benign adnexal tumours - med.alexu.edu.eg
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Benign Adnexal
TumoursDr. Amira Badawy
Ass. Prof. Ob/Gyn
Faculty of Medicine
Alexandria University
Normal Ovaries
▪ Size = 5 x 3 x 3 cm
▪ Located in the ovarian fossa.
▪ Best detected by TVS.
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Normal Ovaries
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Ovarian Tumours (masses)
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Benign
Malignant
Border-line
Benign Ovarian Massses
Non-neoplastic
Functional Others
Neoplastic
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❖ Follicular cyst.
❖ Corpus luteum cyst.
❖ Theca lutein cyst.
❖ Pregnant luteoma.
❖ PCO.
❖ Endometrioma.
❖ TOA.
❖ Serous cystadenoma.
❖ Mucinous cystadenoma.
❖ Brenner.
Epithelial
❖ Mature teratoma
(Dermoid).
Germ cell
❖ Fibroma.
❖ Thecoma.
❖ Andro-blastoma.
Sex cord
Functional
Ovarian
Cysts
Follicular Cysts
▪ The commonest functional ovarian cyst.
▪ Due to hyper E2.
▪ Lined by granulosa cells.
▪ Thin walled, uni-locular, uni- or bi-lateral.
▪ Cystic follicle > 3 cm, Rarely > 8 cm.
▪ Discovered accidentally on pelvic examination.
▪ Usually resolves within 4 – 8 wks.
▪ May occasionally rupture or twist ➔ pain.
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Follicular Cysts
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Follicular Cysts
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Corpus Luteum Cysts
▪ Less common than follicular cysts.
▪ Due to over active CL. Lined by lutenized granulosa cells.
▪ usually uni-locular, pink or haemorrhagic, yellow-orange
cut section, filled with blood clots.
▪ May reach 10 cm, surrounded by a circle of blood flow
detected by colour Doppler.
▪ If ruptures ➔➔ haemo-peritoneum (more with anti-
coagulant intake or with bleeding tendency).
▪ If un-ruptured ➔ pain (due to bleeding into an enclosed
cyst cavity).
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CL Cysts
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Theca Lutein Cysts
▪ The least common functional ovarian cysts.
▪ Due to ovarian hyper-stimulation by excess ß-hCG, as
in:
▪ Lined by theca lutein cells &/or granulosa lutein cells.
▪ Usually bilateral, multi-cystic, greyish blue, filled with
straw coloured fluid or blood.
▪ May attain big sizes (up to 30 cm), & resolve
spontaneously.
▪ Rupture & torsion is more common
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❑ OHSS after IO, or
❑ VM, or
❑ choriocarcinoma, or
❑ multiple pregnancy.
Theca Lutein Cysts
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CL Th. Lutein(Least common)
Age group
Adolescent &
reproductive
+/- perimenopause
Reproductive Reproductive
Cause Hyper-E2 Over activity of CL ↑↑ ß-hCG (GTD or IO)
Size 3 – 8 cm 3 – 10 cm Up to 30 cm
Laterality Bi- or Uni-lateral Uni-lateral Bi-lateral
Gross Thin walled
Uni-locular
Filled with straw coloured
fluid
Pink or haemorrhagic
Yellow-orange cut
section
Filled with blood clots
Multi-cystic
Greyish blue
Filled with straw
coloured fluid or blood
Histology (lining cells)
Granulosa cells Lutenized granulosa
cells
Theca lutein cells &/or
granulosa lutein cells
C/P Asymptomatic
Accidentally discovered
Dull unilat pelvic pain
Rupture & haemoperit
is more common
Small➔ asymptomatic
Large➔ pain +
discomfort
Rupture & torsion is
more common
Management of Functional Cysts
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▪ Expectant.
▪ Usually resolves spontaneously after 2-3
cycles.
▪ N o ro l e fo r C O C s.
▪ No role for COCs.
▪No role for COCs.
▪ Surgery may be indicated in persistent, or
complicated cysts.
Polycystic
Ovaries
PCO
▪ PCOS is diagnosed by the presence of > 2 of the
Rotterdam criteria (2003):
1. Oligo-ovulation (cycles > 35 days, or < 9 cycles / year),
2. Clinical or laboratory hyperandrogenism (acne,
Hirsutism, high S. testosterone, …)
3. US morphological features (≥ 12 antral follicles in
each ovary measuring 2-9 ml, or ovarian volume > 10
cm2).
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PCO
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OHSS PCO
Endometrioma
Endometrioma(Chocolate Cysts)
▪ They are pseudo-cysts.
▪ Cyst wall is usually thick & fibrotic.
▪ In US ➔ an-echoic cysts with diffuse low-level
to solid echoes.
▪ May be uni-locular to multi-locular.
▪ Malignant transformation 0.3 – 0.8 %.
▪ Rx ➔medical or surgical.
