Benign Tumors of the Female Genital System PDF

BENIGN TUMORS OF THE FEMALE GENITAL SYSTEM ASS.PROF.DR.ASENA AYAR MADENLİ ISTINYE UNIVERSITY, MEDICAL FACULTY   To analyze the risk factors  To explain the pathogenesis  To suggest theories on the occurrence  To classify benign tumors...

BENIGN TUMORS OF THE FEMALE GENITAL SYSTEM ASS.PROF.DR.ASENA AYAR MADENLİ ISTINYE UNIVERSITY, MEDICAL FACULTY   To analyze the risk factors  To explain the pathogenesis  To suggest theories on the occurrence  To classify benign tumors of the uterus and ovaries, taking OBJECTIVES into account their histological structure, localization, clinical symptoms  To interpret features of clinical picture taking into account their histological structure and localization  To learn the diagnostic approach   Benign tumors of External Genitalia (vulva & vagina) GUIDE  Uterine Tumors  Ovarian Tumors Benign Tumors of External Genitalia Vulva & Vagina  Benign Neoplasms of Vulva  Solid Tumors  Cystic Lesions  Acrochordon (skin tag)  Bartholin Cyst  Seborrheic Keratosis  Keratoacanthoma  Skene gland cyst  Leiomyoma  Urethral diverticule  Fibroma  Epidermal inclusion cyst  Lipoma  Cyst of Canal of Nuck  Ectopic breast  Condyloma   tumor growing out of the muscle fibers, primarily from tissue of labia majora, rarely-out of the vaginal wall  They are distinguished by the morphological structure:  Leiomyoma -a tumor of the smooth muscle fibers;  Rhabdomyoma-a tumor of the striated/skeletal muscle fibers LEIOMYOMA  It is localized mainly in the thickness of the labia major;  It has thick elastic consistency;  mobile, separated from the surrounding tissue;  It grows slowly;  treatment -surgery.   Tumor of connective tissue, mostly single, usually solid formation of round or oval shape, wide base or a thin stem, not united with the surrounding tissue  It is localized mainly in the thickness of the labia majora or in the submucosal layer of the vagina;  characterized by slow expansive growth; treatment FIBROMA - surgery (removal of the tumor).   It develops mainly from adipose tissue, which is contained in the pubic area and labia major;  formed by mature adipose tissue with layers of connective tissue; LIPOMA  relatively mobile, it has a soft consistency;  treatment -surgery.   It develops from the mesenchyme residues;  localized in the subcutaneous MYXOMA adipose tissue of pubis and superior (NUCK`S aspect of labia majora; DIVERTICULU M)  Corresponds to varicosele in men  treatment -surgery.   Composed of small capillary vessels with a larger feeding vessel  Most cases arise in children,equal gender distribution  Tumor develops as a node,size increases rapidly, can reach large sizes;  It is bluish, purple or red spot, which is slightly raised above the level of the mucous membrane or skin;. HEMANGIOM  Treatment: topical or systemic beta blockers A surgery, coagulation or sclerosing agents   It develops from lymphatic vessels of varying sizes. May be either macrocystic or microcystic  Many lymphatic malformations show somatic mutations in PIK3CA LYMPHANGIOM  Predominant in children and young adults, mostly in skin A around groin (lymphatic  treatment –surgery malformation is the new sclerotherapy suggested terminology)   Tumor of the surface epithelium in the form of papillary proliferation, with exophytic growth mainly in the area of the labia major;  macroscopically- limited single or multiple tumor on a thin stem or broad-based, with a rough, or fine-or coarse-grained surface, often covered with processes that look like cauliflower of different colors - from white to brown;  Usually due to HPV 6-11  Course is mostly benign, possible malignancy under certain PAPILLOMA conditions;  treatment –medical (imiquimod,TCA,Podofilin, 5FU) coagulation, cryo surgery.   It develops from the cells of sweat glands;  It occurs mainly at the age of 15-20 years;  Localization –labia majora, pubis;  multiple symmetrical lesions in the form of flat, HYDRADENO round or oval nodules. The size of 0.2-1.0 cm; MA colouring-from pink-yellow to yellow-brown;  treatment -surgery.   