CLASSIFICATION, ETIOPATHOGENESIS &

MANAGEMENT OF BENIGN OVARIAN TUMOURS

The ovary is complex in its embryology, histology, steroidogeneis, and has the potential to develop malignancy. Therefore, the ovarian neoplasm exhibit a wide variations in structure and biological behaviour. Unlike the cervix and uterus, the ovaries are not clinically accessible and therefore easy screening methods for detecting ovarian neoplasm are not available.

The ovary after the uterus, is the most common site for development of gynaecological malignancy and prognosis remains poor.

• About two-third of ovarian tumours are encountered during the reproductive years. Most ovarian tumours (80-85%) are benign and 2/3rd of these occurs in women between 20 to 44 years of age.

• The chance that a primary ovarian tumour is malignant in a patient younger than 45 years is less than 1 in 15.

• The peak incidence of invasive epithelial ovarian cancer is at 56 to 60 years of age.

• Ovarian cancer is the 7th most common cancer in women in United States and accounting for 30% of all malignancy and 60% of death from cancer in women and almost 1/3rd of invasive malignancy of female genital tract.

• Ovarian cancer is the 5th most common cause of death from malignancy in women.

• A women’s risk at birth of having ovarian cancer sometimes in her life is 1% to 1.5% and that of dying from ovarian cancer almost 0.5%.

During the reproductive years of the female the most common ovarian tumours are benign. These can be :

Non-neoplastic (Functional ovarian cyst)Neoplastic :

Benign neoplasticMalignant :

- Primary

- Secondary

The ovaries are paired gonadal structures that suspended between the pelvic wall and the uterus by the infundibulopelvic ligament laterally and the uteroovarian ligament medially. Inferiorly, the hilar surfaceof each ovary is attached to the broad ligament by its mesentery (mesovarium), which is dorsal to the mesosalpinx and fallopian tube.

The normal ovary varies in size, with measurements up to 5x3x3cm and is oval in shape, pinkish-grey in colour and the surface is scarred during reproductive period.

Variation in size results from endogenous hormonal production, which varies with age and with each menstrual cycle.

Exogenous substances includes oral contraceptives, GnRH analogue, or ovulation inducing medicines may either stimulate or suppresses ovarian activity and therefore affect the size.

Ovary consists of a cortex and medulla. It is covered by single layer of flattened cuboidal

to low columnar epithelium i.e. continuous with peritoneum at the mesovarium.

The cortex is composed of a specialized stoma and follicles in various stages of development or attrition.

The medulla occupies a small portion of the ovary in its hilar region and is composed primarily of fibromuscular tissue and blood vessels.

NON-NEOPLASTIC OVARIAN TUMOUR

The enlargement of ovary is due to accumulation of fluid inside the functional unit of the ovary. The causes includes :

- Follicular cyst- Corpus luteal cyst- Theca lutein and granulosa lutein cyst- Polycystic ovarian syndrome- Endometrial cyst

Except the last one, all functional cysts of the ovary are loosely called “cystic ovary”.

The features of the functional cysts are : a) Related to temporary hormonal disorders.b) Rarely becomes complicated.c) Sometimes confused with neoplastic cyst but

can be distinguished by the following features.- Usually not exceeding 5cm.- Spontaneous regression usually following

correction of the functional disturbances to which it is related.

- Unilocular- Contains clear fluid inside unless haemorhage

occurs.- Lining epithelium corresponds to the functional

epithelium of the unit from which it arise.

Follicular Cyst :

Represents enlargement of unruptured graffian follicles. These are the commonest functional cysts.

• They are usually multiple, but may be single.• The cysts are always small, when they occur

singly and having diameter 3-5cm, rarely exceed 8cm.

• Cyst is lined by granulosa cells without lutein cells or the cells may be flattened due to pressure.

• The functional activity of cysts variable, often it is insignificant and they does not interfere with normal ovulation occurring in other graffian follicles.

• The cyst remains asymptomatic or may produce vague pain.

• Can cause acute abdomen, if haemorrhage, torsion and rupture occurred.

