benign adnexal tumours - med.alexu.edu.eg

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.

27 March, 2020Benign Ovarian Tumours

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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


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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15 Follicular(commonest)

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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36 Mucinouscyst-adenoma

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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39 BrennerTumour

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


42 Ovarian Fibroma

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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