rounded formation sizes from 1 to 4.5 cm, a cavity is bounded by dense capsule, within which the liquid is contained;  cause of the disease is predominantly Bartholinitis, BARTHOLIN'S which is resulted by obstruction of the properly gland, and therefore violated the outflow of CYST secretions produced.  large cysts may cause discomfort during moving and intercourse.   treatment -surgery: the removal of the cyst capsule and marsupialization-formation of a new duct.  Methods: under local anesthesia, a small incision is made on the mucous of labia minora, perform inversion of the mucosa and then suture it to the vulval mucosa.  The wound heals within a few weeks, and the process of BARTHOLIN'S forming a new duct ends in 1-2 months. CYST BARTHOLIN CYST TREATMENT Marsupialization Excision   Most common benign cystic vaginal lesion  Wolff (Mesonephric canal) remnant  Lateral Wall of vagina  No malignancy  Surgical excision if needed VAGINAL CYSTS UTERINE TUMORS FIBROID-LEIOMYOMA   Fibroid is the most common benign tumor of the uterus and also the benign solid tumor in female.  Histologically it is composed of smooth muscle and fibrous connective tissue, so named as uterine leiomyoma, OVERVIEW myoma or fibromyoma.  Incidence: at least 20 % of women at the age of 30 + By the age of 50 the incidence may be as high as %70   Etiology still remains unclear. Possible hypothesis is that, it arises from the neoplastic single smooth muscle cell of myometrium.  The growth is predominantly oestrogen-dependent. The tumour may overexpress certain estrogen or progesterone receptors Risk factors:  early menarche, ETIOLOGY  nulliparity  obesity  hyperoestogenic state,  late onset of menopause,  positive family history  А. localization: 1) subserous – growth in the direction of the perimetrium; 2) intramural (interstitial) – growth into the thickness of the uterine wall; CLASSIFICATI 3) submucous – node growth into the uterine cavity; 4) atypical – retrocervical, retroperitoneal, antecervical, ON subperitoneal, pericervical, intraligamentous. В. size (small, medium, and large). С. position (in the uterine fundus, body, isthmus, or neck).Body is affected in 95 % cases, Cervix– in 5 %.   Asymptomatic (75%). They may be accidentally discovered by the physician during routine examination or at laparotomy or laparoscopy.  Menstruation abnormalities. Menorrhagia is the classic symptom of symptomatic fibroid,  Metrorrhagia or irregular bleeding. SYMPTOMS  Dysmenorrhea  Infertility  Pain in the lower abdomen  Pressure symptoms  Abdominal enlargement  Reccurent pregnancy loss (miscarriage, preterm labour)  1. Abdominal examination – if the uterus body is enlarged up to 12 weeks of pregnancy, the uterus body may be palpated through the abdomen. It feels firm, more towards hard, surface in nodular, mobility may be restricted. DIAGNOSIS 2. Pelvic examination: The uterus is not felt separated from the enlargement, the cervix moves with the movement of the tumour felt per abdomen. the size, motility, nodularity should be evaluated  3. Ultrasound and Colour Doppler: uterine contour is enlarged and distorted, may be hypoechoic or hyperechoic. Transvaginal ultrasound can accurately assess the myoma location, dimensions and volume 4. Saline infusion sonography 5. Magnetic resonance imaging – not used routinely for the diagnosis. Though it has not been shown to differentiate leiomyosarcoma from myoma it may still be utilized in case of DIAGNOSIS suspicion (CONTINUED) 6. Laparoscopy – it may differentiate a pedunculated fibroid from ovarian tumour 7. Hysteroscopy is of help to detect submucous fibroid in unexplained infertility and repeated pregnancy loss. 8. Uterine curettage – in the presence of irregular bleeding, to detect any co- existing pathology and to study the endometrial pattern, currettage may be helpful. additionally helps to diagnose a submucous fibroid by feeling a bump.   