Various types of benign conditions of the ovaries. The pathology, histopathology, clinical features, investigation plan and findings and management plan are mentioned.

1. Dr. Aeysha Begum
MBBS, FCPS, MCPS
Trained in Palliative Care
Assistant Professor
Department of Obstetrics & Gynaecology
Khwaja Yunus Ali Medical College
Benign Lesions of the Ovary

2. OVARIAN ENLARGEMENT
1. Non-neoplastic (Benign)
2. Neoplastic

3. Non-neoplastic
The non-neoplastic enlargement of the ovary is usually due to
accumulation of fluid inside the functional unit of the ovary.
The causes are:
1. Follicular cysts.
2. Corpus luteum cyst.
3. Theca lutein and granulosa lutein cysts.
4. Polycystic ovarian syndrome.
5. Endometrial cyst (chocolate cyst).
Except the endometrial cyst , all are functional cysts of the ovary and are
loosely called cystic ovary.

4. The features of the functional cysts
• a. Related to temporary hormonal disorders.
• b. Rarely becomes complicated.
• c. Sometimes confused with neoplastic cyst but can be
distinguished by the following features:
I. Usually 6–8 cm in diameter.
II. Usually asymptomatic.
III. Spontaneous regression usually following correction of the functional
disturbances to which it is related.
IV. Unilocular.
V. Contains clear fluid inside unless hemorrhage occurs.
VI. Lining epithelium corresponds to the functional epithelium of the unit from
which it arises.

5. Follicular Cysts
• Follicular cysts are the commonest functional cysts.
• They are usually multiple and small as seen in cases of cystic glandular
hyperplasia of the endometrium or in association of fibroid. Hyperestrinism
is implicated as its cause.
• An isolated cyst may be formed in unruptured Graafian follicle, which may
be enlarged but usually not exceeding 5 cm.
• The cyst is lined by typical granulosa cells without lutein cells or the cells
may be flattened due to pressure.
• In majority of cases, the detection is made accidentally on bimanual
examination, sonography, laparoscopy or laparotomy.
• The cyst may remain asymptomatic or may produce vague pain.

6. Follicular Cysts
• Management:
1. A follicular cyst < 3 cm requires no further investigations.
2. A simple cyst, < 8 cm, unilocular, echo free without solid areas or
papillary projections, with normal serum CA 125 should be followed up
with repeat ultrasound in 3 to 6 months time.
3. Whenever a cyst persists or grow, it should be removed by
laparoscopy/laparotomy.

7. Corpus Luteum Cysts
• Corpus luteum cyst usually occurs due to overactivity of corpus luteum. There is
excessive bleeding inside the corpus luteum. In spite of the blood filled cyst, the
progesterone and estrogen secretion continues.
• As a result, the menstrual cycle may be normal or there may be amenorrhea or
delayed cycle. It is usually followed by heavy and/or continued bleeding. It is then
confused with a case of threatened abortion or else, if the intracystic bleeding is
much, it may rupture producing features of acute intraperitoneal hemorrhage
with clinical picture simulating disturbed tubal ectopic pregnancy.
• It may often be associated with pregnancy and persists for about 12 weeks.
Unless complicated, spontaneous regression is expected.
• If features o acute abdomen appears, laparotomy with enucleation of the cyst is
to be done along with resuscitative measures as in disturbed tubal pregnancy.
• These two types of cysts are rather uncommon in women taking oral
contraceptive pills. As such, if the cyst persists after three months of pill therapy,
it is more likely to be a neoplastic cyst.

8. Follicular Cysts
Corpus Luteum Cysts
• These two types of cysts are rather uncommon in women taking oral
contraceptive pills. As such, if the cyst persists after three months of
pill therapy, it is more likely to be a neoplastic cyst.

