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Complications and Possible Differentials • Complications

• Rupture or torsion or twisting of the pedicle o Torsion of an ovarian new growth


o Torsion is more common – due to the torsion of  Untwist tumor and then perform
infundibulopelvic ligament (torsion and rupture oophorocystectomy especially in young
happens because of a process) patients
 The infundibulopelvic ligament contains the o Rupture
ovarian artery and nerves
 The vein will be compressed first because of
the thinner wall, if the vein is the only one
obstructed  congestion
 If the artery is involved  ischemia 
prolonged  necrosis  prone to rupture
o Rupture at once if with
 Trauma
 Malignancy
o Infection
o Intracystic tumor – bleeding within the tumor
 But there are no peritoneal signs so it’s not
considered
Differential Diagnosis:
• Follicular Cyst Adenomas
• Benign Cystic Teratomas

Management:
• Think:
o OVARIAN NEW GROWTH is present
o Any complication is an emergency.
 Pain is considered as an emergency in this
case.
o Emergency laparotomy  the presentation would
dictate the urgency of intervention.
• Work-up before surgery:
o CBC
o Bleeding parameters
o Blood Typing and cross matching especially with
cystic hemorrhage
o Ultrasound  determine the component but more
on counseling
o X-ray of the chest
o Urinalysis
• Surgical Management:
o Cystectomy
o Oophorectomy if the whole ova is already
pathologic.

Lecture-ish session and Run-down review


• Origins of ovarian neoplasms
o Epithelium – 80%
o Germ Cell
o Stroma – fibrous tissues
• Primary follicle growing follicle  mature follicle --?
Ovulation  empty follicle  corpus luteum
o First half – follicular cyst
nd
o 2 half – corpus luteum
• Corpus luteum
o Yellow body cyst
• Follicular cyst
o No intervention unless there is torsion or the size
is more than 8 cm.
o If there is still normal ovary, do
oophorocystectomy instead.
• Serous Cyst
o No obvious septations
o Transillumination
• Mucinous
o Bigger size
o Multiloculated
o Viscid mucinous fluid
o Associated with Pseudomyxoma peritonae 
gelatinous ascites
 Remove the tumor intact to avoid spillage of
contents
• Mature Cystic Teratoma (dermoid cyst)
o Most common
• Fibroma
o Associations with Meig’s syndrome
 Ascites
 Pleural Effusion “Ask and you shall receive. Give before you take. Selfishness won’t do the world
o Ddx: Advanced ovarian cancer any good.” - M
• Brenner
o Thecoma
o Solid mass
o Estrogen effects if from stroma These are just notes taken down by a nocturnal medical student at 7 AM in the
morning. Study at your own risk.

