Benign Ovarian Neoplasms Dr H.K.Cheema- M.D(OBG).A.C.M.E.(2017)FAIMER FELLOW(2019) Professor-OBG, Punjab Institute Of Medical Sciences,Jalandhar

3. Variation in dimensions, in reproductive age group, can result
• Endogenous hormonal production(varies with age & menstrual cycle)
• Exogenous substances, including OCs, GnRH agonists, or
ovulation-inducing medication, may affect size.
Ovary Normal ovary Menopausal ovary
Size 3x2x1 Cm3 2x1.5x1cm3
Volume 10cm3 3cm3

4. OVARIAN
MASSES
FUNCTIONAL INFLAMMATORY NEOPLASTIC OTHERS
FOLLICULAR CYST
CORPUS LUTEUM
CYST
THECA LUTEIN C.
TUBO OVARIANABSCESS BENIGN
BORDERLINE
MALIGNANT
ENDOMETRIOMA
PCOS
PARVARIAN CYST

5.  Functional Cysts
 1. Follicular cyst
 2.Corpus luteal cyst
 3.Theca lutein cyst
 Benign Neoplasm
 1.Epithelial cell tumors
 2. Germ cell tumours.
 3. Sex chord stromal tumours.
 Others
 1.Endometrioma
 2.PCOS
 3.OHSS

6. Functional ovarian cysts
Follicular cysts
Corpus luteum cysts
Theca lutein cysts
Luteomas of pregnancy
By far the most common clinically detectable enlargements of
the ovary in the reproductive years.
All are benign and usually asymptomatic.

7. Follicular cysts
Cystic follicle is defined as Follicular cyst of diameter > 3cm
Most common functional cysts, may produce OESTROGEN
Rarely larger than 8cm.(Temporary hormone imbalance)
Lined by granulosa cells, unilocular, straw- colored fluid
Found incidentally on pelvic examination,
Symptoms, associated pathology
Usually resolve within 4 – 8 weeks with expectant management
May rupture or may have torsion occasionally causing pain and peritoneal
symptoms.

8. Follicular cyst

9. Follicular cyst-Gross Exam

10. Follicular cysts

11.  < 3 cm.—no further investigations
 < 7 cm., uni-locular, without solid area
 /papillary projections & CA 125-Normal
 =follow up repeat USG 3-6 months
 > 7cm ,Persistent/ grows
 Rx= Surgery (laprotomy/ laproscopy)
 Operation= Ovarian Cystectomy
Management of Follicular O.Cyst

12. Corpus luteal cyst
After ovulation, bleeding in corpus luteum, size 3-10cm.
In reproductive age group, may produce PROESTRONE.
(delayed menses, amenorrhea followed by heavy bleeding.
dull ache or unilateral pain)
Cut section=yellowish orange filled with blood clots
Regress spontaneously, asymptomatic, observe,
can present in pregnancy upto 12 weeks
Unruptured cysts may cause pain because of bleeding into enclosed ovarian
cyst cavity
May rupture leading to hemoperitoneum and requiring surgical
management== simulates ectopic pregnancy—Rx-laprotomy

14. Corpus luteal cyst

15. Theca lutein cysts
 Result from overstimulation of the ovary by chorionic
Gonadotrophins { β- hCG }
 Usually bilateral
 Often associated with hydatidiform moles, choriocarcinoma,
 multiple gestations.
 Ovulation induction drugs use of clomiphene (OHSS)
and Gonadotrophins.
 May be quite large (up to 30 cm) , multicystic, and
regress spontaneously.-conservative Rx.

16. Theca lutein cysts

17. Endometriomas
Most common site of involvement is the ovary.
Endometriomas are pseudocysts formed by invagination of the ovarian
cortex, sealed off by adhesions.
They may completely replace normal ovarian tissue. Cyst walls are usually
thick and fibrotic.
USG: anechoic cysts to cysts with diffuse low-level echoes to solid-
appearing masses.
Fluid–fluid or debris–fluid levels may also be seen.
They may be unilocular or multilocular with thin or thick septations
Malignant transformation: 0.3% to 0.8%
Management: medical and/ or surgical

19. .
In pre-menarchal girls and post-menopausal women adnexal
massshould be considered highly abnormal – requires
immediate investigation.
In menstruating patients differential diagnosis is varied.

20. Lifetime Risk of ovarian neoplasm
A woman has 5–10% lifetime risk of undergoing surgery
for a suspected ovarian neoplasm and
13–21% of these will be found to be have an ovarian
malignancy

21. Management of functional cysts
Expectant
Watchful waiting for two or three cycles is appropriate.
Combined oral contraceptives appear to be of no benefit.
Should cysts persist, surgical management is often
indicated.
Oral contraceptives for functional ovarian cysts(Review)
Cochrane Database of Systematic Reviews 2011

22. Management Of Ovarian Cyst
 Pre- Menopausal
 ↓ ↓

 <7 cm >7cm
 ↓ ↓
 Clear solid
 ↓ ↓
 O.C.pill Surgery
 3-6 months
 wait & Watch
 Post- Menopausal
 ↓
 Surgery

23. Management of Ovarian Cyst in Pregnancy
 size < 5 cm
 ↓
 wait & watch
 Size 5-10 cm.
 ↓
 USG/MRI
 ↓ ↓
 Solid area clear fluid
 ↓ ↓
 Operate W&W
 in 2nd Tri
>10 cm.
↓
Operate in 2nd trimester
In Emergency( Torsion/Rupture
Immediate surgery
Irrespective of size and weeks of pregnancy

26.  ‘Neo’- new
 ‘Plasm’- Growth
 Any abnormal new growth of tissue which results from
abnormal division of cells, anywhere in the body, that
possesses no physiological function, is called neoplasm.
 It can be
 1.Benign
 2.Borderline malignant
 3.Malignant.

28. Epithelial Tumours
60-70%
1.Serous tumour
2.Mucinous cyst
3.Brenner tumour
4.Endometroid tumour
Sex Chord stromal t
6-10%
1.Granulosa cell T
2.Thecoma
3.Fibroma
4.Androblastoma
(Sertoli-leydig cell t)
5.Gynandroblastoma
Germ cell Tumours
20-25%
1. Dysgerminoma
2. Teratoma
3. Endodermal sinus t
4.Embroynal call carcinoma
5. chorio-carcinoma

29. Benign ovarian tumors
Serous cystadenoma
Mucinous cystadenoma
Dermoid cyst
Fibroma
Thecoma
Brenner‟s tumor
1-3% incidence
75% Benign

30.  1.Serous tumour
 2. Mucinous T
 3.Endometroid T
 4.Clear cell T
 5.Brenner tumour
 6.Squamous cell T
 7.Mixed epithelial T
 8. Undifferenciated T
1. Epithelial Cell Tumours [60-70%]
1. Benign
2. Borderline
3. Malignant

31. SEROUS CYSTADENOMA
Generally benign epithelial tumour—40% of all ovarian
tumours
Bilateral – 40%
Risk of malignancy : 5 – 10 % borderline malignant
40% malignant
GROSS : multilocular with papillary components.
MICRO : low columnar epithelium with cilia.
Characteristic psammoma bodies (end products of degeneration
of papillary implants)are found.
Associated fibrosis may lead to ―cystadenofibroma‖

32. Ovarian Serous Cystadenoma

34. Psammoma Bodies

35. Papillary Projections-Serous type
Borderline
malignant

38. MUCINOUS CYSTADENOMA
20-25%,Have tendency to become huge masses
Round to ovoid masses with smooth capsules that are
usually translucent or bluish to whitish gray.
Interior divided by discrete septa into loculi containing
clear , viscid fluid.
Epithelium – tall, pale staining, secretary with basal nuclei
and goblet cells
B/L 10% , 5 – 10% are malignant
Largest benign
ovarian tumour

39. Mucinous cystadenoma

41. Mucinous Cyst-adenoma Ovary

42. Pseudo myxoma Peritoni

43.  1-2% incidence
 8-10%-B/L
 Solid tumour, < 2cm in diameter
 >40 yrs women
 Arises from squamous metapalsia of surface epiltheium
 Similar as Fibroma of ovary
 Usually benign, may secrete Ostrogen
 Abnormal bleeding
 Rx-young pt-Unilateral oophorectomy
 Old pt-TAH with B/L S.O.
Brenner Tumour

44. BRENNER TUMOR
Uncommon tumor, grossly identical to fibroma
Histologically islands of Transitional epithelium (walthard nests)
In compact fibrous stoma are seen.
Nucleus Coffee Bean shape.

