PRESENTATION ON BENIGN OVARIAN TUMOURR.ppt

Presentation on Benign ovarian tumor

1. BENIGN OVARIAN
TUMOURS
DR KAYODE AFOLABI
CONSULTANT OBGYN
UNIVERSITY COLLEGE HOSPITAL,
IBADAN

2. Introduction/Clinical anatomy
The ovary in the adult female is a pinkish-white oval
structure measuring 3x2x1cm.
It lies posterio-lateral to the uterus and attached to it by
ovarian ligament and to the pelvic side wall by
infundibulopelvic ligament.
It is derived from the coelomic epithelium of the posterior
abdominal wall.
The arterial supply is directly from the abdominal aorta.
Direcly posterior to the ovary in the ovarian fossa is the
ureter

3. Introduction/Clinical Anatomy 2
Surface: Covered by single layer of epithelial cells
Cortex: Follicles (with oocyte), granulosa
layer/theca
Stromal medulla
Hilum: entry point for vessels through
mesovarium
Mean volume-6.8cc(premenopausal);
3.0cc(postmenopausal)

4. Introduction3
Cyclic stimulation predisposes ovaries to cystic changes
Graafian follicle –first half of cycle
Corpus luteum –second half
Presentation –adnexal mass (uterus, colon, urinary tract)
Challenges –
early recognition of malignant ovarian mass
Higher incidence of malignancy in ovarian tumours than other pelvic
tumors
Infancy/childhood –10% of ovarian tumours are malignant
Reproductive years –most ovarian tumours are functional/non-neoplastic
Menopause –Half of all ovarian tumours are malignant

5. An Ovarian Tomour

7. EPIDEMIOLOGY
Ovarian tumours may be physiological or
pathological, and may arise from any tissue in
the ovary.
Most benign ovarian tumours are cystic.
Benign ovarian cysts are common, frequently
asymptomatic and often resolve spontaneously.
The finding of solid elements makes malignancy
most likely.

8. EPIDEMIOLOGY 2
Amongst those that require surgery,13% are malignant
in premenopausal women but 45% -50% are malignant
in postmenopausal women.
The main objectives of management are to exclude
malignancy and to avoid cyst accidents, without causing
undue morbidity or impairing future fertility in younger
women.
There is an increase in benign tumours in the fifth
decade (40-49 years) and in malignant tumours from 50
years of age onwards.
Ovarian tumours constitute 35% of all gynecological
malignancies..

9. NON-NEOPLASTIC CYSTS
1) FOLLICULAR CYST(S) (’CYSTIC OVARY’)
Due to enlargement of one or more follicles which fail to
rupture.
Seldom more than 5 cm in diameter except when due to over
dosage with clomiphene or HMG (To Stimulate ovulation).
Often associated with:
----Anovulatory cycles
----Fertility drugs
----Polycystic ovary syndrome (PCOS)
The majority are symptomless.
Pain (usually mild but sometimes severe) is due to rupture of /
haemorrhage into the cyst or torsion
(If unilateral pain is accompanied by slight menstrual
disturbance an ectopic pregnancy must be excluded).

10. NON-NEOPLASTIC CYSTS 2
2)THECA-LUTEIN CYSTS
A corpus luteum becomes cystic and persists in a
functional state for longer than normal; or the
granulosa and theca cells of a follicular cyst become
luteinised.
Characteristically, short periods of amenorrhoea are
followed by heavier than usual uterine bleeding.
The endometrium is secretory.
Multiple and sometimes moderately large theca-lutein
cysts are associated with trophoblastic tumours and
hyperplacentosis.This is due to hCG stimulation.

11. Other tumour-like conditions
Luteoma of pregnancy
Germinal inclusion cysts
Endometriotic cysts

12. MANAGEMENT
If an ovarian enlargement estimated at 4-6 cm is found
at pelvic examination----carry out pelvic ultrasound.
-----If the presumed diagnosis is a ‘cystic ovary’ rather
than a neoplasm no immediate action is necessary.
-----Re-examine in 2 weeks; a follicular cyst will usually
have disappeared.
-----If the cyst is unchanged or larger, further
investigation (e.g. laparoscopy) is warranted.

13. MANAGEMENT 2
If discovered or confirmed by laparoscopy, the
cysts can be aspirated. Laparotomy is not
necessary.
Send the fluid for cytology to definitely exclude
neoplasia.
Treat any underlying condition.

