Benign ovarian tumours

Question 1

what are the categories of benign ovarian tumours?

Answer 1

Physiological cysts
Benign germ cell tumours
Benign epithelial tumours
Benign sex cord stromal tumours

Question 2

What are the types of physiological cysts? When are they normal

Answer 2

Follicular cyst

• commonest
• due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
• commonly regress after several menstrual cycles

Corpus lute cyst

• during menstrual cycle if pregnancy doesn’t occur, the corpus lute usually breaks down and disappears
• if this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst

Normal if <5cm
May cause pain by rupture failing to rupture at ovulation or bleeding

Question 3

What is the presentation of benign ovarian cysts?

Answer 3

Asymptomatic - incidental finding
Chronic pain with dull ache
Dyspareunia
Cyclical pain
Pressure effects
Acute pain due to bleeding into cyst, ovarian torsion, or rupture
Irregular vaginal bleeding
Hormonal effects - sudden development of androgen features
Abdominal swelling or mass

Question 4

What are benign germ cell tumours?

Answer 4

Dermoid cyst (mature cystic teratomas)
Usually lined with epithelial tissue and may contain skin appendages, hair and teeth
Most common in young women - 30
Bilateral in 20%
Usually asymptomatic

Question 5

What are benign epithelial tumours?

Answer 5

Arise from ovarian surface epithelium

Serous cystadenoma:

• most common benign epithelial tumour
• develop papillary growths that may be so prolific the cyst appears solid
• 30-40 years old
• 30% bilateral
• 30% malignant serous cystadenocarnioma

Mucinous cystadenoma

• Commonest large ovarian tumour, can become massive
• filled with mutinous material and rupture may cause pseudomyxoma peritonei
• 30-50 years
• 5% are malignant, mucinous cystadenocarcinoma
• Remove appendix at operation

Question 6

What is a Brenner tumour?

Answer 6

Contain Walthard cell rests (benign cluster of epithelial cell
Coffee bean nuclei

Question 7

What examination in ovarian tumour?

Answer 7

Abdominal examination may reveal mass rising from pelvis, tenderness, peritonism or ascites
Vaginal examination may show vaginal discharge, bleeding, cervical excitation, adnexal mass or tenderness

Question 8

What investigations in ovarian tumour?

Answer 8

FBC
CA125
If woman <40 check AFP, CA19-9, LDG, hCG and CEA

TVS
MRI if cyst > 7cm
MRI and CT for staging malignancy

Question 9

What are concerning features on TVS?

Answer 9

Multilocular cyst
Large papillary cyst wall projection
Solid areas
Metastases
Ascites
Bilateral lesions

Question 10

What is management of benign ovarian tumours?

Answer 10

Pre-Menopausal women:
Aim to rpeserve fertility and exclude malignancy
Rescan in 6 weeks
If no features of malignancy and asymptomatic with cyst < 5cm no intervention is required
If cyst > 5cm, symptomatic or features of dermoid or endometriosis, arrange laparoscopic ovarian cystectomy
- Avoid spilling cyst contents!

Post-menopausal women:
Calculate Risk of Malignancy Index:
US score, menopausal status CA125 level
Low risk cysts <5cm can be managed conservatively with repeat scan and CA125 every 4 months
Moderate risk requires bilateral oophorectomy
High risk cysts require staging laparotomy

Question 11

What are endometriomas?

Answer 11

Ovarian cysts filled with old blood

Question 12

What are fibromas?

Answer 12

Small, solid, benign, fibrous tissue tumours
Associated with Meigs’ syndrome:
Pleural effusion, often right sided + benign ovarian fibroma + ascites
Typically occur around menopause casing a pulling sensation in pelvis

Question 13

What is ovarian torsion?

Answer 13

Partial torsion of the ovary on it’s supporting ligaments that may compromise blood supply
If Fallopian tube is involved, it may be referred to as adnexal torsion

During torsion, venous return from ovary is occluded causing ovary to become oedematous leading to interruption of arterial supply

Question 14

How does ovarian torsion present? Investigation?

Answer 14

Severe lower abdominal pain
Vomiting
Pain starts to improve after 24h as ovary starts to die

Vaginal exam may reveal adnexial tenderness

USS may show free fluid

Laparoscopy is diagnostic and therapeutic

Question 15

Simple vs complex cysts?

Answer 15

Simple: unilocular, more likely to be physiological or benign
Complex: multilocular, more likely to be malignant

Question 16

What mx approach on ovarian enlargement in premenopausal women?

Answer 16

Conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common.
If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign.
A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists

Question 17

What Mx approach on ovarian enlargement in postmenopausal women?

Answer 17

By definition physiological cysts are unlikely
Any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment