BENIGN OVARIAN

TUMOURS

SEMINAR 11
 GROUP MEMBERS

❏ MUHAMMAD HAZMI BIN AULIA MOHAMED

❏ HAMEED ABDULLA
❏ SAKTHYNATHAN A/L S MAGESH KUMAR
❏ SANTHIRA RUPINII A/P SELVA KUMAR
❏ CHARRMETHA A/P NANTHA KUMAR
❏ KAMALDHEEN RIYAZDEEN
 Contents
1. Anatomy of the ovary
2. Risk Factors of Benign Ovarian Cyst
3. Types of Benign Ovarian Cyst
a. Functional
b. Inflammatory
c. Germ Cell
d. Epithelial
e. Sex Cord Stromal
4. Staging
5. Tumour markers
6. Screening
7. Prevention
 Anatomy of Ovary
The ovaries are a pair of oval shaped organs located in the female
reproductive system.

● Located at the either side of uterus within the pelvic cavity.

● Each ovaries is connected by a fibrous band called ovarian
ligament which helps ovary to stay at its place.
● Each ovaries is approximately 3 to 5 cm long and 1 to 2 cm
wide.

The main function of ovaries are:

● Ovulation: During the menstrual cycle, one or more ovarian follicles

mature and release a mature egg in a process called ovulation.
● Hormone Production: The ovaries produce two primary female sex
hormones: estrogen and progesterone.
Layers of Ovaries

The ovary is composed of four layers that are:

1. Germinal Epithelium: The outermost layer of the ovary. It is a layer

of simple cuboidal or squamous epithelial cells that covers the
surface of the ovary.
2. Tunica Albuginea: Beneath the germinal epithelium lies the tunica
albuginea, which is a dense connective tissue layer. It surrounds
the ovary and provides structural support.
3. Cortex: The cortex is the outer layer of the ovarian tissue, located
below the tunica albuginea. It contains numerous ovarian follicles,
which consist of an oocyte
4. Medulla: The medulla is the central region of the ovary, surrounded
by the cortex. It consists of loose connective tissue, blood vessels,
lymphatic vessels, and nerves. The medulla provides the blood
supply, lymphatic drainage, and innervation to the ovary.
Risk Factors of Benign Ovarian Cyst

Increased risk of ovarian cancer

Nulliparity

Intrauterine

Endometriosis

Cigarette smoking (mucinous tumours only)

Obesity
Types of Benign Ovarian Cyst
FUNCTIONAL CYSTS(FOLLICULAR CYST)

● Develops when a Graafian follicle

does not rupture and release the
egg (ovulation) but continues to
grow
● Diagnosis can be made when the
cyst measures > 3 cm
● Eventually develops into a large
cyst (∼ 7 cm) lined with
granulosa cells
● Associated with
hyperestrogenism and
endometrial hyperplasia
FUNCTIONAL CYSTS (CORPUS LUTEAL
CYST)

● Enlargement and buildup of

fluid in the corpus luteum
after failed regression
following the release of an
ovum
● Produces progesterone, which
may delay menses.
● Associated with progesterone
only contraceptive pills and
ovulation-inducing medication
● Common during pregnancy
 FUNCTIONAL CYSTS (THECA LUTEIN
CYST)
● Theca lutein cysts are luteinized ovarian
follicle cysts due to overstimulation from
high levels of human chorionic
gonadotropin (hCG), hypersensitivity to
hCG or ovarian hyperstimulation
syndrome (OHSS).
● This is a rare condition of bilateral ovarian
cysts, which are characteristically benign,
multilocular, functional cysts with thin
walls and clear, straw-colored fluid.
● It is associated with gestational
trophoblastic disease and multiple
pregnancies
● They cause ovarian enlargement and
often pelvic pain due to fullness and
compression.
● Usually resolve once β-hCG levels have
normalized
 Functional Cyst
Clinical features Management
❏ Usually asymptomatic (incidental ❏ Pain management: NSAIDS (first line),
finding) opioids (only for severe cases)
❏ Larger cyst can cause lower abdominal ❏ If asymptomatic, watchful waiting with
pain repeated ultrasounds is indicated
❏ If there are any complications, large or
Complications
persistent painful cysts, cystectomy is
❏ Ovarian torsion indicated.
❏ Hemorrhage
❏ Ruptured ovarian cyst