• In majority of cases, the detection is made accidently on bimanual examiantion, sonography, laparoscopy or laparotomy.

Treatment – If uncomplicated then followed up for 3 cycles at monthly intervals with combined steroidal contraceptive pills prescription, if not contraindicated. The functional cyst regress itself. However, if size increases, or complications occurred, then surgical intervention to be done.

LUTEIN CYSTS OF THE OVARY

There are two types recognised :- Granulosa lutein cysts found within the C.luteum- Theca lutein cyst associated with trophoblastic

disease and chorionic gonadotropin therapy.Corpus Luteum (Granulosa Lutein) Cysts : Are functional, non-neoplastic enlargement of the

ovary. Sometimes corpus luteum of menstruation not

only become cystic but its lining of granulosa lutein and para lutein cells continues to produce progesterone and ostradiol for longer time than normal can cause prolonged menstrual periods followed by heavy continuous bleeding.

This clinical picture simulating that of early pregnancy failure or ectopic pregnancy.

It may be associated with pregnancy and persists for 12 weeks and spontaneous regression expected, unless complications occur.

Its size occasionally exceed more than 3cm, if occurred then presents with delayed menstruation, adenexal mass and pain.

If features of acute abdomen appears then treatment is laparotomy.

Theca Lutein Cyst : Theca lutein cysts are less common than follicular

and corpus lutein cysts. They are usually bilateral Multicystic Larger in size (upto 25cm)In all cases the excessive luteinization is the result of

high output of gonadotrophins and are associated with molar pregnancy, choriocarcinoma, multiple pregnancy and also seen with ovulation induction with clomiphene citerate or gonadotrophin.

No treatment required. The abnormal tissue disappears spontaneously

when the cause is removed.

Luteoma of Pregancy : Solid multiple foci of luteal tissues are

sometimes found in one or both ovaries during pregnancy, either intrauterine/extrautrine.

Luteoma represents hyperplastic conditions. These are separate from corpus luteum of

pregnancy. Vary in diameter 8-20cm. Cut surface is orange-yellow to greyish-yellow. Assymptomatic, accidently found on caesarean

section.

Arise from theca or stroma cells under the influence of chorionic gonadotrophin and disappears spontaneously after pregnancy.

Otherwise symptom less, occasionally have androgenic action cause minor degrees of virilization of mother or her female child.

Polycystic Ovarian Syndrome : Earlier known as Stein-Levanthal syndrome. 1%

female suffers from PCOS. Most of are 15-25 years of age group.

PCOS includes chronic non-ovulation and hyper androgenimia associated with normal or raised oestrogen (E2), raised LH, low FSH/LH ratio.

Macroscopically, the ovaries enlarged bilaterally, with thick capsule.

The surface may be lobulated, but peritoneal surface is free of adhesions.

Multiple cysts 0.5 to 1mm and at times 20mm in size are localized along the surface of the ovary giving a ‘necklace’ appearance on USG.

These are atretic follicles.Theca cell hyperplasia produce excess of

testosterone secretions.Young women with complains of

oligomenorrhoea, often ammenorrhea of few months of duration.

Infertility in 30%. Obesity, hirustism are the additional features. USG confirms the diagnosis for PCOS by

showing several subscapsular cysts of varying sizes.

In other cases low FSH/LH ratio

- Raised testosterones

- Raised androstendione

- Raised DHEA Laparoscopic evaluation not only confirms the

diagnosis but also have therapeutic value.

Treatment – • Weight loss >5% of the previous weight will help in

restoring the hormonal milieu. • Avoid cigarette smoking.• Estrogen with progesterone supresses the androgen and

adrenal production. So to be prescribed. • Dexamethasone 0.5mg or prednisolone 5mg at bedtime

also reduce androgen production.• Hirsutism is treated with cyproterone acetate or

spironolactone.• Infertility is treated with clomiphene & other ovulation

induced drugs. • Surgery comprises laparoscopic multiple punctures of

the cysts with electrocautery or laser.

Ovarian endometrioma : It is the presence of functioning uterine glands

and stroma into the ovarian tissue. It is prevalent in women of reproductive age

group but has been reported in adolescent and in post menopausal women receiving hormonal replacement.

