Benign ovarian masses include functional cysts and tumors; most are asymptomatic.Most functional cysts and benign tumors are asymptomatic. Sometimes they cause menstrual abnormalities. Hemorrhagic corpus luteum cysts may cause pain or signs of peritonitis, particularly when they rupture. Occasionally, severe abdominal pain results from adnexal torsion of a cyst or mass, usually > 4 cm. Treatment varies depending on the patient's reproductive status.

1. BENIGN OVARIAN TUMOURS
Dr. NIRANJAN CHAVAN
Professor & Unit Chief
LTMMC & LTMGH Hospital , Sion, Mumbai -22
Chairperson, FOGSI Oncology & TT Committee.(2012-2014)
Convener & Chair, FOGSI –Violence against Doctor Cell (2015-2016)
Member, Oncology Committee AOFOG (2013-2015)
Managing Committee Member ,AFG & IAGE
Editor-AFG Times Newsletter
Director, Chavan Maternity & Nursing hOME
J.P. Road, Andheri West, Mumbai 53

2. NORMAL OVARIES
Normal size 5 x 3 x 3cm
 Variation in dimensions can result from
Endogenous hormonal production(varies with age
and menstrual cycle)
Exogenous substances, including OCs, GnRH
agonists, or ovulation-inducing medication, may
affect size.

4. BENIGN OVARIAN TUMOURS
 Epidemiology
 Embryology
 Etiology
 Risk factors
 WHO classification
 Pathology of ovarian tumours
 Management
(diagnosis & management)
 Surgery

5. EMBRYOLOGY OF THE OVARY
 Primitive gonads appear around the 5th week of IUL as the gonadal ridge from
the coelomic epithelium on the medial aspect of the urogenital ridge.
 In the xx embryo , the cortex develop as the ovary and the medulla regress to a
small area.
 The ovarian serosa is the direct descent of the coelomic epithelium and it give
rises to endocervical,endometrial,endosalphinx and the epithelium of the
urogenital system.
 The undifferentiated serosal cells can undergo neoplastic changes and lead to
tumours of the above tissues.

7. BENIGN OVARIAN
TUMOURS
FUNCTIONAL INFLAMMATORY NEOPLASTIC OTHERS
►FOLLICULAR CYST
►CORPUS LUTEUM
CYST
►THECA LUTEIN
CYST
►TUBO OVARIAN
ABSCESS
►BENIGN
►BORDERLINE
►MALIGNANT
►ENDOMETRIOMA
►ENLARGED PCO
►PAROVARIAN
CYST

8. (I) Functional
(II) Inflammatory
(III) Others
(IV) Neoplastic
(1) Germ cell
(2)Epithelial
(3)Sex cord stromal
(a) Follicular cyst
(b) Corpus Luteal cyst
(c) Theca Luteal cyst
(a) Tubo-ovarian abscess
(a) Endometrioma Ovary
(a) Benign teratoma/ Dermoid Cyst
(a) Serous cyst adenoma
(b ) Mucinous cyst adenoma
(c) Brenner tumour
(d) Fibroma
(e) Thecoma
(a) Granulosa cell , Sertoli- leydig cell
CAUSES OF BENIGN OVARIAN CYSTS

9. OVARIAN TUMOUR SCREENING MULTI MODEL
Ca 125 and Ultrasound scanning
Ca 125 >30 uml is abnormal
Ca 125 is an antigen found in the foetal amniotic and coelomic epithelium.in adults it is
found in mesothelial cells of pleura
Pericardium and tubal, endometrial, endocervical and the ovary.
The surface epithelium of normal foetal and adult ovaries does not express the antigen ,
except in inclusion cysts, papillae or metaplasia
An elevated level is found in 50% of stage 1 and >90% in women with advanced disease.
Sensitivity is 97% Specificity is 96%
False positive in
ca endometrium ,ca colon, endometriosis, fibroid, PID, pregnancy and menstruation

10. CLASSIFICATION OF OVARIAN MASS
1. Simple cyst
2. Hemorrhagic cyst
3. Hyperstimulation in women who have undergone fertility treatment
4. Luteoma of Pregnancy
5. Endometrioma
6. Brenners tumour
7. Epithelial tumours
Serous and mucinous, endometroid and clear cell tumours.
8. Sex cord and Mesenchymal tumours
Fibrothecomas, granulosa cell , sclerosing stromal and sertoli-
leydig cell tumours.
9. Germ cell tumours
Mature and immature teratomas, dysgerminomas, endodermal
sinus tumours, embryonal carcinomas.

