Benign Ovarian Tumors: An Overview

Introduction to Benign Ovarian Tumors

• Human ovaries are particularly susceptible to developing a wide variety of tumors.
• The majority of ovarian tumors are benign.
• Approximately 90% of ovarian tumors are benign, with the percentage varying by age.

Normal Ovary Characteristics

• Normal ovarian size is about 3 x 2 x 1cm.
• Dimensional variations can result from endogenous hormonal production, which changes with age and the menstrual cycle.
• Exogenous substances, like OCPs, GnRH agonists, or ovulation-inducing medications, can cause dimensional variations.

Embryology of the Ovary

• Primitive gonads appear around the 5th week of intrauterine life.
• These gonads develop from the coelomic epithelium on the medial aspect of the urogenital ridge.
• In female embryos, the cortex develops as the ovary, and the medulla regresses to a small area.
• Ovarian serosa is a direct descent of the coelomic epithelium
• Ovarian serosa gives rise to endocervical, endometrial, endosalpinx, and the epithelium of the urogenital system.
• Undifferentiated serosa cells may undergo neoplastic changes, that can lead to tumors

Definition of Benign Ovarian Tumors

• Benign ovarian tumors are lesions (mitotic or non-mitotic) in the ovary.
• These lesions are not life-threatening.

Classification of Benign Ovarian Lesions

• Functional lesions can occur as follicular cysts, corpus luteal cysts, theca lutein cysts, and luteoma of pregnancy.
• Inflammatory lesions can occur as tubo-ovarian abscesses.
• Other lesions include endometrioma, haemorrhagic ovarian cyst, polycystic ovarian syndrome, and ovarian hyperstimulation syndrome.
• Neoplastic tumors are another classification.
• Germ cell tumors can occur as benign teratoma/dermoid cysts.
• Epithelial tumors can occur as serous cystadenoma, mucinous cystadenoma, or Brenner tumors.
• Additional epithelial tumors include fibroma, and thecoma.
• More classifications are sex cord stromal tumors which can occur as Sertoli-Leydig cell tumors and granulosa cell tumors.

Ovarian Tumor Screening

• Screening involves CA 125 and ultrasound scanning.
• A CA 125 level greater than 30 u/ml is considered abnormal.
• CA 125 is an antigen found in fetal amniotic and coelomic epithelium, and in adults found in mesothelial cells.
• CA 125 is found in the mesothelial cells of the pleura of the lungs, pericardium, tubal, endometrial, endocervical and the ovary

Functional Ovarian Cysts

• Functional ovarian cysts include follicular, corpus luteum, and theca lutein cysts, as well as luteomas of pregnancy.
• These cysts are the most common clinically detectable ovarian enlargements in reproductive years.
• All functional ovarian cysts are benign and usually asymptomatic.

Follicular Cysts

• A follicular cyst is defined as a follicular cyst with a diameter greater than 3cm.
• Follicular cysts are the most common type of functional cysts.
• They are rarely larger than 8cm.
• Follicular cysts are lined by granulosa cells.
• These cysts are often found incidentally on pelvic exams.
• Follicular cysts usually resolve within 4-8 weeks with expectant management.
• Rupture or torsion may cause pain and peritoneal symptoms.
• Simple cysts are usually follicular cysts and rarely malignant
• Most simple cysts will resolve on their own in 1-2 months.
• Simple cysts are anechoic, have smooth, thin walls, no internal flow on Doppler, and posterior acoustic enhancement.

Corpus Luteal Cysts

• These corpus luteal cysts are less common than follicular cysts.
• Rupture may lead to hemoperitoneum, requiring surgery.
• Ruptures are more common in patients taking anti-coagulants or with bleeding diathesis.
• Unruptured cysts can cause pain from bleeding into the enclosed ovarian cyst cavity.

