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CLASSIFICATION OF OVARIAN TUMORS

BENIGN LESIONS OF THE OVARY

Symptoms commonly associated with a ovarian tumors:

- Pressure symptoms/pain
- Pelvic mass (abdominal, iliac, or hypogastric)
- Dysmenorrhea
- Asymptomatic (majority) -> reason why majority of ovarian tumors are diagnosed in the advanced stages

PHYSIOLOGIC/FUNCTIONAL CYSTS
Key features to remember:
1. Usually will not need surgery unless there are complications such as: torsion, leakage, or rupture
2. You do not see physiologic cysts in premenarchal & menopausal women because the cysts occur/grow within the menstrual cycle
o Follicular cysts: during follicular phase
o Corpus luteum cyst: after ovulation

Benign Lesion Description Characteristic Features Diagnosis Treatment

Follicular Cysts Most frequent cystic structure
in normal ovaries
May appear as translucent,
thin – walled, cyst filled with
clear to straw colored fluid
Depend on gonadotropins
for growth : due to excess
FSH
Most commonly found in young, menstruating women (rare in Usually discovered during ultrasound
childhood; high incidence in perimenarcheal period) of the pelvis
May result from 2 events:
1. Dominant mature follicle fails to rupture Characteristics suggesting
2. Immature follicle fails to undergo normal process of malignancy:
atresia - Septations
Majority are asymptomatic but may present with signs & - Internal papillations
symptoms of ovarian enlargement -> need to differentiate from a - Loculations
true ovarian neoplasm - Solid lesions/cystic lesions
with solid components
- Smaller cysts adjacent to or
part of the wall of the larger
cyst
- Bilaterality
- Free fluid in cul –de – sac
LDH levels: most promising marker to
differentiate benign vs malignant
disease
CA – 125: may be used to evaluate
cysts in pregnancy
- Must normalize beyond
12wks AOG
Initial management: conservative observation
because majority disappear spontaneously w/in 4 –
8 wks of initial diagnosis
Cystectomy and oophorectomy – operative
choices; usually indicated in persistent ovarian
masses
- Remove the cyst in peri/postmenopausal
if:
o CA – 125 is abnormal (>35)
o Large cyst (>10cm)
- Cystectomy (laparoscopic) may be done in
premenopausal women as long as they
fulfil the ff pre – op criteria:
o Premenopausal age
o Size is resectable
o Ultrasound characteristics:
nonadherent, smooth, thin –
walled, w/o papillae/internal
echoes
OCPs – can be given to px to remove gonadotropin
influence on cyst
- 80% disappear
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Corpus Luteum Only termed as cysts if at
Cysts least 3cm in diameter
Corpora lutea develop from
mature graafian follicles
Gives rise to symptoms similar to that of ectopic pregnancy Work ups: For unruptured CL cysts: conservative
May be associated with: 1. B-hCG to rule out ectopic If persistent cyst or w/ intraperitoneal bleeding:
- Normal endocrine function or, pregnancy Cystectomy
- Prolonged secretion of progesterone 2. TVUS
Hct > 15% in posterior cul – de – sac requires
Symptoms: dull, unilateral lower abdominal & pelvic pain Differential diagnosis for ruptured CL operative treatment
cyst:
Halban’s triad (also seen in ectopic pregnancy): Ectopic pregnancy
- Delay in normal period Ruptured endometrioma
- Spotting Adnexal torsion
- Unilateral pelvic pain

Women with bleeding diathesis or taking warfarin: at risk to

Theca Lutein Least common of the 3
Cysts
Usually associated with
gestational trophoblastic
disease (50% of molar
pregnancies; 10% of
choriocarcinoma)
develop hemorrhage from rupture of the CL cyst
- Bleeding usually occurs in day 20 – 26 of the cycle
Almost always bilateral & produce moderate to massive Presence established by palpation; Conservative – because they usually regress
enlargement of the ovaries (20 – 30cm) confirmed by ultrasound spontaneously
Arise from prolonged or excessive stimulation of the ovaries by If incidental finding during CS, do not attempt to
endogenous or exogenous gondatropins drain/puncture cyst -> may lead to hemorrhage that
is difficult to control
Hyperreactio luteinalis: ovarian enlargement secondary to
development of multiple luteinized follicular cysts (honeycomb
appearance)

