Benign tumours of the ovary ppsx

Benign germ tell tumours Germ cell tumours aie among the commonest ovarian urtiours seen in ^vomen less than 30 yean* of age.. Malign J M I tumours are usually solid, although benign for

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

Presentation 122 Treatment Differential diaanosiB 123

124 125 127

t^c (chocolate) cysts of the

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 atpc^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 fomalutrophnblastn: disease

and m women

<:y$t

Lined by ftfanulo^dcdU^ lliis is lliCLinvinionc!,ll>cnignovarian 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 Afblliculai cy&t can pciiiit lor w tr.'l rncoilnul chidesjntl 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 J M 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

t u m o u r 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* bronchusand 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 isused The classic examples are carcinoid and strumaovarii, which contains honnonally active ihyroidtissue Primary Cdrcinoid lumo u rs, of the ovary rarelymetastasire, hut 30 per cent may give rise to typicalearcinoid symptoms -'Saundcrs et al., i960! Thyroidtissue is found in 3-20 per ie.nl of cystic ler.itonias

Tlie term 'struma ovarii' should be leserved fortumours, composed predominant!; of thyroid tissueanil as such comprise only 1.4 percent of •.vslk lerrflo-mafi Only 5-6 per cent of struma ovarii producesufficient thyroid hormone to cause bypertbyioidi&m

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

'Hie majority (611 per centi of dermoid o'ats arcasymptomatic 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 acuteabdomen and a chemical peritonitis, or slowly, caus-ing chrome t^ranulomatous peritonitis >Vs the lattermay also jrisu following inlraoperative spillage, greatcare should he taken to avoid this event, and thor-ough peritoneal Livagc must be performed if it dotsoccur, During, pregiidiiev rupture is more commondue to external pressure from the expanding graviduterus 01 to trauma during delivery

About 2 per cent are said to contain a malignantcomponent, usually J squamous- carcinoma in womenovei 41) yeais old Poor prognosis is indicated bjnon-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 111the dermoid cvsr> but there ^ire fe\v cy&iic Jte^s Th*

must be differentiated trom immature teratoiwhich are malignant (see Chapter 13}

Benign epithelial lumours

'Che majorily of ovarian neopla^ia, both benign aimalignant, arise from the ovarian surface epitheln

The) in? therefore e&dcnvijig horn the Dthe embronic

result in developmentcvjtadenijmata:, endor

a uniloculj r cyst with |

•mer surface and occaTilt epithelium on theinllimnarrtnd maybccitoncentric calcified bo*

n these evsts, J>u( moreccxinterprtrtj Hie cyst I

bf lining epithelium ccells The cyslrare loin plica lion L

Ikn following intraoperj

•tntonei is commonly

••Hours, of the apptndieoviiiyanil appendix ai

^differentiated careimVnhcimetaLl4<J4).Trfiieh continue lo secrrgether and consequent

ne S-^-ear survival rule Lthy 10 years js few as

! loid tysfadet

emgn endoinetriuid cysovarian

lir and nervous tissue.

pde thyroid, bronchus

mn may he lepiebeiited

• rksue may be pieseni,

ooodcrmal teratoma is

IT carcinoid and struma

nonally - active thyioid

•ours of the ovary rarely

nm fcive rise to lypical

mci al., 19601 Thyroid

cent ot cysiic teratomas

should be reserved for

manlK' ot thvi\>id tissue

I per cent of cystic

teralo-f teralo-flmma ovarii produce

o ca u HC hypei thy™ i idism.

uma ovaiii develop inio

nil of dermoid <_ysts arc

-10 per Lent nav undeigo

IpercentJ.iheymayrup-, causing an acute

I, Ol blOWly,

C3US- peritonitisC3US- A« the Li Her

Inoperative spillage, great

oid (his event, and

thor-fl be performed if it due*

•uptuie is more common

am the expanding gravLd

•faery

d to contain a nialignani

carcinoma in v*onieB

is indicted t"

and cap^uldr lupdire

T 20 year>> up tn ^D per cer*

•due lli germ cell Hi in nun

in iiulurc tuples iLibt li^a

• are few cystic are,i5- Thq

in develcipment along eiirfnoervi^jl (muanuiii), cndometrral (endnmetrinid) or tululpathways or uriiepfJhtlial 'Prcnnerl linesrespectively Although beniftii eplllielidl dimouri, tend

to occur jl a blighdy younger age than t h e i r ntnligiianlcounterparts, [bey are musl common in women over

10 ears

t cystadenomg

Thi*, is (he must common benign epithelial lumour

and is bilateral in about 10 per cent Ii is usually

a uniloculjr cyst wi[ll papillilbroui processes on iheinner surface and occasionally on the ouler surface

The epithelium on Ihe inner smface is cuhnidil i>rcolumnar and may be cilidletl Psammoma bodies are

•Dcenlric calcified bodies which occur utca&ionallv

in ihesc iy>li, but moie frequently in their ni^li^nant

counterparts, T h e c y & i fluid h thrn and serous I'hey tn- seldom as large as mucinotis Uimouis

unous

e^f: ixmstitule 15-25 per cent of all ovarianrnnurs j u d dre the ii<:cund most common epithelialmour Tliey are typkillv Urge, unilateral, multiloc

r cy^li wild a smooth inner surface ^ specimen al

innne rsmilh ilobpii^l, London, weighed over ]4 \fg'.