Theca Lutein Cysts

• Theca lutein cysts are the least common and usually bilateral.
• These cysts result from overstimulation of the ovary by B-hCG.
• Theca lutein cysts do not commonly occur in normal pregnancy.
• Commonly associated with hydatidiform moles, choriocarcinoma, multiple gestations, clomiphene use, and GnRH analogues.
• They may be large (up to 30 cm), multi-cystic, and regress spontaneously.

Luteoma of Pregnancy

• These are rare and non-neoplastic lesions of the ovary.
• These lesions are caused by the hormonal effects of pregnancy on the ovary
• Usually asymptomatic, ovarian enlargement may be found incidentally on ultrasound.
• They may cause virilization, hirsutism, deepening of the voice, or temporal balding in few cases in late pregnancy.
• Luteoma of pregnancy resolves spontaneously after delivery.

Management of Functional Cysts

• Expectant management involves watchful waiting for two to three cycles.
• Combined oral contraceptives are of no benefit.
• Surgical management is indicated if cysts persist.
• Asymptomatic simple cysts smaller than 5cm are likely physiological, without a need for follow-up.
• Asymptomatic simple cysts between 5 and 7 cm require a yearly ultrasound scan.
• Asymptomatic simple cysts larger than 7cm require further imaging and/or surgical intervention.

Inflammatory Conditions

• Includes Tubo-ovarian abscesses.
• Tubo-ovarian abscesses are present in 15-40% of patients hospitalized with pelvic inflammatory disease (PID).
• These abscesses are commonly seen in patients with poor access to routine gynaecologic care.
• Traditional PID diagnosis criteria include bilateral abdominal pain, and adnexal and cervical motion tenderness.
• Hydrosalpinx is generally anechoic, whereas a pyosalpinx may have increased echoes within the fluid.
• Treatment of tubo-ovarian abscess primarily involves surgical drainage.
• More treatments involve parenteral and oral antibiotics, plus supportive care.

Endometrioma

• Common site of involvement for endometriosis is the ovary.
• Endometriomas are endometriotic deposits in the ovary.
• Endometriomas may replace normal ovarian tissue.
• Cyst walls are usually thick and fibrotic
• Ultrasound scan imaging shows anechoic cysts to cysts with diffuse low-level echoes to solid-appearing masses.
• Fluid-fluid or debris-fluid levels may also be seen.
• May be unilocular or multilocular with or without thin septations.
• The rate of malignant transformation is 0.3% to 0.8%.
• An endometrioma can be medically and surgically managed.

Benign Ovarian Tumors (Epithelial)

• Serous cystadenoma
• Mucinous cystadenoma
• Dermoid cyst
• Fibroma
• Thecoma
• Brenner's tumour

Serous Cystadenoma

• Generally benign
• Bilateral in 10% of cases.
• The risks for malignancy are 5-10% borderline and 20-25% malignant.
• Macroscopically, serous cystadenomas are multilocular with papillary components.
• Microscopically, these serous cystadenomas has low columnar epithelium with cilia.
• This also has characteristic psammoma bodies.

Serous Cystadenoma (Continued)

• Associated fibrosis may lead to cystadenofibroma.

Mucinous Cystadenoma

• Mucinous cystadenomas tend to become huge masses.
• Macroscopically, they are round to ovoid masses with smooth, translucent or bluish-white capsules.
• The interior is divided into loculi containing clear, viscid fluid.
• Microscopically, they have epithelium-tall, pale staining, secretary cells with basal nuclei and goblet cells.
• 5-10% are malignant.

Dermoid Cyst / Benign Cystic Teratoma

• These are often bilateral in 15-25% of cases.
• Macroscopically, appears as a thick, opaque, whitish wall.
• Macroscopic contents include hair, bone, cartilage, and a large amount of greasy sebaceous material.
• Microscopically, all three germ layers (ectoderm, mesoderm, and endoderm) are seen.
• Malignant change occurs in 1-3%, usually as a squamous type.
• The risk of torsion is 15%.
• An ovarian cystectomy is almost always possible, even if only a small amount of ovarian tissue remains.
• Ultrasound scan appearance includes focal or diffuse hyperechoic component with distal acoustic shadowing.
• Appearance can also have hyperechoic lines and dots, dermoid mesh, or fluid-fluid level with echogenic component.