Diagnosis

❏ Pelvic ultrasound
 INFLAMMATORY CYSTS (TUBO-OVARIAN
ABSCESS)
● Tubo-ovarian abscess (TOA) is a recognized and serious
complication of untreated pelvic inflammatory disease
(PID).
● It most commonly affects women of reproductive age
and nearly 60% of women with TOA are nulliparous.
● TOA is defined as an inflammatory mass involving the
tube and/or ovary characterized by the presence of pus.
● The most common cause is ascending/upper genital
tract infection when purulent material can discharge
through the tube directly into the peritoneal cavity
causing initial PID and progression to form a TOA.
● TOA carries a high morbidity and can be life threatening.
● Symptoms and signs TOA :
○ Adnexal tenderness (bilateral or unilateral)
○ Cervical excitation
○ Abnormal cervical or vaginal discharge
● Diagnosis:
❏ Increased WBC, Inflammatory marker (high CRP and
ESR)
❏ Ultrasound ,laparoscopy
● Treatment
❏ Antibiotics (IV clindamycin, IV metronidazole and IV
cefoxitin), surgical drainage and excision.
● Potential long-term consequences of a TOA includes
infertility, an increased risk of ectopic pregnancy and chronic
pelvic pain.
 INFLAMMATORY CYSTS (ENDOMETRIOMA)

◦Endometriotic cyst in the ovaries are called as

endometriomas

◦ This cyst may be large and contains old, altered blood that
has a thick brown appearance and it is frequently referred to
as a ‘chocolate cyst’.

◦Endometriomas may or may not cause symptoms. When

symptoms do occur, they are the same as the symptoms of
endometriosis :
a)Dysmenorrhea
b)Oligomenorrhea
c)Menorrhagia
d)Dyspareunia
◦Diagnosis:
❏ Transvaginal ultrasounds (characteristic ground
glass appearance),laparoscopic

◦Treatment
❏ NSAIDS,COCP, Progestins, GnRH agonist,
laparoscopic drainage and excision
 DERMOID CYST (MATURE CYSTIC TERATOMA)
◦It is the most common ovarian tumors in young women aged 20–40
years, accounting for more than 50% of ovarian tumors in this age
group with a peak incidence in the early 20s.

◦It contains fully differentiated tissue types derived from all three
embryonic germ cell layers (mesenchymal, epithelial and stroma).

◦Dermoid cyst is usually full of sebaceous material and hair but may
contain teeth, skin, cartilage, fat, or bone.

◦Up to 10% of dermoid cysts are bilateral, seldom large and often
asymptomatic. But large tumors may cause increase abdominal girth
and lower abdominal pain.

◦Complications :
a) Leakage or spillage of dermoid cyst contents can cause chemical peritonitis
b) Ovarian torsion
c) The risk of malignant transformation is rare (<2%) usually occurring in
women over 40 years.
◦Diagnosis
❏ It is usually confirmed with a pelvic USS and
because of the high fat content present in
dermoid cysts, MRI may also be useful where
there is uncertainty.

◦Management
❏ Ovarian cystectomy is indicated because
spontaneous resolution is unlikely
❏ Cystectomy will prevent ovarian torsion and
provide tissue for histological analysis.
 Serous Cystadenoma
Definition
● Serous cystadenoma is a non-cancerous ovarian
tumor made up of fluid-filled cysts.
● Affects women of reproductive age.
● Measures more than 1 cm in size.
● Composed of cells resembling of epithelium of
fallopian tube and epithelium of ovary.
Characteristics
● Greater than 1 cm
● Benign, Asymptomatic
● Unilocular and multilocular cysts
Pelvic Discomfort (due to the pressure)
Clinical Features
● Abdominal Distension
● Palpable Abdominal Mass
● Menstrual Irregularities
● Urinary Symptoms (increased frequency, urgency,
or difficulty in emptying the bladder)
 CT
Radiological ● Often seen as a unilocular (typically) or
Findings multilocular cystic mass with a thin
Ultrasound regular wall or septum.
● Cysts can be quite large in size and have
● Usually seen as a unilocular
the potential to be seen filling most of the
cystic/anechoic adnexal lesion
lower pelvis with extension into the upper
● Papillary projections are absent
abdomen.
● it is thin, with an acute angle
with the cyst wall and has a
regular surface.

MRI
● The typical MR imaging appearance of
serous cystadenoma is a unilocular thin-
walled adnexal cyst.
● MRI may show a beak sign which may
suggest an ovarian origin.
Complications
1. Torsion: Risk of ovarian twisting leading to reduced blood supply and tissue damage.
2. Rupture: Potential for sudden abdominal pain, internal bleeding, and peritonitis.
3. Pressure Symptoms: Compression of nearby organs causing urinary, bowel, or
abdominal discomfort.
4. Malignant Transformation: Rare chance of developing borderline or malignant features
requiring further evaluation and treatment.
5. Impact on Fertility: Large or bilateral cysts may affect ovarian function and fertility.
6. Recurrence: Small possibility of cysts returning after surgical removal.
Management
● Symptom Management: Pain management or hormonal
therapy (such as oral contraceptives)
● Surgical Intervention: Surgical removal of the serous
cystadenoma may be necessary. Surgical options include
cystectomy (removal of the cyst while preserving the
ovary), oophorectomy (removal of the affected ovary), or
salpingo-oophorectomy (removal of the affected ovary
and fallopian tube).
● Unilateral salpingo-oophorectomy or ovarian cystectomy
is the adequate treatment of ovarian cystadenomas.
Mucinous Cystadenoma

● Mucinous cystadenoma consists of multiple cysts and glands lined by a

simple non-stratified mucinous epithelium.
● This epithelium resembles the lining of the stomach or intestines and
contains goblet cells, which produce mucus.
● The surrounding ovarian stroma may show increased cellularity and areas
of stromal luteinization, which refers to the presence of cells resembling
lutein cells that produce hormones like progesterone.
Characteristics
1. Frequently in ages 35-55
2. Multilocular
3. Unilateral
4. Rarely malignant

Clinical Features
1. Large abdominal mass or swelling
2. Pelvic pain or discomfort
3. Abdominal distension or bloating
4. Changes in bowel habits, such as constipation or diarrhea
5. Urinary urgency or frequency
6. Menstrual irregularities or abnormal vaginal bleeding
7. Ascites
 Radiological findings

Ultrasound MRI

1. Large cystic adnexal 1. Large multilocular cysts

mass 2. Contains fluid of various
2. Multilocular with viscosity
numerous thin 3. May have stained glass
septations appearance
Complications Management
1. Torsion (ovarian twisting)
1. The primary medical
2. Rupture
management of mucinous
3. Infection
cystadenoma involves surgical
4. Intestinal obstruction
removal of the tumor through
5. Malignant transformation (rare)
procedures like cystectomy or
6. Impact on fertility
oophorectomy.
7. Recurrence
Brenner Tumour
1. A Brenner tumor is a type of ovarian tumor characterized by the presence of
transitional or urothelial-like epithelium within a fibromatous stroma.
2. These tumors can be classified as benign, borderline, or malignant based on
the growth pattern and cytological features of the epithelial cells.

Characteristics
1. Benign Brenner tumor: Adenofibromatous architecture with nests of bland transitional epithelium
present within fibromatous stroma.
2. Borderline Brenner tumor: Papillary architecture with papillae covered by multilayered transitional
epithelium.
3. Malignant Brenner tumor: Stromal invasion by carcinoma with transitional cell features.
Clinical features
1. Benign Brenner tumors are
Complications
usually asymptomatic 1. Complications of Brenner

2. Borderline and malignant tumors may include local

Brenner tumors are larger and invasion, metastasis,

usually present with findings tumor rupture, recurrence.

secondary to an adnexal mass.

Radiological findings
1. Radiological findings for Brenner tumors include Management
solid, well-defined masses on imaging studies such as 1. Oophorectomy
ultrasound, CT, or MRI. They can appear hypoechoic 2. No adjuvant treatment for benign or borderline Brenner
or isoechoic on ultrasound, have low attenuation on tumors
CT with calcifications, and show low signal intensity 3. Adjuvant chemotherapy for advanced stage malignant
on MRI. Brenner tumors.
Fibroma
Definition Clinical features
A fibroma is a type of benign stromal
1. Symptoms of ovarian fibromas may include abdominal
tumor that consists of fibroblastic cells
pain, distension, and increased urinary frequency.
embedded within a stroma that contains
2. Ovarian torsion
varying amounts of collagen.
3. Large ovarian fibromas (> 10 cm) may cause ascites.
4. Sometimes may lead to misdiagnosis, as calcified uterine
Characteristics leiomyoma.
5. Renin-secreting ovarian fibromas can lead to gestational
1. Benign stromal tumor
hypertension.
2. Found in women who are in
6. Recurrence of ovarian fibromas is possible.
perimenopause or post menopause
3. Composed of spindled, ovoid to round cells
Radiological Findings

