BENIGN TUMOURS OF

THE OVARY
DR. KABIRU A. RABIU, M.B;B.S (Nig), FWACS, FMCOG, FMAS, Cert. Gyn.
Oncology
TYPES
 1. PHYSIOLOGICAL (FUNCTIONAL) CYSTS
 2. NON-FUNCTIONAL CYSTS
 3. BENIGN OVARIAN NEOPLASIA/
PHYSIOLOGICAL (FUNCTIONAL
CYSTS)
 Follicular cysts
 Corpus luteum cysts
 Theca lutein cyst.
 Luteoma of pregnancy
FEATURES OF FUNCTIONAL CYSTS
They are rarely complicated in appearance.
They are related to hormonal changes.
 Usually do not exceed 5cm in diameter.
 They are mostly unilocular and contain clear fluid.
FOLLICULAR CYSTS
• Commonest functional cysts
 Results from non-rupture of a dominant follicle/failure of atresia in a non-
dominantbfollicle
A follicle becomes a cyst when the diameter exceeds 3cm
 Can persist for several menstrual cycle s usually not exceeding 5 cm but may reach a
diameter of up to 10cm.
 Occasionally continue to produce oestrogen.
Usually assymptomatic and detection is accidental on bimanual examination,
sonography, laparoscopy or laparotomy
May however bleed, rupture, tort causing pain ± signs of peritoneal irritation
A simple cyst < 7cm, unilocular, echo free without solid areas or papillary projections
with normal serum CA 125 should be followed up with repeat ultrasound in 6 weeks as
cyst usually regresses.
Combined oral contraceptive pills (ovarian suppression) will prevent development of new
cysts
When cysts persists or increases in size, it should be removed by laparoscopy or
laparotomy
LUTEAL CYST
Due to overactivity of the corpus luteum when it fails to
regress after 14 days becoming cystic or haemorrhagic
Oestrogen and progesterone secretion continues
The menstrual cycle may be normal or there may be
amenorrhoea or delayed cycle
It is usually followed by heavy and/ or continued bleeding
Can be associated with pregnancy and usually disappears
around 12 weeks.
 Can cause rupture & intraperitoneal bleed especially on the
right due to the anatomy of the ovarian vein.
Management is similar to follicular cysts.
THECA-LUTEIN CYSTS
Due to atretic follicles stimulated by abnormal B-HCG levels
Usually bilateral
Associated with molar pregnancy, multiple gestation, diabetes,
ovulation induction with clomiphene citrate, hMG, hCG
Management is usually conservative
Cysts will regress as B-hCG falls
LUTEOMA OF PREGNANCY
Usually bilateral
Due to prolonged elevation of B-hCG
Associated with multiple pregnancy
Management is conservative
Regresses Postpartum
NON-FUNCTIONAL CYSTS
 Endometrioma
 Polycystic ovaries
 Inflammatory cysts
BENIGN OVARIAN NEOPLASIA
Epithelial tumours

Serous crystadenoma

Mucinous crystadenoma

Endometroid cystadenoma

Transitional(Brenner)

Clear cell tumour
Germ-cell tumours

Mature cystic teratoma(Teratoma)

Mature solid teratoma
Sex cord stromal tumours
Theca-cell tumour

Fibroma
Sertoli-Leydig cell tumour.
BENIGN OVARIAN NEOPLASIA CONTD
majority of ovarian tumours are epithelial in origin.
Arise from the ovarian surface epithelium
Most common in women over 40 years though they tend to occur at
a slightly younger age than their malignant counterparts
SEROUS CYSTADENOMA

Common-25% of all benign epithelial tumours. (commonest)

Bilateral in 20% of cases
 Usually unilocular and filled serous fluid and has papilliferous
processes on their inner surface.
Epithelium on inner surface is cuboidal or columnar and may be
ciliated
Shows presence of Psammona bodies which are areas of fine calcific
granulation, may be scattered within the tumour and may be visible
on radiograph
MUCINOUS CYSTADENOMA
Constitutes 15-25% of all ovarian tumours
Bilateral in 10% of cases
Second most common epithelial tumour
May typically reach a very large size
Typically unilateral
Typically multiloculated with smooth inner surface
Lining epithelium consists of columnar mucus-secreting cells and the cyst fluid is
generally thick and gelatinous
Associated with psedomyxoma peritonei:
 more often present before the cyst is removed rather than intraoperative rupture.
These are well differentiated carcinomas or borderline tumours which secrete mucin
 Even after removal of the tumour, they continue to secrete mucin.
 More commonly associated with mucous secretion of the appendix
 Synchronous tumours of the ovary and appendix are common
 Prognosis is poor
BRENNER TUMOURS
Account for only 1-2% of all ovarian tumours
Bilateral in 10-15% of cases
Resembles fibroma of the ovary
About half are incidental findings been recognised only by the pathologist
The tumour consist of islands of transitional epithelium (Walthard nests)
in a dense fibrotic stroma, giving a largely solid appearance
Majority are less than 2cm in diameter
Some secrete estrogen causing abnormal vaginal discharge
Pseudo-meigs syndrome can be seen
ENDOMETROID CYSTADENOMA
Difficult to differentiate from ovarian endometriosis

