benign tumors of the ovary

1. Benign ovarian conditions
Dr Mbirige Joseph
Dr Ibanda Hood
Tutor: Dr Mutyaba

2. objectives
• Clinical presentation ovarian masses
• Investigation done when a patient is suspected of having an ovarian
mass
• Tumor markers
• Functional ovarian cysts
• Neoplastic masses of the ovary

3. Clinical presentation of ovarian masses
• Ovarian mass may be felt by the patient.
• Pelvic pain (Acute/Chronic). If twisted, pain may be acute and severe.
• Pressure effects of the mass.
• Effects of the hormones secreted by the mass (E2 or T)
• Ovarian mass can be found incidentally at routine pelvic examination
or ultrasound scan.

4. Investigations for suspected ovarian mass
• The first line of investigation is history taking:
• Detailed history of presenting complaints
• Menstrual history
• Contraceptive history
• Family history of ca ovary
• Past gynecological history
• Drug history
• Other history(class contribution)
• Clinical examination including:
• General examination
• Tanner staging if young
• Asses if there are feature of excessive Estrogen
• Bimanual examination
Other investigations are shown next.

5. Investigations done when suspecting ovarian mass
Investigation Normal range(where possible) Rationale for the test
CBC, CRP NR Infections like TOM, PID,
Appendicular mass
Tumor Markers Many (see next table) Preoperative, & Follow up
Ultrasound scan TAS
TVS
If mass reaches abdominal cavity
If mass is pelvic, better resolution
Help in finding RMI if needed
MRI, CT scan - Help delineate the mass, & plan
the surgery.
Biopsy - Laparotomy/Laparoscopy best for
getting a sample of the mass for
histopathology. It can be curative
EMB, ECC, Biopsy of SCJ, Hormonal
levels, VIA/VILI
- To exhaust causes of AUB
Suspecting GCT, or Excessive E2
If any screening test is positive

6. Tumor markers used in the investigation and
follow-up of ovarian cysts
Tumor marker, Ovarian tumor type uses
Ca 125 Epithelial ovarian Ca(serous),
borderline ovarian Tumors
Preoperative, follow-up
Ca 19-9 Epithelial ovarian Ca(mucinous),
borderline ovarian tumors
Preoperative, follow-up
Inhibin Granulosa Cell Tumors Follow-up
β -hCG Dysgerminoma, choriocarcinoma Preoperative, follow-up
AFP Endodermal yolk sack, Immature
teratoma
Preoperative, follow-up

7. Types of ovarian masses
Function (follicular , luteal , theca lutein , luteoma, & PCOS)
Inflammatory (TOM, Endometrioma)
Neoplastic (Benign tumors: epithelial, Germ cell tumor, sex cord-stromal)

8. Types of Benign Ovarian swellings
Functional cysts Follicular cysts
Corpus Luteum cyst
Theca Lutein cyst
FSH secreting pituitary adenoma
Polycystic ovary syndrome
Inflammatory Tubo-ovarian cyst
Endometrioma
Germ Cell Benign Teratoma (dermoid Cyst)
Epithelial Serous cystadenoma
Mucinous cystadenoma
Brenner tumor
Sex cord stromal Fibroma
Thecoma

9. Follicular Cyst
• They are less than 5cm, single or multiple, Unilateral or bilateral
• Pathophysiology: They result from failure of absorption of follicular
fluid after anovulation or failure to absorb fluid in an incompletely
grown follicle.
• Clinical features: They are asymptomatic but may cause pain due to
stretch, rupture, hemorrhage, and/or torsion. Dyspareunia, pelvic
pain. They disappear in 4-8 weeks.
• Treatment: COC (4-6/12); medroxyprogesterone or Norethisterone
for 5/7 help bring about menstruation. COC will resolve most cysts.
If cyst persist beyond 3 months or greater 7cm, check it for neoplasia.

10. Theca Lutein cyst
• Theca lutein cyst may enlarge to so several cm.
• Pathophysiology: They are found in molar pregnancy or
choriocarcinoma. They can also form when clomiphene or hCG is
used for COH.
NB: Most functional cysts are: < 7cm, unilocular with clear fluid, and
regress after some time. So consider checking for neoplasia.
• Treatment: Stop exposure to the hCG by, stopping hCG
administration, evacuating the mole, chemotherapy for the
choriocarcinoma.

11. Corpus Luteum cyst
• It’s also called Granulosa lutein cyst
• Persistent corpus Luteum cyst will cause delay in menstruation. And at
ultrasound scan, it may appear like ectopic pregnancy (not ruptured).
So, hCG is needed.
• It may remain asymptomatic till torsion or rupture.
• Treatment: No treatment is needed. Observe just. But pain killer may
be needed.