ic lining e p i t h e l i u m coclbiitb of columnai cells The cyst fluid ii generally thick and

mucus-A rare complication is pM'iidomysoma pentonei,htthib more often presenr before (he iv^i ib R-moved

«n Follow ing intiaoperatiye rupture, fseiidurnyxomjntonei is commonly associated ivith inucinnusmouvs of the appendix Svnchronous tumours of(ovary and appendix are common, nie&en re usuallyril-differenlidled larcinomas or borderline tumoursfttrthenuet j[., 1994) I'beyre&ull in ittxilmg groivtli^

4ich continue to secrele mucin Causing mattingpellnjr and consequent nbslruction of bowel loops

W 5-year s u r y f r d l r a f e i b Approximately 5(1 pei cent,

n by lOyeaisasfewas I f i percent are alive.

Brenner

The«e account for only 1-2 per cent of all oranan

tumours, and are bilateral in 10-15 per cent ufcabcs

The>r probably arise trorn Wolffian metaplasia of theSurface epilhelium The lumour consists of islands of

transitional epithelium (Wallhard nests] in a densefibrotic stroma, giving a largely sol id appearance Thevast maiority are bcnign, but borderline or malignantspecimens have been reported Almost three-quartersoccur in women over the age of 40dild aboul half areincidenlal findings, being recognised only by ihepathologist All hough some can be large, the majorityaie less than 2crn in diameter Some secret uestro-gens, and abnormal vaginal bleedinp is a commonpcesenliiikm

Clear cell (mesonephroid)

Those aiibcrromserosal cells showing little alioti, and are onlv rarely benign The typical histn-lopical appearance is of clear or 'hobnail' cells arranged

differenti-in mixed patterns

Benign sex cord sirornal tumours

Sex cord stromal tuinnur', represenl only 4 per cent

ol benign o.'anan tumours They occur at an,1 aye,from I'repuberUl fblldren toelderly>postmenopausa]vi'omen Many secrete hnrmones a n d |ire-bent 'vith theresults ot inappropriate norirmne effects

Granulosti ceil tumours

These are all mahgnant tumours but are mentionedhere because they are generally confined to the ovarywhen they present and so have a good prognosis.However, ihey do grow very slowfy and recurrencesare oflen si'en 10-20 ye;us latei They are largely solid

in nuifit cases- Call-Liner bodies aiepathognomonic

but are seen in less than half of granules*! cell tumours

Some produce oe^trogens and most appear to secrete

!•"• Benign lumoursol the ovary

Pibtoma

These u n u s u a l tumours, are tiii>sl frcqatnl around

50 years of age Most are derived frnm stromal eel Is

and are similar to thecomas The)1 are bird, mobile

and lobule Led -*ith H gliiU-nmg while burfacc Less

lhan 10 per cent aie bil.iler.il While as^ites occurs

manyol ihe largci fibromas, Meigs syndrome

-and pleura! effusion in association mth a

fibroma of tlie ovary - is seen in only I per oenl of

Z3SCS.

Presenlation

^

cdl tumours

These are usually of low-grade- malignancy Most are

found around H) vents of age They are rare,

com-prising Icib than 0.2 per cent ol ovarian tumours

They are often difficult to diblinguibh from oilier

avarian tumours because nf the variety of cells ami

sirtnilccturc seen Many produce androgens, and

signs of virih^tion art jeen in three -quarleis of

paiieutfi Some secrete estrogens, I'Liey JTO usually

small and umlaleral

Ape distribution of ovarian tumours

In younger women, the moit common benipi ovar

lan neoplafiin is the germ cell tumour, artiongil older

women, itiitlie epithelial eel I tumour (Fig, 1 LI), The

[lerccnirfgc- of ovarian ni'oplaima rhal arc benign also

changes with the age of the woman [Fig 11.2 J

The presentation of benign ovarian tumours Is 35 follows

Mady benign ovarian lumaurs are found inditcnlally

in fhe course of investigating another unrelated lem or d u r i n g a routine examination while perform-

prob-ing 3 cervical imeai or at an antenalal clinic As pelvic

ultrasound, and particularly Iramva^inal iidnning,

is now used more frequently, physiological cystsdetected more alien, \\lieie ultrasound was used inLriala of JirLcnin^ for ovarian cancer, the maioritynimoursdetecred were benign, Aboul SO j>cr cejilnfsimple o'sts less than 6cm in diameler w i l l lesolve

sponlancuuily rf ob&erved over a period of t>

monlhs-A furiher 25 per cent regre-ss in the following 2

Use of an oral contraceptive pill does not encouragethe resolution of physiological cysts

90-

Pain

r>.iiTi ym an cr

i, rupture, hacius-u.ill; gives rise to b)r iscliaertua ol rhe cyHaemorrhage into ihpp&ulcLs '.tretchedr Jning ectnpK pregnancylumour I h i i happen*(ysT Chronic lowerresults from Jhe pressubulls irinn-wrnmon ipresent

