BENIGN & Malignant

LESIONS OF OVARY
BY

izhad farooq
haris rehman
abdullah tahir
saadullah khalid
 CONTENT
- Non neoplastic cyst & benign neoplastic
tumours
- Clinical features
- Diagnosis
- Differential diagnosis
- Management
- Complications
 OVARY
THE HUMAN OVARY HAS A STRICKING PROPENSITY TO
DEVELOP A WIDE VARITY OF TUMORS MOST OF WHICH
ARE BENIGN.

80% OF ALL OVARIAN TUMORS ARE BENIGN,ALTHOUGH

THIS VARIES WITH AGE.
 BENIGN LESIONS OF OVARY

NON NEOPLASTIC NEOPLASTIC(BENIGN)

FUNCTIONAL PATHOLOGY
1.Follicular cyst 1.PCOS A. SURFACE EPITHELIUM
2.Corpus luteal cyst 2.endometrioma 1. Serous
3.Theca lutein & 3. T O mass 2. Mucinous
granulosa lutein cyst 3. Endometroid
4. Brenner

B.GERM CELL TUMOUR

(BENIGN)
C. SEX CORD / STROMAL
1. thecoma/fibroma
2. androblastoma
 FOLLICULAR CYST CORPUS THECA LUTEIN
(commonest) LUTEUM CYST CYST

AGE GROUP Adolescent, Reproductive age Reproductive age

reproductive age
groups ,can occur
in perimenopause

CAUSE Hyperestronism Over activity of Excess chorionic

gonadotropin
corpus luteum
secreted in GTD,
following to ovulation
induction drugs

Size Grow ≥3 & ≤8 cm 3 – 10 cm Large upto 30 cm

Laterality B/L or U/L U/L B/L

 FOLLICULAR CYST CORPUS LUTEUM THECA LUTEIN CYST
CYST

GROSS Thin walled , Pink or Multicystic, greyish

unilocular , filled haemorrhagic cyst, blue colour, filled
with straw coloured cut section with straw colour
fluid yellowish orange, fluid or blood
filled with blood
clots

Histology Lining epithelium Luteinised Theca lutein

Granulosa cells granulosa cell cells,granulosa
lutein cells

C/F Usually Dull with U/L pelvic Small are

asymptomatic , pain asymptomatic, large
diagnosis incidental Rupture with -discomfort , pain
hemoperitoneum Rupture/torsion
more common (more common)
 Hemorrhagic cyst with unusual
appearance simulating a neoplasm
Shows enlarged uterus in the centre and bilateral Theca
lutein cysts. The cyst on the left shows a breach in the
capsule and the right cyst with thin hemorrhagic area
suggestive of impending rupture
PCOS:
-0.5-4%, infertile women, young reproductive age
-excess androgen , chronic anovulation
-Pathology: ovaries enlarged, stroma increased, capsule
thickened, pearly white
-c/s: multiple follicles in cortex
-Histo: thickened tunica albuginea, stromal hyperthecosis
-insulin resistance (acanthosis nigricans)
-CF: amenorrhoea, hirsutism, obesity, enlarged PCO.
-Investigations
Management – Wt. reduction
COCP
Tt. Of hirsutism
Tt. Of infertility
BENIGN OVARIAN TUMORS

Ovarian neoplasm may be divided generally by cell type

of origin into three types:
1.epithelial
2.stromal
3.germ cell
 BENIGN OVARIAN NEOPLASMS
EPIDEMOLOGY:
-Incidence: 1-3% among outpatient , 75% -benign
-Racial factors: higher in white population, lowest in japan
-Economic status: higher in industrialised countries
-Environmental factors:

PATHOLOGY:
-Origin: mesoepithelial cells on ovarian surface
-Incidence: epithelial tumours—80% of all ovarian tumours
serous cystadenoma– 50% of all epithelial tumours
mucinous cysts—12-15%
endometroid—10%
unspecified—25-27%
Benign MUCINOUS SEROUS BRENNER BENIGN
ovarian CYST CYST CYSTIC
tumors ADENOMA ADENOMA TERATOMA

