CASE 14: BENIGN LESIONS OF THE OVARIES

- Significance: if the patient is pregnant with CLC

Mostly, benign lesions are asymptomatic hence discovered & you remove it knowing it’s physiologic – this
incidentally but if there would be complaints, the most would lead to MISCARRIAGE since you
common is: removed the source of hormone maintaining
 Abdominal/ Hypogastric mass: depending from the the pregnancy.
growth, it would alter the anatomy of the pelvic cavity
 Sexual Hx
Accompanying symptoms: - Not sexually active: CL would lead to atresia
 Pressure symptoms: Mass Effect - Sexually active: rule out ectopic pregnancy
- Abdominal pain presenting as an adnexal mass
- Anteriorly: (Urinary) Dysuria, Frequency, - OCP: Family planning Measure to rule out
Hesitancy or UTI, ectopic pregnancy if taken regularly
- Posteriorly: Constipation - PID & Lower Genital Tract Infection: DDX: TOA
- Dysmenorrhea
 Specifically, for E secreting tumor, it would present with  OB Hx
advance sexual characteristics of breast enlargement, - IUD: nevus for infection, possibility of PID
stimulation of early menarche & etc.
Physical Exam
Complication: There are 2 areas to concentrate:
 Leakage from a weak point 1. Abdominal Mass
 Rupture or frank explosion 2. Is it Benign or Malignant?
The release of the contents of the cyst into the abdominal
cavity would lead to severe abdominal pain BENIGN MALIGNANT
 Torsion/ Twisting: can be loose or tight, compromising Borders Well Defined Undefined
the BS, leading to more pain, hemorrhage & necrosis felt Smooth Irregular
as an acute abdomen Mobility ✓ (Mobile) ✕ (Fixed)
Laterality Unilateral Bilateral
Spectrum of Pain Consistency Cystic Solid (Exc: Fibroma)
Rate of Growth Slow (Years) Rapid (Months)
Pain Acute Abdomen Hemorrhagic Shock Ascites ✕ ✓(Except: Fibroma)