46.  1.Dysgerminoma
 2.Teratoma—immature
 --Mature [ Dermoid Cyst ]
 3.Endodermal sinus tumour
 4.Ebryonal cell carcinoma
 5.Chorio-carcinoma
 6.Mixed form
2.Germ cell tumours [20-25%]

47. DERMOID CYST
Arises from Germ cells , 97% of teratoma,Often bilateral (15 -25%)
GROSS: moderate size,thick capsule, opaque , whitish wall.
Cut section-Solid projection area-ROKITANSKTY’S protubrance.
CONTENTS: hair, bone, cartilage, and a large amount of greasy sebaceous
material.thyroid,tooth, common elements are Ectodermal.
MICROSCOPICALLY : all the three germ layers (ectoderm,
mesoderm and endoderm)
Malignant change occurs in 1-3%. Usually of a squamoustype.
Risk of torsion is 15% [most common], rupture rare
An ovarian cystectomy is almost always possible, even if it appearsthat
only a small amount of ovarian tissue remains

48. Dermoid cyst with teeth & hair

51. Dysgerminoa

53. Dysgerminoma-microscopic exam.

54. Dysgerminoma-histology

55.  1. Granulosa cell tumour
 2. Theca cell tumours
 ----Fibroma
 ----Thecoma
 ----unclassified
 3. Androblastoma
 -sertoli cell tumour
 -sertoli-leydig cell tumour
 -Hilus cell tumour
 4.Gynandroblastoma
Sex Chord stromal tumours [6-10%]

56. FIBROMA
Most common benign, solid neoplasms of the ovary.
Compose approx 5% of benign ovarian neoplasms and 20% of allsolid
tumors of the ovary.
Frequently seen in middle-aged women.
Characterized by their firmness and resemblance to myomas
Misdiagnosed as exophytic fibroids or primary ovarianmalignancy
Not hormonally active
Fibromas may be associated with ascites or hydrothorax as a result of
increased capillary permeability .
Mieg’s syndrome (ovarian fibromas, ascites and hydrothorax)
is uncommon and usually resolves after surgicalexcision.

58.  Ascites + Right sided Hydrothorax+ Ovarian Tumour
 In association with
 Fibroma of ovary/
 Thecoma/
 Brenner tumour/
 Granulosa cell tumour
 Rx= surgical removal of tumour=complete spontaneous remission of
ascites & hydrothorax
 Pseudo-meigs syndrome
 A+ H+ any other tumour than ovarian—Fibromyoma uterus
Meigs’ Syndrome

59. Meigs’ Syndrome

60. THECOMA
Solid fibromatous lesions that show varying degrees of yellow or
orange discoloration
Almost always confined to one ovary
Usually >40 years, 65% after menopause
May be hormonally active and hence associated with estrogenic or
occasionally androgenic effects.
Luetinised thecoma – younger, sclerosing peritonitis and ascites
Leydeig cell thecoma – ass. with Reinke crystals
Rarely malignant

61. GONADOBLASTOMAS
Gonadoblastoma is a rare benign tumor that has the potential for malignant
transformation and affects a subset of patients with an intersex disorder or
disorder of sex development (DSD).
Contain both germ cells and sex cord stromalcells.
Arise in patients with dysgenetic gonads - 46 XY f/b 45XO/ 46 XYmosaic.
Presents usually as phenotypic female <30 years with primary amenorrhea
and virilization.
Treatment – laparoscopy or laparotomy with removal of b/l dysgenetic
gonads.
Further treatment depends on malignant germ cell component

