Benign tumours of the ovary ppsx

C h a rj I e r 11

levels to prevent

1 w'th p'OQftogeiiB,

BbBis is either minimally

nque& or radical. Mth total

Wsalpingn-nophorectomY

Bui. pre&en^i ng v/rth pamftil

•hlheirlalarhLrLiHor

Benign tumours of the ovary

Pathclagy 119 Investigation

Aye dislr bulion of ovarian fumnurs 122 Mdnapemeni:

Presentation 122 Treatment

Differential diaanosiB 123

124

125

127

t^c (chocolate) cysts of the

73

•feOuB to menstrual

SIB nito \T\e peritoneal cavily

t?a-ey

OVERVIE W

Benign civanan cysts aie comnon, Itequenlty dsvrri|)tijrnatk" ami often resolve spnifEneous.y Tliey are fha fourth flu

gynaecological cause of hospital Edmigs-oa By the aga of 65yE3r& 4 p&rcent ulall women '"ill luve been admired ID hpspiial

af rpquira surgery. f3 pgrcenl

in ptemenn|i5usal ^omg/i ^re malidnd^l dnd 45 per uenl in po&lrnsnapau?a '"omen are mjlignanl The main ab|cctive^ of

manage merit art ID exclude malignancy T.nd to a™d t/Bl^ciOen^, ivllnoulcau&lna undue morbidity 01 impai ring future fertilify￾in Vonii^ei^omen.

DvEri^ntumniir^mavb'iphysiologlcjIorpdfhologifa.l and may jn^e from any lifsifeinirfEnvaF^.MDsi benign rj.>arlaFitiliT|D[jrs

are cystlt Tiie finding cf solid ^lemflifs makes ifiahgiianoy mere likeh/. Ho'vever, flbronws. rhKLomi5, da^nmids *id Btenper

tumours u I •• , .H .| .1 ><i inn

Pathology

Physiological cysts

•*iii.h foini in (he ovary during the nornul ^v.iri.iri

•Kle Mnsr A re ^svinplonulii incidental rlndnigs at

pc^K examination or ultrasound scdrl. ^

mf itirtv mLur in any premenopausal woman,

H ino&l common in voung w-omeii. They are an

JIL commonly mulciple. They may al^o nccur

in prernsliire fomalu

trophnblastn: disease.

and m women

<:y$t

Lined by ftfanulo^dcdU^ lliis is lliCLinvinionc!,ll>cnign

ovarian tumour and [^ in oat often found incidenulh\

lr results fiom lilt non-rupliirc of ,i domiiwrt foflidt

or the failure of atresia in j non-dominint foOidf. A

fblliculai cy&t can pciiiit lor w tr.'l rncoilnul chides

jntl mjyrfLhJL^LjdiamckTofijplO 10cm- Smaller o;J

-

are more likely to resnlve, but may require intervention

! ' i Benign tumours oflhE ovary

if symptoms develop or if they do nol resolve

W-16 weeks, Occasionally they may I'onlinsic (u pro￾duce oestrogen, causing nienstru.il disturbances and

tndometrial hvperplasia.

common than tollicular cysts, these are more

likely lo present with rntrapcritoneal bleeding. This, is

more lommon on the right side> possibl]. as a result of

increased intraluminal pressure secondary to ovarian

vein .anatomy. They may also rupture. This usually

happens on davs20-2fiof the cycle. Corpora hi tea are

not called luce.il cys.fi iinlesfi they are mote than 3cm

[n diametei.

Benign germ tell tumours

Germ cell tumours aie among the commonest ovarian

(urtiours seen in ^vomen less than 30 yean* of age.

Overall, only 2-3 per cent are malign-mi* bul in

me undcr-twciitic; this proportion may me to a third.

Malign JM I tumours are usually solid, although benign

forms also commonly II.HC a solid element, 'llius the

tradition?] classification into solid 01 cystic germ cell

tumours* signifying malignant or benign respectively,

may be misleading,. -\s the (Hint suggests, (hey urise

tram totipotential gei m cell?,, and may therefore contain

dementi of all three gcim laycis (onbryoirk ditferent￾iaiion). Differentiation iiilo

ies.ults.[n ovariancboriocarciiionij

tumour. When neither embiyonic nor extra embryonic

differentiation occurs^ n tlf^gemiinoma itsLilti.