Abdominal swell -i

Parienli beldom note

Tumour n iiy large

ocw&iouallv JT11 (he enti

Big of which women c

loan ov.irinn lumour

Miscellaneous

Gastrointestinal or uifrom pressure effects, Ii

e veins 31

times uterine piv

ui awonianwilh

ly paiient

• bill ihis nia

UC lo the tuinuur Rar

!nl with oCilroeci', menorrhagia

>t enfar^emenr 01LLion of and rumensill), prugressiiiji lo

or ihe voice 01 difo:d, thyrniu^icosis n

of thvroid hormoo

!\}\ a patient with

found to have anwhidi ia lolfowed bvi'L Surprfsin;

Differential diagnosis ;

Pain

is as follows

arc found incidentally

another unrelated

prob-mnation vbile

perform-intenaial dime :\fi pelvic

f trail waginal rearming,

y, pbysiolojital cysls are

' ultrasound v,a\> used in

• canter, the majority of

pir Abcmt 50 per c^nl of

in diameter will resolve

vera period of 6 months,

sin tbe following 2 years,

c pill docs not entourage

bg ectopic pregnancy may result from rupture nftbe tumour This, happens most frequently with a luteal cysl Chronic lo^cr abdominal pain bomciimt-i result from the pressure of a benign ovarian tumour, but is more common if endomeli losis or [nfecliou is prtscnl.

or urinary symptoms may

mi pressure efi^ts In iinreme cases, osdema of the t£s, varicose veins and liaemorrhoid^ may result- Sornetimea uterine prolapse u the presenting com-

^4in[ in j ^'onirfn wilh an o'anan cyst.

Occasionally patienu coni]>Uin of menstrual

dis-L _rbance^, but this, may be coincidence rather than d-JL lo lh>: lumuur Rarely, so.corJ blrom^l lumourb

prebccu wilh oestro^cn elfctU i,uch <\* pretotious

ubertv; metmrrbagii and glJikdular hyper pi as ia,

rast cnlargemenl or poitmcnopau&al bleeding, fcictionofjndrogcns may cause hksutism and dene

•lilially, progressing to frank virili&m with

deepen-of the voice or clitoial hypertrophy Very rarely

:fd, thyrotoncosia may rc&dt from cctopic

&ccr:->n of Ihyroid hormone.

Rarely, a patient with an abuoimal cervical smear

I be found lo havt an ovarian lumour, (ht removal which is followed by resolution of [he cyfological litA- Surprisingly, these are nften benign

Tht diffcrenlial di^nosis of benign ovarian tumours

is broads reflecting the vide range ol presenting symptoms.

1 Differential diagnosis of benign ovarian lum ours

Pain

Sponlarieou 5 abortionAppend icitis Meckel's

Abdominal swelling Pregnanl uterus Fibroid iiTe-us

I n 1 1 1, d er Distended sov-el Ovarian Coloreclal

PraEEura Eflecls Urinarj1 Iract Conslipalion

iliedifferen-Fibroidi can be irnpijs&ibh 1 to tUilin^uijll from ovarian

lunionrs Rarely, a Umbrijl cv*!t nijy gi\nv sufficicndy

tn cause anxiety.

Ectopic prcgnaimj ma.' pristnl d^ i pelvic mass and lower abdominal pain, ^peddlly if there has been chronic imraperilnneal bleeding Oricn a ruptured, bleeding corpus lute urn i* ill bt: nmlaken IbranecUppic gustation, ll m^\ be difficult to differentiate between appendicitisund an ovarun CVSL Cooperaiic»n bctvMTfn gj-naecologisi jnd ^uigctm is tiscnial lo avoid unneces- sary iLirgt.iv on simple ovarian cysts in younj- women

24 Benign lu incurs of I he ouaty

and the effetlithiimav have upon subsequent fertility.

Pelvic ijjllaniflifltolydiwas* may give fise lo a nus-s ot

adherent bowd, a hydros !]pin* or pjoialpin.v

IT the tumom is ovarian, maligning 1 musl be

excluded In the v^sl majority of cases this can only be

done b} 1 a laparotomy h\en iben, careful histological

examination inaj be necessary Ho exclude invjiion.

Fvo/en sectiojl will only rarely be of value \ pelvic

mass may also be caused by H ret,lal Humour 01

diver-liculilii llodgkm's disease in ay present jj -A pelvic

afenlargw pclvjclyinph node*,.

Investigation

The invest i^ilioni required w[l I depend upon

ihetir-cumstances of ibe prr&entation Patients presentiDg

widi acute symptoms will usually require emcigency

surgery, nhenJdi a&j mptomatic patients or v,omen

with chronic problem^ rrw.y benefit from move detailed

preliminary as-ses^inent.

Gynaecological history

of Ibe presenting symptoms and ,1 full

gynae-cological his lory should be obtained with particular

reference to the dj[e of Ihc l;iii menilrual period, the

regularity of the menitiual cycle, any previous

prcg-nancie*,, con[r.iccplion, medication and family

his-toiy fpariiculjrlyofiivrfrirfn, breaa or bowel cancer)

General history and examination

tric cancer meiasLa&iiingto the peJvis Similarly, a

bia-tory of altered bowul habil 01 itclal bJeeding would

iiiggtit diverticulitLs or ret(Hl ^drcfnoma Howerei,

ovarian laruntfrna ma}r al.so present with these frdliircs.

