BENIGN OVARIAN MASS

~ Dr. Siddhartha Majumder

Assistant Professor, Department of Obstetrics

and Gynaecology,
ESIC PGIMSR Medical College and Hospital,
Joka, Kolkata.
  ASFDASFAFDASDF
A 19 year old college student, Miss B
developed severe acute lower abdominal
pain while attending a lecture
demonstration session. She also vomited
once. She had noticed mild lower
abdominal distension during the past 6
months but had put it down to general
weight gain. Her teachers rushed her to
the emergency department at the
hospital.

Dr. Siddhartha Majumder 4/16/2020 2

 INTRODUCTION
 Occurs due to hormonal stimulation, neoplasm,
or other benign conditions.
 Cut off for diagnosing ovarian enlargement
varies with the menopausal status of the patient
as a post menopausal ovary undergoes atrophy
and is smaller.
(volume is 10-18mm pre menopausal and 3-8mm
in post menopausal)

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 BENIGN CONDITIONS CAUSING
OVARIAN ENLARGEMENT
 FUNCTIONAL CYSTS  Germ cell tumors
 Follicular cysts  Stromal tumors
 Corpus luteum  OTHERS
cysts  Endometrioma
 Theca lutein cysts PCOS (Polycystic
 Benign neoplasms ovarian syndrome)
 Epithelial cell OHSS (Ovarian
tumors hyperstimulation
syndrome)

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 Follicular cyst
 Most common functional cyst.
 Etiology- May be caused due to temporary
variation in gonadotrophin levels.
A normal follicle can develop into a cyst when it
fails to rupture or fail to undergoe atresia.
 Age group- adolescents, early reproductive age
group, perimenopausal women with anovulatory
cycles.

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 Clinical investigations- Usually asymptomatic ,
ruptures occasionally.
 Diagnosis is incidental- The size of the follicle
should be greater than 3cm to be called a follicular
cyst. Thin walled, unilocular, filled with straw
coloured fluid.
 Prognosis- May regress spontaneously in 4-6 weeks.

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 CORPUS LUTEUM CYSTS
 Etiology- When the corpus luteum persists after
ovulation and becomes cystic.
 Age group- Reproductive age group.
 Size- 3-10cm.
 Clinical features-
-Dull unilateral pelvic pain.
-May cause delay in menstruation or amenorrhea
by secreting progesterone.
-Rupture with haemoperitoneum is more common
and occurs between day 20 and 26 of the cycle.

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Diagnosis – Urine β-hCG level and TVS are useful. (mimics
ruptured ectopic pregnancy).

Treatment and Prognosis-

-Unruptured cysts are observed and regress spontaneously.
-Laparoscopic removal of ruptured cysts leaving behind normal
ovarian tissue.
[ Gross & cut section- Pink or haemorrhagic cyst. Cut section appears
yellowish orange filled with blood clots. Due to lutenisation of lining cells ]

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 Theca lutein cysts
 Least common functional cyst.
 Etiology-
- Due to excessive endogenous or exogenous(OHSS)
gonadotrophin secretion.
-Associated with molar pregnancy/ choriocarcinoma
(high hCG).
 Size-Large upto 30cm.
 Bilateral, multicystic.
 Clinical features-
-Smaller cysts are asymptomatic
-Large cysts produce discomfort, dull ache, feeling
of pressure.
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 Diagnosis- Ultrasonography
 Treatment and prognosis-

-Usually regress when the gonadotrophin levels decline.

-Occasionally undergo torsion or rupture.
-Conservative treatmentwith COC ( combinde oral
contraceptive) pills
[Gross & cut section- Greyish blue, honeycombed, straw coloured
fluid. Cysts are filled with straw coloured fluid or blood. ]
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 BENIGN OVARIAN
NEOPLASMS
Can arise from the ovarian surface epithelium, germ
cells, or stromal cells.
Surface Epithelium -
Cells covering the outer
lining of the ovaries.

Germ Cells - Cells that

are destined to form eggs.

Stromal Cells - Cells

that release hormones and
connect the different
structures of the ovaries.

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 WHO CLASSIFICATION OF
OVARIAN TUMORS
SURFACE EPITHELIAL GERM CELL TUMOR SEX CORD STROMAL
TUMOR TUMOR

MUCINOUS DYSGERMINOMA Sertoli leydig cell tumor

MIXED EPITHELIAL Endodermal sinus Fibroma
TUMORS Teratoma Thecoma
SEROUS Choriocarcinoma Granulosa theca cell tumor
BRUNNER
ENDOMETRIOD
CLEAR CELL

My Mothers’ Sister Begun Doctor Examined The She Felt Tad Good
Experiencing Cancer Cancer

Dr. Siddhartha Majumder 4/16/2020 12

 Benign epithelial tumours
 60% of all ovarian tumours are of epithelial
origin.
 Classified according to cell type.
 Can occur at all ages though certain types, cluster
around certain age groups.