Usually discovered in latter months of pregnancy often with

conditions that produce large placentas: twins, DM, Rh
sensitization

Luteoma of pregnancy: related to theca lutein cysts; not a true

neoplasm but a specific, benign, hyperplastic reaction of ovarian
theca lutein cells

BENIGN NEOPLASMS OF THE OVARY

BENIGN Features MALIGNANT
Slow Progression Rapid
Well – defined Definition of borders Ill – defined
Cystic Consistency Solid
Mobile Mobility Fixed
(-) Ascites (+)*
*Exception to the rule:
Meig’s Syndrome: the only benign tumor (solid tumor/fibroma) that is associated with ascites and hydrothorax
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1. Ultrasound
- Defines borders
- Consistency (solid vs cystic): the presence of white streaks may
suggest malignancy
Types of Ovarian Tumors - Absence/presence of fluid
1. Germ cell tumors – always consider this in a young patient - Color flow (shows vascularity of mass)
o Benign cystic teratoma (Dermoid cyst: most common) o If very vascular: implies a significant malignant tumor
2. Sassone scoring (based on inner wall structure, wall thickness, septa,
2. Epithelial tumors echogenicity)
o Serous cyst adenoma - >9 = malignant
o Mucinous cyst adenoma - < 9 = benign
o Endometrioma 3. Lerner scoring (based on Dra. Dee notes)
- >13 = malignant
3. Sex – cord/Gonadal stroma tumors - < 13 = benign

Benign Description Characteristic Features Diagnosis Treatment

Neoplasms
Dermoid Cyst Most common ovarian Often pedunculated -> makes ovary heavier than normal & Semisolid mass palpated anterior to Cystectomy with preservation of as much normal
neoplasm in prepubertal usually found in the cul – de – sac or anterior to the broad broad ligament ovarian tissue as possible
females; also common in ligament (laparoscopic cystectomy: 10cm diameter cut – off)
teenagers Xray: show pelvic calcifications
On palpation: have cystic & solid components; doughy If diagnosed during pregnancy: conservative mgmt
consistency Often an incidental finding in radiologic (surgery offers no benefit if the mass if <10cm); but
exam of GU or GI tract if surgery is needed, cystectomy is preferred.
50 – 60% asymptomatic
Presenting symptoms may include: pain and sensation of pelvic
pressure Characteristic ultrasound picture:
3 medical diseases associated: - Dense echogenic area within
- Thyrotoxicosis a larger cystic area
- Carcinoid syndrome - Cyst will w/ bands of mixed
- Autoimmune hemolytic anemia echoes
- Echoic dense cyst
Struma ovarii: teratoma in w/c thyroid tissue has overgrown other
elements & is the predominant tissue

Complications: torsion, rupture, infection, hemorrhage, malignant

degeneration
- Torsion: most frequent complication; associated with
being pedunculated
o More common in younger women
- Rupture or perforation: more common in pregnancy
o Most serious complication