Fibroma

• Fibromas are the most common benign, solid neoplasms of the ovary.
• They make up about 5% of benign ovarian neoplasms.
• They make up 20% of all solid tumours of the ovary.
• Frequently seen in middle-aged women.
• Characterized by their firmness and resemblance to myomas/fibroids.
• They are often misdiagnosed as exophytic fibroids or primary ovarian malignancy.
• Fibromas are not hormonally active.
• Fibromas may be associated with ascites and/or hydrothorax.
• Meigs syndrome (Ovarian fibroma, Ascites and Hydrothorax) usually resolves after surgical removal of fibroma.

Thecoma

• Solid fibromatous lesions that can appear in shades of yellow or orange
• The lesions are almost always confined to one ovary.
• Typically occurs above 40 years of age, and roughly 65% of cases are post-menopausal.
• Thecoma may be hormonally active.
• Activation is generally associated with estrogenic as well as androgenic effects.
• Luteinized thecomas are found in younger women and are associated with sclerosing peritonitis and ascites.
• Rarely malignant.

Brenner's Tumor

• Named after Fritz Brenner who characterized it in 1907, with the term first used by Robert Meyer in 1932.
• It is an uncommon tumor grossly identical to fibroma.
• Brenner tumors arise from Walthard cell rests, the surface epithelium, rete ovarii and ovarian stroma.
• These tumors are usually found incidentally at pathologic evaluation, often with a mucinous cystadenoma or dermoid cyst.
• They are relatively rare and most common in the fifth to sixth decades of life.
• Microscopically, there is a hyperplastic fibromatous matrix interspersed with nests of epithelioid cells showing a coffee bean pattern.
• Brenner's tumor is considered uniformly benign.
• There are scattered reports of malignant Brenner's.
• Brenner's tumour Is endocrinologically inert.
• Occasionally, but may be associated with virilization and endometrial hyperplasia.

Ovarian Gonadal Sex Cord Stromal Tumors

• Includes Granulosa cell tumours.
• Includes Sertoli-Leydig cell tumours.

Granulosa Stromal Sex Cord Tumors

• Granulosa cell tumors are found in all age groups.
• Granulosa cell tumors are associated with the pseudo precocious puberty.
• Early breast development, menstrual disorders, and postmenopausal vaginal bleeding are the characteristic symptoms.
• Studies show an increased number of mature epithelial cells in the vaginal cytologic specimen.
• Also cause lab-demonstrates elevated urinary and serum estrogen levels.
• Variable degree of endometrial proliferation is a characteristic symptom.
• Microscopically identified as characteristic round or slightly ovoid granulosa cell with dark nucleus.
• Granulosa is aso associated with “Call Exner bodies”.

Sertoli Leydig Cell Tumors

• Sertoli Leydig Cell Tumors, which are also called Androblastoma.
• They often affect females under the ages of 40yrs.
• These tumors are usually luteinised, simulating the classic pattern of the testes and producing steroids.
• Generally benign they may produce masculinisation.
• Sertoli Leydig Cell Tumors are also associated with Reinke crystals.

Treatment of Neoplastic Tumors

• Treatment involves simple excision of solid tumors.
• Simple excision is especially used in women in their reproductive age group.

Clinical Presentation of Benign Ovarian Tumours

• Can be asymptomatic and accidentally discovered on ultrasound.
• Chronic pelvic pain can be present.
• Increasing abdominal girth over months or weeks can happen.
• A patient can experience symptoms of anorexia, nausea, vomiting, and urinary frequency.
• There can be primary or secondary amenorrhea, menstrual irregularities, virilization, and precocious puberty.
• These can become acutely symptomatic if torsion, rupture or haemorrhage undergo.

