Benign ovarian tumours By Dr. Khattab KAEO Prof. and Head of Obstetrics & Gynaecology Department Faculty of Medicine, Al-Azhar University, Damietta

Functional (Hormone-dependent) cysts

-Follicular cyst: It occurs due to failure of ovulation. Usually regresses within 8 w - Corpus luteum cyst: <4 cm fluctuant and may cause haemo-peritoneum when ruptures. Usually regresses within 8 weeks.

-Stein – Leventhal syndrome. - Chocolate cyst. - OHSS.

- Theca Lutein cyst. Occurs in 30% of hydatidiform moles & in 5-10% of choriocarcin- oma. Almost always bilateral,  >15 cm. - Ovarian hyperthecosis.

Luteoma of pregnancy: Benign, solid, uni-/bi-lateral, may be as large as 20 cm. Hyperreactio luteinalis: Similar, cystic,   hCG.

Complications of ovarian cyst: Torsion: The cyst uses the adjacent tube & broad ligament as a pedicle Rupture This may occur spontaneously or after examination, trauma, etc. Infection.Haemorrhage. Malignant transformation in some benign tumours and spread of malignant ones.

Benign tumours

Thecoma occurs at all age groups but more common in the 50s and 60s. It is a gonadal stromal tumour.

Benign cystic teratomas (Dermoid cyst): These are the most common ovarian tumours at the age of 20s and account for nearly 20% of the ovarian neoplasms. They occur at an earlier age, often in childhood. They are frequently bilateral, ovoid and uni- locular. They are particularly liable to have a long pedicle and easily undergone torsion or interfere with the movement of the pregnant uterus. The wall consists of dense fibrous tissue lined by stratified squamous epithelium The cyst is filled with thick yellow sebaceous material. Teeth are found in 33% and hair in 20% of cases. 1-2% are potentially malignant (immature teratoma).

Struma ovarii: = 5-10% of benign cystic teratomas (germ cell tumour). 5% are thyrotoxic. 50% will have a disappearance of symptoms after excision. 5%  carcinoma.

Brenner tumour: It is most common in the 6th decade. It forms 2% of all ovarian solid tumours. It is mainly solid and resembles fibroma, but composed of fibrous and epithelial elements.

Fibroma: = 3-5% of ovarian tumours. It is a gonadal stromal tumour and may be impossible to differentiate from thecoma. Average diameter is 6 cm. Bilateral in 10% of case. Occasionally multiple. Feels hard and homogeneous; occasionally cystic because of marked oedema. <5% of them is associated with Meig ’ s syndrome (= any benign solid ovarian tumour associated with ascites, right hydrothorax, pyrexia &, more importantly, cure of fluid after removal of the tumour). Although it is hormonally inert, oestrogenic activity may associate (resulting from stimula- tion & luteinisation of non-neoplastic theca cells). The median age is 48 y, so, the usual treatment is TAH BSO.

Serous cystadenoma: with psammoma bodies and proliferative papillae. Histologically, broad papillae are covered by a single layer of columnar epithelium. The latter resembles that of the endosalpinx i.e. composed of cilia- ted cells, secretory cells and peg cells. Mucinous cystadenoma : The lining columnar cells resemble the secretory cells of the endo-cervix. The intracyto- plasmic mucin and basal location of the nuclei are characteristic. Pseudomyxoma peritonei may be of intestinal origin or from mucinous cyst adenoma.

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Treatment Benign tumours >10 cm must be removed. If <10 cm in <35 years old women, the case may be reviewed in a few months if there is no suspicion of malignancy. A follicular or luteal cyst may resolve spontaneously.

Indications for surgery in adnexal mass:

Treatment Cystectomy is enucleation of the tumour from its capsule. This is not feasible in very large tumors or in those with previous inflammation. Ovariotomy is removal of an ovary containing a tumour.

Ovarian Mass 90% of ovarian masses are fun- ctional cysts that disappear spon taneously within 2-6 months. Otherwise, aspiration can be applied. Ovarian cyst is present in 6% of asymptomatic women. They develop as luteinized un- ruptured follicles which occur in 10% of cycles of infertile couples

Ovarian cysts in postmenopausal women Prevalence: ±22% (common). Diagnosis: Clinical & US. Doppler examination, CT and MRI do not improve the diagnostic capability of differentiating benign from mali- gnant tumors. Complications: A torted cyst will be purple black. Rupture  shock or peritonitis.

Management The low risk of malignancy of many of these cysts suggests that not all of them need sur- gery. The risk of malignancy can be assessed using CA125 (>30 u/ml) & TVS. Larger cysts may need to be assessed by TAS. Color-flow Doppler sonography may be of benefit. Ultrasound scan looks for multi locularity; evidence of solid areas; evidence of metasta- ses; ascites & bilaterality. Simple, unilateral, unilocular ovarian cysts, 50% of these cysts will resolve spontaneously within 3 months. Such cysts in the presence of normal levels of serum CA125 can be managed conservatively with a follow-up TVS after 4 months. This, of course, depends upon symptoms and clinical assessment.

Surgical management may be achie- ved by aspiration, laparoscopy or laparotomy. Aspiration is not recom- mended in postmenopausal women This is because cytological exam of ovarian cyst fluid is poor at disting uishing between benign and malig- nant tumours. In addition, there is a risk of cyst rupture, and if malig- nant, this would have an unfavour- able impact on disease free survival Laparotomy: Staging laparotomy may include bilateral selective pelvic and para-aortic lymphadenectomy.

Laparoscopy: Functional cysts are treated by laparoscopic fenestration & coagulation of the cavity, while benign tumours are best treated by striping of the capsule. The main reason for operating upon postmenopausal women with ovarian cysts is to exclude malignancy. This is best achieved by a staging laparotomy. Laparoscopy, therefore, should be reserved for those women who are not eligible for conserva- tive management, but still have a relatively low risk of malignancy. It is recommended that laparoscopy should include oophorectomy (usually bilateral) rather than cystectomy. Uni or bilateral oophorectomy this will be partially deter mined by the wishes of the woman. If a woman with intermediate risk is going to be managed by laparoscopic oophorectomy, they should be counseled preoperatively that a full-staging laparotomy would be required if evidence of malignancy is revealed.

work-up Premenopausal Postmenopausal Simple on US, <6cm Simple on US, <3cm & normal CA-125 & normal CA-125 (the risk of being malign. is 2%) (the risk of being malign. is 2%) Observe for 6-8 w + OCP Observe + FU Observe for 6-8 w + OCP Observe + FU Persistent on US, Solid/complex, Solid/complex on US, Persistent on US, Solid/complex, Solid/complex on US, >6cm or  CA-125 >3cm or  CA-125 >6cm or  CA-125 >3cm or  CA-125 Surgical Evaluation Surgical Evaluation

Borderline tumours (WHO) 10-15% of all ovarian malignancies are semimalignant (hyperplastic ovarian tumours without histologic stromal invasion but with peritoneal implants). Carcinoma of low malignant potential (FIGO ). They are characterized by LACK OF STROMAL INVASION and tendency to spread locally. They are frequently diag- nosed in the reproductive age women, 10 years younger than that of frank malignancy. Borderline tumours are of EPITHELIAL origin.

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