It is the common site of endometriosis, starts with superficial implants over the ovarian surface and gradually invades the ovarian stroma.

Cyst formation is due to periodic shedding and bleeding from the implant.

Epithelial lining of the cyst contains endometrial glands and stroma.

On the rupture of cyst the characteristic thick, tarry fluid (chocolate) material escapes.

Rupture of the cyst with consequent acute abdomen is confused with rupture or torsion of the ovarian tumour, ectopic pregnancy, appendicitis or diverticulitis.

If it is asymptomatic then confused with benign ovarian tumour and symptomatic one with malignant.

Laparoscopy confirms the diagnosis. Clinical features are pelvic pain, dysmenorrhoea

and infertility. Malignancy is rare, if occur then commonest one

being adenocanthoma.

Treatment – • Small endometrioma (<3cm) is aspirated,

irrigated with normal saline and cyst wall epithelium destroyed with laser vaporization.

• Large endometrioma (>3cm) often associated with extensive adhesions should be aspirated followed by incision and removal of the cyst wall from the ovarian cortex.

• To prevent recurrence cyst wall of the endometrioma should be removed and normal ovarian tissue must be preserved.

NEOPLASTIC OVARIAN TUMOUR

The incidence of ovarian tumours amongst gynecological admission varies from 1-3%.

Benign 80% Malignant 20% - Primary (80%) - Secondary (20%)70% of primary tumours are bilateralAll secondary tumours are bilateral• Only 16% benign tumours are bilateral• Most benign tumours are cystic except fibroma,

thecoma, dermoid cyst and Brenner tumour are solids

• Younger the women more chances of benign tumours and malignant one are germ cell tumours.

• Among older, epithelial tumours are more common.

• Peak age of ovarian tumour is 65-70 years.• Only 3% of ovarian cancer are seen in females

<35 years, majority of which are non-epithelial such as germ cell tumours.

Etiology

Age – Benign tumours usually commence their growth before the menopause, although they may not become apparent until afterwards.

Primary ovarian tumour are commonly found in 40-60 years of age with the exception of teratomas and special sex cell tumous which have their own age incidence.

Epithelial tumours mostly associated with nulliparity, early menarche, late menopause (long estimated years of ovulation).

There may be history of ovulation induction especially with gonadotrophins.

Previous radiotherapy. Chemical irritants e.g. Abestos and Talc. Ovarian tumours are common among females of

affluent class probably because of high fat content in diet.

Familial pattern have been seen in less than 5% of cases of epithelial ovarian cancer.They fall into one of these catagories.

• Site specific ovarian cancer – Here the pattern is autosomal dominant with reduced penetrance, if two first degree relatives are affected the risk is as high as 50%. With one first degree relative affected, risk is 2-4 fold.

• Hereditary breast/ovarian familial cancer syndrome. Combination of these two types of cancer seen in first and second degree relatives.

• The BRCA1 gene and BRCA2 located on 17q chromosome has been associated with the syndrome.

• BRCA1 HAVE 80-90% risk of developing breast CA and 50% risk of developing ovarian CA.

• Lynch-II syndrome – This includes familial colon (lynch-I), ovarian, endometrial and breast cancers as well as other malignancies of the gastrointestinal and genitourinary system. The malignancy appearing before the age of 40 years 3 times more risk that in general population.

Molecular biology more than 60 oncogene have been identified.

Her-2/neu is an oncogene that is over expressed in 30% of ovarian CA and may indicate poor prognosis.

Mutations in tumour supressor P53 gene are seen in half of women with advanced disease.

OCPs, pregnancies and breast feeding play a protective role.

ACOG recommndation for care of female with strong family history of epithelial ovarian cancer are –

• 6 monthly screening of patient who wants to preserve fertility.

• Prophylactic oophorectomy when child bearing is complete.

• OCPs to young women before she has children.• Female with history of lynch-II syndrome should

be treated by periodic screening with mammography, colonoscopy and endometrial biopsy.

CLASSIFICATION OF NEOPLASTIC OVARIAN TUMOURS

Ovarian tumours classified histologically according to the WHO classification and nomenclature of the ovarian tumours.

