Benign Ovarian Tumor – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

The ovaries are a source of many tumor types (benign and malignant) because of the histologic variety of their constituent cells.Benign ovarian tumors create difficulties in differential diagnosis because of the need to identify malignancy and discriminate tumor from cysts, infectious lesions, ectopic pregnancy, and endometriomas.Tumors are often clinically silent until well developed; may be solid, cystic, or mixed; and they may be functional (producing sex steroids, as with arrhenoblastomas and gynandroblastomas) or nonfunctional.System(s) affected: Endocrine/Metabolic; Reproductive

Geriatric Considerations

Because incidence of malignancy increases with age, postmenopausal patients warrant comprehensive evaluation and follow-up.

Pediatric Considerations

Malignancy must be ruled out in premenarchal patients. Early neonatal cysts are rare.

Epidemiology

Incidence

30% of regularly cycling females50% of women without regular cyclesPredominant age: Premenarchal girls have a 5–35% risk of cancer in an ovarian tumor, and postmenopausal women have a 30% risk.

Risk Factors

As yet poorly characterized for benign tumors; cigarette smoking increases the relative risk for developing functional ovarian cysts 2-fold.Possible contributory factors are early menarche, obesity, infertility, and hypothyroidism.Risks for ovarian cancer include age >60 years; early menarche; late menopause; nulliparity; infertility; family history of ovarian, breast, or colon cancer; or a personal history of breast or colon cancer; or BRCA mutation.Risk for ovarian cancer is decreased in women who have used OCPs, been pregnant, or breastfed.

General Prevention

Although oral contraceptives do not appear to increase rates of cyst resorption, they do decrease risk for forming new ovarian cysts.A large British cohort of 5,479 women demonstrated that the resection of benign cysts has no impact on future risk for ovarian cancer.A case-control study of 299 women found no evidence that ovulation-induction treatment predisposes women to the development of borderline ovarian growths.

Etiology

Endometriosis with localized, repeated ovarian hemorrhagePhysiologic cystsTumorigenesis, with genetics as yet poorly defined

Diagnosis

A careful history is important.Usually asymptomaticPain related to torsion, endometriosis, or rupture

History

Early satietyDyspepsia/bloatingIncreased abdominal girthBowel pressure or bladder pressure sensationsMenstrual irregularitiesDyspareuniaHirsutism or sexual precocitySevere acneDeepening of the voiceVirilization

Physical Exam

Examine lymph nodes for enlargement.Chest auscultation can reveal a pleural effusion.Abdominal exam may identify ascites, masses, or increased abdominal girth.Pelvic exam is recommended.

Diagnostic Tests & Interpretation

Lab

Initial lab tests

Complete blood count for WBCs helpful if pelvic inflammatory disease (PID) suspectedPregnancy testUrinalysisSerum estrogens and androgens if signs of androgen excessSerum tumor markers may be considered but often confuse rather than help to resolve diagnosis; choose carefully: CA-125 should not be ordered in a premenopausal patient for screening purposes. If an ovarian tumor in a premenopausal patient is highly suspicious for cancer by US, a CA-125 level greater than 200 u is concerning. In a postmenopausal patient, cancer must be ruled out and a CA-125 >35 u is concerning.a-Fetoprotein and human chorionic gonadotropin (hCG) can be ordered for suspected germ call tumorDisorders that may alter lab results: CA-125: Endometriosis, peritonitis, PID, Meigs syndrome, uterine fibroids, hepatitis, pancreatitis, systemic lupus erythematosus, diverticulitisß-hCG: Pregnancy, hydatidiform molea-Fetoprotein: Hepatocellular carcinoma, hepatic cirrhosis, acute or chronic hepatitis

Imaging

Transvaginal US is the best means to determine the architecture of an ovarian cyst or mass.Transvaginal ultrasonography may differentiate tumors from other pelvic lesions and identify features that place the patient at greater risk for malignancy (e.g., solid component, papillations, multiple septations, ascites, bilaterality, fixed and irregular, rapidly enlarging, accompanied by cul-de-sac nodules).Transabdominal US can help identify ascites.Color-flow Doppler evaluation also may be helpful. Color flow to the solid component of the tumor is concerning for cancer. Gray scale may be an important method of differential diagnosis of ovarian growths.MRI with apparent diffusion coefficient mapping may be useful in the differential diagnosis of cystic masses. MRI can be helpful in better defining masses in women with low risk of ovarian cancer but who have an “indeterminant” mass on US.Cystoscopy if hematuria is present in the absence of infection or if IV pyelogram reveals intravesical surface irregularityAbdominopelvic CT scan with contrast material, if MRI unavailableBarium enema, colonoscopy, or IV pyelogram, as indicated

Diagnostic Procedures/Surgery

Exploratory laparoscopy or laparotomy

Pathological Findings

Follicular (fluid distension of atretic follicle) and corpus luteum cysts (corpus luteum hematoma). Follicular cysts are the most common ovarian cysts in the premenopausal nonpregnant female.EndometriomaPregnancy luteoma (composed of hyperplastic stromal theca–lutein cells)Serous and mucinous cystadenomas and mixed serous/mucinous cystadenomasGranulosa cell tumorsBenign connective tissue tumors (thecomas, fibromas, Brenner tumors)Cystic teratoma (dermoid cyst); teratomas are the most common benign neoplasms.Germinal inclusion cyst (regarded by some as the precursor for epithelial ovarian cancer)

Pregnancy Considerations

Most cysts discovered during pregnancy are corpus luteum or follicular cysts.The 2 most commonly encountered tumors during pregnancy are cystadenomas (serous or mucinous) and dermoid cysts.

