1. BENIGN TUMOURS OF THE OVARY

2. Benign ovarian cysts are common, frequently asymptomatic and often resolve spontaneously. They are the fourth commonest gynaecological cause of hospital admission. By the age of 65 years, 4 per cent of all women will have been admitted to hospital for this reason.

3. Ovarian tumours may be physiological or pathological, and may arise from any tissue in the ovary. Most benign ovarian tumours are cystic. The finding of solid elements makes malignancy more likely. However, fibromas, thecomas, dermoids and Brenner tumours usually have solid elements

5. I-Physiological cysts Physiological cysts are simply large versions of the cysts which form in the ovary during the normal ovarian cycle. Most are asymptomatic incidental findings at pelvic examination or ultrasound scan. Although they may occur in any premenopausal woman, they are most common in young women

7. 1-Follicular cyst Lined by granulosa cells, this is the commonest benign ovarian tumour and is most often found incidentally. It results from the non-rupture of a dominant follicle, or the failure of atresia in a non- dominant follicle

8. A follicular cyst can persist for several menstrual cycles and may achieve a diameter of up to 10 cm. Smaller cysts are more likely to resolve, but may require intervention if symptoms develop or if they do not resolve after 8-16 weeks. Occasionally, they may continue to produce oestrogen, causing menstrual disturbances and endometrial hyperplasia

9. 2-Luteal cyst Less common than follicular cysts, these are more likely to present with intraperitoneal bleeding. This is more common on the right side, possibly as a result of increased intraluminal pressure secondary to ovarian vein anatomy

10. They may also rupture. This usually happens on days 20-26 of the cycle. Corpora lutea are not called luteal cysts unless they are more than 3 cm in diameter.

11. II-Benign germ cell tumours Germ cell tumours are among the commonest ovarian tumours seen in women less than 30 years of age. Overall, only 2-3 per cent are malignant, but in the under-twenties this proportion may rise to a third

12. 1-Dermoid cyst (mature cystic teratoma ) The benign dermoid cyst is the only benign germ cell tumour that is common. It results from differentiation into embryonic tissues. It accounts for around 40 per cent of all ovarian neoplasms and is most common in young women. The median age of presentation is 30 years

13. Dermoid Cyst: mamillae or Rokitansky's protuberances

14. It is bilateral in only about 11 per cent of cases. However, if the contralateral ovary is macroscopically normal, the chance of a concealed second dermoid is very low 0-2 per cent), particularly if preoperative ultrasound is normal.

15. A dermoid is usually a unilocular cyst less than 15 cm in diameter, in which ectodermal structures are predominant. Thus it is often lined with epithelium like the epidermis and contains skin appendages teeth, sebaceous material, hair and nervous tissue. Endodermal derivatives include thyroid, bronchus and intestine, and the mesoderm n ay be represented by bone, cartilage and smooth muscle,

16. Occasi nally only a single tissue may be present, in which case the term monodermal teratoma is used. The classic examples are carcinoid and struma Ovarii, which contains hormonally active thyroid tissue. The term 'struma ovar ii' should be reserved for tumours composed predominantly of thyroid tissue and as such comprise only 1.4 per cent of cystic teratomas.

17. The majority (60 per cent) of dermoid cysts are asymptomatic. However, 3.5-10 per cent may undergo torsion. Less commonly (1-4 per cent), they may rupture spontaneously, either suddenly, causing an acute abdomen and a chemical peritonitis, or slowly, causing chronic granulomatous peritonitis

18. 2-Mature solid teratoma These rare tumours contain mature tissues just like the dermoid cyst, but there are few cystic areas. They must be differentiated from immature teratomas, which are malignant

19. Cystic Teratoma

20. II-Benign epithelial tumours The majority of ovarian neoplasia, both benign and malignant, arise from the ovarian surface epithelium

21. 1-Serous cystadenoma This is the most common benign epithelial tumour and is bilateral in about 10 per cent. It is usually a unilocular cyst with papilliferous processes on the inner surface and occasionally on the outer surface. The epithelium on the inner surface is cuboidal or columnar and may be ciliated

22. Psammoma bodies are concentric calcified bodies which occur occasionally in these cysts, but more frequently in their malignant counterparts. The cyst fluid is thin and serous. They are seldom as large as mucinous tumours

23. Serous Cystadenoma

24. 2-Mucinous cystadenoma These constitute 15-25 per cent of all ovarian tumours and are the second most common epithelial tumour. They are typically large, unilateral, multilocular cysts with a smooth inner surface. The lining epithelium consists of columnar mucus secreting cells. The cyst fluid is generally thick and glutinous.