The symptoms are usually due to pressure effect on the surrounding structures  Anterior cervical –bladder symptoms, posterior cervical – CERVICAL constipation, lateral cervical – vascular or ureteral FIBROID obstruction, central cervical – predominantly bladder symptoms.  Treatment – myomectomy, hysterectomy, MR-HIFU   The pathologies that share the same signs and symptoms of leiomyoma should be evaluated  PALM-COEİN a mnemonic for structural and non structural causes of AUB may be helpful Polyps Adenomyosis Differential Leiomyoma diagnosis Malignancy Coagulopathy Ovulatory dysfunction Endometrial factors İatrogenic Not yet classified   Persistant vaginal bleeding in the form of meno/metrorrhagia that leads to severe anaemia  Renal complications due to pressure of the large fibroids on the lateral sides Complications  Ischemia or necrosis of the fibroid nodes, leading to acute pain due to peritonitis  Sarcoma (malignant changes in the uterus) (1/340 of unsuspected leiomyoma operations) Over age 75 the incidence rises to 1/98   Surveillance is mostly the preferred method if the fibroid is asymptomatic  Medical management: OCPs, MEDICAL levonorgestrel iud, TREATMENT GnRH Agonists (leuprolide)- strong suggestion on its use presurgically NSAIDs Other – aromatase inhibitors, SERMs, Tranexamic Acid   Endometrial ablation- limited use in AUB due to leiomyoma  UAE- uterine artery embolization SURGICAL  Myomectomy TREATMENT  MRI guided focused ultrasound surgery  Hysterectomy (total,subtotal? Abdominal,laparascopical? With salpingoopherectomy ?) decision depends on individual patient   Embolization of the uterine arteries is a promising method of surgical myoma treatment. it is a minimal invasive method based on the conduct of subsequent pelvic arteriography with selective embolization of small branches of the uterine artery supplying the fibroid, resulting in focal infarct, fibrosis and UTERINE hyalinization ARTERY  Embolization of the uterine arteries in most cases cures EMBOLIZATIO excess bleeding due to myoma in one day at minimal discomfort for the patient. However only limited studies show N its efficacy in fertility preservation  embolic agents : polyvinyl alcohol particles with size of 350 -700 microns.  1. Excessive menstrual bleeding, which leads to anemiae of the patient. 2. The tumor size of 12 and more weeks, even if there are no complaints 3. The tumor size, which is accompanied by dysfunction of SURGICAL the adjacent organs (renal dysfunction, frequent urination, disturbed defecation ). TREATMENT 4. Rapid growth of the tumor (by 4–5 weeks and more than indications by 12 months). In such cases a malignant tumor may be suspected. 5.Pedinculated Subserous fibroids may lead to pedicle torsion, which requires urgent operative intervention. 6. Myomatous node necrosis – acute pelvic pain  7. Submucous myoma. They cause severe bleeding. Irrespective of the myoma size, such patients require surgical treatment. Small nodes may be removed by hysteroscopy. 8. Intraligamentous myomas which cause renal dysfunction due to SURGICAL urinary tract compression. TREATMENT 9. Nodes, which grow from the vaginal part of the uterine cervix. indications 10. Combination of myoma with other pathological states: ovarian tumors, prolapse of uterus, hyperplasic conditions of the endometrium, which are insensitive to hormonal therapy. 11. Secondary infertility  Adnexal masses/ OVARIAN TUMORS   Ovarian tumors rank second in the structure of female genitalia neoplasms, according to different authors, their incidence in recent years comprises 6–10 % of cases.  The incidence of benign ovarian tumors is 70–80 %, and one third of them are tumor-like processes. OVERVIEW  A peculiarity of ovarian neoplasms is their high propensity for malignization, and the prophylactic and diagnostic work of gynecologists on timely detection of tumors of this localization remains subpar.  The histological type of an ovarian tumor is the one and the foremost prognostic factor of the disease course.  