INCIDENCE 12-15 % of 50 % of all 2 – 3 % of all 95 % of Germ

Epithelial Epithelial Epithelial cell tumors
tumors tumors tumors
15 – 20% of all
20-25% of all 40% of all 1 -2% of all ovarian tumors
OV.tumors ovarian tumors ovarian tumors

Bilateral 10% 40% 8 -10% 15 -20%

Malignant 5 –10% 40% rare 1 -2%

chance
20- 40 % of all
ov. Tumors in
pregnancy
TUMOR MUCINOUS SEROUS DERMOID
Totipotent surface Totipotent surface germ cells arrested
ORIGIN epithelium of ovary epithelium of after 1st meoitic
ovary division

naked eye : huge size naked eye: naked eye:

PATHOLOGY & wt 5-10 kg smooth, shiny, moderate size,
pedunculated, largest. greyish white capsule tense &
smooth, lobulated exuberant smooth
with whitish or papillary
bluish white , projections .
translucent tumor.

c/s: thick, visid c/s:multilobulated c/s: trabeculated

mucin (glycoprotein) clear fluid (serum) appearance ,
colourless proteins (albumin sebaceous material
& globulin) with hair , clear
multiloculated with
rokitansky’s
papillary. honey
protruberance
combed appearance
-microscopy: microscopy:-
lined by 1 layer of lined by cubical micro: stratified
tall coloumnar epithelium squamous
epithelium with - papillary epithelium,granulat
ion tissue, may be
dark staining structures –
transitional/
basal nuclei dense fibrous columnar
without any cilia. stroma covered
Epithelium by single or .
resemble to those multiple layers of
of endocervix. columnar
epithelium.
ciliated secretory
-complication: & peg cells.
rupture Epithelium
pseudomyxoma resemble to those
peritonei & of endosalpingeal
shows adhesions epithelium
with visera .
MUCINOUS CYSTADENOMA
SEROUS CYSTADENOMA
SEROUS /MUCINOUS
CYSTADENOMA

Gross appearance of a mucinous (A) and serous (B) cystadenoma of

the ovary. The mucinous type is generally multiloculated and can be
quite large.
BRENNER TUMOUR
-U/l , small to moderate, seen after 50 years
-Gross: resembles fibroma, smooth solid tumour
-C/s: gritty, yellowish grey
-Histology: fibrous tissue with transitional epithelium ( walthard cell nests)
-Cf: pmb, pseudo meig

ENDOMETROID TUMOUR:
-2% of all ovarian tumours
-Lined by glandular epithelium
-Moderate size, solid, with cystic areas with haemorrhagic fluid.
Gross appearance of a cut-open Brenner tumor.
 2. SEX CORD STROMAL OVARIAN
NEOPLASMS

Hormone secreting tumors of the ovary.

These tumors include fibromas, Ser toli-Leydig cell

tumors (Arrheno–blastomas or androblastomas).
FIBROMA:
-origin: stromal cells of ovarian cortex
-small sessile nodule, long pedicle ,solid,smooth surfaced tumour
-c/s: white
-microscopy: interlacing bundles of spindle shaped cells
-complication: torsion ,meig syndrome

ANDROBLASTOMA/SERTOLI-LEYDIG CELL TUMOR

-testicular adenoma
-androgen secreting tumour
-seen in women less than 30 year
-gynandroblastoma (granulosa + androblastoma cells)
-cf: amennorhoea, atrophy of breasts, enlargement of clitoris, body hair
growth, deepening of voice.
Gross appearance of an ovarian
fibroma.
 3. GERM CELL TUMORS
TUMORS OF GERM CELL ORIGIN MAY REPLICATE STAGES RESEMBLING
THE EARLY EMBRYO

CAN OCCUR AT ANY AGE

12-15% OF OVARIAN NEOPLASM

60% OF GCTS OCCURS IN CHILDREN

MOST COMMON BENIGN TYPE IS ‘BENIGN CYSTIC TERATOMA’

DERMOID CYST
 On clinical examination
Character Benign Malignant
1. Age ◼ younger • older
2. Laterality ◼ unilateral • Bilateral
3. Mobility ◼ Mobile • Fixed
4. Feel ◼ Cystic • Solid
5. Surface ◼ Smooth • Irregular
6. Ascites ◼ Absent • Present
7. Growth ◼ Slow • Rapid
8. nodules ◼ Absent • Present
 Criteria on USG