Dermold cyst (mmurt; cystic ceratnma)

The benign dennoidcv^t [& (he only benign geim cell

tumour lh;il ib common, ll re&ulti from difit:renti￾atinn into embryonic tissues II account forsround

40 per cent of all ovarian neoplasms and is most

eommon in young women. The median age of pw￾nelttation is 30years (Comerci«aL, 1994), II is bilateral

in about 11 per cent df cases. However, if the connralat￾cral ovary is macroscopically normal, the chance of a

concealed second dermoid is very low (1-2 percent),

piiiticularly [t preoperative ultiasound is normal,

A dermuiil is usually a miilocular cyst less Chan

13cm in diameter, in which eclodrnnd] structures are

predominant. Thuii it is often lined with epithelium

tiki: the epidermis and contains skin appendages..

teeth, sebaceous material, hair and nervous tissue.

Liido'lerm^l derivatives include thyroid* bronchus

and mEesline, and the nic^odcrni niavbe represented

by bdne, cartilage and smooth muscle.

Chciisionall;1

onlv a single tissue- may be present*

in which case the term moiiodennal teratoma is

used. The classic examples are carcinoid and struma

ovarii, which contains honnonally active ihyroid

tissue. Primary Cdrcinoid lumo u rs, of the ovary rarely

metastasire, hut 30 per cent may give rise to typical

earcinoid symptoms -'Saundcrs et al., i960!. Thyroid

tissue is found in 3-20 per ie.nl of cystic ler.itonias.

Tlie term 'struma ovarii' should be leserved for

tumours, composed predominant!; of thyroid tissue

anil as such comprise only 1.4 percent of •.vslk lerrflo￾mafi. Only 5-6 per cent of struma ovarii produce

sufficient thyroid hormone to cause bypertbyioidi&m.

Some 5-10 per cuit ol struma uvarii develop in(o

cardnoma.

'Hie majority (611 per centi of dermoid o'ats arc

asymptomatic. However 3.5-10 pei cent mayunderV

(oi^sion. Less commonly {1—4 per cent), thev m^y rup￾ture ipontaneousiy, either suddenly, causing an acute

abdomen and a chemical peritonitis, or slowly, caus￾ing chrome t^ranulomatous peritonitis. >Vs the latter

may also jrisu following inlraoperative spillage, great

care should he taken to avoid this event, and thor￾ough peritoneal Livagc must be performed if it dots

occur, During, pregiidiiev. rupture is more common

due to external pressure from the expanding gravid

uterus 01 to trauma during delivery.

About 2 per cent are said to contain a malignant

component, usually J squamous- carcinoma in women

ovei 41) yeais. old. Poor prognosis is indicated bj

non-squamoiis histologv and capaular rupture.;

Amongst women ^ged under ZOywrs, up to Mil per

of ovarian malignancies, a re due In germ cell luinm

(see Chapter 13).

Mature <olid terarawia

These rare lumours lontain mature tissues iuit 111

the dermoid cvsr> but there ^ire fe\v cy&iic Jte^s. Th*

must be differentiated trom immature teratoi

which are malignant (see Chapter 13}.

Benign epithelial lumours

'Che majorily of ovarian neopla^ia, both benign ai

malignant, arise from the ovarian surface epitheln

The) in? therefore e&

dcnvijig horn the D

the embronic

result in development

cvjtadenijmata:, endor

serous) pathways Or

respectively. Mthough 1

to occur ataslightlyyo

i, the jrci

Serous fystndeiwma

This is the most comn

and is bifateraf in abo

a uniloculj r cyst with |

•mer surface and occa

Tilt epithelium on the

inllimnarrtnd maybcci

toncentric calcified bo*

n these evsts, J>u( more

ccxinterprtrtj. Hie cyst I

« seldom as huge is m

utnatu i'

:se constitute 15-?

und are the sec

Th^i1

are tyjiica.

wirh a smooth

Hammersmith Hospital,

bf lining epithelium c

cells. The cysl

rare loin plica lion L

Ikn following intraoperj

•tntonei is commonly

••Hours, of the apptndi

eoviiiyanil appendix ai

^differentiated careim

VnhcimetaLl4<J4).T

rfiieh continue lo secrr

gether and consequent

ne S-^-ear survival rule L

thy 10 years js few as

! loid tysfadet

emgn endoinetriuid cys

ovarian