If the palieiil has presented a& an acute emergency;

look for evidence ol hypovoUerniii I lyptmniion 15 a

relatively InLtiign of blood lt>s.s, as the blond prtiMirc

will be maintujisd for some tune by peripheral

arlcnolarand cenrr.il vtiiiuiLi 'fljoconitriction When

decompensdUi>n occurs, H often does >,o v e r y rapidly,

It is vHal lo recogni/i.' ibe carlv ^[3113 tacbycardid

and cold peripheries.

The bTCJ$(i should be palpated ind ihe neck,

axillae and groim tx.imined lor lymphadenopalhy.

A malignant oyarian tumour may caufle a pleural effusion This ii much less commonly found with a benign tumour Soil]<jp;iLii:n(b rrwA'ha'eankJc- oedema.

Very occasionally, foot drop nw\ br noted at a reiiilt ol\umprii&ion ol pelvic nerve roots TTiis would not

occur with A benign liimour, but suggests a

malig-nanq-with lymphatic involvement,

Abdominal examinalion

The abdomen should he inspected for signs, of

disten-sion by fluid or by the tumom itself Dfljted veins may he seen ml ihe lover abdominal wall Gentle pal- pation will reveal areas of lendcTiicwf, ,md pcritoniiin may be elicited by asking the patient to cough or sudt

in dud bluw out her abdominal ivall Male hair di.slrf bution niays-u^esrarare^iLtrogcn-prod^ininglumoiir The best way of detecting a nus^s that arises, from ihe pelvii jj ti> palpatt gently with the radial bolder

of the left hand, starting in the upper abdomen and woiking caudilly This is [he reverse of Ihe protcw (fluent Lo OUT)' medical sludent for feeling the liver

edge Using only the right hand, is the commonest

reason for tailing rn detetl peM-a bduminal maiucs.

Shifting dullness is probably me e^sies^t way of demonstrating abcittb, but it remains a very inaensi' tive technique- It is aiwa}'5 worth listening for bowel bounds in any patient with an acute ahdnmcTi Ilieir complete abicntc in the presence ol peritonism is ominous sign.

Bimannai examination

This, is an esi-^ntial component ol the assessment because, even in evperi hsinili, ullr^&ound examin- ation is not infallible By palpating the m-iss between bold ihe I'rfginaf and abdominal hands, its mobility texture and co nsisl em y, the presence of nodules in the pouch ol Douglas and the degree of lend OTKM can

he determined (Fig lL3j \Miile it is ini|>o&s.ibfc

to make a firm didgnoiis iMihbimanual examination

a hai-d, irreguljii, fixed m.jss is likely tu be

Ultrasound

diological invest

transvaginal ultrasound demon strate |he presence of an ovarian mass reasonable sen%itivity,md fair spivifial' and>altn<

Ma nay erne nl 125

oncnl of Ihe assessment

Luds ultrasound

eAiimin-Jpating the niabs between

minal handb, L L J mobility

proence of nodules in ihc

kgree of tenderness can all

Figure 11 3 Bimanual examination involves palpating ths

pelvis organs between both hands.

il can !i tn ilisiinguish rclubK between benign dndrnalignanl tumouis solid ovarian masses are morelikíly lu be malignant than their cystic counterpart

The use i>f colour- flow ttiippler nwy increase the ability of uHr^ininil Neither Lom^uicrícd tom-ographic scanning nor magnetic resonance imaging

reli-lias iip.niliịdnl advantages om ullrnsound in Ihiisituation, and borli are innre expensivẹ

Ultrasound-guided diagnostic ovarian :yst aspiration

This invrestigat[on has been introduced giadually into

piactice from the subspecially of

ivproduilkm, VH\KK ullriib^o mid-guided cg^

tr.lleciion is now cnniinojipl^cer This hd5 happenedwithout the benefit of appiopriace dial^to indicate itspulcnlial cfficaci1

Unforr.iinicely, thisfechniqueh^s tiptoả! percent

•he-negative rate and ? 1 per tent false-positive late

forme cytalagical diagno-jis of malignancy !Diemiitnị

tt j]., 19&7J Thcrt ib 4 rib-k of dLbJumindlin^

mali^-nanl cells along the needle track or in to ihe peritoneal

cavity, bal the size of thai risk is noE established The

kysl often fills d^din with fluid,Overall, ullrasound-guided js.pir,ition nf ovarian

tysts cannot he recommended as a diagnostic toolRadiological investigations

AchtatX-rnv ib ci&^nlut to detecl L&oQflatic disease in

ibe lungs or -• [>leur^l effuiiiin ihjii mnv be loo small

to detecl clinicallỵ Occaiioiiiillv an iiniai show (.alcitkalion, &u^^c^(ing ihe possibilil! of

a benign teratomạ An intravenous uvogram ịs oftenperformed but is seldom useful A barium enema isindicated only it' the- miisi ii irregular or liAcd, or ifthere arc buwel byiiiploms A ^ o m p u t e r i r e d toniog-rafihy scan ịs seldom indicated