25. Mucinous Cystadenoma:

26. Myxoma peritonei This occurs if the tumour bursts spontaneously or during surgery so the cells seed on the surface of the peritoneum &grow continue secret mucin so abdominal&pelvic cavities slowly filled with mucin&tumor. when this occur it may be a borderline malignant potential.

27. 3-Endometrioid cystadenoma Benign endometrioid cysts are difficult to differentiate from ovarian endometriosis

28. 4-Brenner tumours These account for only 1-2 per cent of all ovarian tumours, and are bilateral in 10-15 per cent of cases. They probably arise from Wolffian metaplasia of the surface epithelium. The tumour consists of islands of transitional epithelium ( Walthard nests) in a dense fibrotic stroma, giving a largely solid appearance

29. The vast majority are benign, but borderline or malignant specimens have been reported. Almost three-quarters occur in women over the age of 40 and about half are inciden tal findings, being recognized only by the pathologist. Although some can be large, the majority are less than 2 cm in diameter.

30. 5-Clear cell (mesonephroid) tumours These arise from serosal cells showing little differen tiation, and are only rarely benign. The typical histological appearance is of clear or 'hobnail' cells arranged in mixed patterns

31. III-Benign sex cord stromal tumours Sex cord stromal tumours represent only 4 per cent of benign ovarian tumours. They occur at any age, from prepubertal children to elderly, postmenopausal women. Many secrete hormones and present with the results of inappropriate hormone effects.

32. 1-Granulosa cell tumours These are all malignant tumours but are mentioned here because they are generally confined to the ovary when they present and so have a good prognosis. However, they do grow very slowly and recurrences are often seen 10-20 years later. They are largely solid in most cases. Call-Exner bodies are pathognomonic but are seen in less than half of granulosa cep tumours

33. Granulosa Cell Tumor:

34. 2-Theca cell tumours Almost all are benign, solid and unilateral, typically presenting in the sixth decade. Many produce oestrogens in sufficient quantity to have systemic effects such as precocious puberty, postmenopausal bleeding, endometrial hyperplasia.

35. 3-Fibroma These unusual tumours are most frequent around 50 years of age. Most are derived from stromal cells and are similar to thecomas. They are hard, mobile and lobulated with a glistening white surface. Less than 10 per cent are bilateral. While ascites occur with many of the larger fibromas, Meig's syndrome - ascites and pleural effusion in association with a fibroma of the ovary - is seen in only 1 per cent of cases.

36. Age distribution of ovarian tumours In younger women, the most common benign ovarian neoplasm is the germ cell tumour; amongst older women, it is the epithelial cell tumour The percentage of ovarian neoplasms that are benign also changes with the age of the woman

37. Presentation The presentation of benign ovarian tumours is as follows. Asymptomatic Pain Abdominall swelling Pressure effects Menstrual disturbances Hormonal effects Abnormal cervical smear

38. Asymptomatic Many benign ovarian tumours are found incidentally in the course of investigating another un related problem or during a routine examination About 50 per cent of simple cysts less than 6 cm in diameter will resolve spontaneously if observed over a period of 6 months. A further 25 per cent regress in the following 2 years.

39. Pain Acute pain from an ovarian tumour may result from torsion, rupture, haemorrhage or infection. Torsion usually gives rise to a sharp, constant pain caused by ischaemia of the cyst. Areas may become infarcted. Haemorrhage into the cyst may cause pain as the capsule is stretched

40. This happens most frequently with a luteal cyst. Chronic lower abdominal pain sometimes results from the pressure of a benign ovarian tumour, but is more common if endometriosis or infection is present.

41. Abdominal swelling Patients seldom note abdominal swelling until the tumour is very large. A benign mucinous cyst may occasionally fill the entire abdominal cavity. The bloating of which women complain so often is rarely due to an ovarian tumour

42. Miscellaneous *Gastrointestinal or urinary symptoms may result from pressure effects. *In extreme cases, oedema of the legs, varicose veins and haemorrhoids may result. *Sometimes uterine prolapse is the presenting complaint in a woman with an ovarian cyst.

43. *Occasionally patients complain of menstrual disturbances, but this may be coincidence rather thandue to the tumour. *Rarely, sex cord stromal tumours present with oestrogen effects such as precocious puberty, menorrhagia and glandular hyperplasia, breast enlargement or postmenopausal bleeding

44. *Secretion of androgens may cause hirsutism and acne initially, progressing to frank virilism with deepening of the voice or clitoral hypertrophy. *Very rarely indeed, thyrotoxicosis may result from ectopic secretion of thyroid hormone.

45. Investigations Ultrasound Transabdominal and transvaginal ultrasound can demonstrate the presence of an ovarian mass it cannot distinguish reliably between benign and malignant tumours, solid ovarian masses are more likely to be malignant than their cystic counterparts

46. The use of colour-flow Doppler may increase the reliability of ultrasound. Neither computerized tomographic scanning nor magnetic resonance imaging has significant advantages over ultrasound in this situation, and both are more expensive

47. Radiological investigations *Occasionally an abdominal X-ray may show calcification, suggesting the possibility of a benign teratoma. *An intravenol s urogram is often performed but is seldom useful. *A barium enema is indicated only if the mass is irregular r fixed, or if there are bowel symptoms.

48. Blood test and serum markers It is always sensible to measure the haemoglobin, and an elevated white cell count would suggest a raised *serum CA 125 is strongly suggestive of ovarian carcinoma, especially in postmenopausal women. Women with extensive endometriosis may also have elevated levels, but the concentration is usually not as high as is seen with malignant disease. *The beta-human chorionic gonadotrophin W-hCG) concentration might be measured to exclude an ectopic pregnancy but trophoblastic tumours and some germ cell tumours secrete this marker.infection

49. *Oestradiol levels maybe elevated in some women with physiological follicular cysts and sex cord stromal tumours. *Androgen concentrations may be increased by Sertoli-Leydig tumours. *Raised alphafetoprotein levels suggest a yolk sac tumour

50. Management The asymptomatic patient *The older woman Women over 50 years of age are far more likely to have a malignancy and have little to gain from the conservative management of a pelvic mass more than 5 cm in diameter laparoscopy may be useful to confirm that the ultra sound lesion is ovarian, but the open approach is still recommended if the ovary is to be removed

51. *Premenopausal women Young women aged less than 35 years are both more likely to wish to have the option of further children and less likely to have a malignant epithelial tumour. However, ovarian cysts more than 10 cm in diameter are unlikely to be physiological or to resolve spontaneously A clear unilocular cyst of 3-10 cm identified by ultraso und should be re-examined 12 weeks later for evidence of diminution in size

52. The use of a combined oral contraceptive is unlikely to accelerate the resolution of a functional cyst and hormonal treatment of endometriosis does not usually benefit an endometrioma. If the cyst does enlarge, laparoscopy or laparotomy may be indicated

53. Criteria for observation of an asymptomatic ovarian tumour Unilateral tumour Unilocular cyst without solid elements PremenopalJ sal women - tumour 3-10 cm in diameter Postmenopausal women - tumour 2-6 cm in diameter Normal CA 125 No free fluid or masses

54. The patient with symptoms The pregnant patient An ovarian cyst in a pregnant woman may undergo torsion or may bleed If an asymptomatic cyst is discovered, it is prudent to wait until after 14 weeks' gestation before removing it. This avoids the risk of removing a corpus luteal cyst upon which the pregnancy might still be dependent

55. Cysts less than 10 cm in diameter that have a simple appearance on ultrasound are unlikely to be malignant or to result in a cyst accident, and may therefore be followed ultrasonographically: many will resolve spontaneously If the cyst is unresolved 6 weeks postpartum, surgery may be undertaken then.

56. The prepubertal girl Ovarian cysts are uncommon and often benign. Teratomata and follicular cysts are the most common. Theca and granulosa cell tumours may secrete hormones. Presentation may be with abdominal pain or distension, or precocious puberty, either isosexual or heterosexual

57. Management depends upon * the relief of symptoms, * exclusion of malignancy and *conservation of maximum ovarian tissue without jeopardizing fertility.