11. 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.

12. FOLLICULAR CYSTS
 Cystic follicle is defined as Follicular cyst of diameter > 3cm
 Most common functional cysts.
 Rarely larger than 8cm.
 Lined by granulosa cells
 Found incidentally on pelvic examination
 Usually resolve within 4 – 8 weeks with expectant management
 May rupture or torse occasionally causing pain and peritoneal
symptoms.

14. CORPUS LUTEAL CYST
Less common than follicular cyst.
May rupture leading to hemoperitoneum and requiring
surgical management( more in patients taking anti
coagulants or with bleeding diathesis)
Unruptured cysts may cause pain because of bleeding
into enclosed ovarian cyst cavity.

15. CORPUS LUTEAL CYST

17. THECA LUTEIN CYSTS
 Least common
 Usually bilateral
 Result from overstimulation of the ovary by β- hCG
 Do not commonly occur in normal pregnancy
 Often associated with hydatidiform moles, choriocarcinoma, multiple
gestations, use of clomiphene and GnRH analogues.
 May be quite large (up to 30 cm) , multicystic, and regress
spontaneously.

18. THECA LUTEIN CYSTS

19. 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

20. ASYMPTOMATIC SIMPLE CYSTS
<5cms Likely physiological
(do not require follow up)
5-7 cms Yearly USG
>7cm Require further
imaging/surgical
intervention.
RCOG 2011

21. (I) Functional
(II) Inflammatory
(III) Others
(IV) Neoplastic
(1) Germ cell
(2)Epithelial
(3)Sex cord stromal
(a) Follicular cyst
(b) Corpus Luteal cyst
(c) Theca Luteal cyst
(a) Tubo-ovarian abscess
(a) Endometrioma Ovary
(a) Benign teratoma/ Dermoid Cyst
(a) Serous cyst adenoma
(b ) Mucinous cyst adenoma
(c) Brenner tumour
(d) Fibroma
(e) Thecoma
(a) Granulosa cell , Sertoli- leydig cell
CAUSES OF BENIGN OVARIAN CYSTS

22. (A) INFLAMMATORY
OVARIAN CYSTS TUBO-
OVARIAN ABSCESS
Are present in 14-38% of patients
hospitalized with pelvic inflammatory
disease (PID) .
Commonly seen in patients with poor access
to routine gynecologic care.

23. The traditional criteria for the diagnosis of PID include
subjective bilateral abdominal pain per patient report and
positive physical examination findings for bilateral adnexal
tenderness at palpation and cervical motion tenderness.
A hydrosalpinx is generally anechoic, whereas a pyosalpinx
may have increased echoes within the fluid.

24. (I) Functional
(II) Inflammatory
(III) Others
(IV) Neoplastic
(1) Germ cell
(2)Epithelial
(3)Sex cord stromal
(a) Follicular cyst
(b) Corpus Luteal cyst
(c) Theca Luteal cyst
(a) Tubo-ovarian abscess
(a) Endometrioma Ovary
(a) Benign teratoma/ Dermoid Cyst
(a) Serous cyst adenoma
(b ) Mucinous cyst adenoma
(c) Brenner tumour
(d) Fibroma
(e) Thecoma
(a) Granulosa cell , Sertoli- leydig cell
CAUSES OF BENIGN OVARIAN CYSTS

25. (A) ENDOMETRIOMA OF OVARY
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.