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 Serous cystadenoma
 Most common benign epithelial tumour and is
bilateral in 10% of the cases.
 Age group- Reproductive years

[ Histopathological examination- Multiloculated

or uniloculated, papillary projections may be
present, lined by columnar/cuboidal epithelium,
filled with thin, clear, yellowish fluid. ]

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 Mucinous cystadenoma
 They are the second most common epithelial tumour (15-
20%). Bilateral in 5% of the cases.
 Age group- 30-50 years.
 Usually multiloculated.
 Size – can be large upto 30cm.
 [Histopathological examination: Surface of cyst wall is
smooth and papillary projection rare. It is lined by
columnar mucin-secreting epithelium. Cut section reveals
multiple locules, filled with thick mucinous fluid and can
be very large. (pseudomyxoma peritonei may result from
rupture). ]
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 Endometrioid cystadenoma
 Benign endometrioid cystadenoma is difficult to
distinguish from endometrioma. The lining cells
resemble that of the endometrium.
 Occurance- 5% of benign epithelial lesions.

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 Mesonephroid (Clear cell)
Tumors
 These are rare tumors, lined by clear cells with
abundant glycogen, called hobnail cells, and are
most often malignant.

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 Brenner (Transitional cell) tumors
 Rare tumors (2-3%).
 Age group- 50-70 years.
 Associated with serous/ mucinous tumours.
 Diagnosed incidentally.

[Histopathological examination- Small (<5cm),

solid, smooth, grey white. It is composed of
transitional cells and fibrous stroma. Cells have
‘coffee bean’ nucleus. ]

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 Germ cell tumours
 Benign (Mature) Cystic Teratoma (aka Dermoid cysts)
 Most common germ cell tumour. 40% of all ovarian tumors.
 Age group- mostly young (median 30years)

 Cystic tumours contain elements from all three germ cell

layers ectoderm, endoderm , mesoderm.
 Usually solid with cystic areas.
 Histopathological Examination- Benign teratomas are filled
with fat, float freely and are often found in the pouch of
Douglas or anterior to the uterus. They are usually filled with
thick, sebaceous material, hair, and contain teeth or cartilage.
 Clinical features- Asymptomatic, pressure feeling, dull ache.
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 Size- few cm to 25cm in size.
 Torsion- 10 %, rarely rupture, infection.
 Mostly asymptomatic.
 Ultrasound- cystic/solid, echogenic internal
components

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 Stromal tumours
 fibroma
 Most common benign solid tumors.
 Size- slow growing, upto 30cm large.
 Age group- post menopausal.
 Clinical features- small are asymptomatic and
large ones present with abdominal mass, feeling
of pressure or ascites.
[Combination of ovarian fibroma, ascites,
hydrothorax- Meig’s syndrome]

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  Thecoma
 Age group– Before 30 years
 Tumours are solid
 Endometrial hyperplasia and carcinoma can occur due to excess
oestrogen.
 Solid tumor
 adenofibroma/cystadenofibroma

 Fibrous and epithelial components.

 Age group - Post menopausal women
 Clinical features - Asymptomatic unless large.

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 Other tumours
 Endometrioma, PCOS and ovarian
hyperstimulation syndrome can be discussed in
other lectures.

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 CLINICAL FEATURES
 SYMPTOMS:
I. ASYMPTOMATIC
II. PAIN: dullache,acute severe
pain,torsion,rupture,hemorrhage,infection
III. ABDOMINAL MASS:
IV. MENSTRUAL DISTURBANCES: delayed
menses,amenorrhea,anovulatory cycles
V. DYSMENORRHEA,DYSPAREUNIA
VI. PRESSURE SYMPTOMS
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 CLINICAL EXAMINATION
 GENERAL EXAMINATION
 Signs of PCOS
 Hydrothorax
 Lymphadenopathy
 ABDOMINAL EXAMINATION (MASS)
 Location and size,consistency,mobility.arising from
pelvis/abdomen,ascitis
 PER SPECULUM EXAMINATION
 PELVIC EXAMINATION
 Mass felt through lateral fornix,mass in pouch of
Douglas, unilateral/ bilateral, mobility,consistency,
tenderness.
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 CLINICAL SIGNS OF BENIGN
OVARIAN ENLARGEMENT
 No weight loss/anorexia
 Age-young/reproductive
 Size- < 8 cm
 Mobile
 Cystic
 Regular and smooth
 No ascitis
 No lymphandenopathy
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 INVESTIGATIONS
 ULTRASONOGRAPHY FEATURES:
 Size < 5 cm
 Cystic lesions, loculi
 No solid areas
 No papillary excrescences
 Uniloculated
 Thin walled
 If multiloculated, thin septae (< 3mm)
 Unilateral
 No ascites/retroperitoneal nodes
 No metastasis
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 TUMOUR MARKERS:
 CA-125
 Used for epithelial tumours
 35U/ml used as cut off
 Elevated in endometriosis,PID,leiomyoma,genital
TB
 Cut off> 200 U/ml is used in premenopausal women
 ALPHA-FETOPROTEIN- GERM CELL
TUMOUR
 Beta-hCG
 Used for trophoblastic tumour, theca lutein cyst,
suspected ectopic pregnancy.
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 OTHER IMAGING
MODALITIES
 DOPPLERFLOW STUDIES- resistance index
A low resistance index of <0.40 is suggestive of
malignancy
 CT AND MRI is useful when malignancy is
suspected