The principal ovarian tissue components from which the ovarian tumours arises are:

• 90% of ovarian tumours are derived from tissue that came from coelomic epithelium or mesothelium.

• Oocytes derived from primitive germ cells.• Mesenchymal elements from gonadal stroma.

• About 80-90% of primary ovarian tumour are the epithelial origin.

• 10% of stromal origin• 5% of germ cell origin. • Remainder fall into other groups.

Classification of Ovarain Tumours

1. Epithelial tumour – These tumours may be benign, borderline malignant or malignant.

• Serous tumour (accounts for 75% of all epithelial tumours) - Endosalpingeal

• Mucinous cyst adenoma (20%) - Endocervical• Endometrioid tumours (2%) - Endometrial• Clear cell tumours (<1%) - Mullerian • Brenner tumours (<1%) - Transitional• Mixed epithelial tumours (<1%)- Mixed• Undifferentiated carcinoma (<1%)- Anaplastic• Unclassified epithelial tumours (<1%)

- Mesothelioma

2. Sex cord stromal tumoursa) Granulosa cell tumours’b) Tumours of thecoma-fibroma group• Thecoma• Fibroma• Unclassifiedc) Androblastoma• Sertoli cell tumour• Sertoli leydig cell tumour• Hilus cell tumourd) Gynandroblastomae) Unclassified

3. Lipid cell tumour4. Germ cell tumour of the ovaryI Primitive Germ cell tumoursA. DysgerminomaB. Endodermal sinus tumourC. Embryonal cell carcinomaD. PolyembryomaE. ChoriocarcinomaF. Mixed germ cell tumours

II. Biphasic or triphasic teratomaA. Immature teratomaB. Mature teratoma1. Solid2. Cystica. Dermoid cystb. Fetiform teratoma (homunculus)III. Monodermal teratoma and somatic-type

tumours associated with dermoid cystsA. Thyroid tumor 1. Struma ovariia. Benignb. Malignant

B. CarcinoidC. OthersIV. Mixed Forms5. GonadoblastomaA. PureB. Mixed with dysgerminoma or other form of

germ cell tumour6. Soft tissue tumours not specific to the ovary7. Unclassified tumours8. Secondary (metastatic) tumours9. Tumour-like conditions.

BENIGN OVARIAN NEOPLASM

1. Epithelial tumour a) Serous cyst adenomab) Mucinous cyst adenomac) Brenner’s tumourd) Endometroid cyst adenoma2. Germ cell tumoura) Benign mature cystic teratoma (dermoid cyst)b) Struma ovarii3. Sex cord stromal tumoursa) Thecomab) Fibroma

SEROUS CYST ADENOMA • These are the most common benign

epithelial tumours & accounts for 20% of all benign ovarian tumours.

• Serous cyst adenoma arises from the totipotent surface epithelium of the ovary.

• 20-30 cm in diameter• Unilateral, can be bilateral• There is more chances of proliferation of

the lining epithelium to form papillary projections.

• On naked eye appearance these occurs as a thin walled, often translucent, greyish-white usually unilocular but had a few daughter cysts in the wall with exuberant papillary projections.

• The content fluid is clear, rich in serum proteins – albumin and globulin.

Histopathology – Lined by single layer of cubical epithelium. Papillary structure consists of broad dense fibrous stroma covered by single or multiple layers of columnar epithelium. There may be presence of ciliated, secretory and peg cell resembling fallopian tube epithelium. PSAMMOMA bodies – are tiny, spherical, laminated, calcified structures which are most often found in area of degeneration.

MUCINOUS CYST ADENOMA • It arises from the totipotent surface epithelium of

the ovary. • It also arise from the teratomata in which the

epithelium of endodermal origin have probably over grown than the other elements and explain its association with dermoid cyst.

• Its association with Brenner tumour suggests its origin as mucinous metaplasia of the epithelium.

• They are quite common and accounts for 20% of all ovarian tumours.

• Appx. 10% cases tumour is bilateral. • Naked eye appearance – They may attain very

large size, may be multilocular.