26. • 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

27. Chocolate
cyst of Ovary
on cut section
Ovarian
Endometrioma

28. (I) Functional
(II) Inflammatory
(III) Others
(IV) Neoplastic
(1) Germ cell
(2)Epithelial
(3)Sex cord stromal
(a) Follicular cyst
(b) Corpus Luteal cyst
(c) Theca Luteal cyst
(a) Tubo-ovarian abscess
(a) Endometrioma Ovary
(a) Benign teratoma/ Dermoid Cyst
(a) Serous cyst adenoma
(b ) Mucinous cyst adenoma
(c) Brenner tumour
(d) Fibroma
(e) Thecoma
(a) Granulosa cell , Sertoli- leydig cell
CAUSES OF BENIGN OVARIAN CYSTS

29. BENIGN OVARIAN TUMORS
Serous cystadenoma
Mucinous cystadenoma
Dermoid cyst
Fibroma
Thecoma
Brenner’s tumor

30. (A) SEROUS CYSTADENOMA
 Generally benign
 Bilateral – 10%
 Risk of malignancy : 5 – 10 % borderline malignant, 20 -25% 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”

31. On USG Serous Cystadenoma
Gross appearance
Gross appearance Cut section appearance
Cut section appearance

32. On MRI Serous Cystadenoma
On USG
Serous
Cystad
enoma

33. (B) MUCINOUS CYSTADENOMA
Have tendency to become huge masses
 Gross : 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.
Microscopy : Epithelium – tall, pale staining,
secretary with basal nuclei and goblet cells
5 – 10% are malignant

34. Epithelium –
tall, pale
staining,
secretary with
basal nuclei and
goblet cells

35. On MRI Mucinous cystadenoma.

36. DERMOID CYST/ BENIGN CYSTIC TERATOMA
 Often bilateral (15 -25%)
 GROSS: thick, opaque , whitish wall.
 CONTENTS: hair, bone, cartilage, and a large amount of greasy sebaceous material.
 MICROSCOPICALLY : all the three germ layers (ectoderm, mesoderm and endoderm)
 Malignant change occurs in 1-3%. Usually of a squamous type.
 Risk of torsion is 15%
 An ovarian cystectomy is almost always possible, even if it appears that only a small amount
of ovarian tissue remains

37. Dermoid Cyst ( Benign Cystic Teratoma)

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

41. OVARIAN FIBROMA
Microscopy..
Gross appearance

42. On MRI Ovarian Fibroma.

43. 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 – associated with Reinke crystals
 Rarely malignant

44. BRENNER TUMOR
 It is named for Fritz Brenner, who characterized it in 1907. The term "Brenner
tumor" was first used by Robert Meyer, in 1932.
 Uncommon tumor grossly identical to fibroma.
 Arise from Walthard cell rests ,also from surface epithelium, rete ovarii and
ovarian stroma.
 Brenner tumors are usually found incidentally at pathologic evaluation, often in
conjunction with a mucinous cystadenoma or dermoid cyst. They are relatively
rare tumors and are most common in the fifth to sixth decades of life.

45. On microscopy – markedly hyperplastic fibromatous matrix interspersed with
nests of epitheloid cells showing coffee bean pattern
Considered uniformly benign. But scattered reports of malignant Brenner’s
available
Endocrinologically inert, but could be ass. with virilization and endometrial
hyperplasia
Cut section
Microscopy

46. Ovarian Gonadal Sex Cord Stromal Tumours
 Granulose theca cell tumours
 Sertoli-Leydig cell tumours

47. Found in all age groups and associated with the pseudo
precocious puberty.
Early breast development , menstrual disorders,
postmenopausal vaginal bleeding make up the
characteristic symptom.
Laboratories studies demonstrate an increase in the number of mature
epithelial cells in the vaginal cytologic specimen, elevated urinary and serum
estrogen levels and varirant degree of endometrial proliferation.
Microscopy :
The characteristic cell is the round or slightly ovoid granulosa cell with its dark
nucleus.
Mitosis are common and the ovumlike “Call Exner bodies “ are classic.
Granulosa stromal Sex cord tumours

48. Sertoli Leydig cell Tumours
Also called as Androblastoma
Often affect females beneath the ages of 40yrs
Usually be luteinised, simulating the classic pattern of the testes and
producing steroids
Generally benign, may produce the masculinisation.

49. TREATMENT OF NEOPLASTIC TUMOURS
In most instances, simple excision of the solid tumors is adequate
therapy, particularly for women of reproductive age.

50. CLINICAL PRESENTATION
 Asymptomatic – accidentally discovered on USG
 Chronic pattern of pain, increasing abdominal girth over months or weeks.
 Associated with secondary symptoms of anorexia, nausea, vomiting,
urinary frequency.
 Could be associated with primary or secondary amenorrhea, menstrual
irregularities, virilization, precocious puberty
 Become acutely symptomatic if undergoes torsion, rupture or
haemorrhage.
Benign ovarian neoplasms are indistinguishable clinically from malignant
counterparts

51. Age : late child bearing age
dermoid , mucinous adenoma common in reproductive age
dermoid common in pregnancy
Symptoms
Asymptomatic , detected accidently during routine abdominal or gynecological
examinations
or during laporoscopic or laparotomy.
Nonspecific symptoms like
Feeling of abdominal distension and vague discomfort.
Features of dyspepsia such as flatulence and eructations.
Gradually more pronounced symptoms appear like
Abdominal swelling which may be rapid
Dull abdominal pain
Respiratory distress which may be mechanical due to ascites/pleural effusion.
Menstrual abnormalities in functioning ovarian tumours.
For other ovarian tumours symptoms may differ eg .Androblastoma - Hirsutism.
Signs
General condition usually remains unaffected.
The patient may be cachectic due to protein loss in huge mucinous cyst adenoma.
CLINICAL PRESENTATION

52. On abdominal examination
Inspection
Bulge of lower abdomen over which abdominal wall moves freely with respiration.
The mass may fill the entire abdominal cavity everting the umbilicus with visible veins
under the skin.the flanks remain flat. Mass is cystic or solid.
Palpation
Surface is smooth ,non tender and freely mobile from side to side but restricted from
above downwards unless pedicle is long.
upper and latearal borders are well defined bt the lower pole is difficult to reach.
Percussion
dull in centre and resonants in the flanks.
A fluid thrill may be elicited
when the wall are thin and the content is watery. A
friction rub may be present over the tumour.
Bimanual Pelvic examination
Uterus seperate from the mass
groove present between uterus and the mass
movement of the mass p/a fails to move the cervix
lower pole of the cyst felt through the fornix
absence of pulsation of uterine vessels through the fornix

53. COMPLICATIONS OF BENIGN OVARIAN TUMOURS
 Torsion : Commonly seen in Dermoid cyst, serous cystadenoma.
 Intracystic hemorrhage : serous Cystadenoma, venous congestion.
 Infection : Following torsion.
 Rupture : Big and tense type,following trauma.
 Pseudomyxoma peritonei : Seen in Mucinous Cystadenoma
 Intestinal Obstruction
 Malignancy : Rare .

54. MANAGEMENT

55. INVESTIGATIONS
Routine
CBC
ESR
CXR
ECG
Urine R.M/C.S.
Liver function test
Renal function test
Specific
Ultrasound
Transabdominal / Transvaginal
Doppler colour flow
C T scan and MRI
Tumour markers
CA125, CEA, CA 19-9, HE4
Genetic Analysis
Endoscopy and Laparoscopy

57. TRANSVAGINAL ULTRASOUND
 Pattern recognition is superior to all other scores.
 Subjective evaluation of ovarian masses based on pattern
recognition can achieve sensitivity of 88% to 100% and specificity of
62% to 96%.
 Adding doppler does not seem to yield much improvement in the
diagnostic precision, but increases the confidence with which a
correct diagnosis of benignity or malignancy is made.

58. simple ultrasound-based rules for the diagnosis of ovarian cancer. ultrasound obstetgynecol2008 RCOG 2011

60. DOPPLER EVALUATION
 Hypoxic tissue in tumors recruit low-resistance, high-flow blood
vessels
 Role in evaluating ovarian mass is controversial – as the ranges of
values of RI,PI,MSV between benign and malignant masses overlap.
PI<1, RI<0.4
 To overcome this, vascular sampling of suspicious areas (papillary
projections, solid areas, thick septations) using both 3D USG and
power doppler both has been evaluated and found effective.