Differential Diagnosis

Ovarian malignanciesEndometriomaUterine leiomyomaAppendicular cystsDiverticulitis or bowel abscessPID with tubo-ovarian abscessDistended urinary bladderEctopic pregnancyHydrosalpinxFunctional cysts (follicular and corpus luteum cysts)Polycystic ovariesOvarian lipoma

Treatment

Medication

Oral contraceptives decrease risk for forming new ovarian cysts. They do not aid in resorption of current ovarian cysts.

First Line

NSAIDs or narcotics may be helpful for discomfort.

Additional Treatment

General Measures

In premenopausal patients with cystic lesions <10 cm in diameter, simple observation for 4–6 weeks is acceptable. No evidence suggests that use of a contraceptive pill is more effective than time alone in facilitating ovarian cyst resorption.If a large cyst remains unchanged after 4–6 weeks of observation, then surgical exploration is indicated.Unilocular ovarian cysts <5 cm in premenopausal patients were not considered suspicious.

Surgery/Other Procedures

Cystectomy or wedge resection for cyst with benign featuresSurgical removal of tumor to establish diagnosis when: Premenopausal cysts >5 cm that persist >12 weeksMass is solid.Mass is >10 cm.Mass in a premenarchal or postmenopausal femaleSuspicion of torsion or rupturePostmenopausal cystsCysts with worrisome features on US (e.g., papillations)For masses that are worrisome for cancer, consider referral to a gyn-oncologist for initial surgery.

Ongoing Care

Follow-Up Recommendations

Patient Monitoring

Most require only yearly exams.Varies by diagnosis

Patient Education

A variety of excellent patient education materials (e.g., “Ovarian Cyst”) can be downloaded from the American Association of Family Physicians and American College of Obstetricians and Gynecologists Internet sites: http://www.aafp.org/afp and http://www.acog.com.

Prognosis

Complete cure

Complications

Complications of untreated dermoid and mucinous cysts may include rupture and pseudomyxoma peritonei.

Additional Reading

1. Borgfeldt C, Andolf E. Cancer risk after hospital discharge diagnosis of benign ovarian cysts and endometriosis. Acta Obstet Gynecol Scand. 2004;83:395–400.

2. Clarke-Pearson D. Screening for Ovarian Cancer. NEJM. 2009;(361):170–7.

3. Crayford TJ, Campbell S, Bourne TH, et al. Benign ovarian cysts and ovarian cancer: a cohort study with implications for screening. Lancet. 2000;355:1060–3.

4. Cusidó M, Fábregas R, Pere BS, et al. Ovulation induction treatment and risk of borderline ovarian tumors. Gynecol Endocrinol. 2007;23:373–6.

5. Givens V, Mitchell G. Diagnosis and Management of Adnexal Masses. AAFP; 2009;80(8):815–822.

6. Holt VL, Cushing-Haugen KL, Daling JR. Oral contraceptives, tubal sterilization, and functional ovarian cyst risk. Obstet Gynecol. 2003;102:252–8.

7. Iyer VR, Lee SI, et al. MRI, CT, and PET/CT for ovarian cancer detection and adnexal lesion characterization. AJR Am J Roentgenol. 2010;194:311–21.

8. Kirilovas D, Schedvins K, Naessén T, et al. Conversion of circulating estrone sulfate to 17beta-estradiol by ovarian tumor tissue: a possible mechanism behind elevated circulating concentrations of 17beta-estradiol in postmenopausal women with ovarian tumors. Gynecol Endocrinol. 2007;23:25–8.

9. Labarge PY, et al. Short-term morbidity and long-term recurrence rate of ovarian dermoid cysts treated by laparoscopy vs. laparotomy. J Obstet Gynecol Can. 2006;28(9):789–93.

10. Marchesiini AC, et al. A critical analysis of Doppler velocimetry in the differential of malignant and benign ovarian masses. J Women Health. 2008;17(10):97–102.

11. Nakayama T, et al. Diffusion-weighted echo-planar MR imaging and ADC mapping in the differential diagnosis ovarian cystic masses: Usefulness of detecting keratinoid substances in mature cystic teratomas. J Magn Reson Imag. 2005;22(2):271–8.

12. Zwiesler D, Lewis SR, Choo YC, et al. A case report of an ovarian lipoma. South Med J. 2008;101:205–7.

Codes

ICD9

220 Benign neoplasm of ovary

Snomed

92260003 benign neoplasm of ovary (disorder)

Clinical Pearls

Cigarette smoking doubles the relative risk of developing a functional ovarian cyst.Transvaginal pelvic ultrasound is the imaging test of choice to initially determine the architecture of an ovarian cyst or mass.Malignancy must be ruled out in both premenarchal and postmenopausal patients.Do not order CA 125 on premenopausal patients with an ovarian mass unless it is highly suspicious for cancer.