• The wall smooth, lobulated with whitish or bluish-white heu.

• The fluid content is thick in consistency and glary. It contains glycoprotein with a high content of neutral polysachrides.

• Colourless, yellow, green or brown depending upon the blood pigments derived from intracystic haemorrhages.

• About 5-10% of mucinous ovarian tumours are malignant. 20% of epithelial ovarian tumours.

• Histologically the cysts are lined by columnar cells and these secretes a mucus material. The epithelium characteristics like those of endocervix.

BRENNER’S TUMOURS• Accounts for 1-2% of all ovarian tumours.• It is an uncommon solid fibro-epithelial tumour.• Generally unilateral and benign having no

endocrine function.• These arise from Wollfian metaplasia of surface

epithelium. • Majority are <2cm in diameter. • On gross appearance it resembles a fibroma of

ovary.• Cut surfaces appears gritty and yellowish-grey.

• Histologically shows background of fibrous tissue, interspersed within it are nests of transitional epithelium (Walthard cell rests). These cells demonstrates a longitudinal groove resembling puffed wheat.

• May be combined with mucinous cyst adenoma. • May cause pseudo meig syndorme.• Rarely 1% turned malignant.

Endometroid cyst adenoma –

• most of these tumours are malignant as benign endometroid cyst are difficult to differentiate from endometriosis.

DERMOID CYST

(MATURE CYSTIC TERATOMA)• Commonest teratoma is benign dermoid cyst

accounts for 10-15% of all ovarian tumours. • Of all cystic tumours 5-10% are dermoid cysts. • Tends to occur relatively early age (median age

of presentation is 30 years).• Bilateral in 12%, may be multiple in one ovary.• Malignant transformation in 1.7% (squamous cell

carcinoma is the commonest).• It is commonly found in pregnancy.

• Naked eye appearance – The cyst is moderate in size, rarely grows larger than melon (15cm) in diameter.

• It is unilocular or has few loculi.• It contains sebaceous material and hair and the

wall is lined in part by squamous epithelium which contains hair follicles, sebaceous glands, teeth, bone, cartilage, thyroid tissue and brochial mucous membranes.

• Occasionally only single tissue may be presents as carcinoid or struma ovarii.

• Histologically the wall is lined by stratified squamous epiethelium at places by granulation tissue. The epithelium may be transitional or columnar. The most common tissue elements are ectodermal.

• The terminology of dermoid cyst is misnomer, as a part from ectodermal elements there may be endodermal and mesodermal tissue as well.

STRUMA OVARII• Consists of thyroid tissue similar to that of thyroid

adenoma. • The tumour is solid consisting almost entirely of

thyroid tissue and should be clearly distinguished from a dermoid cyst with thyroid tissue in its wall.

• Naked eye appearance – Tumour resembles a small mucinous cyst adenoma but material contains vesicles is colloid and gives reaction to iodine.

• Most of the tumours are benign but malignant transformation is there.

• Histogenesis is supposedly a dermoid in which the thyroid tissue dominate at expense of other elements.

THECA CELL TUMOUR• These are rare, almost all are benign.• Solid and unilateral.• Usually arise after menopause.• These are associated with endometrial cancers.

FIBROMA• Comprises 3% of ovarian tumours. • 10% are bilateral • Frequent around the age of 50 years• It is oval in shape, smooth surface with large

veins noticable in the capsule.

• Firm in consistency with cystic space in centre because of degenerations.

• Usually 15cm in size.• Associated with Meig syndrome in 10% i.e.

ascites and right sided pleural effusion.• Microscopically tumour is composed of network

of spindle shaped cells which closely resemble the spindle cell of the ovarian cortex.

• The association of the Brenner tumour with ovarian fibroma is well known.

CLINICAL FEATURES OF B.OVARIAN TUMOURS

Age – Predominantly manifest in the late child bearing period. However, dermoid (90%), specially with mucinous cystadema is common in reproductive periods. Dermoid cyst is more common during pregnancy (10%)

Parity – No relation with parity.Symptoms 1. Benign ovarian cyst frequently give rise to

enormous tumours. They cause relatively few symptoms. First symptom – abdominal swelling.