Endometriomas May appear as small,
superficial blue black implants
(1 – 5mm) to large,
multiloculated, hemorrhagic
cysts (5 – 10cm)
Rare for large cysts to reach
15 – 20cm
Areas of ovarian
endometriosis are termed
endometriomas
One of the most common
causes of ovarian
enlargement
Fibroma Most common benign, solid
neoplasm of the ovary
Low malignant potential
Extremely slow growing
tumor
Arises from undifferentiated
fibrous stroma of the ovary
Transitional Cell Result from metaplasia of
Tumors – coelomic epithelium into
Brenner Tumors uroepithelium
Adenofibroma & Both consist of fibrous &
Cystadenoma epithelial (mostly serous)
components
- ovary
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Appear as chocolate cysts Ultrasound characteristics: Medical vs Operative Mgmt depends on:
Frequently bilateral - Thick – walled cyst - Patient’s age
Most women are asymptomatic - Homogenous echo pattern - Future reproductive plans
- If symptomatic, most common symptoms are: pelvic (echolucent) - Severity of symptoms
pain, dyspareunia, infertility (usually secondary to
inflammation & adhesions) Medical therapy is rarely successful in treating
Pelvic exam: tender & immobile ovaries (adherent to surrounding ovarian endometriosis
structures) Surgical therapy complicated by formation of de
novo & recurrent adhesions
Diameter is important because the incidence of ascites is directly Any woman with a solid ovarian tumor should
proportional to the size of the tumor undergo exploratory operation because a solid
- 50% of px with tumors >6cm will present with ascites tumor + ascites usually indicates a malignancy. So
you need to rule it out right away
Often seen in postmenopausal women
Meig’s syndrome: association of an ovarian fibroma, ascites, Simple excision is all that is needed.
and hydrothorax
- Resolve after removal of the ovarian tumor In postmenopausal women: bilateral salpingo –
- Not specific for fibromas; similar clinical picture may be oophorectomy + TAH
seen in other ovarian tumors
Bilateral ovarian fibromas seen in women with basal cell nevus
syndrome
Generally asymptomatic Often discovered incidentally during Operative procedure of choice: simple excision
- Large tumors may present with unilateral pelvic gynecologic surgery
discomfort
- Postmenopausal bleeding may be seen sometimes Histologic diagnosis
- Coffee bean nucleus
Usually occur in women ages 40 – 60 y/o
Unilateral 85 – 95% of the time
Grossly resemble fibromas; also slow growing
25% of the tumor consist of fibrous connective tissue Bilateral salpingo – oophorectomy + TAH (because
majority are found in postmenopausal women )
Adenofibromas
- Small fibrous tumors that arise from the surface of the In younger women: simple excision
- Bilateral (20 – 25%)
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- Usually in postmenopausal women

Seen under microscope as true cystic gland spaces lined by
cuboidal epithelium

Mucinous cystadenoma
- Endocervical glands secrete mucin
- Ascites
- Usually large
- US: multiloculated

Serous cystadenoma
- Fallopian tube
- Simple columnar epithelium
- Usually smaller
- US: unilocular

Complications
1. Torsion
o Important cause of acute lower abdominal & pelvic pain
 Usual presentation: acute, severe, unilateral lower abdominal & pelvic pain
 Fever indicates necrosis of the adnexa
o Most commonly, torsion of ovary & fallopian tube occur together
o Occurs most commonly during reproductive years (20s)
 In postmenopausal women, it is usually a complication of benign ovarian tumors
 Pregnancy: predisposing factor
o Most susceptible: ovaries enlarged due to ovulation induction during early pregnancy
o Most common cause of adnexal torsion: ovarian enlargement by an 8 – 12cm benign mass of the ovary
o Management:
 Conservative operation (young women):
 Laparoscope or via laparotomy -> gentle twisting of the pedicle, cystectomy and stabilization of the ovary with sutures
 If w/ severe vascular compromise: unilateral salpingo – oophorectomy
 Be careful in untwisting! There is a 0.2% risk of thromboembolism

2. Ovarian Remnant Syndrome

o Chronic pelvic pain secondary to a small area of functioning ovarian tissue following intended total removal of both ovaries
 Pelvic pain is usually cyclic and exacerbated by coitus
o Usually seen in women who had endometriosis or chronic PID and extensive pelvic adhesions
o If not palpable, TVUS or MRI may be helpful
 Premenopausal FSH/estradiol levels helps establish diagnosis in a px who has a history of bilateral salpingo – oophorectomy
o Management: Sources:
 Surgical removal of ovarian remnant via laparoscopy or laparotomy w/ wide excision of the mass Comprehensive Gyne 6th ed
 Recurrence rate: ~10% Dra. Punsalan’s lec
Dra. Dee notes 