BENIGN OVARIAN MASS

Dr. VIDHI CHAUDHARY

ASSISTANT PROFESSOR
OBS& GYNAE, LHMC, DELHI.
Ovarian masses are a common finding.
It is often difficult to clinically
differentiate between benign and
malignant conditions
Neoplasms constitute a significant
number, and most are benign.
CLASSIFICATION
FUNCTIONAL OVARIAN CYSTS INCLUDES:
a. Follicular cysts
b. Corpus luteum cysts
c. Theca luten cysts

BENIGN OVARIAN NEOPLASM
1. Serous cystadenoma
2. Mucinous cystadenoma
3. Endometrioma
4. Dermoid cysts
5. Fibroma

FUNCTIONAL CYSTS
- disruption of normal ovulation & altered
Angiogenesis
- derive mass from accumulation of
intrafollicular fluids rather than cellular
proliferation
- most common detected cysts in the
reproductive age group
- Usually asymptomatic
- Resolve spontaneously.
- surgical evaluation -required for persistent
cysts.



FOLLICULAR CYSTS

Follicular cysts -Hormonal dysfunction
prior to ovulation results in expansion of
the follicular antrum with serous fluid and
formation of a follicular cyst.


CORPUS LUTEUM CYST
Results from Hemorrhage inside a corpus luteum.
"great imitators"
Immediately following hemorrhage into its cavity,
the cyst appears echogenic and mimics a solid
mass.
reticular pattern develop
retracting clot -intramural nodule.
transvaginal color Doppler -brightly colored ring
because of increased surrounding vascularity k/a
ring of fire.


Theca luteal cysts
Result from over stimulation of the
ovary by HCG.
Common in molar pregnancy,
choriocarcinoma, IVF pregnancy

Risk Factors

Smoking- changes in gonadotropin
secretion and ovarian function .
progestin-only contraceptives
Tamoxifen- 15 to 30 percent

Symptoms

Asymptomatic.
Symptoms -pain and vague pressure
sensations are common.
acute severe pain ruptured corpus
luteum with hemorrhage.
Diagnoses

Pelvic examination-
mobile, cystic, nontender, and found
lateral to the uterus
Transvaginal Scan-rounded anechoic
lesions with thin, regular walls
TUMOR MARKERS- Detection of serum
beta hCG to differentiate ectopic
pregnancy or a corpus luteum of
pregnancy

Follicular cyst
smooth walls and lack of internal echoes.
Diffuse low level echoes
Reticular interfaces :resolving
hemorrhagic cyst
Theca lutein cysts
Management

Observation -spontaneously regress within
6 months of identification.
Post menopausal
-sonographic evidence of
1. thin-walled, unilocular cyst
2. (2) cyst diameter less than 5 cm
3. (3) no cyst enlargement during
surveillance
4. (4) normal serum CA125 levels

Management
OCP- unclear role.
Surgical Excision
- persistent cysts & >3 cm &> 5cm
diameter(premenopausal&
postmenopausal respectively)
Laparoscopic cystectomy.

Benign Neoplastic Ovarian
Cysts
Most common :
serous and mucinous cystadenomas
(surface epithelial neoplasia group)
mature cystic teratomas (germ cell)
Serous cystadenoma-
5% to 10% -borderline malignant potential
20% to 25% are malignant.
multilocular, with papillary components.
The surface epithelial cells secrete serous
fluid, resulting in a watery cyst content.
Psammoma bodies, (areas of fine calcific
granulation), if present can be seen on
radiograph.

Mucinous ovarian tumors-
grow to largesize.
bilateral in 10% .
5-10% are malignant.
They have lobulated, smooth surface,
multilocular, . Mucoid material is
present within the cystic loculations . It
is difficult to distinguish histologically
from metastatic gastrointestinal
malignancies.


6,810 grams, 20 cm X 40
cm
Benign serous
cystadenoma
Teratoma
Teratomas arise from a single germ cell.
can contain any of the three germ
layersectoderm, mesoderm, or
endoderm.
Types
a. mature b.immature
Mature teratoma
benign tumor
mature forms of the three germ cell
layers
(1) Mature cystic teratomas /benign
cystic teratoma /dermoid cyst
(2) Mature solid teratomas-elements
formed into a solid mass
Mature teratoma

(3) Fetiform teratomas or
homunculus.
(4) Monodermal teratoma-composed
one highly specialized tissue type.
Eg.thyroid tissue are termed struma
ovarii.

b. immature -This neoplasm is
malignant. Immature tissues from one,
two, or all three germ cell layers are
found and frequently coexist with
mature element.
Mature cystic teratomas
peak incidence -20 to 40 years ,pregnancy.
bilateral -10 percent .
10 to 25 percent of all ovarian neoplasms
60 percent of all benign ovarian
neoplasms
Malignant transformation -1 to 3 percent-
most common squamous cell carcinoma
80%, sarcoma
Mature cystic teratomas
Pathology Smooth walled,unilocular
with an area of localized growth that
protrudes into the cystic cavity.
Inner surface has a localized nodule, k/a
Rokitansky protuberance, composed of
adipose tissue (embryonal node)
Hair and fatty secretions +
Tumor Origin-genetic material
contained within a single oocyte

Diagnosis

Tip of the iceberg" echogenic interfaces of
fat, hair, and tissues in focus that shadow
and thus obscure structures behind it.
Fat-fluid or hair-fluid levels linear
demarcation where serous fluid interfaces
with sebum or hair.
Hairlines and dots.
Rokitansky protuberancehyperechoic, and
creates an acute angle with the cyst wall.


Mature cystic teratomas
Complications

-15 percent torsion.
-cyst rupture (rare)- acute granulomatus
peritonitis

Other benign tumors
Fibromas (a focus of stromal cells)-
associated with Meigs syndrome (pleural
effusion with benign pelvic tumors)
Pseudo-Meigs syndrome consists of
pleural effusion ,ascites, and benign
tumors of the ovary other than fibromas.
tumors of the fallopian tube or uterus
,mature teratomas and struma ovarii.

Treatment

SURGICAL EXCISION
-definitive diagnosis, affords relief of
symptoms, and prevents complications of
torsion, rupture, and malignant
degeneration.
ROUTE-laparoscopic or laparotomy/ minilap
LAPROSCOPY -increased rates of cyst
rupture with the risk for tumor spill and
malignant seeding .

Treatment

Surgery influenced by lesion size, age,
and intraoperative findings
-cystectomy preservation of
reproductive function
-oophorectomy- postmenopausal women
-Staging -Clinical findings of malignancy
RADIOLOGICAL FEATURES OF BENIGN
OVARIAN MASSES:

1. Unilocular
2. Smooth surface
3. No solid elements
4. No external or internal outgrowth
5. No ascites
6. Unilateral
7. Normal doppler flow
CA-125 in:
Leiomyoma
Endometriosis/adenomyosis
PID
Pregnancy
Malignancies-lung, breast, colon
Pancreatitis
Cirrhosis

Epithelial ovarian cancer, stage
1C
ovarian
capsule