Blond test and serum markers

It is always sensible to mcabiire lh<: hmmóglobin, -uld

an domed while cell count would surest infection.Pktelel count and clotting screen maybe uselul intlic

rare case ola large ultra -abdominal blevtl Blood mfty

be cro S3- matched if ncn&barỵ

iei-um miirkeri have venoếablish a rnle in the tine management of moil ovarian tumours HOWOLT,

rou-a rrou-aised scrum CA 12!> is strongly suggtstive ul nvrou-ar-iiin L;irtineim^, cipecịilK in postmenopausal women.Women with extensive endnmetnosịs may al.sn

nvar-elevated levels, but the concentration h iibu-jllynol

gonadotrophin (p-hCCi) concentrationmight be nicaMirtd to exdiule an L'ctopie pr<:gniincv,but taophoblabtic tumour:, anil bonnjgernne-11 tumoursbctrttt thii [jwrker Oêtradiol levels maybe el^ated insome women with physiological folhcular cysts and &c.\coid&tiomal tumours Andiogen conccntrationb nu>

bi: increased bv!>ertolil eyd ig tumours KaLsed alpha feloprotein levels siiflgẹjt a yolk sac tumour

The ttliier woman

Women ovci 50 years of agt arc far rnurclikeiv t'1 have

a nijligmncy and have linfle to gam from the vative management ot a pelvic maw more ihan 5<;m

conser-in diameter (Rulm & Pits[onh 19R7) Mhỵsiological

cys(s are, \w definition, unlikely However, the

cap-acity ot the postmtnopausal ovary to gcneiiiLc: benigncysts is greater thiin pruvjuusly Ihoughl, occurring id

2ri Benign in incurs ol Ihe ovary

may biL u&enil to confirm Lhrtl (hi1 iound legion isiivrfrirfn, but the open approach is slill

ultr^-tobc-rcmoved

Aye (years}

Figure 11 4 TN incidence of ovarian cancer In Enyland and

Wiles fOfficeof Populallon Censuses and 1 Surveys 19S5) Note

how uncommon ovarian cancer is befirp Ihe age of 35 years

up lo 17 pci ceni of asymptomatic women ', Irvine

et al., 1992;., Mure than 5(1 per ^nl oi smalL simple

cysts will resi.iK'e:>pontanenuslv hut almost 30 per cent

is ill remain static ^Levme et aL, 1992) hVen in this

age £riiu[>, ojilv 2y-!>0 per cent of ,.11 ovarian cysts will

be mdignanl (Fig 11.4)

Therefore, efforts haw bean made to defino-erilciia

that would enable unnecessary Mir.gi.Ti- in he avoided in

this older age group Evaluation of Int cyst with tumour

markeis^ ultrasound and colour flowDopplet studies,

and ^-aieful follow-up ^u^^at that simple, uniUlcr^l

^rst3 leqs th,if) 6 t m i n diameter williCA 125 leas than

35rjiU'mT, and norm^d •ajcular resi stance piiLEiTns aie

likely to bebsnigD and nidv safely be uuiuged c

vatively |Go3d3(ein, l99,=Jj Haikyctal., I W S j I n

cases, if t\n-^- h no change in the tybt at the second

uflr.i&ound at i months, follow-up with fi-nionthly

ultrasound iind CA 1ZS eslinidlion is sate Most will

resolve in 1 v^-ns, but some dn |>ersiM fur up to 7 years

The lole of laparos^opic Mirgevy in |Jic si&sc«ment

arid Irc^tmeiU of ^|lpar^Jntly benign cysts in ihis age

group is conlruvcraial (Fnwler & Curler, 1995; Parker,

1995^ UHiilfll iht imalJ q^sts described abo\c may be

niJMjgod witliuut surgery, (here may be a small minor

role for lht kparo&copic ,iss:c^ms:nt and treatment of

larger (perhaps up to U>cm) hut olhcrvvi&c apparently

benign cysts Nonetheless, this should only bi' in the

hands of Ihojie who are Ixnh Uparoscopically

experi-enced and prepared to perform definil ivc siirg^ci' tor ail

nmpecled ovarian carcinoma under me

sjrni'jmacs-efk Com pick- and mtacr rcnujval of the cvst should

adbcvrd For ihc more general gynaecologist

Prensftsi>j>ui/s{>! women

Young i.-onien aged Icsi than 3^ years are both innrelikuly to wish to haw [he oplion of furthei childrenand less likdv tu hitve a mall^njint epithelial lumour

Howe\rer ovarian tvjis moic (han U J c n i in dfaineler

AIC unlikely to lie physiological or to resolve

spon-tanwiisK A noimalfofliculnir c;^l up lo 3 cm in eter requires nu fiirlhiT investigation AclearunilocidarCyst of 3^ 10 cm i d e n t i f i e d by ultiiiiound should here-c\amiin'd 12 ^>eeks later for evident c of diminution

diam-in si7£ I fthf 171! persists, such women nmyliefolloivLd

with ivmoiulily ullr^sound and CA 1Z5 estin],i|iiirii,i$

diiiribcd above Tlie use of a combined oral ceptive is unlikely to accelerate tlie resolution of 9functional cyst (l>(einLimpli Hammond, 19yi|;> jrulhormonal treatment ofundumrtriosis does not usu-ally bi'ndil an endonietrioinA, If die LVbtdota en laige,laparoscopy Or lap jrutomy may he i

contra-Crileria for observation of an asymptomatic ovarian tumour

The patient with symptoms

if (fit pjhcnt presents willi si^crc, acute pain or signs

of hiitvaperilluieal bleeding, an emergent]1 kipaioicopy

or laparotomy will be rcquinxi More t h r n n i c toms of p,iin or pressure may pus.lhy pcd.'ic ultrasound

iymp-it no mas?, C^ii be felt, butultrasouni] \$ unlikely to

con-tribute to the invest igation of a woman in whom bothcan be clearly fell lo be of 3 nomial sire

The piegftarss patient

An Ovarian cyst in a pnjgiwnl woman may undergo

toision or m,n bleed There LS said \<? bu sin increased

incidence of these complications ill pri-gnancy;

the female fetus

Fnal ovarian j

12 irecks', andoe.stradic

Thus small

occasion-on ultrasound, and Occasioccasion-onally at Caesarean sectioccasion-on.