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 RISK OF MALIGNANCY INDEX
(RMI SCORE)
CRITERIA SCORING
RMI score in ovarian SYSTEM
tumours is a validated MENOPAUSAL STATUS(A)
clinical tool used for risk PREMENOPAUSAL 1
stratification of ovarian POSTMENOPAUSAL 3
lesions to guide further ULTRASOUND
FEATURES(B)
management MULTILOCULATED No feature= 0
RMI SCORE> 200 is high
SOLID AREAS 1 feature=1
risk and needs referral to
BILATERAL >1 feature=3
specialist gynecology ASCITIS
cancer service with METASTASIS
staging CT scan. SERUM CA-125(C) Absolute level
RMI=A*B*C
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 MANAGEMENT
Management of women with asymptomatic benign neoplastic lesions
depends on :
AGE
MENOPAUSAL STATUS
SIZE OF MASS
SONOGRAPHIC MORPHOLOGY
TUMOUR MARKER LEVELS

Further management in pre and post

menopausal women are
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Management in premenopausal women
OVARIAN CYST

Cystic Simple cyst

Size: 5-8cm All other cysts
teratoma
Benign morphology
CA-125<200 U/ml

Laparoscopic Follow up 3-6 months Laparoscopy/Lap

surgery arotomy

Increase in size Symptomatic

Yes No

Laparoscopic
Follow up
cystectomy Dr. Siddhartha Majumder 4/16/2020 33
Management in postmenopausal
women OVARIAN CYST

Simple cyst
Size: 3-5cm
Benign morphology Size: >5cm
CA-125<35U/ml Morphology suspicious
Doppler RI>0.40 CA-125>35U/ml

Follow up 6 weeks
Laparotomy
Increase in size
CA-125 rising

Yes No

Laparotomy FollowDr.upSiddhartha Majumder 4/16/2020 34

 MANAGEMENTOF
SYMPTOMATIC CYSTS
 SURGICAL MANAGEMENT:
 ULTRASOUND GUIDED ASPIRATION- Procedure is of
limited use and is restricted to pregnant women with simple
cysts where aspiration helps in postponement of surgery till
delivery
 LAPAROSCOPIC SURGERY-
I. DIAGNOSTIC- Inspection of tumour , adhesions,
infiltration to other structures, peritoneal washing for
cytology, evaluation of other organs, inorder to exclude
malignancy
II. THERAPEUTIC- cyst aspiration,
cystectomy,oopherectomy/salpingo-oopherectomy. If found
to be malignant laparotomy is recommended.
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 CYST ASPIRATION- May be performed
under ultrasonographic guidance or
laparoscopic guidance if probability of
malignancy is low. This has the disadvantage
of spill of tumour cells if malignant and
reaccumulation of fluid. May be performed
prior to cystectomy to reduce the tumour size.
 OVARIAN CYSTECTOMY- Procedure of
choice in premenopausal women specially
when reproductive function is desired. Normal
ovarian tissue should be left behind

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 OOPHORECTOMY/SALPINGO-
OOPHORECTOMY - Entire ovary with the tumour
has to be removed if the woman is perimenopausal or
when the entire ovary is replaced by tumour with very
little or no visible normal ovarian tissue.
 LAPAROTOMY-It is required when malignancy is
suspected,when the tumour is large and multiloculated
or when tumour is solid.
 -Postmenopausal women with ovarian mass requiring
surgery are better managed by laparotomy.
-Tumour tissue must be sent for frozen section.
--Oophorectomy,salpingo-oopherectomy or
hysterectomy with bilateral salpingo-oopherectomy is
performed depending on age,histology and
menopausal status
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4/16/2020
 MANAGEMENT OF BENIGN
LESIONS OF OVARY
 FOLLICULAR/CORPUS LUTEUM CYSTS
 Observation
 Combined OC pills 3-6 cycles
o THECA LUTEIN CYSTS
 Evacuation of molar pregnancy
 Chemotherapy if required
o ENDOMETRIOMA
 Laparoscopic cystectomy
 Medical therapy
o POLYCYSTIC OVARIAN SYNDROME
 Combined OC pills
 Other medical therapy
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COMPLICATIONS OF
OVARIAN TUMORS
P- Pseudomyxoma peritoni
P

H- Haemorrhage
H

E- Extraperitoneal spread
E
R- Rupture
R

M- Malignancy
M
I- Infection
I

T- Torsion
Dr. Siddhartha Majumder 4/16/2020 T 39
“The world is going through a period of crisis, but
whether we look at it as a crisis or as an opportunity
to reshape our thinking, depends on us. So use this
period as a lesson on how to live life with a concern
for all of humankind.”

THANK YOU

Dr. Siddhartha Majumder 4/16/2020 40