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Case 14 – Benign Lesions for Ovaries  Endometrial cyst that is movable via de novo
Discussion with Dr. Gonzalez pathogenesis
o Brenner Tumor  benign  transitional
A 17 year old high school student was brought to the epithelium of the urinary tract
emergency room because of sudden, moderate to severe right • Benign  suffix: cyst adenoma or cyst
iliac pain since 3 hours ago. She also noted a progressively • Malignant  adenocarcinoma
enlarging mass on the right side of the lower abdomen since 1
year ago. On PE, she was conscious, cooperative, though in Few associations:
obvious pain. BP – 100/70, PR – 98, RR – 22, T – 36.8 C. • Serous
Abdomen- presence of a tender, cystic, movable, right iliac o Watery
mass, about 12 cm in diameter. External genitalia – intact o Generally, unilocular
hymen. Rectal examination: cervix – long, firm, movable; • Mucinous
uterus – normal in size, slightly deviated to the left and o Mucoid, viscid fluid, slimy contents
posteriorly; (+) tender, slightly movable, 12 cm. Diameter o In general, multiloculated, septations
cystic mass with solid components located to the right of the o Tends to grow larger
uterus. • Endometroid
o Thick chocolate
Review • Brenner Tumor
• Physiologic Mass (Generalities) o Solid, benign  fibroma, thecoma and Brenner
o Size: Relatively small – 8 cm or less  The exceptions to the rules.
o Consistency: Cystic without any solid areas
 Regress by themselves, no intervention Classifications
necessary. • Benign
o OCPs may alter them but the further studies are • Low Malignant Potential / Atypical Proliferative
necessary. Tumors (Borderline)
o There is pseudostratification already
Physiologic Masses o No stromal invasion
• Follicular cyst o 3 layers thick stratification
o Arises from the follicle which is a normal o Not used anymore
component. However, in this case, it’s an • Malignant
exaggeration.
o Normal: After follicular development and the Generalities for Germ Cell
arising of a mature follicle, some of the follicles • Usually happens in the younger age group
may persist or progress in maturation due to • Benign versus malignant
GnRH. • Dermoid Cyst – Mature Cystic Teratoma
 However, these generally regress within 3 o Most common benign  Mature Cyst
cycles.  Teeth, hair, bone, cartilage, GI epithelium,
o Manifestation: Cystic growth in adnexal area thyroid epithelium
(purely cystic), freely movable, 6-8 cm in size.  Sebum
o Ultrasound: denotes purely cystic structure o Most common malignant  Dysgerminoma
o If asymptomatic, just observe then after 3  Other malignant
months, follow it up • Endodermal Sinus Tumor
• Corpus Luteum Cyst • Immature Teratoma  immature if there
o Corpus luteum should only last for at about 2 is presence of neural structures.
weeks and regresses if pregnancy does not
occur. Generalities of Stromal Tumors:
o Hemorrhagic phase – part of the regression • Benign
 May get exaggerated and the corpus luteum o Thecoma
may be filled up with blood. o Fibroma
o Corpus luteum may persist to function and may  Made up of fibroblasts that are present all
cause: over the body.
 PE: Missed period + tender unilateral mass  Meig’s Syndrome
• Ddx – Ectopic Pregnancy • Associated ascites and pleural effusion
o Serial pelvic examinations should be done with a solid tumor  mimics advanced
o UTZ: lace-like pattern with streaks of blood. ovarian malignancy
• Theca Lutein Cyst • Malignant
o Stromal cells that produces estrogen o Granulosa Cell Tumor  low grade malignancy
o Associated with pregnancy and hydatidiform mole • Thecoma and GCT produces the ovarian hormones.
o HCG stimulates ovaries to produce the cyst, they They are the factories of estrogen. When they grow,
are generally bilateral  stimulates both ovaries they are highly likely functional and are hormone
unlike the follicular cyst which may be unilateral. producing
o Regresses once the HCG levels go down • Generally causes 10-12 cm endometrium  medium
o Generally not removed unless they become sized
symptomatic • PE finding:
Review: o Thickened endometrium  abnormal bleeding
• Ovary (unopposed estrogen)
o Follicles – germ cell
o Theca and Granuloma Cells – stroma Case Discussion
o Capsule – Epithelium  Low cuboidal • Ask for the rate of growth:
 80% of the tumors  generalities o Rapid growth leans towards a malignancy.
• Neoplastic • How relevant is the information about the intact
o Beyond 8 cm hymen?
o Persist for more than 3-4 months o Rule out possible pregnancy or it lowers the
possibility of it.
Epithelial tumors • Cystic mass with solid components would mean?
• Replicates or mimics the lining epithelium of Mullerian o Cystic would mean benign
tissues/derivatives o Solid components may point to malignant mass
• If the tumor that arose from the ovary histologically • Movability
looks like the: o Movable - benign
o Mucosa of the fallopian tube (low cuboidal o Fixed – malignant
ciliated)  Serous cyst adenoma  Except endometrioma
o Endocervix  Mucinous • Pain
o Endometrial Tissue  Endometrioid o Caused by compression presenting as a pressure
symptom

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