Thepregnanl woman with an ovarian cvst is a cial Usi1 because ot the dangers to the fetus of surgery,These have probably been eiaggcialed in the past,and no urgent operation should IK postponed solelybecause of a pregnancỵ Thus, if the paiierH preicmswill] acule pain due to torsion 01 haemorrhage into

spe-an ovarispe-an tumour or if appendicitis is j possibility, thecorrect course is to undertake a faparotoiny regardless

of ibes la ge of the pregnancỵ The likelihood of labourensuing i« small, llôuver, the operation should becovered by tocolytic drills and performed in a centrewith intensive neonatal care when possible

Tf an asymptomatic cyst is discovered, it is prudent

to wait uniil after 14 weeks* yeslaiion before ing it This avoids the risk of removing a corpus hiRalCÝI upon which the pregnancy might s l i l l be depend-ent Tn the second a n d lliird trimester, the manage-ment of an asymptomatic ovarian cysl rnay be eilherCnnsen'aiiie 01 suigical The risks to the mother andfetus of in elective procedure need to be balanced

remov-•gainst the chances of a cyst dttident, an unexpectedmalignancy or spontaneous resolution Cyslsle&s thjn1C cm in diameter that have a simple appearance onultrasound are unlikely in be malignant or to result in

cyst accident, and may therefore be followed ôraphically; many will resolve spontaneously(Thomion & Wtlls> L987.J If the cyst is umesolved

ultra-4 weeks postpartum, surgery m,iy be undertakenitcn The role for cyst aspiration in pregnancy, eillifrIfc^nnstkall]1 or Iherapeulically, is small

Ovarian cancer is ujicommun in pregnancj,

occur-•Mig in less than 3 per cent of c>-gtsr However, a cyst

h features suggestive otmaligiianq'oii ullrasound,one thai is growing, should be removed surgically,tumour marker CA 1Z5 is not useful in the preg-

I «vman> since elevated lếels occur frequently asapparently phyiiologkal changẹ Management maywed to include a Caessirean hysterectomy, bilateralgo-oophorectoinyand oinentectoniị

ovarian andropen synthesis commences jtwicks', andoestradiol andprogesierorieai 20 weeks',Llion Thus iimall tolhculai cysts up lo 7 mm in

diameter may oicunn up to a third ol'newborn girlsHowever, larger cvsls ire rare and> usujllv,findings Most are follicular cysis* althoughcibts, q^tic teratomata and panulôa cell lumoursalso oocur, 'iTiey rruy undergo torsion or haemor-rhage, and occasionally necrosis of the pedicle mayresult in the 'disappearancé of the ovarỵ Rarely, small-bowel lompression may cause polyhvdiamnios, butdiaphragmatic s p l i n t i n g and consequenl pulmonaryhypoplasia does not seem lo occur Most rẹsolvespon-laneously, either antcnataily or, more commonly, post-naiallỵ Consideration may need lo be given to theanlenatal aspiration of a vei y large cyst if il is fell lhat

it may obstruct laboui or be ruptured dui ing vagina]delivery, dlthoug.il Ihis is reported rarck Therefore,

delivery by Caesarean section is not indicalcd, Cysls

thai have not lesolved by 6 months of age should beexplored surgicallỵ

The pieptibertal girl

Ovarian cysts are uncommon and often benign'IcnHOrtUlsi ,md follicular cysts are the most common.Theca and granulnsa cell tumours may secrete hor-mone* Priientrftion mair be with abdominal pain ordislension or precocious puberlv, LIUILI isosexiuil orheterosexual Management depends upon ihe relief

ot symptoms, exclusion of malignancy and vation of maximum ovarian tissue without leopaidiz-ing fertilitỵ

conser-Treat rneril

K H U H ni is mostly surgical, allhough there may he

•i few women in ivhom cyst aspiration is indicated

Therapeutic ultrasound-guided cyst aspiration

The theoretical advantages ol this technique are thatjurgeri1 is avoided and c^bt accidents arc reduced.However, ii assumes thai the cyst fluid, is unable lore-accumulate, and thai bolli physiological (lifcely toicsolve spontaneously) and malignant cysts can bereliably excluded beforehand, Cytological JiStismenl

of the aspiraled fluid is performed routinely but not be relied upon !o exclude malignancy lseeabo\re|LThe rok of this iedinigue ihercforc remains con-troversial The hesi candidate is a voting woman