Signs of Benign Ovarian Tumours

• On abdominal examination, a bulge of the lower abdomen is seen.
• The abdominal wall moves freely with respiration.
• The tumor volume may fill the entire abdominal cavity, everting the umbilicus with visible veins under the skin
• Palpation may reveal a surface that is smooth, non-tender, and mobile from side to side.
• But is restricted inferiorly unless the pedicle is long.
• Upper and lateral borders are well defined but the lower pole is difficult to palpate.
• In a bimanual pelvic exam, the uterus can be separated from the mass.
• Percussion yields a dull sound in the centre and a resonant sound in the flanks.
• A fluid thrill can be felt with thin contents.

Complications of Benign Ovarian Tumors

• Complications include torsion commonly occurring in dermoid cysts and serous cystadenomas.
• Intracystic Hemorrhage can occur as a serous cystadenoma
• Infection can be caused following torsion
• Ruptures can occur with big, tense types, following trauma
• Pseudomyxoma peritonei is seen in mucinous cystadenoma
• Intestinal Obstruction
• Malignant transformation is rare

Management of Benign Ovarian Tumours

• Involves History
• Examination
• Investigation
• And also Treatment

Investigations for Benign Ovarian Tumours

• Routine investigations include CBC, ESR, CXR, ECG, and urine analysis.
• Additional testing: Liver and renal function tests.
• Specific investigations include ultrasound, transabdominal or transvaginal, and Doppler flow studies.
• CT scan and MRI is performed.
• The doctor will examine tumor markers, such as, CA125, CEA, CA 19-9, and HE4.
• Genetic Analysis is also examined.
• Endoscopy and Laparoscopy can be performed.

Ultrasound Scans for Benign Ovarian Tumours

• Ultrasound is the first line for detecting, localizing, and characterizing adnexal masses.
• Roughly 90% of adnexal masses are correctly classified as benign or malignant on ultrasound.
• Doppler improves trans-abdominal images.
• Two routes are available: trans-abdominal and transvaginal.
• This procedure is not invasive.

CT scans & MRI - Other Imaging Techniques

• CT scans are used to examine Lymph node involvement
• Omental deposits in malignant tumours can be caused.
• Obstructive uropathy is studied.
• Used with MRI scans.
• PET scans also are used.

Tumour Markers

• Common tumour markers include:
  • CA125
  • CEA
  • CA19-9
  • HE4

Tumour Markers Details

• A CEA level greater than 5mg/L is seen in approximately 85-90% mucinous tumours.
• It can also be seen in approximately 30% of epithelial tumours.
• Increased CA19-9 causes mucinous ovarian malignancy.
• HE4 can be tested.
• HE4 (Human epididymis protein 4) is produced mostly by ovarian epithelial cancer cells.
• Checking HE4 and CA125 assays together is a more reliable way to check for ovarian malignancy.
• HE4 levels greater 70pmol/L can be linked to ovarian cancer in more than 50% of situations with normal levels of CA125.

Indications for Surgery

• Any solid ovarian lesion.
• Any ovarian lesion with papillary projections on the cyst wall.
• Any adnexal mass is greater than 10cm in diameter.
• Palpable adnexal mass in premenarchal and postmenopausal women.
• Torsion or suspected rupture.

Surgical Options

• Laparotomy
• Laparoscopy

Surgical Procedures

• Young women
  • Ovarian cystectomy
  • Unilateral Ovariectomy or Oophorectomy
  • Salpingo-oophorectomy or Ovariectomy
• Multiparous women
  • Total abdominal hysterectomy using Bilateral oophorectomy
  • Total abdominal hysterectomy via bilateral ovariectomy
• Others
  • Individualise

Conclusion About Benign Ovarian Tumours

• Ovarian masses are commonly seen in the general population.
• Most of the time, they are spontaneously, simple functional tumors that have resolved between six to eight weeks.
• An in-depth recognition of the many types of ovarian masses is needed to prevent incorrect diagnoses.
• Imaging studies and ultrasound are a top tool for diagnosing ovarian tumours.
• It's important to take care of the woman’s need when you address and select any treatment.