14. Classification of benign ovarian tumours
WHO Committee on the Nomenclature and
Terminology of Ovarian Classification
Divided by cell type of origin into three main
groups:
Epithelial -the most common group of tumours.
(Epithelial tumours categorized as benign, of
borderline malignancy i.e carcinoma of low
malignant potential and malignant)
Germ cell
Stromal

15. Cystic epithelial tumours
Serous cystadenomas
Usually multi-locular and may reach a very large
size
Consists of clear watery fluid (occasionally
haemorrhagic/brownish)
Finger-like projections arise from the wall
(papillary excrescences)

16. Cystic epithelial tumours(Contd)
Mucinous cystadenomas
Can attain a huge size
Usually multi-locular
Sometimes associated with mucocele of the
appendix
Content is clear, thick and viscid
Pseudomyxoma peritonei –follows rupture of
mucinous tumour of ovary; tumour continues to
secrete mucin

17. Solid epithelial tumours
Cystadenofibromas and fibroadenomas
Solid tumours
Termed cystadenofibromas when a cystic change
has taken place
Termed fibroadenomas when there is significant
stromal element present

18. Solid epithelial tumours(Contd)
Fibromas
Solid tumour with smooth surface resembling a
fibroid (may also, but rarely undergo all the
degenerative changes found in a fibroid)
Associated with Meigs Syndrome–presence of
ascites +hydrothorax. Fluid transudes through
capsule from intermittent torsion or
compromised venous/lymphatic drainage

19. Solid epithelial tumours(Contd)
Brenner tumours
Similar in appearance to fibroma
Vaginal bleeding is a common feature
Endometrial hyperplasia is occasionally
present

20. Germ cell tumours
Benign cystic (mature) teratomas
Accounts for about 95% of germ cell tumours;
single most common benign ovarian tumour
Commoner in 16 –30 year age group
Also called ‘dermoid cyst’-predominant
composition of skin/skin-like structures
Contains all three germ layers: cartillage, teeth,
hair, sebaceous glands, brain, bone
Cystectomy is the standard management

21. GERM CELLS TUMOUR:
DERMOID
Dermoid cysts are the commonest ovarian
tumours in young women.
They usually symptomless, but torsion or
rupture may produce signs and symptoms of an
acute-abdomen.
Bilateral in 10% of cases and seldom larger than
12cm in diameter.

22. GERM CELLS TUMOUR:
TERATOMA
Lined by stratified squamous epithelium with its
usual cutaneous element –Hair, sebaceous and
sweat glands. Teeth, neural tissue, cartilage,
alimentary and respiratory epithelium and even
active thyroid tissue may be present.
Solid teratomas may be benign but are usually
malignant.

23. GERM CELLS TUMOUR
The degree of malignancy and prognosis is
related to the maturity of the component tissues.
True malignant change (usually squamous
carcinoma) can develop in any of the tissue
types found in a mature dermoid.

24. Sex-cord {Gonadal} stromal tumours
Introduction
Thecomas, Granulosa-theca cell tumours,
Gonadoblastomas, Fibromas
Tumours are composed of cells of ovarian
stroma: granulosa cells, theca cells, Sertoli cells,
Leydig cells, fibroblasts
Usually hormonally active (functioning)
Either feminizing or virilizing
Usually presents with irregular bleeding

25. GONADAL STROMAL
TUMOURS
The stromal cells retain a potential for differentiation
into any of the cells or tissues arising from the
mesenchyme of the gonad (i.e. Granulosa ,Theca,
Leydig and Sertoli cells).
These rare tumours may therefore secrete any or all of
the ovarian steroids.
They tend to be classified according to morphology:

26. GONADAL STROMA 2
I) GRANULOSA –THECA CELL GROUP( which may
produce OESTROGEN)
----Granulosa –cell tumour –not infrequently malignant but
usually low grade
----Thecoma –Fibroma
II) SERTOLI –LEYDIG CELL GROUP ( which may
secrete ANDROGENS )
----Sertoli –Leydig cell tumour (Androblastoma,
Arrhenoblastoma)
----Sertoli –cell tumour
----Leydig –cell tumour ( Hilus or lipoid cell tumour)

27. GONADAL STROMA 3
III) MIXED–Elements of Granulosa cell tumour
and arrhenoblastoma present
(Gynandroblastoma).
Feminising ( Oestrogen –producing) tumours cause :
----Precocious puberty.
----Cystic glandular hyperplasia in menstruating women
----Postmenopausal bleeding in older women.
Masculinising (Androgen –producing) tumours will
initially result in defeminisation, including secondary
amenorrhoea then hirsuties, enlargement of the clitoris
and deeping of the voice.

