Benign Ovarian Mass
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BENIGN OVARIAN MASS
Dr. VIDHI CHAUDHARY
ASSISTANT PROFESSOROBS& GYNAE, LHMC, DELHI.
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Ovarian masses are a common finding.
It is often difficult to clinicallydifferentiate between benign and
malignant conditions
Neoplasms constitute a significant
number, and most are benign.
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CLASSIFICATION
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FUNCTIONAL OVARIAN CYSTS INCLUDES:
a. Follicular cysts
b. Corpus luteum cysts
c. Theca luten cysts
BENIGN OVARIAN NEOPLASM1. Serous cystadenoma
2. Mucinous cystadenoma
3. Endometrioma4. Dermoid cysts
5. Fibroma
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FUNCTIONAL CYSTS
- disruption of normal ovulation & altered
Angiogenesis
- derive mass from accumulation of
intrafollicular fluids rather than cellular
proliferation
- most common detected cysts in the
reproductive age group
- Usually asymptomatic
- Resolve spontaneously.
- surgical evaluation -required for persistent
cysts.
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FOLLICULAR CYSTS
Follicular cysts -Hormonal dysfunction
prior to ovulation results in expansion ofthe follicular antrum with serous fluid andformation of a follicular cyst.
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CORPUS LUTEUM CYST
Results from Hemorrhage inside a corpus luteum.
"great imitators"
Immediately following hemorrhage into its cavity,the cyst appears echogenic and mimics a solidmass.
reticular pattern develop
retracting clot -intramural nodule.
transvaginal color Doppler -brightly colored ringbecause of increased surrounding vascularity k/ar ing of f i re.
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Theca luteal cysts
Result from over stimulation of theovary by HCG.
Common in molar pregnancy,choriocarcinoma, IVF pregnancy
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Risk Factors
Smoking- changes in gonadotropin
secretion and ovarian function .
progestin-only contraceptives
Tamoxifen- 15 to 30 percent
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Symptoms
Asymptomatic.
Symptoms -pain and vague pressuresensations are common.
acute severe pain ruptured corpus
luteum with hemorrhage.
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Diagnoses
Pelvic examination-
mobile, cystic, nontender, and foundlateral to the uterus
Transvaginal Scan-rounded anechoiclesions with thin, regular walls
TUMOR MARKERS- Detection of serumbeta hCG to differentiate ectopicpregnancy or a corpus luteum ofpregnancy
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Follicular cyst
smooth walls and lack of internal echoes.
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Diffuse low level echoes
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Reticular interfaces :resolving
hemorrhagic cyst
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Theca lutein cysts
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Management
Observation -spontaneously regress within6 months of identification.
Post menopausal-sonographic evidence of
1. thin-walled, unilocular cyst
2. (2) cyst diameter less than 5 cm
3. (3) no cyst enlargement duringsurveillance
4. (4) normal serum CA125 levels
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Management
OCP- unclear role.
Surgical Excision - persistent cysts & >3 cm &> 5cm
diameter(premenopausal&
postmenopausal respectively)
Laparoscopic cystectomy.
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Benign Neoplastic Ovarian
CystsMost common :
serous and mucinous cystadenomas(surface epithelial neoplasia group)
mature cystic teratomas (germ cell)
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Serous cystadenoma-
5% to 10% -borderline malignant potential
20% to 25% are malignant.
multilocular, with papillary components. The surface epithelial cells secrete serous
fluid, resulting in a watery cyst content.Psammoma bodies, (areas of fine calcific
granulation), if present can be seen onradiograph.
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Mucinous ovarian tumors-
grow to largesize.
bilateral in 10% . 5-10% are malignant.
They have lobulated, smooth surface,
multilocular, . Mucoid material ispresent within the cystic loculations . It
is difficult to distinguish histologically
from metastatic gastrointestinal
malignancies.
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Benign serous
cystadenoma
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Teratoma
Teratomas arise from a single germ cell.
can contain any of the three germlayersectoderm, mesoderm, or
endoderm.
Types
a. mature b.immature
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Mature teratoma
benign tumor
mature forms of the three germ celllayers
(1) Mature cystic teratomas /benign
cys t ic teratoma /dermo id cyst
(2) Mature solid teratomas-elements
formed into a solid mass
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Mature teratoma
(3) Fetiform teratomas orhomunculus.
(4) Monodermal teratoma-composed
one highly specialized tissue type.
Eg.thyroid tissue are termed st ruma
ovar i i.
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b. immature -This neoplasm is
malignant. Immature tissues from one,
two, or all three germ cell layers are
found and frequently coexist with
mature element.
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Mature cystic teratomas
peak incidence -20 to 40 years ,pregnancy.
bilateral -10 percent .
10 to 25 percent of all ovarian neoplasms
60 percent of all benign ovarian
neoplasms
Malignant transformation -1 to 3 percent-
most common squamous cell carcinoma
80%, sarcoma
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Mature cystic teratomas
PathologySmooth walled,unilocular
with an area of localized growth that
protrudes into the cystic cavity.
Inner surface has a localized nodule, k/a
Rokitansky protuberance, composed of
adipose tissue (embryonal node)
Hair and fatty secretions +
Tumor Origin-genetic material
contained within a single oocyte
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Diagnosis
Tip of the iceberg"echogenic interfaces offat, hair, and tissues in focus that shadowand thus obscure structures behind it.
Fat-fluid or hair-fluid levelslineardemarcation where serous fluid interfaceswith sebum or hair.
Hairlines and dots. Rokitansky protuberancehyperechoic, and
creates an acute angle with the cyst wall.
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Mature cystic teratomas
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Complications
-15 percent torsion.
-cyst rupture (rare)- acute granulomatusperitonitis
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Other benign tumors
Fibromas(a focus of stromal cells)-
associated with Meigs syndrome (pleural
effusion with benign pelvic tumors)
Pseudo-Meigssyndrome consists of
pleural effusion ,ascites, and benign
tumors of the ovary other than fibromas.tumors of the fallopian tube or uterus
,mature teratomas and struma ovarii.
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Treatment
SURGICAL EXCISION
-definitive diagnosis, affords relief of
symptoms, and prevents complications oftorsion, rupture, and malignantdegeneration.
ROUTE-laparoscopic or laparotomy/ minilap
LAPROSCOPY -increased rates of cystrupture with the risk for tumor spill andmalignant seeding .
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Treatment
Surgery influenced by lesion size, age,
and intraoperative findings
-cystectomy preservation of
reproductive function
-oophorectomy- postmenopausal women
-Staging -Clinical findings of malignancy
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RADIOLOGICAL FEATURES OF BENIGN
OVARIAN MASSES:
1. Unilocular
2. Smooth surface
3. No solid elements4. No external or internal outgrowth
5. No ascites
6. Unilateral
7. Normal doppler flow
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CA-125 in:
Leiomyoma
Endometriosis/adenomyosis
PID
Pregnancy
Malignancies-lung, breast, colon
Pancreatitis
Cirrhosis
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i
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E ith li l i t
ovarian
capsule