12. Tubo-ovarian Mass
• Pathophysiology: It is a complication of pelvic inflammatory disease
• Management: Antibiotics, then surgery if no resolution

13. Endometrioma
• Pathophysiology: Endometriosis of the ovary leads to collection of
menstrual blood in a cyst within the ovary. Chocolate cyst is its other
name.
• Management: Conservative or Cystectomy.

14. Pituitary FSH secreting adenoma
Presenting complaints: In addition to symptoms of the cysts,
Amenorrhea, oligomenorrhea, or infertility are complaints.
Investigation:
• This adenoma causes multiple cyst, the cysts are more than 1cm.
• FSH and Estradiol are increased.
• LH is reduced.
• Hemoconcentration and coagulopathy, features of ovarian hyperstimulation are absent.
• MRI and CT will show the adenoma.
Treatment: Transphenoidal excision of adenoma resolves the cysts.

15. Neoplastic swellings of the ovary

16. Ovarian Mucinous
cystadenoma

17. Mucinous cystadenoma (continued)
• Mucinous cystadenoma of the ovary is at the benign end of the
spectrum of mucin-containing epithelial ovarian tumors.
• Epidemiology: estimated peak incidence is at 30-50 years of
age. 80% of mucinous ovarian tumors are mucinous cystadenoma;
and 20-25% of all benign ovarian tumors are mucinous cystadenoma
• Clinical features: The tumors grow so big, and the mass and its effects
are presenting complaint

18. Mucinous cystadenoma (continued)
• Ultrasound findings: only 2-5% bilateral. Large cystic masses,
with multiple locules/thin septation. Low echo content (mucin)
• Treatment: Unilateral salpingo-oophorectomy
• Pathological findings: Large multiloculated cystic tumor with gel
like mucin filling the cysts. Microscopy, the cyst wall are lined by
columnar cell, endocervical or intestinal type. The cells secrete
mucin.

19. Thecoma
Thecoma is a Stromal tumor composed of lipid-containing
cells resembling theca cells with a variable fibromatous
component

20. Thecoma: clinical features
Incidence and Location
Approximately one-third as common as granulosa cell tumors
95% are unilateral
Morbidity and Mortality
Thecoma, derived Estrogen causes endometrial hyperplasia
Age Distribution of the histological subtypes
Conventional Thecoma: mostly postmenopausal women
(mean age 59 years)
Luteinized Thecoma: 30% in patients ≤ 30 years

21. Thecoma, clinical findings, treatment and Prognosis
• Pelvic mass or swelling
• Vaginal bleeding (both conventional and luteinized Thecoma)
• Endometrial adenocarcinoma in one-fifth of patients (20 E2)
• Virilization (more common in luteinized Thecoma)
Prognosis and Treatment
All but rare cases benign
Unilateral salpingo-oophorectomy (unless associated with
endometrial adenocarcinoma: hysterectomy and bilateral
salpingo-oophorectomy)

22. Fibroma
Fibromas occur primarily in postmenopausal women, although
they can occur in any age group.

23. Clinical features and treatment of Fibroma
• Fibromas are benign
• Fibromas are not hormonally active. But cellular fibromas have
been described and are considered to be of low malignant
potential
• Fibromas may secrete VEGF, which increases capillary
permeability, leading to Meig’s syndrome
• Meig’s syndrome is Ovarian fibroma + ascites + hydrothorax.
• Treatment: unilateral salpingo-oophorectomy

24. Gynandroblastoma
• Gynandroblastomas are considered a mix of both Granulosa cell and
Sertoli-Leydig cell tumors because histologically, they contain both.
• Clinical features: Gynandroblastomas are rare. They occur in the
young <30years old.
• Since they GCT, they secrete Estrogen, but their remaining
components may secrete other hormones causing Virilization.
• Histology: >/=10% GCT, the rest is sertoli-Leydig cell, and various
tissues.
• Treatment: Surgery: Unilateral salpingo-oophorectomy. This is
because these tumors are always benign and are diagnosed early.

25. Brenner tumors
• 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. Brenner tumors may be benign, intermediate, or
malignant transitional cell tumors.
• These tumors are usually small, firm, and solid, and when confined to
the ovary, they carry a good-to-excellent prognosis, depending on the
malignancy status

26. Dermoid Cyst (mature cystic teratoma)
• A dermoid cyst is a Germ cell tumor, it is mostly benign. It comprises
of tissues derived from all the 3 germ layers. Hair, nails, thyroid tissue
and other issue can all be found in a Dermoid cyst.
• 1-3% can undergo malignant transformation, especially in
postmenopausal women.
• Treatment: Salpingo-oophorectomy. If menopausal, TAH+BSO.

27. References
• Kumar, S. (2018). Shaw's textbook of Gynecology, Elseviers,
Philadelphia
• Crum et al .(2018). Diagnostic gynecologic and Obstetric pathology.
Elseviers, Philadelphia.