9. Lutein cysts
• Lutein cysts are usually bilateral and caused by excessive chorionic
gonadotropin secreted in cases of gestational trophoblastic tumors.
• These may also be formed with administration of gonadotropins or
even clomiphene to induce ovulation.
• These are usually lined either by theca lutein cells, called theca lutein
cyst or by granulosa lutein cells, called granulosa lutein cyst.
• Spontaneous regression is expected within few weeks following
effective therapy of the tumors with the gonadotropin level returning
back to normal.

10. Benign Ovarian Neoplasms

11. • Incidence
• The incidence of ovarian tumor amongst gynecologic admission varies
from 1–3%. About 75% of these are benign.

12. WHO classification of ovarian tumor
I. Epithelial tumor (60–70%)
• These tumors may be benign, borderline malignant or malignant.
• a) Serous tumor
• b) Mucinous cyst adenoma
• c) Endometrioid tumors
• d) Mesonephroid or clear cell tumors
• e) Brenner tumors
• f ) Mixed epithelial tumors
• g) Undifferentiated carcinoma
• h) Unclassified epithelial tumors

13. WHO classification of ovarian tumor
II. Sex cord stromal tumors (6–10%)
• a) Granulosa cell tumors
• b) Tumors of thecoma-fibroma group
• Thecoma • Fibroma • Unclassified
• c) Androblastoma
• Sertoli cell tumor
• Sertoli leydig cell tumor
• Hilus cell tumor
• d) Gynandroblastoma
• e) Unclassified

14. WHO classification of ovarian tumor
III. Lipid cell tumor
IV. Germ cell tumors of the ovary (20–25% of all primary ovarian
neoplasms)
• I. Germ cell tumors
• a) Dysgerminoma
• b) E ndodermal sinus tumor
• c) E mbryonal cell carcinoma
• d) Polyembryoma
• e) Choriocarcinoma

15. WHO classification of ovarian tumor
III. Lipid cell tumor
IV. Germ cell tumors of the ovary (20–25% of all primary ovarian neoplasms)
• f ) Teratoma:
i. Immature;
ii. Mature (Dermoid cyst);
iii. Monodermal: • Struma ovarii • Carcinoid
• g) Mixed forms (combinations of types A to F)
• II. Tumors composed of germ cells and sex cord stromal derivatives
• a) Gonadoblastoma
• b) Mixed germ cell — sex cord stromal tumor
V. Gonadoblastoma
VI. Unclassified
VII. Secondary metastasis

16. • The common varieties are:
1. Mucinous cyst adenoma
2. Serous cyst adenoma
3. Brenner tumor
4. Dermoid cyst
5. Endometrioid tumors
6. Clear cell tumors

17. MUCINOUS CYS T ADENOMA
• Origin
The following diverse modes of origin of mucinous cyst adenoma are
described:
• It arises from the totipotent surface epithelium of the ovary.
• Its association with Brenner tumor suggests its origin as mucinous
metaplasia of the epithelioid cells.
• Pathology
• These are quite common and account for about 20–25 percent of all
ovarian tumors.
• The tumors are bilateral in about 10 percent cases.
• The chance of malignancy is about 5–10 percent.

18. Naked eye appearance
• It may attain a huge size if left uncared for. In fact, it is the largest
benign ovarian tumor.
• The wall is smooth, lobulated with whitish or bluish white hue. At
places, it is thin so as to be translucent.

19. On cut section
• The content inside is thick, viscid, mucin — a glycoprotein with high
content of neutral polysaccharides.
• It is colorless unless complicated by hemorrhage.
• The cyst is frequently multiloculated, sometimes with papillary
growth arising from the septum.

20. Microscopic examination
• The cyst is lined by a single layer of tall columnar epithelium with dark
staining basal nucleus but without any cilia.
• The epithelial characteristics are like those of endocervix.

21. SEROUS CYST ADENOMA

22. SEROUS CYST ADENOMA
Origin
• Serous cyst arises from the totipotent surface epithelium of the ovary.
• It is quite common and accounts for about 40% of ovarian tumors. It
is bilateral in about 40 percent and chance of malignancy is about
40%.