NON-NEOPLASTIC  Follicular cyst  Corpus Luteal cyst  Theca-Lutein cyst (hyperrectio lutealis)  Endometrioma cyst NEOPLASTIC Germ cell benign ovarian tumors  Mature teratoma (Dermoid Cyst) HISTOLOGICA Epithelial ovarian tumors  Serous cystadenoma L CLASSIFICA  Mucinous cystadenoma  Endometrioid cystadenoma/adenofibroma TION  Brenner’s tumor  Benign ovarian clear cell tumor Benign sex cord / stromal ovarian tumors  Thecoma  Fibroma  fibrothecoma  Leydig cell tumour  Stromal luteoma  Sertoli/leydig Major Benign Ovarian Tms 1-Serous / mucinous cystadenoma 2-Mature cystic teratoma (dermoid) 3-Thecoma/ Fibroma 4-Paraovarian / paratubal cysts  Pelvic pain, pressure symptoms,abdominal bloating, urinary symptoms, feeling full quickly are some of the common symptoms that may accompany ovarian masses If the ovarian tumor is hormone-producing, clinical presentation may be connected with the specif ic action of the hormones CLINICAL produced by the tumor. PRESENTATİ In granulosa cell tumor and thecoma hyperestrogenism signs ON are obse r ve d (irre gular vaginal ble e dings, e ndom e t rial hyperplasia). If patients age is juvenile, signs of precocious puberty are seen..if menopausal, postmenopausal bleeding may occur. If a patient has an androgenic hormone producing tumor: defeminization or androgenization symptoms   IMAGING MODALITIES Pelvic US (TAUSG, TVUSG, TRUSG)- shows size, uni l at e ral o r bi l at e ral i nv o l v e me nt , mass morphology, associated f indings such as ascites) sensitivity predicting malignancy is %85-97 whereas its specif it y is ranges from %56-95. Utilization of colour Doppler USG helps identify neo- DIAGNOSIS vascularization CT- may provide additional information on the anatomy of the mass, upper abdominal f indings, LAP, ureteral patency MRI- Excellent tissue characterization, suggested use for indeterminate lesions if results will alter management   Colonoscopy & endoscopy may be helpful in intestinal involvement DIAGNOSIS  Cancer antigen CA-125 %80 elevated in non mucinous ovarian epithelial tm but also may be found elevated in endometriosis, liver cirrhosis, PID, uterine fibroids   Diverticulitis  Tubo-ovarian abscess DIFFERENTIA  Carcinoma caecum,sigmoid L DIAGNOSIS  Pelvic kidney  Pedinculated or intraligamentary myomas   Family history !!! Strongest risk factor (%20 of high grade serous ovarian carcinomas have genetic predisposition) (e.g lynch type 2 synd)  Older age RISK FACTORS  Nulliparity FOR  Alcohol MALIGNANCY  Obesity  Smoking (higher risk for mucinous carcinomas)  Long term HRT use (%20 higher risk)   Uniloculated – unilateral Imaging  No septa  Little or no existence of internal echoes criteria  Absence of solid components suggesting  Smaller than 8-10 cm benign lesion  Regular borders  Thin-walled   Multiloculated, septate  Papillary projections  Containing nodularity  Solid component Risk factors  Containing dense internal echoes for  Presence of abdominal ascites malignancy  Bilateral  Irregularly contoured  Neovascularized areas in the Doppler   The incidence of epithelial neoplasms is the highest among ovarian tumors (60–70 %)  Serous benign ovarian tumors are the most common epithelial tumors and account for about 50% of malignant and 20% of benign cysts. 20% of benign cysts are bilateral Ovarian and classically they are unilocular, can reach huge epithelial dimensions with tendency to torsion, and contain a straw coloured fluid (light serous contents). Macroscopically neoplasms serous cystadenoma is a round tumor with thin walls, uni- or bilocular, of dense elastic consistency, filled with serous fluid. Such tumors undergo malignization in 25–50 % cases, which should be always taken into account when the treatment method is being chosen.   Mucinous benign ovarian tumors rank second according to Ovarian their incidence among all ovarian tumors. In most cases these epithelial neoplasms are large, have a multilocular structure, filled with jelly-like contents. Unlike serous tumors they secrete mucin – neoplasms mucus. Malignization of mucinous tumors is observed in 5–17 (continued) % cases.   