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Endometrioma(Chocolate Cysts)
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Tubo-ovarian
Abscess
TOA
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Benign
Neoplastic
Tumours
▪Serous cystadenoma.
▪Mucinous cyst adenoma.
▪Brenner’s tumour.
▪Fibroma.
▪Thecoma.
▪Dermoid cyst.
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Serous cystadenoma
▪ Generally benign.
▪ 10% bilateral.
▪ risk of malignancy:
» 5-10 % border line tumour.
» 20-25 % malignant tumours.
▪ Gross ➔multi-locular + papillary components.
▪ Microscopic ➔ low columnar epithelium with
cilia.
▪ Ch.ch. ➔ Psammoma bodies (end product of
degeneration of papillary implants).
▪ If associated fibrosis ➔ “serous
cystadenofibroma”.
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Serouscyst-adenoma
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13 cm
Mucinous cystadenoma
▪ Tendency to form huge masses.
▪ risk of malignancy:
» 5-10 % malignant tumours.
▪ Gross ➔ round-ovoid, with smooth capsule.
Usually translucent or bluish-whitish grey.
▪ Multilocular, containing viscid fluid.
▪ Microscopic ➔ tall columnar secretory
epithelium with basal nuclei + goblet cells.
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14 cm
Brenner Tumour
▪ Uncommon, usually seen > 50 years.
▪ Usually unilateral, small to moderate size.
▪ Origin ➔ Walthard cell rests, or surface
epithelium, rete overii, & ov. stroma.
▪ Mostly benign (some cases of malignant Brenner’s were
reported).
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Brenner Tumour
▪ Endocrinologically inert, but may be ass. with
virilization & endometrial hyperplasia, & may
➔ peri-menopausal uterine bleeding, &/or
pseudo-Meig’s syndrome.
▪ Gross ➔ smooth solid tumour (as fibroma),
gritty yellowish-grey in cut section.
▪ Microscopic ➔ fibrous tissue with nests of
epithelial cells showing coffee bean pattern.
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4 cm
Fibroma
▪ Seen in middle aged women.
▪ Origin ➔ stromal cells of ovarian cortex.
▪ Gross ➔ smooth solid tumour, white in cut section,
either a small sessile nodule or with long pedicle.
▪ Microscopic ➔ spindle-shaped cells.
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▪ Most common benign solid ovarian
tumour (5% of benign ovarian tumours &
20% of all solid ovarian tumours).
▪ Risk of malignancy = 1%
Fibroma
▪ Not hormonally active (dd from other sex cord tumours).
▪ Firm (as uterine myomata) ➔may be mis-diagnosed
as exophytic fibroid or ovarian malignancy.
▪ May (1%) ➔ ascites +/- hydrothorax (due to
increased capillary permeability due to ↑↑ VEGF).
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= ovarian fibroma + Ascites + Hydrothorax
It is uncommon & resolves after surgical excision
Meig’s Syndrome
Outer surface
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Meig’s Syndrome
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Thecoma
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▪ Mostly benign, unilateral solid ovarian tumour.
▪ Usually > 40 years (65% after menopause).
▪ Origin ➔ stromal cells of ovarian cortex.
▪ Gross ➔ solid, with yellow-orange discolouration.
▪ Microscopic ➔ as theca cells.
» Luteinized Thecoma ➔ younger, sclerosing peritonitis & ascites.
» Leydeig Cell Thecoma ➔ ass with Reinke Crystals.
▪ Mostly secretes E2 (or Androgen) ➔ AUB.
Thecoma
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Gonado-blastoma
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▪ Rare benign tumour (with malignant potentiality).
▪ Occurs in dysgenetic gonads (46XO, 46XY mosaic, …)
▪ C/P: females < 30 ys + 1ry amenorrhea + virilization
(breast atrophy, hirsutism, clitorial enlargement, deepening of
voice).
▪ Microscopic ➔ germ cells+ sex cord stromal cells.
» Testicular adenoma ➔ androgen secreting.
» Gyn-androblastoma➔ ass with Reinke Crystals.
▪ Rx ➔ bilateral godanectomy.
Dermoid CystBenign or Mature cystic teratoma
▪ Germ cell tumours may replicate stages
resembling the early embryo.
▪ Occur at any age, 60% in children.
▪ 12-15% of all ovarian tumours.
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▪ The most common type of Germ Cell
Tumours.
Dermoid CystBenign or Mature cystic teratoma
▪ Bilateral in 15 – 25 %.
▪ Gross ➔ thick, opaque, whitish wall.
▪ Contents ➔ hair, bone, cartilage, greasy
sebaceous material.
▪ Microscopically ➔ all 3 germ layers
(ectoderm, mesoderm, & endoderm).
▪ Risk of malignancy is 1-3% (usually of
squamous type).
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Dermoid
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Diagnosis of
Benign Ovarian
Tumours
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In general
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