61. OTHER IMAGING MODALITIES
 CT, MRI, PET not recommended in the initial evaluation
 CT scan: evaluating
 LN involvement,
 Omental mets, peritoneal deposits, hepatic mets,
 obstructive uropathy
 or a probable alternate primary site when cancer is suspected based upon TVS
 MRI : differentiating non adnexal pelvic masses (like leiomyomata), expensive and inconvenient.
 ACOG GUIDELINES 2007

62. TUMOR MARKERS
CA125
CEA
CA 19-9
HE4

63. SENSITIVITY SPECIFICITY PPV NPV
61-90% 71-93% 35-91% 67-90%
CA125
Most useful when non-mucinous epithelial cancers are
present
Elevated in 80% of patients with epithelial ovarian Ca but
only in 50% of patients with stage I disease
Increased sensitivity in post menopausal women esp. when
associated with relevant clinical and USG findings
Cut-off of 30 u/ml, sensitivity of 81% and specificity of 75%

64. Levels higher than 5 mg/Lare seen in 85-90% of mucinous
tumours but only in 30% of other epithelial cancers.
CEA
It is elevated in mucinous ovarian malignancy.
CA 19.9

65. 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.
 HE4 when studied in the premenopausal group of patients was able to discriminate
benign tumors from malignancies
 As a single tumor marker, HE4 had the highest sensitivity for detecting 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 the patients with ovarian
cancer with normal serum CA125 levels (>35 U/ml)
Moore et al. / Gynecologic Oncology, 2008

66. Benign Ovarian tumour Malignant Ovarian tumour
Common in middle age group
Painless unless compicated
No edema
No varicosities
Generally unilateral
Unilocular
Thin walled
Thin septae if present
No papillae or solid contents
Normal or decreased vascularity on
doppler
No metastasis
Slow growing
Smooth, cystic
Freely mobile
No ascites or if present clear fluid on
paracentesis
Seen at extremes of ages
May be painful
Edema maybe present
Varicosities may be present
May be bilateral
Multilocular
Thick walled
Thick septae
Mixed echogenicity
High vascularity, low pulsatility index and
low resistance index
Metastasis in advanced disease
Rapidly growing
Solid, nodular, irregularly shaped
Fixed
Ascites present and on paracentesis the
fluid may be blood stained.

67. TREATMENT

68. INDICATIONS FOR SURGERY
 Any solid ovarian lesion
 Any ovarian lesion with papillary vegetation on the cyst wall
 Any adnexal mass >10cm in diameter
 Palpable adnexal mass in a premenarchal or postmenopausal
women
 Torsion or rupture suspected

69. Ovarian mass in reproductive age group
<5 cms. >/= 5 cms
USG USG
cystic
observation
Complex,
solid,
suspiciou
s
Persistence or progression
surgery

70. CYST ASPIRATION
 Diagnostic cytology has poor sensitivity to detect malignancy,
ranging from 25% to 82%
 Not therapeutic, even when a benign mass is aspirated
 Approx. 25% of cysts will recur within 1 year
 Aspiration of a malignant mass may induce spillage and seeding
of cancer cells into the peritoneal cavity.

71. OPERATIVE MODALITIES
 Laparoscopy vs laparotomy – decision based on suspicion of
malignancy and technical expertise
 No RCTs comparing recurrence rates following laparoscopy or
laparotomy.
 The objective is to try cystectomy if possible.
 Laparoscopic surgery for benign ovarian tumours is associated with less
pain, shorter hospital stay, and fewer adverse events than with
laparotomy.
Cochrane Database of Systematic Reviews 2009

72. SURGERY
Young women : Ovarian cystectomy
Oophorectomy ( salpingo ophorectomy)
Parous women : Total Abdominal Hysterectomy with Bilateral ophorectomy
Others : Individualisation

73. The standards for laparoscopy in benign tumours
1. careful examination of the external surface of the
tumour and sampling of the peritoneal cavity
2. avoidance of any tumoral rupture
3. protection of the ovarian tumour with an endoscopic
bag before removal

74. ROLE OF FROZEN SECTION
The diagnostic accuracy of frozen section analysis
is high for malignant and benign ovarian tumours,
but accuracy is poor in the case of borderline
ovarian tumors.
Medeiros 2005

76. Conclusion
Ovarian masses are very commomly seen in general population.Most
of the times these are simple functional tumours which resolve
spontaneously within six to eight weeks.However an indepth
understanding of the ovarian masses is needed as th the grave
consequences that may follow if there is a wrong diagnosis.Imaging
studies especially ultrasound is a prime tool in diagnosing ovarian
tumours. Careful consideration to woman’s need should be addresses
before selecting any method of treatment.