can-i Bencan-ign tumours al (lcan-ie ovary

a unilateral, unNWilrir., anechom, thin-walled

k&b than 10cm in dijrnetcr The recurrence rate is

27 per rani if the lluid is clear ami Is3 per cent il'it is

bloodstained (De Ciespigny et al , 1989) A tumour

ma young wo nun lhal appears to be largely solid on

ultrasound is likely to he 3 germ rail tumour and

requires removal An acutely painful ovary may be

due to torsion, ami burgm is essential

There may be a small pljce for cyit aspiration in

women in whom surgery is conflidfrtd lo be high

risk, either beta UK of coexisting medical prnbkm&or

because dense pelvit;]illusions envelop the ovaries

Examination under anaesthesia

Prior lo any lapaioscopy or laparolomy for a

sus-peeled ovarian lumour, il is prudent to perform a

biinamial examination u n d e r aiiat&thcsia Co confirm

the pro^no; of the mass

Lapamscopic procedures

Lapaioscopy may be of value if there is uneertjinlv

about the natiue of ihe pelvic m^jirThuiH may be

pos-sible to a^oiJ a laparoto my when there ib no pathology

However, il can be difficult Co exclude n v a r i j n dibtab^

in ihc presence of marked pelvk inflammatory disease

' I h e second indication for laparoswpy Is it' Ihe

patient hap a cj/SL builable for laparoscopic Surgery

iNfihat el al W&y; 'ihii decision should be tnj.de

afier a full history and careful bimanual examination,

ultrasound ,is!rt&bineni and a thorough

appraisal ol the whole abdominal cavit}-,

ihe contralafpraJ ovary The parieiil should be aware

ol ihe possibility,, and consented for, d laparulomy In

case rnalignjiicy ib found 01 unexpected Lit^rOic

complications are encountered

Indications for laparoscopy

Uncertainty aboul Ihe nature ol the mass

Tumour suitable lor laparnacopLC surgery

- aga 1*55 than 35 years

- ulTrasound sJiun'E nc solid

- simple ovarian cy&f

The advantages are lho>e of inpaiobcopic surgery

in general: less posioperarive pain, shurlcr hospitalslay a n d qukket rcium lo normal activiries Jt mayalso result in Icsi adhcaion formation than an openprocedure, although ihe cvidtnte i& not ccm.mcmg.However, the consequences of spillage ft cy$< i-.m-

tents, incomplrn; t-xciiion of ihe q-st ^all and anunexpected histologicril disgnyib of malignanq areconsiderable disad\ranijjie'i- Up (o 8^ ptr tent ofmalignant ovarian tumours found by chance al alaparoscopic operrilion for a *cyst* are treated inad-equately ^Mainian et al , 1491) [Hirnoid cv^fb areheller removed bylaparolomy because of the seriouscon sequences of ledkdg,*; of the cy-it contents

Laparoscopic surgery is bebl rebv:rved for youngwomen, undei 35 >-ears of age, in whom ihe likdi-hood of macgnaDf disease is small and in wJiom inn-icrvation of ovarian tissue ti more important Theseoperalionb require considerable expertise inscopic numpulalion and should not hewith out ap prupriak-training

Laparotorny

A ilinkal diagnosis may no[ l>e po^bible without aIttpoiotomy and c\cn then liistologiu-il ev.irnin^iion isessential for a conndtntconclusion Fiozen section isseldom of value m thiisitoadon, asa tliorou^h exam-ination of ihe liimour is required to exdude inv.isKedisease

If there is any possibilily ofinvasive disease, a tudinal skin incision should be used loalkm adequateexposure in (he upper abdomen Tf wider exposure Ulequired after m a k i n g ^ Iranb^-erie masion, the ends

longi-of the wound can be extended crjnMly LO fashion aflap from iht1 uppci cdyeof the wound, A wmple-ofascitic fluid or ptrilonoal washings should he sent forcycolopcal examination nil ihe beginning of the oper-ation, ll ij csb^nlial to explore ihe vbnlu abdomen

thoroughly and lo inspect both ovaries.

In a young woman less than 35 ytari oi age, an ian I umourib very unlikely to lie malignant Even iilhcmass is a primary ovarian malignancy, H ifilikuly to be

ovar-a germ eel I tumour thovar-a I is responsive to chemotherovar-apiThus, ovariao cystenomy or ujiilaieral ouphorectoJ

is a sensible and safe treatment tor unila'era] civdriaflma ses in this age yroup -'Bianchi et al., 19fl9) It HIsonittimcs said that the conliiilateral o.'arvshould t-ehisecled and a sample sent for histology in taw; Ihc

tumour ib malignant In practice, niosl are unwilling lo biopsy an appaiently healtbv ovary lest this result*, in infertility Ironi pen-ovarian adbe-

• !• Even when the lesion is bilateral- c\ciy effort

should bi 1 made to conserve ovarian tissue, Ihib icy is made possible by the cllccliveness of modern themutherapy for germ cell tumouri.

pol-Since epithelial cancer is so much mure likely m a woman over/ ihc dgc: of 44 vears with a unilateral ovanan mass, ulie is prubdbK be-st advised to have

rf lotal abdominal liysterectoniy, bilateral

ialpingo-•Bpborectomy and infracolJc nmentectomy ever, there is evidence to suggest that unilateral