23. SEROUS CYST ADENOMA
Pathology
• The cysts are not so big as that of mucinous type.
• As the secretion is not abundant, there is more chance of
proliferation of the lining epithelium to form papillary projection.
• Intracystic hemorrhage is more likely. Often, the papillary growth
projects outwards perforating the cyst wall in about 15% cases.

24. SEROUS CYST ADENOMA
Naked eye appearance
• The wall is smooth, shiny and greyish white.
• At times, there are exuberant papillary projection. It may be
multilobulated on cut section.
• The content fluid is clear, rich in serum proteins—albumin and globulin.

25. SEROUS CYST ADENOMA
Microscopic examination
• It is lined by a single layer of cubical epithelium.
• The papillary structures consist of broad dense fibrous stroma
covered by single or multiple layers of columnar epithelium. There
may be presence of ciliated, secretory and peg cells resembling tubal
epithelium.

26. Psammoma Bodies:
These are tiny, spherical, laminated calcified structures which are most
often found in areas of cellular degeneration (15%).
Its presence per se does not denote malignancy. It is not present in
slow growing tumor.

27. Endometrioid tumors
These tumors are rare (5%) and consists of epithelial cells
resembling those endometrium. Endometroid carcinomas
(malignant variety) may occur.
Clear cell (mesonephroid) tumors
The tumors contain cells with abundant glycogen and are
called hobnail cells. The nuclei of the cells protrude into the
glandular lumen. They occur in women 40–70 years of age
and are highly aggressive.

28. BRENNER TUMOR

29. BRENNER TUMOR
• Brenner tumor account for 1–2 percent of all ovarian tumors, 8–10 percent
are bilateral and usually seen in women above the age of 40. Majority are
solid and are less than 2 cm in diameter. It usually arises from squamous
metaplasia of surface epithelium.
• Gross picture of Brenner is similar to that of fibroma.
• Histologically islands of transitional epithelium (Walthard nests) in a
compact fibrous stroma are seen. The cells look like “coffee bean” as the
nuclei have longitudinal grooves.
• They are usually benign in nature. Estrogen is secreted by the tumor and
the woman may present with abnormal vaginal bleeding.
• Unilateral oophorectomy in a young woman and total hysterectomy and
bilateral salpingo-oophorectomy in elderly women is the treatment choice.

30. DERMOID CYST

31. DERMOID CYST
Origin:
Dermoid cyst arises from the germ cells arrested after the first meiotic
division.
Pathology:
Dermoid cyst constitutes about 97 percent of teratomata. Its incidence
is about 30–40 percent amongst ovarian tumors.
The tumor is bilateral in about 15-20 percent. It constitutes about 20–
40 percent of all ovarian tumors in pregnancy. Torsion is the most
common (15–20%) and rupture is an uncommon (1%) complication.
The chance of malignancy is about 1–2 percent. Squamous cell
carcinoma is the commonest.

32. DERMOID CYST
Naked eye appearance
• The cyst is of moderate size.
• The capsule is tense and smooth.
• On cut section, the content is a predominantly sebaceous material with
hair. There may be clear fluid (cerebrospinal fluid) derived from the
neural tissues (choroid plexus).
• There is one area of solid projection called Rokitansky’s protuberance
which is covered by skin with sweat and sebaceous glands.
• It is here that teeth and bones are found.

33. DERMOID CYST
Microscopic examination
• The wall is lined by stratified squamous epithelium; and at places by
granulation tissue.
• The epithelium may be transitional or columnar.
• The most common tissue elements are ectodermal.
• The terminology of ‘dermoid cyst’ is misnomer, as apart from
ectodermal element, there may be endodermal and mesodermal tissues
as well.
• Besides dermal components bone, cartilage, neural tissue, thyroid and
salivary gland tissues are often present.

