumors in

women
 highest prevalence occurring during the fifth decade
of a woman’s life
 Leiomyoma

Prevalence
 vary
 African-American women
 White women
 perimenopausal women

 third of myomas will become symptomatic

 prone to grow and become symptomatic in
nulliparous women.
 Leiomyoma

 Symptomatic uterine leiomyomas

 primaryindication for approximately 30% of all
hysterectomies
 Leiomyoma

Risk factors
 increasing age
 early menarche
 low parity
 tamoxifen use
 obesity
 African-American women( highest incidence)
 familial tendency
 Smoking has been found to be associated with a
decreased incidence of myomata
 Leiomyoma

The three most

common types
 intramural
 Subserous
 Submucous

 broad ligament and

parasitic myomas
 Leiomyoma

Submucosal tumors

 -5% to 10% of myomas

 most troublesome clinically
 associated with abnormal
vaginal bleeding or
distortion of the uterine
cavity that may produce
infertility or abortion
 enlarges and becomes
pedunculated.uterus will
try to expel it  prolapse
 Leiomyoma

Subserosal myomas
 give the uterus its
knobby contour during
pelvic examination.
 Further growth may lead
to a pedunculated
myoma wandering into
the peritoneal cavity
 Leiomyoma

 Only 25% of tumors extend beyond the broad

ligament – intraligamentary myoma

Parasitic myoma
 outgrow its uterine blood supply
 obtain a secondary blood supply from another organ,
such as the omentum
 Adenomyosis

 “endometriosis interna”
 derived from aberrant glands of the basalis layer of
the endometrium
 do not usually undergo the traditional proliferative
and secretory changes that are associated with cyclic
ovarian hormone production
 found in up to 60% of hysterectomy specimens in
women in the late reproductive years
 greater than 50 %: asymptomatic
 Adenomyosis

 histogenesis :direct
extension from the
endometrial lining

 associated with
 increased parity
 uterine surgeries
 traumas
 Adenomyosis

Pathogenesis
 unknown
 theorized to be associated with disruption of the
barrier between the endometrium and myometrium
as an initiating step.
 Adenomyosis

Pathology
 diffuse involvement of both
anterior and posterior walls
of the uterus- most common

 posterior wall > anterior wall

 focal area or adenomyoma

 asymmetrical uterus
 pseudocapsule
 Adenomyosis

hyperplasia and hypertrophy

of individual muscle fibers

globular enlargement of the

uterus
 Adenomyosis

Histologic Examination :

 benign endometrial glands, and stroma are within

the myometrium

 standard criterion used in diagnosis of adenomyosis

 finding of endometrial glands and stroma more than one low-
powered field (2.5 mm) from the basalis layer of the
endometrium
 Adenomyosis

Clinical Diagnosis
 classic symptoms
 secondary dysmenorrhea and menorrhagia
 dysmenorrhea becomes increasingly more severe as the disease
progresses.

 pelvic examination
 uterus is diffusely enlarged (2-3X LARGER)

 The uterus is globular and tender immediately before

and during menstruation
 Adenomyosis

Diagnosis

 retrospectively
 Adenomyosis

Diagnosis
 Transvaginal
ultrasonography
 sensitivity between 53%
and 89%
 a specificity of 50% to
89%
 MRI
 more sensitive, ranging
between 88% and 93%
 higher specificity (66% to
91%)
 Adenomyosis

Management

 no satisfactory proven medical treatment for

adenomyosis

 GnRH agonists, cyclic hormones, or prostaglandin

synthetase inhibitors
 Hysterectomy :definitive treatment

 For the woman in her late 40s, the ovaries are often
removed as a risk-reducing measure against ovarian
carcinoma.
OVIDUCT
 Adenomatoid Tumors

 The most prevalent benign

tumor of the oviduct
 small, graywhite,
circumscribed nodules, 1 to 2
cm in diameter
 unilateral and present as
small nodules just under the
tubal serosa
 Adenomatoid Tumors

 (-)pelvic symptoms or signs

 also found below the serosa of the fundus of the

uterus and the broad ligament
 Adenomatoid Tumors

 Microscopically
 composed of small tubules
lined by a low cuboidal or
flat epithelium.