CC: MASS  Presence of Nodules: Consider Endometriosis

 Age
- Physiologic: Reproductive age group Work Ups
- Pathologic: Premenarcheal, Postmenopausal  UTZ (TVS, TRS, TAS):
 Menstrual Hx (LMP, PMP) - To plan for large ovarian new growths
- Missed Period: DDX - Ectopic/ Tubal pregnancy - To look for smaller lesions
with presumptive symptoms of pregnancy - SASSONE SCORE
- Dysmenorrhea: DDX – Endometriosis  Color Doppler:
- Physiologic: To identify what day in cycle is she - Malignancy: ↑ Vascularity ↓ Resistance
in with the presence of ovarian cyst - (Except: Fibroma)
 1st half: Follicular Cyst
 2nd half: Corpus Luteum Cyst SASSONE
Parameters:
 Since it is physiologic, no intervention is needed, just - Wall Thickness
observe the patient. - Echogenicity
 CLC: - Inner Wall Structure
- Lifespan: 9 – 11 at most 14 days - Septa
- If rescued by HCG, it would go on in pregnancy SCORE:
of 8 - 10 weeks  > 9: Higher Risk for Malignancy
 < 9 : Benign
Exemption: will regress in size upon evacuation of H-mole (8 - 12
1. Dermoid (GCT) solid structures within the cyst, weeks)
2. Endometrial Cyst: Blood hyperechoic with cystic areas
 Not Fibroma: No septations Pathologic
 Epithelial
More common
Tumor Markers  Germ Cell
 Very useful for follow up of response of the treatment,  Gonadal
 Presence of recurrence or need of chemotherapy
Epithelial
If malignant process: od CT scan, MRI, CXR (for metastasis)  Cystadenomas (Serous or Mucinous)
 Endometrial cyst (Similar: Inner lining of the uterus) with
Classification of Benign Ovarian New Growth: fluid inside (Low to medium echoes within as old blood)
 Functional/ Physiologic
 Neoplastic (Benign or Malignant)
Serous Mucinous
Physiologic Lining the same as Fallopian Tube Endocervical Gland
 “Functional”: after day of the cycle the cyst will regress Epithelium Simple Columnar Tall Columnar with
 Follicular Cyst, Corpus Luteum Cyst, Theca Lutein Cyst or Flat with Cilia Palisades & Goblet
 TLC: with ↑HCG consider pregnancy or H Mole Locules Unilocular Multiloculated
(Amenorrhea + Vaginal bleeding + Uterine enlargement)
presenting as grape like tissues or vesicular tissues. TLC
Germ Cell Radical:
 Dermoid/ Benign Cystic Teratoma  Mutilate one side of adnexa thru
- Malignant: Immature & Benign: Mature - Oophorectomy: removal of ovary,
- UTZ: Hyperechoic/ solid areas in the structure, - If tube is affected: USO
- Typical Finding: Contains fat (sebaceous - If post-menopausal: TAHBSO
gland), teeth, cartilage, bones
- Consistency: Cystic to Doughy Structure Remember main function of the ovary:
- IE Finding: Anterior to the uterus,  Folliculogenesis or Hormogenesis
- Why anterior? Heaviness of the contents
 Struma Ovarii: In pursuing conservative management for young patients, &
- Contains thyroid tissues (can be combined with there is possibility of malignany, do Frozen Section.
dermoid)  Cancer can b e conservative up to Stage 1A
- Not only a mass with pressure symptoms, but  Admission: Acute surgical abdomen - rupture, torsion
presents with HYPERTHYROIDISM - Rupture: Sudden pain
- Torsion or Leakage: On & off pain becoming
Gonadal continuous + vomiting
 Sertoli Leydig Tumor: Uncommon
For Torsion:
MX:  MX: Untwist in the pedicle.
 Remember that ovarian growth can be physiologic,  With torsion, it is believed that there would be stasis
pathologic or inflammatory (TOA) causing blood formation that would make blood clot
 Physiologic: observation thrown in the circulation causing embolism.
 Follicular cyst: observe for 1 or 2 - 3 cycles, then repeat  But these do not happen ergo you can untwist, then if
UTZ & IE. If persistent: give OCP & to consider serous cyst from color blue it becomes pinkish: Do
 Neoplasm: Surgical excision (Conservative or Radical) oophorecystectomy
 But if nothing happens & it remain blue: do USO (Radical)
Conservative:
 Oophorocystectomy, Remember
 Aspiration is not recommended  Adolescence: Germ cells
 20 - 50 : Epithelial
 Beyond 50: Malignancy

Case 14
A 17 year old high school student was brought to the ER because of sudden, moderate to severe iliac pain since 3 hours ago. She
also noted a progressively enlarging mass on the R side of the lower abdomen since 1 year ago. On PE, she was conscious,
O
cooperative though in obvious pain. BP 100/70, PR 98, RR 20, T 36.8 C. Abdomen: presence of tender, cystic, movable, R iliac
mass about 12 cm in diameter. External genitalia: intact hymen. Rectal examination – cervix: long, firm, movable; uterus –
normal in size, slightly deviated to the left & posteriorly; + tender, slightly movable, 12 cm, diameter cystic mass with solid
components located to the right of the uterus

Impression: Ovarian New Growth

 Uterus deviated to the back ∴ Anterior Mass: DERMOID
 Abdomen: Sudden pain ∴ RUPTURE (ER)

MX:
 Do cystectomy (Age: 17 years old
 Approach: Ideally Laparoscope

UTZ not necessary always

 Distended urinary bladder: mistaken as an ovarian cyst

Chocolate colored cysts:

 Endometrial cyst: Endometrial glands & stroma
 CL Hemorrhagic Cyst: Hemosiderin laden macrophages