28. Diagnostic/Prognostic considerations in ovarian
tumours
Age –least risk of malignancy in reproductive years; higher
in pre-pubertal and peri-/post-menopausal women
Size –large tumours often benign
Mobility –fixity/poor mobility suggests malignancy
Bilaterality –present in 15 –20% of benign ovarian cysts
Malignant potential –highest with epithelial cysts, nil with
functional cyst/endometriotic tumours; dermoid cyst-1%
Rapidity of growth, Pain and tenderness, Ascites and
consistency are other prognostic factors

29. Symptoms
May be asymptomatic
Pain usually mild: worsened by torsion,
haemorrhage or rupture
Abdominal swelling
Nausea/vomiting
Cachexia
Dyspnoea
Urinary retention
Menstrual disturbances: amenorrhoea,
intermenstrual bleeding

30. CLINICAL FEATURES OF
OVARIAN TUMOURS
The peak age incidence is between 40 and 60 years, with the
exception of teratomas and gonadal stromal tumours which
occur at any age.
Ovarian tumours rarely give rise to specific symptoms early in
their course.
The commonest presenting features are vague gastrointestinal
upset (usually dyspepsia) or increasing abdominal girth, usually
ascribed to ‘middle age spread’ by patients and medical
attendants.
This means that :
----they are often found accidentally
Abdominal swelling may be present but ignored by the patient.
Menstrual function is not usually affected (except by the rare
gonadal stromal tumours).

31. CLINICAL FEATURES IN
MALIGNANT VERSUS BENIGN
TUMOURS
Age----tumours in childhood are frequently malignant.
In older women the risk of malignancy is proportional
to age; 45% of tumours removed from women age 45
years or over are malignant.
Pain and tenderness----benign tumours are never
painful unless complicated. A sudden severe pain
suggests torsion or rupture. Dull aching pain may
suggest malignancy. Sacral nerve root pain is strongly
suggestive of malignancy.
Rapidity of growth ----suggests malignancy.

32. MALIGNANT VS BENIGN
Numbers of tumours ----75% of malignant tumours
are bilateral, and 15% of benign tumours are bilateral.
Consistency of tumours ----solid, nodular and irregular
growths are more likely to be malignant.
Fixation ----is suggestive of malignancy, but not
necessarily so.
Ascites ----is usually a sign of peritoneal metastasis
(especially if the fluid is blood stained).
Remember the possibility of Meigs syndrome.

33. MALIGNANT VS BENIGN
Oedema of the legs and vulva or evidence of venous
obstruction ----are suggestive of malignancy.
Metastatic deposits ----Remote metastases are not
common, but in advanced disease supraclavicular nodes
may become enlarged. The pouch of Douglas may
contain irregular deposits which can be felt on bi-
manual examination.
The majority of patients with ovarian cancer present
with advanced disease.

34. DIFFERENTIAL DIAGNOSIS
Ovarian tumours must be distinguished from a whole
variety of pelvic and abdominal swellings. Among the
most common are a
full bladder or rectum;
corpus luteum;
intrauterine pregnancy;
uterine fibroids; and
hydrosalpinx.

35. COMPLICATIONS OF
OVARIAN CYSTS
Torsion ----Acute or subacute pain may be accompanied by mild
shock. The lower abdomen is tender with guarding and rigidity.
Pelvic examination reveals a tender adnexal mass. Laparotomy is
indicated and removal of the ovary usually necessary.
Rupture ----The signs and symptoms will vary. The contents of
chocolate (endometriotic) and dermoid cysts are extremely
irritant and therefore may cause severe symptoms.
Haemorrhage into or from cyst ----The signs and symptoms will
vary according to the degree of haemorrhage.
Infection ----This is not a common complication of ovarian
tumours.
Malignant change ----This occurs mostly in serous and mucinous
cystadenoma. New symptoms are not produced.

36. Investigations
Ultrasound –to characterize mass: cystic/solid;
multiloculation; thick septa; disruption of capsule;
presence of tooth
X-ray (Chest/abdominal)
IVU
Laparoscopy
FBC/LFTs/E&U

37. Definitive Management of Benign Ovarian
Tumours
Laparotomy is mandatory
Ovarian cyst in young women: Ovarian cystectomy
Perimenopausa/postmenopausal women: Total abdominal
Hysterectomy and bilateral salpingo-oophorectomy
Young women with suspicion of malignant change on one
side: ipsilateral oophorectomy, frozen section of
contralateral ovary (with conservation if healthy)
Guiding principle: Type of tumour/Age/Desire for future
childbearing

38. MANAGEMENT 2
A combination of the following features found at
laparotomy may indicate (a higher risk of) malignancy:
The tumour is totally or partly solid
Bilateral tumours
There is fungation through the capsule (not merely papillary
growths)
Large vessels on the tumour surface
Blood –stained ascites
Invasion of / or adhesion to surrounding structures
Metastatic deposits.

39. CONLUSION
Ovarian tumours are common and mostly
benign.
There is no proper screening method for the
disease.
Early diagnosis and prompt proper management
are essential.

40. Thank you for your attention