 Histologic studies
 established that the thin-
walled channels that
comprise these tumors are
of mesothelial origin
 Paratubal Cysts

 frequently incidental discoveries during gynecologic

operations for other abnormalities
 often multiple and may vary from 0.5 cm to more
than 20 cm in diameter
 Paratubal Cysts

 majority :small,
asymptomatic, and slow
growing
 third and fourth decades
of life
 Hydatid cysts of
Morgagni : pedunculated
paratubal cysts and near
the fimbrial end of the
oviduct
 Paratubal Cysts

 are thin-walled and smooth and contain clear fluid.

 When symptomatic
 produce a dull pain

 Treatment : simple excision.

OVARY
 FUNCTIONAL CYST

 FOLLICULAR CYST
 CORPUS LUTEUM CYST
 THECA LUTEIN CYST
 Functional Cysts

Follicular Cysts
 most frequent cystic structures in normal ovaries
 multiple and may vary from a few millimeters to as
large as 15 cm in diameter.
 A minimum diameter to be considered as a cyst is generally
considered to be between 2.5 and 3 cm
 not neoplastic
 dependent on gonadotropins for growth
 Follicular cysts

 are translucent, thin-walled, filled with a watery,

clear to straw-colored fluid
 situated in the ovarian cortex
 sometimes appear as translucent domes on the
surface of the ovary
 Follicular cysts

 may result from either the dominant mature

follicle’s failing to rupture (persistent follicle)
 or an immature follicle’s failing to undergo the
normal process of atresia.
 Follicular cysts

 The majority are

asymptomatic and are
discovered during ultrasound
imaging of the pelvis or a
routine pelvic examination
 Thin: may rupture during
examination.
 The patient may experience
tenesmus, a transient pelvic
tenderness, deep
dyspareunia, or no pain
whatsoever
 Follicular cysts

 initial management :conservative observation.

 majority disappear spontaneously by either

reabsorption of the cyst fluid or silent rupture within
4 to 8 weeks of initial diagnosis.

 Persistence:  operative intervention to

differentiate a physiologic cyst from a true neoplasm of
the ovary
 Follicular cysts

 cyst should be removed if there is any

suspicion of malignancy.

CA-125
 helpful in evaluating the adenexal mass in
postmenopausal women
 In premenopausal women, rarely helpful unless the
mass is extremely suggestive of malignancy
 Follicular cysts

Surgical!
 CA-125 is abnormal (>35)
 or if the cyst is persistent or large (>10 cm)
 Corpus Luteum Cysts

 may be associated with

either normal endocrine
function or prolonged
secretion of progesterone
 Grossly
 they have a smooth
surface, purplish red to
brown
 Cut Section
 the convoluted lining is
yellowish orange
 the center contains an
organizing blood clot
 Corpus Luteum Cysts

 Produce dull, unilateral, lower abdominal and pelvic

pain.

 enlarged ovary is moderately tender on pelvic

examination

 menstrual bleeding may be normal or delayed

several days to weeks with subsequent menorrhagia
 Depending on the amount of progesterone secretion associated
with cysts,
 Corpus luteum cysts

Halban’s classic triad

1. delay in a normal period/spotting

2. unilateral pelvic pain
3. small, tender, adnexal mass
 Corpus luteum cysts

 may cause intraperitoneal bleeding

 often follows coitus, exercise, trauma, or a pelvic examination.

 Bleeding occurs usually between days 20 and 26 of

the cycle

 Oral contraceptives
 used to suppress ovulation and avoid recurrent
hemorrhage
 Corpus luteum cysts

Cystectomy
 Operative treatment of choice, with preservation of
the remaining portion of the ovary
 Theca Lutein Cysts

 least common of the

three types of physiologic
ovarian cysts
 almost always bilateral
 produce moderate to
massive enlargement of
the ovaries
 Theca Lutein Cysts

Causes
 prolonged or excessive stimulation of the ovaries by
endogenous or exogenous gonadotropins
 increased ovarian sensitivity to gonadotropins.