1. Ultrasonography typically shows a solid, homogeneous, hypoechoic mass resembling

a pedunculated subserosal uterine leiomyoma.
2. CT usually reveals a slightly hypoattenuating solid mass with poor and very slow
contrast enhancement. Calcifications are rare.
3. MRI findings include:
❖ T1-weighted images show homogeneous low signal intensity.
❖ T2-weighted images show a well-circumscribed mass with low signal intensity.
Hyperintense areas may indicate edema or cystic degeneration.
● Ovarian fibromas on imaging studies can occasionally mimic malignancy, requiring
further evaluation to differentiate them.
Management

● Surgical excision (salpingo-oophorectomy, oophorectomy, or ovarian sparing

with/without hysterectomy) is the main treatment.
● Cellular fibromas require long-term follow-up, especially in cases of ovarian
surface involvement.
Thecoma
Definition Clinical features
Thecomas are benign 1. Thecomas can cause irregular or heavy menstrual
oestrogen-secreting tumours. bleeding in premenopausal and postmenopausal women.
2. Excess estrogen production by thecomas can result in
hormonal imbalances. This can lead to symptoms such as
Characteristics
breast tenderness, breast enlargement, and mood swings.

1. solid, well-defined tumors that can vary in 3. Some women with thecomas may experience pelvic

size. discomfort or pain. This can be due to the presence of the

2. Found in women who are in tumor itself or associated ovarian enlargement.

premenopausal and postmenopausal

3. Thecomas have the capacity to produce
estrogen, leading to elevated estrogen
levels in the body
Thecoma
Gross Histology

• Diffuse sheets of cells with pale grey

● 5 - 10 cms
cytoplasm and indistinct cell membranes
• Solid yellow / gray / white cut
• Ovoid / round occasionally grooved nuclei
surface
• Absent or low mitotic activity
• Luteinized thecomas contain nests, single
or nodules of luteinized cells
Radiological Findings
1. Ultrasonography
● an echogenic mass with distal acoustic attenuation
● a well-defined hypoechoic mass, or
● an anechoic lesion with through-transmission

Secondary features of hyperestrogenism, such as endometrial thickening, also may be seen.

1. CT: Typically appear as unilateral, solid ovarian masses.

Management
● Oophorectomy if fertility sparing is desired
● Total hysterectomy with bilateral salpingo-oophorectomy is indicated in postmenopausal patients

https://www.youtube.com/watch?v=PeL-5GV5GUA
Staging
Tumor Markers
 Screening Of Benign Ovarian tumor

Screening for Ovarian Cancer includes :

❏ Transvaginal Ultrasound as a primary screening
method
❏ Measurement of serum CA-125
❏ Tumor associated antigen (MUC 16)
❏ Liquid biopsy using patient blood/plasma
 Prevention Of Benign Ovarian tumor

❏ Women who test positive for BRCA mutation can be offered risk reducing
prophylactic BSO when they have completed their family.
❏ Prophylactic surgery reduces the risk of ovarian cancer by 90%
❏ Performing bilateral salpingectomy with delayed oophorectomy in the 30s
and early 40s may offset the morbidity associated with a surgical
menopause in young women while reducing the risk of cancer
❏ Recent data indicates that the opportunistic removal of the Fallopian
tubes during hysterectomy for benign indications also reduces ovarian
cancer risk in women at average lifetime risk of ovarian cancer.
❏ Chemoprevention using COCP reduces ovarian cancer risk by up to 50%
in both BRCA mutation carriers and women at average risk of ovarian
cancer.
 References

● Gynaecology 20th edition by Ten teachers

● Oxford handbook of obstetrics and gynaecology
● Niknejad, M. (2023, February 20). Ovarian thecoma: Radiology
reference article. Radiopaedia Blog RSS.
https://radiopaedia.org/articles/ovarian-thecoma