BENIGN MALIGNANT
• U/L ,uni/multi locular • B/L, thick wall, thick
Cystic areas with septa, echogenic areas
regular thin wall thin in cavity Irregular
septa and heterogenous parts
nonechogenic cavity
• TVS neovascularisation
• TVS(doppler) shows
• Low RI & PI
regular vascular
branching
 USG:

• Benign • Malignant
 CLINICAL FEATURES
AGE:- late child bearing age
-dermoid, mucinous adenoma common in reproductive
-dermoid common in pregnancy
symptoms: -asymptomatic
- detected accidently
-heaviness in lower abdomen, mass
- dull aching pain,
- cardiorespiratory & gastrointestinal upset
(nausea, indigestion)
-menstrual pattern unaffected except in hormone
producing tumours
signs: cachetic , pitting edema legs
ABD EXAMINATION
Inspection -- bulging of lower abdomen
mass – central/ one side/ whole abdomen
visible veins , flanks – flat
Palpation -- cystic / tense cystic
freely mobile from side to side with restricted in above down,
smooth surface , nontender

Percussion -- dull in center resonant in flanks

fluid thrill +
Auscultation -- friction rub +

Bimanual pelvic examination --

uterus separated from mass
groove + between uterus & mass
movement of mass p/a fails to move cx
lower pole of cyst felt through fornix
absence of pulsation of ut vessels thro fornix
 D.D

1. Full bladder
2. Pregnancy
3. Pregnancy with fibroid
4. Ascites
5. Fibroid uterus
6. Encysted peritonitis
 INVESTIGATION

To confirm diagnosis
USG
Tumor markers
Straight x-ray abdomen
Paracentesis
Laproscopy
 COMPLICATIONS
1. Torsion
2. Intracystic hge
3. Infection
4. Rupture
5. Malignancy
6. Pseudomyxoma peritonei

Torsion: (axial rotation)

• 10 – 15%
• moderate size & wt
• free mobility & long pedicle
• common in dermoid or serous cystadenoma
Causes:
-Trauma, violent physical movement, contraction of preg uterus,
intestinal peristalsis.
• Hemodynamic theory
• Symptoms- acute pain + lump, vomiting, fever, shock ,
tachycardia.
P/A: tense, tender, cystic mass with
restricted mobility
P/v: mass abd separate from uterus
DD:
1. Disturbed ectopic preg
2. Acute hydramnios
3. Perforating h mole
4. Torsion of subserous pedunculated fibroid
Rx:
Pain– morphine
Laparotomy ( cystectomy/ salpingoophorectomy)
INTRACYSTIC HGE:
-serous cystadenoma, malignancy.
-venous congestion.
INFECTION:
-following torsion
-organisms – from intestine, uterine tubes.
RUPTURE:
-big & tense cyst
-trauma, malignancy, papillary type.
PSEUDOMYXOMA PERTONEI:
-mucinous ascites
-asso with mucinous cyst adenoma ovary, mucocele appendix & gall bladder,
intestinal malignancy.
-spontaneous perforation
-recurrence high, prognosis poor ( infection, intestinal obstr)
-Rx: hystrectomy, BSO with removal of mucin, peritoneal implants with
appendix.
 OVARIAN CYST
premenopause
women

Cystic teratoma Simple cyst size 5-8 cm All other cyst

Benign morphology
CA-125 ≤35IU/L
Laproscopy /
Laproscopic surgery Follow up 3-6 month or laparotomy
COCP

Increase in size
symptomatic

Yes No

Laproscopic cystectomy Follow up

 Ovarian cyst
postmenapause

Simple cyst size 3-5

cm, Benign Size ≥ 5 cm
morphology Morphology
CA-125≤ 35IU/L suspicious
Doppler RI ≥0.4 CA-125 ≥35IU/L

Follow up 6 weeks

Increase in size Laparotomy

CA-125 Rising

Yes No

Laparotomy Follow up
SURGERY:
young women- ovarian cystectomy
Oophorectomy (salpingoophorectomy)
parous women- TAH+BSO
others- individualisation.
laparoscopic cystectomy / ovariotomy
laparoscopy/ USG guided aspiration of cyst.
THANK YOU