2. Menstrual cycles • Even bilateral ovarian tumours do not effect

the menstrual cycle. • Only tumours causing menorrhagia are

granulosa and theca cell tumour by virtue of their estrogen hormone.

• Musculizing tumour cause virilization and ammenorrhoea.

• Post menopausal bleeding cause by Brenner’s tumour.

3. Pressure symptoms • Frequency of micturation and even retention of

urine.

• Musinous tumours casue dyspnoea, palpitation and pitting oedema of feet.

4. Pain• Benign tumours never cause pain • Mucinous tumour cause abd. discomfort on

walking because of large size.• Acute abd. can occur if torsion, rupture of the

cyst occur.• Pain with pyrexia can occur in infected

dermoid cyst.

Signs General conditions of the patient is uneffected.

However, in high mucinous cyst adenoma the patient may be cachetic due to protein loss.

Pitting edema of legs may be present when a huge tumour pressure on the great veins.

Abdominal examination • On inspection – Bulging of the lower abd over

which the abdominal wall moves freely with respiration. Mass may be placed centrally or in one side. Sometimes, the mass fills the entire abdominal cavity everting the umblicus with visible veins under the skin; the flanks remains flat.

• On palpation – Feel is cystic or tense cystic. Benign solid tumours are rare. Upper and lateral borders are well defined but the lower pole is difficult to reach suggestive of pelvic origin. Surface over the tumour is smooth but often grooved in lobulated tumours. Usually not tender.

• Percussion – Note is dull in the centre and resonant in the flanks.

• Auscultation – Friction rub may be present over the tumour.

Pelvic examination

Bimanual examination reveals• The uterus felt separated from the mass. • The groove is felt between the uterus and the

mass.• Movement of the mass per abdomen fails to

move with cervix. • On elevation of the mass p/a, the cervix remains

in stationary position. • The lower pole of the cyst can be felt through

the fornix.

• Absence of the pulsation of the uterine vessels through fornic.

• If a cyst is felt lying anterior to the uterus, it is more likely to be dermoid.

SPECIAL INVESTIGATIONS1. Sonography – can identify the uterus and the tumour in

the same scan. TVS with color doppler flow gives information about

tumour volume, cyst wall, septa and vascularity. Doppler color flow also distinguish b/w the benign and

malignant tumours. Ultrasound guided ovarian cyst aspiration helps to

distinguish b/w benign and malignant tumours. CT Scan, MRI identify dermoid cyst , heamorrhagic

cyst, fibroma , endometriosis. 2. Straight X-ray abdomen – finding of a shadow of teeth

or bone is a direct evidence of dermoid tumour.

3. EUA especially in virgins4. Laparoscopy5. Laparotomy6. Cytology7. Tumour markers – raised serum CA 125

strongly suggestive of ovarian cancer esp. in post menopausal women.

CEA > 5mg/liter seen in mucinous ovarian tu. -HCG levels raised in ectopic pregnancy,

choriocarcinoma and H.mole. Elevated estradiol levels signifies physiological

follicular cyst and sex cord stromal tumours. Raised -feto proteins levels suggest yolk sac

tumour.

DIFFERENTIAL DIAGNOSIS

D/D of benign tumour is broad, reflecting the wide range of presenting symptoms :

Pain• Ectopic pregnancy• Spontaneous abortion• Pelvic inflammatory disease• Appendicitis• Meckel’s diverticulum• DiverticulitisAbdominal swelling• Pregnant uterus

• Fibroid uterus• Full bladder• Distended bowel • Ovarian malignancy• Colorectal carcinomaPressure effects• Urinary tract infection• ConstipationHormonal effects• All other causes of menstrual irregularities,

precocious puberty and postmenopausal bleeding.

COMPLICATIONS

1. Torsion of the Pedicle – Axial rotation is more likely to involve small tumours because large ones are restrcted in their movement, but no type is immune. Because they are usually relatively small and mobile, by reason of a long pedicle, dermoid cysts are said to be the most prone of all tumours to suffer this accident.