34. Struma Ovarii and Strumal Carcinoids
• Rarely ovarian teratomas contain a specialized tissue type. Struma ovarii is
composed of thyroid tissue.
• This accounts for less than 3% of mature teratomas.
• Malignant changes in a struma ovarii is extremely rare.
• Strumal carcinoids are also rare teratomas.
• Primary carcinoid tumors of the ovary account for less than 5% of ovarian
teratomas. These tumors may be hormonally active with secretion of serotonin,
bradykinin and other peptide hormones from the argentaffin cells as found in
gastrointestinal tract or bronchial tissues.
• Carcinoid syndrome is characterized by episodic facial flushing, abdominal pain,
diarrhea and bronchospasm.
• Metastatic carcinoid tumors are often bilateral.
• Carcinoid syndrome is more common in metastatic carcinoid than in ovarian
primaries.

35. CLINICAL FEATURES OF BENIGN TUMORS

36. CLINICAL FEATURES OF BENIGN TUMORS
• Age: Benign tumors predominantly manifest in the late childbearing
period. However, dermoid (90%) specially with mucinous cyst
adenoma, is common in the reproductive period. As such, the
dermoid is more common during pregnancy (10 percent).
• Parity: There is no correlation with parity of the patient (c.f. Fibroid —
more related with nulliparity).

37. CLINICAL FEATURES OF BENIGN TUMORS

38. CLINICAL FEATURES OF BENIGN TUMORS
Symptoms:
Most tumors are asymptomatic. These are detected accidentally by a general
physician to find a lump in the lower abdomen during routine abdominal
palpation or by a gynecologist to find a tumor during pelvic examination,
laparoscopy or laparotomy.
the patient may present the following symptoms:
• Heaviness in the lower abdomen.
• A gradually increasing mass in lower abdomen (ovarian tumor grows in
months — c.f. fibroid).

39. CLINICAL FEATURES OF BENIGN TUMORS
Symptoms:
• Dull aching pain in lower abdomen.
• In neglected cases, the tumor may be big enough to fill whole of the
abdomen. It then produces cardiorespiratory embarrassment or
gastrointestinal symptoms like nausea or indigestion.
• Menstrual pattern remains unaffected unless associated with hormone
producing tumors — menorrhagia or postmenopausal bleeding or
precocious puberty in feminizing tumorlike granulosa cell tumor or
amenorrhea in masculinizing tumor-like Sertoli-Leydig cell tumor.

40. CLINICAL FEATURES OF BENIGN TUMORS
Signs
• General condition remains unaffected.
• However, in huge mucinous cyst adenoma, the patient may be cachetic
due to protein loss.
• Pitting edema of legs may be present when a huge tumor presses on the
great veins.
• Abdominal examination: An ovarian tumor which is enlarged sufficiently
so as to occupy the lower abdomen presents with the following:
• Inspection: There is bulging of the lower abdomen over which the
abdominal wall moves freely with respiration. The mass may be placed
centrally or in one side. At times, the mass fills the entire abdominal cavity
everting the umbilicus with visible veins under the skin; the flanks remain
flat (c.f. Flanks are full with ascites).
• Palpation •
•Feel is cystic or tense cystic. Benign solid tumors such as
fibroma, thecoma, Brenner tumor are rare.

41. CLINICAL FEATURES OF BENIGN TUMORS
Palpation
• Freely mobile from side to side but restricted from above down unless the
pedicle is long.
• Too big a tumor or adhesions make its mobility restricted.
• Upper and lateral borders are well-defined but the lower pole is difficult to
reach suggestive of pelvic origin.
• However, with long pedicle, the tumor may be displaced upwards so as to
reach the lower pole.
• Surface over the tumor is smooth but often grooved in lobulated tumor.
• It is usually not tender.