Hyperreactio luteinalis(Development of multiple luteinized

follicular cysts)  ovarian enlargement

 50% of molar pregnancies and 10%of choriocarcinomas

 (+) bilateral theca lutein cysts
 Theca Lutein Cysts

Grossly
 external surface of the ovary appears lobulated.
 The small cysts contain a clear to straw-colored or
hemorrhagic fl uid.

Histologically
 lining
 composed of theca lutein cells (paralutein cells), believed to
originate from ovarian connective tissue
 luteinization of granulosa cells
 Theca Lutein Cysts

 The presence of theca lutein cysts

 palpation

 confirmed by ultrasound examination

Treatment
 conservative
Benign Neoplasms of the
Ovary
 Benign Cystic Teratoma
(Dermoid Cyst, Mature Teratoma)

 cystic structures
 histologic examination: contain elements from all
three germ cell layers

 Teratoma A.K.A. “monstrous growth.”

 may be benign or malignant
 Benign Cystic Teratoma/Dermoid

 benign cystic tumor

 composed of mature cells
 malignant variety is composed of immature cells (immature
teratoma)
 preponderance of ectodermal tissue with some
mesodermal and rare endodermal derivatives
 Benign Cystic Teratoma

 Among the most common ovarian neoplasms

 account for more than 90% of germ cell tumors of
the ovary.
 20% to 25% of all ovarian neoplasms
 33% of all benign tumors
 Benign Cystic Teratoma

 most common ovarian neoplasm in prepubertal

females and teenagers
 25 -50 years – 50%
 Bilaterality: 10% to 15%
 Benign Cystic Teratoma

 unilocular
 The walls of the cyst are a
smooth, shiny, opaque
white color
 Cut Section:
 thick sebaceous fluid pours
from the cyst, often with tangled
masses of hair and fi rm areas of
cartilage and teeth
 Benign Cystic Teratoma

 50% to 60% asymptomatic

 Presenting symptoms : pain and the sensation of
pelvic pressure

Complications
 torsion
 rupture
 Infection
 Hemorrhage
 malignant degeneration.
 Benign Cystic Teratoma

 chromosomal makeup of 46,XX

 tubercle of Rokitansky
 protrusion or nipple (mamilla) in the cyst
 Benign Cystic Teratoma

Three medical diseases also may be associated with

dermoid cysts:

 thyrotoxicosis
 carcinoid syndrome
 autoimmune hemolytic anemia

 Struma Ovarii – contains thyroid tissues

 2-3% of teratomas
 Benign Cystic Teratoma

 The diagnosis of a dermoid cyst is often established

when a semisolid mass is palpated anterior to the
broad ligament
 Approximately 50% of dermoids have pelvic
calcifications on radiographic examination
 Benign Cystic Teratoma

ultrasound picture

 Dense echogenic area

within a larger cystic
area
 a cyst filled with bands
of mixed echoes
 an echoic dense cyst
 Benign Cystic Teratoma

Operative treatment
 cystectomy
 with preservation of as much normal ovarian tissue as possible
 Laparoscopic cystectomy
 Benign Cystic Teratoma

 If a teratoma is diagnosed incidentally during

pregnancy
 removal in the second trimester
 Dermoids have a higher incidence of torsion and potential for
rupture during pregnancy.
 Fibroma

 most common benign, solid neoplasms of the ovary

 Low malignant potential: <1 %
 approximately 5% of benign ovarian neoplasms
 approximately 20% of all solid tumors of the ovary
 Fibroma

 extremely slow-growing tumors

 vary in size from small nodules to huge pelvic tumors
weighing 50 pounds.
 incidence of associated ascites is directly
proportional to the size of the tumor
 Fibroma