2. Intracycstic hemorrhages – More common in serous cyst adenoma with papillary varieties. Occurs following venus congestion due to axial rotation of the pedicle.

3. Infection – is common following torsion. The organisms derived from the intestines or uterine tubes when they are adherent to the cyst.

4. Rupture – usually occur in big and tense cysts with degeneration of a part of cyst wall. It may occur due to direct trauma, in papillary varieties.

5. Pseudomyxoma Peritonei – It is a condition of the mucinous ascites secondary to mucinous tumour of intra abdominal origin (associated with mucinous cyst adenoma of the ovary, mucocele of the appendix and gall bladder and intestinal malignancies.

Spontaneous perforation of mucinous cyst may lead to implantation of the cell of low grade malignancy on the peritoneum. The mesothelium of the peritoneum is converted to high columnar epithelium with secretory activity. Even after the removal of ovarian tumour, these cells continue to secrete mucin.

6. Malignancy – The malignant potential is maximum in serous cyst adenoma and least in dermoid cyst.

MANAGEMENT

The management will depend upon the severity of the symptoms, age of the patient, risk of the malignancy and her desire for further children.

If the patient is asymptomatic –• Clinically and ultrasound diagnosis of benign

ovarian cyst i.e. unilateral, normal vascular pattern, moblie, cystic and no family history.

If patient is symptomatic –• i.e. severe acute pain, signs of intraperitnoneal

hemorrhage, then emergency laparotomy or laparoscopy is to be done.

Treatment is mostly surgical, although there may be few women in whom cyst aspiration is indicated.

Treatment -1. Therapeutic ultrasound guided cyst

aspiration-• The best canddiates are young women with

unilateral, unilocular, anechoic, thin walled cyst less than 10cm in diameter.

• There is small place for cyst aspiration only in women in whom surgery is considered to be if high risk either because of coexisting medical problem or dense pelvic adhesions.

Advantages – Surgery is avoided and cyst accidents are reduced. But this is a controversial procedure because in 1-2/3rd women the fluid will reaccumulate.

2. Laparoscopic procedure- Patient fit for laparoscopic procedure is

• Age <35years• USG show no solid component (Simple ovarian

cyst)• Benign cystic teratoma• Endometrioma

Various laparoscopic procedures used commonly are :

- Aspiration and fenestration- Cystectomy (Removal of the ovarian tumour

leaving behind the healthy ovarian tissue)- Oophorectomy/Salpingo oohorectomy

Advantages – • There is less post operative pain, less

hospitalisation, quick recovery.• Patient can be prepared for surgical staging if

ovarian malignancy is found.

Disadvantages – • Spillage of cyst contents can occur.• Incomplete excision of cyst wall.• Unexpected histological diagnosis of

malignancy.3. Laparotomy- When clinical diagnosis is not

possible without laparotomy and histopathological examination.

Ovarian cystectomy/Ovariotomy (Removal of the tumour alongwith healthy ovarian tissue)

• In young women <35 years , irrespective of parity and conservation of healthy ovary desirable.

• When tumour is less likely to be malignant.• It is often said that biopsy of contralateral ovary

should be taken. But most of the gynaecologists are unwilling to take biopsy from healthy ovary as this may result in infertility from periovarian adhesions.

TAH with B/L salpingo oophorectomy • Patient >44 years of age• Epithelial tumour is more likely to be• Even tumour is benign• To avoid second surgery if evidence of

malignancy in histological specimen.

• Patient 35-44 years• Individualised the treatment about conservative surgery

where there is greater benefits to the patients and less risks.

• If conservative surgery is planned – preliminary hysteroscopy with curretage of uterus is essential to exclude endometrial tumours.

• Thorough exploration is necessary and an appropriate plan of action must be decided in advance with the patient have more widespread disease be found.

Prophylaxis

1. Women on ART (Assisted reproduction treatment) and ovulation induction drugs should be monitored by USG regularly.

2. Benign tumour should be removed on diagnosis.

3. Perimenopausal hystrectomy should be accompanied by BSO.

4. Ovaries should be routinely seen and palpated during caesarean section.