42. CLINICAL FEATURES OF BENIGN TUMORS
Percussion:
• Percussion note is dull in the center and resonant in the flanks (c.f. In
ascites — just the opposite).
• A fluid thrill may be elicited when the walls are thin and the content is
watery.
• Co-existing ascites may be present even in a benign solid tumor
(fibroma) and is called Meigs’ syndrome.

43. Meigs’ syndrome
• Ascites and right side hydrothorax in association with fibroma of the
ovary, Brenner, thecoma and granulosa cell tumor is called Meigs’
syndrome.
• There is spontaneous remission of ascites and hydrothorax on
removal of the tumor.
• Ascites and hydrothorax when present in conditions other than those
mentioned above, are called pseudo-Meigs’ syndrome.

44. CLINICAL FEATURES OF BENIGN TUMORS
Auscultation:
A friction rub may be present over the tumor (Hissing sound over a
vascular fibroid, gargling sound in ascites and FHS over a pregnant
uterus).

45. DIFFERENTIAL DAGNOSIS OF A BENIGN OVARIAN TUMOR
• Full bladder
• Pregnancy
• Fibroid
• Chocolate cyst of the ovary
• Encysted peritonitis
• Ascites
• Functional ovarian cyst
• Pregnancy with fibroid.

46. INVESTIGATIONS OF BENIGN TUMORS
Special Investigations
• Sonography—
Sonography (TV) of a benign
ovarian cyst—
multilocular with thin septum

47. INVESTIGATIONS OF BENIGN TUMORS
Special Investigations
• CT —
CT scan shows a typical benign
cystic teratoma containing fat,
dental elements (arrow) and a
fat-fluid level.

48. INVESTIGATIONS OF BENIGN TUMORS
Special Investigations
• MRI — is helpful to determine whether the cyst is likely to be benign or malignant. It is
not done as a routine.
• Serum CA 125
• EUA — In doubtful diagnosis especially in virgins, EUA is helpful.
• Laparoscopy — This is of help to differentiate a painful cystic mass with disturbed
ectopic pregnancy.
• Straight X-ray of the abdomen over the tumor — The finding of a shadow of teeth or
bones is a direct evidence of a dermoid cyst. An outline of a soft tissue shadow may also
be visible.
• Laparotomy — If the clinical and ancillary aids fail to diagnose the mass, laparotomy is
justified to arrive at a diagnosis. This is especially indicated when a suspected functional
cyst fails to regress in follow up.
• Cytology — When the patient presents with ascites or pleural effusion, cytological
examination of the aspirated fluid is done for malignant cells. Ultrasound guided cyst
aspiration for cytological diagnosis of malignancy is not recommended.

49. Complications of Benign Ovarian Tumors
• Torsion of the pedicle (axial rotation)
• Intracystic hemorrhage
• Infection
• Rupture
• Pseudomyxoma peritonei
• Malignancy

50. Summary of torsion of ovarian pedicle
• Common in dermoid or simple serous cyst.
• Partial axial rotation followed by complete torsion.
• Symptoms of acute hypogastric pain with a lump.
• General condition remains unaffected.
• Abdominal examination: a tense cystic tender mass in the
hypogastrium arising from the pelvis.
• Pelvic examination: mass is separate from the uterus.
• Treatment : Laparotomy/Laparoscopy and ovariotomy.

51. • Intracystic Hemorrhage
• Infection
• Rupture
• Pseudomyxoma Peritonei
• Malignancy

52. MANAGEMENT OF A BENIGN OVARIAN TUMOR

53. MANAGEMENT OF A BENIGN OVARIAN TUMOR
• Once an ovarian tumor is diagnosed, the patient should be admitted
for operation — sooner the better.
• This is because, the complication can occur at any time and the
nature of the tumor cannot be assessed clinically.
• A clinically benign tumor may turn into a malignant one at operation.

54. MANAGEMENT OF A BENIGN OVARIAN TUMOR
Definitive surgery
• In young patients
• In parous women around 40 years
• In between these two extremes of age