Benign ovarian tumours (cysts)

Question 1

What are ovarian cysts?

Answer 1

Very common, typically physiological follicular cysts or corpus luteal cysts

Question 2

Are ovarian cysts of concern?

Answer 2

In women of reproductive age, cysts <5cm are not of concern unless imaging shows complex/suspicious features or if she is symptomatic (classically pain)

Question 3

Are ovarian cysts malignant?

Answer 3

Most are benign (but important to identify cysts with high risk of cancer to begin treatment sooner)

Question 4

How do ovarian cysts present?

Answer 4

Asymptomatic (incidental finding on imaging)
Chronic pain with dull ache, dyspareunia, cyclical pain or pressure effects
Acute pain (from bleeding into cyst, ovarian torsion or rupture)
Irregular vaginal bleeds
Hormonal effects e.g. sudden development of androgenic features
Abdo swelling/mass (ascites suggests malignancy)

Question 5

What may the presenting features of ovarian cyst be confused with?

Answer 5

Cyclical pain and deep dyspareunia often similar to endometriosis (best visualised by TVS vs USS)

Question 6

What is ovarian torsion?

Answer 6

Uncommon
Presents with severe lower abdo pain + vomiting with pain improving after 24hrs (as ovary starts to die)
Venous return from ovary occluded in torsion, causing oedematous ovary and eventual interruption of arterial supply

Question 7

What Ix would help diagnose ovarian torsion?

Answer 7

WCC and CRP normal or raised

Question 8

What may present in a similar manner to torsion? What distinguishes these conditions?

Answer 8

Cyst rupture

Additional feature of haemorrhagic shock likely to be present in rupture (vs torsion)

Question 9

What kind of ovarian tumours may be seen?

Answer 9

Functional cysts
Endometriomas
Serous cystadenomas
Mucinous cystadenomas
Fibromas
Teratomas
Other germ cell tumours
Sex-cord tumours

Question 10

What is a functional cyst?

Answer 10

Enlarged or persistent follicular or corpus luteal cysts
Very common
May be considered normal if small (<5cm)
May cause pain by rupture, failing to rupture at ovulation, bleeding
Usually resolve over 2-3 cycles if <5cm

Question 11

What are endometriomas?

Answer 11

Ovarian cysts filled with old blood; chocolate cysts

Question 12

What are serous cystadenomas?

Answer 12

Develop papillary growths that may be so prolific that the cyst appears solid
Commonest in 30-40y
30% bilateral
30% malignant

Question 13

What are mucinous cystadenomas?

Answer 13

Commonest large ovarian tumours (can be enormous)
Contain mucinous material and may be multilocular
Rupture may rarely cause pseudomyxoma peritonei (although PP rarely cause by ovarian cyst rupture - 90% arise from GI source)
Commonest 30-50y
5% malignant
Remove appendix at operation with suspected mucinous cystadenoma and send to histology (ovarian tumours may be secondary to GI tumours)

Question 14

What is a fibroma?

Answer 14

Small solid benign fibrous tissue tumour
Associated with Meig’s syndrome (pleural effusion + benign ovarian fibroma (or thecoma, cystadenoma, granulosa cell tumour) + ascites)

Question 15

What is a teratoma?

Answer 15

Arise from primitive germ cells
Benign mature teratoma (dermoid cyst) may contain well differentiated tissue (hair, teeth etc)
20% are bilateral
More common in young women
Poorly differentiated malignant teratomas are rare

Question 16

What are other germ cell tumours (apart from teratoma)?

Answer 16

All are malignant and rare
Non-gestational choriocarcinomas (secrete hCG)
Ectodermal sinus tumours (yolk sac tumour - secrete AFP)
Dysgerminomas

Question 17

What are sex cord tumours?

Answer 17

Rare, usually of low grade malignancy
Arise from cortical mesenchyme
Granulosa-cell and theca-cell tumours produce oestrogen
May present with precocious puberty, menstrual problems, PMB
Arrhenoblastomas secrete androgen

Question 18

What features would be seen on examination of ovarian cyst?

Answer 18

Normal (if small cyst/obese)
Shock in acute presentation
Pelvic mass
Tenderness, peritonism
Ascites
Vaginal exam - discharge, bleeding, cervical excitation, adnexal mass, tenderness

Question 19

What Ix would be performed for suspected ovarian cyst?

Answer 19

FBC
CA125 in >40y
Check AFP, CA19-9, LDH, hCG and CEA

Question 20

What would imaging demonstrate?

Answer 20

Start with TVS
Concerning features include
-multilocular cyst
-large papillary cyst wall projections
-solid areas
-metastases
-ascites
-bilateral lesions
If cyst extends out of pelvis, consider abdo USS
If cyst >7cm consider MRI (distinguish benign vs malignant)
MRI and CT used for staging maligancy

Question 21

How would ovarian cysts be generally managed?

Answer 21

Admit if acute onset symptoms + pain
If stable - TVS
If unstable - urgent laparoscopy

Question 22

What is the management for ovarian cysts in pre-menopausal women?

Answer 22

Preserve fertility
Exclude malignancy
Rescan in 6w
-If cyst <5cm and no signs of malignancy = no intervention required
-If cyst >5cm or symptomatic or features of dermoid/endometriosis = arrange laparoscopic ovarian cystectomy; avoid spilling cyst contents (can cause chemical peritonitis and seeding if malignant)

Question 23

What is the management for ovarian cysts in post-menopausal women?

Answer 23

Calculate risk
Low risk cysts <5cm managed conservatively with repeat TVS and CA125 every 4m; if no change after 1y discharge
Moderate risk cysts require (usually) bilateral oophorectomy
High risk cysts require referral to cancer centre for staging laparotomy