62. CLINICAL PRESENTATION OF BENIGN O.
TUMOURS
Age
Reproductive age
Late child bearing
age
Parity
Usually
Nulliparity
Symptoms
1. Asympatomatic-
accidental detection
2.Big size-
. Heaviness in lower abd.
. Increasing mass in
lower abd.
.Dull aches
If hormone producing-
only then menstrual
symptoms

63.  General condition-
 unaffected, if huge tumour-
cachetic look
 Pitting Oedema of legs-in
huge tumour
Signs Of Benign OvarianTumors

64. Benign Ovarian Tumour-Examination
Abdominal Examination
Inspection-bulging of lower abdomen
over tumour, abd. freely moves with
respiration
Palpation-non tender,Cystic feel, freely
mobile from side to side
Borders-upper and lateral borders can
be defined but arises from pelvis, so
lower border can’t be reached.
Percussion-dull note
Auscultation-friction rub, hissing sound
over vascular t,gargling sound in ascites
& FHR in pregnancy.

65. Benign Ovarian tumour

66. Benign Ovarian Tumour

67. Uterus felt separate from mass, groove felt in between,
Movement of mass fails to move cervix.
On elevation of mass, cervix not pulled up.
Absence of pulsations of uterine vessels
Imp. Point
If u feel cyst anterior to uterus
It is Dermoid cyst.
Bimanual Pelvic Examination

68.  USG---TVS with colour flow Doppler study
 (tells tumour volume, cyst wall, septa, vascularity)
 High Risk for malignancy
 1. Multi-locular cyst
 2. Presence of solid areas
 3. Metastasis
 4.Ascites
 5.Bilateral
 6.High blood flow
Special Investigations

69.  CT-Scan
 MRI
 Ovarian tumour markers-CA-125,Alpa-fetoproteins
 FNAC and cyst aspiration—to be avoided
 Straight X-ray Abdomen-dermoid cyst
 Laproscopy
 Laprotomy
 Cytology of ascites, pleural fluid
Investigations

70.  Full Bladder
 Pregnancy
 Fibro-myoma
 Chocolate cyst of ovary
 Encysted peritonitis
 Ascites
 Functional cyst
 Pregnancy with fibroids
D/D Of Benign Ovarian Tumour

71. COMPLICATIONS
Torsion
Intracystic hemorrhage
Infection
Rupture
Pseudomyxoma peritonei
Malignancy

72. Torsion of Ovarian Cyst

73. Torsion Of Ovarian Cyst
Precipitating Factors
Haemodynamic theory->
Axial rotation-> venous
occlusion->Partial arterial
compression->Intermittent
arteial pulsation-> further
torsion complete
occlusion ischaemiaTissue
necrosis->
Signs & Symptoms
Severe acute abdominal pain,
tenderness +++, tense cystic
mass
Partial occlusion-may untwist

74. Torsion Of Ovarian Cyst
Common in tumours
1.Dermoid cyst
2.Serous cystadenoma
Factors
1.Moderate size,round
contour
2. Moderate weight
3.Free mobility
4.Long Pedicle
Predisposing factors
1.Trauma
2.Violent physical
movement
3.Contraction of pregnant
uterus
4.Intestional peristalsis
Complete torsion
Immediate
Laprotomy/Laproscopy
Operation=
De-torsion of adenxa+
Ovarian Cystectomy
If gangreneous tissue—
then ovariotomy/
Salpino-oophorectomy of
affected side.

75. Management-Benign O.Tumours
Once diagnosed-Admit the
patient
(Risk of complication and risk
of malignancy-anytime)
Ovarian mass> 8cm
Before puberty
After Menopause
Solid tumour at any age
needs evalution
USG, tumour marker
Plan surgery
Steps of surgery
Incision always-
1.Vertical para-median
2.Remove enmass.
3.Inspect para-colic
gutters
4.Take peritoneal
washings for
cytological exam
5.Inspect other ovary,
omentum, liver,under
diaphragm,para-aortic
Lymph nodes
Definitive Surgery
1.Young patient wants
pregnancy
1.Ovarian cystectomy
2.Ovariotomy/salpino-
oophorectomy
2. woman> 40 yrs
TAH with B/L S.O.
Important
Always send tumour
for HPE after surgery.
Borderline Malignancy
Young patient-Unilateral oophorectomy
Old patient-TAH+ B/L S.O + excision of involved Peritoneum

78. Benign/Malignant Ovarian Tumour
 Benign
 1. Reproductive age
 2.Cystic
 3. Unilocular
 4. Mobile
 5.Smooth surface
 6.No ascites
 7. slow growth
 8. CA 125-not raised
 9. Adhesions-absent
 10. No areas of Hge & necrosis
 Malignant
 1. Post-menopausal age
 2. Solid
 3. Multilocular
 4. Fixed
 5. Irregular surface
 6. Ascites +
 7. Rapid growth
 8. CA 125- raised
 9. Adhesions-+++
 10. Multiple areas of Hge & necrosis
Family
History +
(10-25% )

79. DIFFERENTIAL DIAGNOSIS OF ADNEXAL MASS
ORGAN CYSTIC SOLID
OVARY Functional cyst, Neoplastic cyst,
Benign, Malignant, Endometriosis
Neoplasm
Benign
Malignant
FALLOPIAN
TUBES
Tubo-ovarian abscess
Hydrosalpinx
Paraovarian cyst
Tubo-ovarian abscess
Ectopic pregnancy
Neoplasm
UTERUS Intrauterine pregnancy in a bicornuate
uterus
Pedunculated or
inteligamentous myoma
BOWEL Sigmoid or caecum distended with gas
or feces
Diverticulitis, Ileitis,
Appendicitis, Colonic cancer
MISCELLANEOUS Distended bladder, Pelvic kidney,
Urachal cyst
Abdominal wall hematoma or
abscess, retroperitoneal

81. Definition
A tumour marker is a biochemical indicator selectively produced by the neoplastic
tissue and released into blood and detected in blood or in other body fluids.
• It may be used to
Detect the presence of a tumour
Monitor the progress of disease
Monitor the response to treatment
They cannot be constructed as primary modalities for diagnosis of tumours

82. •Cell surface antigens.
•Cytoplasmic proteins.
•Enzymes.
•Hormone.
•Criteria of an Ideal Tumour Marker
•Specific
•Sensitive
•The method of assay must be cheap &
easy
Types of Tumour markers
•Cell surface antigens.
•Cytoplasmic proteins.
•Enzymes.
•Hormone.
•Criteria of an Ideal Tumour Marker
•Specific
•Sensitive
•The method of assay must be cheap & easy

83. Gynaecological Tumour Markers
Cancer Antigen-125 ( CA125)
Alfa Feto Protein (AFP)
Human Chorionic Gonadotrophin (HCG)
CA 19-9
Carcino Embryonic Antigen (CEA)
Placental Alkaline Phosphtase (PLAP)
Squamous Cell Carcinoma Antigen (SCCA)
CA15-3, ( Also known as HER, OVX1, OVX2).

84. SENSITIVITY SPECIFICITY
61-90% 71-93%
CA125
Elevated in 80% of patients with epithelial ovarian Carcinoma
Most useful when non-mucinous epithelial cancers are present
Increased sensitivity in post menopausal women esp. when
associated with relevant clinical and USG findings.

88. HE4
HE4 is a precursor to the epididymal secretory protein E4 and in normal
ovarian tissue, there is minimal gene expression and production of HE4.
As a single tumor marker, HE4 had the highest sensitivity fordetecting
ovarian cancer, especially Stage I disease.
Combined CA125 and HE4 is a more accurate predictor of malignancy
than either alone or to any other dual combination of markers
HE4 levels(>70 pM) were found to be elevated in over half of thepatients
with ovarian cancer with normal serum CA125 levels (>35U/ml)
HE4 when studied in the premenopausal group of patients was ableto
discriminate benign tumors from malignancies
Moore et al. / Gynecologic Oncology, 2008