How-oophoiectoniy in selected cases of epithelial oma confined to one ovary may give equally guc-d results nb die tciiditional radical approach (Mangiorii

carcin-et al , iyS4,^ ll ^voiild bte-m rciibonable lo ize die treatment of women igeil 35-'H ^'ars where Inert dre greater benefits to the patknt from a conser- vative approach jnd wbtru iht ribk^ niiiy v.-ell be less.

individual-If conservative •iiirgery is planned, preliminary Le/i-yitopy and curcttage ol' the uterus are efisenti^l to exclude J toniomit^nt sndometrial tumour; a thor- ough laparotoinvisespedallvlm^rliiril and an appro- piiateplan of action must he decided in advance ivirh [he imiem should more widespread disease be found.

hys-D simple o.>a nan ^Is often resolve 5pint.inoiiu&ly.

i>.arian D/sU^rev°ry rarely mahgndntbelDre Ihe ipenf ^5.

e&pee.idlly 'iihen IRSS [han 10 cm in diameter

So lid ovarian tumours are often malignant - in young women

* There is only a limited place for aspiration

• Conservative management is apprppnate lor most young

- DbEEr.>ati(in of cyclic lemons ^-10 cm

- unilateral oDphDreDtDnri/flvgnlDrsDlid lesions

Women 0'/Er45 '/pirs cljicf "'ith a cyst greater IhanGcmor-Hitnany O'^'iantLimoiirshoulO usually bs dd'.ised -o have tgt.il abdominal hysterectomy and bilateral

A bl manual examination under naesthesia should In perrormfd prnr In anvsurgen/ lor ovarian Ivmou is lu

F invasive disease, Li

bcuscd lo allow adequate

nen If wider exposure is

isvcise iiiciiion the cuds

led craniillv to fjqhion a

"the mmnd A sample nf

things should he sent for

he beginning ot the oper<

lore the whole ;ihdomcn

mil for unilateral ovaiian

Bianchietal 19&9), Iti*

itralaieral ovaiv should be

I for histology in case ihe

UelanO FR Land GLel al.The malignant

11 women over 50 years cf age

3-J.

ftanohi UA, Fa'/alli G Sarlaii E p t a l Limited surpe'V in epit-ipli.il ovarian caiioer In: Conte PF Ragni N HDS&D P

non-Vermorken JB leds'i MvlUmotJailtfSitfrWttof ottttan uancer

New York: Raven P'e&& 1969.119-26 Comerci JT, Licciardi F, Bergh PA Gregon t Green JL

Mdlure tj'stic tEratoma ?, cllnlcopflUiulDglcal evaluation ol

517^ase&sna review Dtthp iteriiture QtnttHtynKQllQM',

W' 22-5.

DeCreEpigny LQ Fttbmgon HP, Davo'en RA Fortune D The 'simple 1 ovarian tyi.1 aspi.-atearnnj'rate^^^^&slff' Gyn3P!7!i/19e9; 96'1035-9.

OiernaesE R^mu&^enJ Soer&en T Ha^he E |)va nan cysts

management j; puncture^ Lg"cen 9&7.I: lOSd.

Fowler JM Carter JR Ld^rascnpiD rnaragemen- n- thf mgss m poslmpiopausal '"omen Jfivnec^ ^c/i 1^95 1:7-10 Goldstein $H Conservative management ol small

l r^-stic masses Gt

Kaon ngs PP (iampbpll K Mishe'l DR, Grlrrias DA.

ol primary u.'anan neoplasms a 1 D your

I3Q Benign tumours of IhE ovary

Vermrjrken JB (eds), MalSimoaai keatment o! ovarian cancer

New York: Raven Press 1989,127-32.

NezhatC, WmejWK NezhalF Uparnscnpic removal of

dermoid cysts Ob&tel GyneeanSHB 73 Z7a-31

Office of Population Censuses and Surveys Cancel statistics

ivgistraliQfi 130V London HM&O, 1955.

ParkprWH Laparoscoplc nidrugemenr of Iheadne^l mis^, in

postmen npaugal worn en, JGyrwcoTac/j 1995.1 3-6

Rulln MC Prestun AL Adnp'gl masses in postmenopausal

women Obsiei Gytiecul 1937 7D 579-81

&aund°rsflM,hertmanVO Malignant curcinoid teraloma of

the ovary Csn MEI!Assw: J I9601 33: 602-6.

SBmkampfMP HammnndKR Hormonal freafmflnl of fuirtional ovarian ov&ts: a rsndur- ned prospective s^dy

ftirtil Stenn 39D, M 775-7.

ThoriiluiiJG.vVell^M fj.^i^n^ysts in pregnancy does ultrasound make "aditlonal nidridgerritinl ir.dppropnafE^

Qbsiet Gynecon 957; 69- 717-20.

Werlheim I Fleischhacker D McUchhnfiM RIM LW.

Berkowitz RS, Goff BA PseudomyxomaperifDnEi:3 reviev 1

4 17-21

Additional reading

familial ovarian cancer ivlth iransvagmal ulfrasonography^nd

CQlrjurflaivimag'ng ffWJ 1993; 306:1025-9

Campbell S.BbanV, Royston P Wlntenead ML Collins WP.

Transabdammal ultrasound screening ior earl 1 / ovarian cance 1

99 1363-7

0 tf E R V I E V

Malignant iliseas