Endometrioid cystadenom/adenofibrom is a rare benign ovarian epithelial tumor. Ovarian  These tumors may occur within an endometriotic cyst epithelial  Appears spongy on imaging due to scattered solid and cystic parts of the tumor neoplasms  Endometrioid borderline tumor (EBT) may arise from adenofibrom (continued) or endometriosis   Teratomas are tumors arising as a result of differentiation of two or three germinal layers.(endo,ecto,mesoderm). Most common benign ovarian tumor in pregnant women. Torsion quite often due to fat content  Mature teratomas are more frequently observed in the Teratoma cystic form (dermoid cyst), less frequently – solid form. Dermoid cyst (a more accurate name – mature cystic teratoma) consists of well-differentiated derivatives of all t hre e ge r m i na l l aye r s wi t h e ct ode r m a l e l e m e nt s prevalence (hair, fat, teeth, etc.).. It is almost always benign, its malignization is observed very rarely.   They are benign solid tumors that develop from the ovarian stroma.  Thecoma can secrete estrogen  Fibromas are associated with some syndromes  Meigs Synd:  Ovarian fibroma Ovarian  Ascites Fibroma/theco  Hydrothorax ma  Gorlin Syndrome:  Ovarian fibroma (calcified and bilateral)  Basal cell carcinoma (skin)  Odontogenic cysts and Falx cerebri calcifications  Medulloblastoma   Follicular cysts - originate from ovarian follicles. These neoplasms are unilocular, thin-walled, with smooth surface, filled with transparent contents.  Corpus luteum cysts morphologically correspond to the yellow body structure, contain granular and theca lutein cells, their walls are thin, the contents are light or Cysts hemorrhagic..  Theca lutein cysts- due to natural overstimulation of the ovarian/paraovaria follicles. linked to choriocarcinomas, multiple gestations, n and molar pregnancy  Paraovarian cysts are tumor-like neoplasms, which arise in the epoophoron located in the mesosalpinx. Macroscopically, a paraovarian cyst is round, has a smooth surface, thin walls, and transparent content.   Cystic lesions stem from a disease ‘endometriosis’  Its content is dark brown endometial fluid therefore commonly called chocolate cysts  Related with: Cysts/  dysmenorrhea endometriom  Pelvic pain a  infertility  Small risk of malignant transition / a meta-analysis showed that the risk of endometriosis is 3 times high among epithelial ovarian cancer patients   The therapeutic approach depends on the patient’s age, character of the tumor, risk of malignancy.  In most cases ovarian tumor diagnosis is an indication to surgical intervention. If there is a small mobile tumor, endoscopic operation is possible in young women. Otherwise laparotomy is carried out.  When one decides the question of surgical intervention volume, TREATMENT excessive radicalism is inexpedient. If the patient has a tumor-like ovarian neoplasm, it may be removed within the limits of unaffected tissue (resection). When one f inds serous ovarian tumors, especially with papillary projections, in young women it is appropiate to remove one ovary, in patients older than 45 years – resection of both ovaries should be recommended. If there is a suspicion of hormone- producing ovarian tumor, the same measures are undertaken.   In women of reproductive age, small simple ovarian cysts (follicular, corpus luteum) may be observed without intervention for 3–6 months.  When the therapy/follow-up is ineffective, surgical treatment is indicated if available which is performed mainly laparascopically. Aim is to enucleate the cyst from surrounding stroma with minimal TREATMENT damage possible  Paraovarian cysts are better diagnosed in the course of surgical intervention, Operation in these cases is the excision of the cyst from the intraligamentous space with dissection of the broad ligament leaf; the ovary and uterine tube are always preserved. Indications for  Ovarian cystic structure 5cm< which has been observed for 6-8 surgery on weeks without regression benign ovarian  Adnexal mass with a diameter of more than 10cms tumors  Adnexal mass in premenarchal and postmenopausal women