 90% - unilateral
 Average age – 48 y/o
 Fibroma

 Pelvic symptoms
 pressure and abdominal enlargement

 there is no change in the pattern of menstrual flow

Meigs’ syndrome
 2% of ovarian fibroma
 ovarian fibroma, ascites, and hydrothorax
 ascites and the hydrothorax resolve after removal of the
ovarian tumor
 Fibroma

Grossly
 heavy, solid, well
encapsulated,
grayish white

Cut surface
 Homogeneous white or
yellowish white solid tissue
with a trabeculated or
whorled appearance
 Fibroma

Histologically
 composed of connective tissue (spindle- shaped
mature fibroblasts), stromal cells, and varying
amounts of collagen interposed between the cells
 Fibroma

Management
 Simple Excision

 Always differentiate with ovarian carcinoma

 Endometriomas

 One of the most common causes of ovarian

enlargement
 Vary from small (few mm) to 5-10 cms in dm
 Most are asymptomatic
 Symptoms:
 Pelvic pain
 Dyspareunia
 infertility
 Endometriomas

 UTZ
 Thick walled cyst with
relatively homogenous
echopattern
 Endometriomas

 Pelvic examination
 Ovaries are tender and
immobile

 Histology
 Endometrial glands
 Endometrial stroma
 Hemosiderin – laden large
phagocytic cells
 Cut section
 Thick walled
 Chocolate – like fluid

(Chocolate cyst)
 Transitional cell Tumor – Brenner Tumor

 Small, smooth, solid,  <5 cm in dm

fibroepithelial tumors  85-95 % unilateral
 Asymptomatic  Classified as epithelial
 Benign, proliferative(low tumor
Malignant potential,  Estrogen- producing 
Malignant) – 2% of endometrial hyperplasia,
ovarian tumors postmenopausal bleeding
 40-60 y/0  1-2% malignant
 30% - with concurrent transformation
serous or mucinous
tumor
 Transitional cell Tumor – Brenner Tumor

 UTZ
 Extensvie amorphous
calcifications within the
solid components of the
mass
 Transitional cell Tumor – Brenner Tumor

 Grossly
 Smooth, firm, gray –
white solid tumors which
resemble fibroma
 Occasionally – yellowish
tinge with small cystic
spaces
 Transitional cell Tumor – Brenner Tumor
 Histologically
 Nest of epithelial cells
surrounded by fibrous
stroma

Coffee- bean appearing

nucleus in the epithelial
cells
 Adenofibroma and Cystadenofibroma

 Benign firm tumors that  Usually occur in

arise form the surface of postmenopausal
the ovary  Bilateral – 20-25%
 Fibrous and epithelial  1-15 cm in dm
component
 Mostly serous epithelial
component
 Preponderance of
connective tissue (25%)
 Adenofibroma

 Grossly  Histologically
 Gray or white tumors with  True cystic gland spaces
cystic spaces lined by cuboidal
epithelium with abundant
fibrous connective tissue
surrounding the the cytic
spaces
 Adenofibroma and Cystadenofibroma

 Management
 TAHBSO
 OVARIAN/ADNEXAL TORSION

 Important cause of acute lower abdominal and pelvic

pain
 Occurs commonly in patients in mid – 20s
 Common with masses 8-12 cms
 Right >left
 OVARIAN/ADNEXAL TORSION

 S/Sx:
 Acute, severe, unilateral, lower abdominal and pelvic pain

 Nausea and vomiting

 Fever

 Leukocytosis
 • Venous and lymphatic obstruction
• Cyanotic and edematous ovary
Initially • Unilateral extremely tender adnexal mass

• Interruption of major arterial blood supply

• Hypoxia, adnexal necrosis
Progressive • Low grade fever, leukocytosis
torsion
 DDx:
 Ruptured corpus luteum cyst

 Adnexal abscess
 Management
 Salpingoophorectomy

 Cystectomy

 Pulmonary embolism – 0.2% risk

Thank you!!!