CLEAR CELL(MESONEPHROID) TUMOURS

 Arise from serosal cells
 Are only rarely benign
 Typical histological appearance is of clear or hobnail cells arranged in
mixed patterns
BENIGN GERM CELL TUMOUR-DERMOID CYST
(MATURE CYSTIC TERATOMA)
Commonest germ cell tumour
Commonest benign ovarian tumour in the reproductive age group but can also be seen in
post-menopausal women as well as new born girls
Commonest ovarian tumour in women below 30 years
Bilateral in 10% of cases
Commonest ovarian tumour complicated by torsion (risk of torsion is 15%)
Risk of malignancy is < 2% ( usually squamous cell carcinoma)
Usually contains derivatives of ectoderm, mesoderm and endoderm
Most common element is ectodermal ( present in 100% of cases)
Characteristically, they are unilocular cysts containing hair and cheesy sebaceous
material, teeth, bones, thyroid tissue and cartilage.
On cross section, they typically show an area of localised growth from which hair projects,
teeth and bone are seen. It is called Rokitansky protuberance or demoid process
Radiographic features: Plain radiograph may show calcific and tooth components within
the pelvis
MATURE SOLID TERATOMA

Rare
Contain mature tissues like Dermoid
cystic areas are also present.
 Must be distinguished from immature variety which is malignant.
BENIGN SEX CORD STROMA TUMOURS
• 4% of benign ovarian tumours,
• Occur at all ages-prepubertal to post-menopausal.
• Many are hormone-producing
• Manifest with inappropriate hormone effect
THECA CELL TUMOUR

Almost all are benign, solid and unilateral

 Usually presents in the 6th decade of life.
Oestrogen production to cause systemic effects: precocious puberty,
PMB, endometrial hyperplasia & endometrial Cancer
Rarely cause ascites/ pseudo-meigs syndrome
SERTOLI-LEYDIG CELL TUMOUR
Most found around 30 years of age
Very rare-0.2% of all ovarian tumours
Usually small and unilateral
Usually of low grade malignancy
Many produce androgen & signs of virilization
Few secrete oestrogen
FIBROMAS
Uncommon
Benign
Most frequent around 50 years of age
Hard, mobile and lobulated with glistening white surface
Meigs syndrome: Combination of fibroma, ascites and hydrothorax,
usually right sided. There is spontaneous remission of ascites and
hydrothorax on removal of the tumour.
Pseudomeigs syndrome: When ascites and hydrothorax occurs with
Brenner tumour, Thecoma, granulosa tumour or fibroids.
Complications of ovarian cysts
Torsion: Most common tumour to undergo torsion is the dermoid
cyst
Rupture: Most common with the corpus luteum cyst
Haemorrhage: Most common with the serous cystadenoma
Infection: Most common with the mucinous cystadenoma
Pseudomyxoma peritonei
Impaction in the pelvis
Malignant transformation
SYMPTOMS

Asymptomatic
Pain
Abdominal swelling
Pressure effects
Menstrual disturbances
Hormonal effects
DIFFERENTIAL DIAGNOSIS
Broad reflecting the wide range of presenting symptoms;
PAIN
Ectopic pregnancy
Spontaneous miscarriage
PID
Appendicitis
Meckel’’s diverticulum
Diverticulitis
ABDOMINAL SWELLING
Pregnant uterus,
Fibroid uterus
Full bladder
Distended bowel
Ovarian malignancy
Colorectal Cancer
Urinary tract infection
Constipation
 HORMONAL EFFECT
All other causes of precocious puberty,
irregular menses & PMBS
DIFFERENCES BETWEEN BENIGN AND MALIGNANT TUMOURS

Xteristics Benign Malignant

I. Size Usually <10cm Any size
II. No &constituency unilocular, cystic multilocular, solid or solid with cystic components
III. Borders Smooth,regular,well-defined Vague borders
IV. Laterality unilateral Bilateral
V. Mobility Mobile Fixed/adherent
VI. Growth rate Slowly enlarging Rapidly growing
VII. Ascites Usually absent Usually present
INVESTIGATIONS

I. LABORATORY TEST :
a. CBC, with WBC differentials to rule out infection(Gynea/Non-Gynae)
b. Beta-HCG
 To rule out cysts associated with pregnancy /ectopic pregnancy
 If levels are unusually high-?molar/choriocarcinoma
c. Gonnorhea/chlamydia screening when? Tuboovarian abscess or PID
d. Tumour markers
 Beta-HCG in molar pregnancy
CA-125 in epithelial ovarian tumuors
Alpha-FP- in germ-cell tumuors
LDH in Dysgerminoma
INVESTIGATIONS CONTD.
Ultrasonography:
Gives information about tumour volume, cyst wall. Septa and the
vascularity.
Presence of the ff Xteristics suggest high risk of malignancy:
Multilocular cysts, presence of solid areas, metastasis, ascites,
bilateral tumours and high blood flow on color doppler
CT
MRI
Plain abdominal X-ray : Finding of shadow of teeth or bone is a direct
evidence of dermoid cyst.
Laparoscopy: may be helpful when diagnosis is not clear and may
help to rule out ectopic pregnancy in ovarian accidents
MANAGEMENT OF OVARIAN MASS OR CYST IN
NON-PREGNANT FEMALES (SURGICAL
INDICATIONS)
Any ovarian mass which shows high risk features on USG
Any ovarian mass > 7 cm and adnexal mass > 10 cm irrespective of
age
Raised CA 125 levels in postmenopausal females
Acute complications of ovarian cysts
MANAGEMENT
MANAGEMENT IN PREGNANCY
MANAGEMENT IN PREGNANCY CONTD.
In case of complicated cyst, e.g., torsion
or rupture, do surgery irrespective of
size or gestational age
Risk of malignancy index
Risk of malignancy index- Interpretation
RMI < 25 = Low risk
RMI 25 – 250 = Moderate risk
RMI > 250 = High risk