GYN 21

• Normal ovary


  Fig. 21.1
• Measurement (average) of a normal ovary

  • Neonate—1.3 cm × 0.6 cm × 0.4 cm
  • Reproductive—4 cm × 2 cm × 3 cm
  • Menopause—2 cm × 1.5 cm × 0.5 cm

  
• Volume of normal ovary

  10 cm3 (maximum 18 cm3)
• Types of ovarian enlargement

  • Non-neoplastic
  • Neoplastic (benign)

  
• Non-neoplastic ovarian enlargement


  Usually due to accumulation of fluid inside the functional unit of the ovary
• Causes of non-neoplastic cysts of the ovary

  • Follicular cysts
  • Corpus luteum cyst
  • Theca lutein and granulosa lutein cysts
  • Polycystic ovarian syndrome
  • Endometrial cyst (chocolate cyst)
• Functional cysts

  • Related to temporary hormonal disorders
  • Rarely becomes complicated
  • Usually ≤7 cm in diameter
  • Usually asymptomatic
  • Spontaneous regression occurs following correction of the temporary hormonal dysfunction
  • Unilocular (on USG)
  • Usually contains a clear fluid
  • Lining epithelium corresponds to the functional epithelium of the unit from which it arises
• Management of follicular cysts

  1. A follicular cyst ≤3 cm requires no further investigations

  2. A simple cyst <7 cm, unilocular, echo free without solid areas or papillary projections, with normal serum cancer antigen (CA 125) should be followed up with repeat ultrasound (endovaginal) in 3–6 months time

  3. COCs suppresses the levels of gonadotropins and reduces the stimulatory effects on the ovaries and the cysts

  4. Low vascular resistance on color flow Doppler study suggests malignancy whereas high resistance usually suggests normal or benign disease

  5. A cyst in a perimenopausal or postmenopausal women should be removed when CA 125 is abnormal (>35 IU/mL) or the cyst is persistently large (>10 cm)

  6. Removal (cystectomy) may be done by laparotomy or laparoscopy

  
• Corpus luteum cyst

  • Usually occurs due to overactivity of corpus luteum with excessive bleeding inside
  • Progesterone and estrogen secretion continues
  • Menstrual cycle may be normal or there may be amenorrhea or delayed cycle
  • Most corpus luteum cysts are small, rarely up to 11-15 cm in diameter
  • Usually followed by heavy and/or continued bleeding
  • May be associated with pregnancy and persists for about 12 weeks
• Management of corpus luteum cysts

  If features of acute abdomen appears, laparoscopy/laparotomy with enucleation of the cyst (cystectomy) is to be done along with resuscitative measures as in disturbed tubal pregnancy

  
• Lutein cysts


  • Usually bilateral and caused by excessive chorionic gonadotropin secreted in cases of gestational trophoblastic tumors
  • May also develop with administration of gonadotropins or even clomiphene to induce ovulation (OHSS)
  • Lined either by theca lutein cells or by granulosa lutein cells
• Treatment of lutein cysts

  Spontaneous regression is expected within few weeks following effective therapy of the tumors with the gonadotropin level returning back to normal
• Combined oral contraceptives (COCs) suppress ovarian activity and protect against ovarian cyst development. Progestin only contraceptives including levonorgestrel-intrauterine system (LNG-IUS) have been associated with development of functional cyst. Tamoxifen use have an increased risk of ovarian cyst formation.
• Classification of ovarian neoplasms (WHO)

  • Epithelial tumors
  • Germ cell tumors
  • Sex cord stromal tumors
  • Lipid (lipoid) cell tumors
  • Gonadoblastoma

  
• Epithelial tumors are the most common ovarian neoplasms, germ cell tumors are the second most frequent and are most common among the younger age, sex cord stromal tumors are the third most frequent ovarian neoplasm

  
• Principal ovarian tissue components

  • Epithelial cells derived from the coelomic epithelium
  • Oocytes derived from the primitive germ cells
  • Mesenchymal elements from the gonadal stroma
• Benign ovarian tumors covered in this chapter

  • Mucinous cyst adenoma
  • Serous cyst adenoma
  • Brenner tumor
  • Dermoid cyst
  • Endometrioid tumors
  • Clear cell tumors

  
• Mucinous cyst adenoma

  Arises from the surface epithelial cells, cells are filled with mucin, resemble the cells of the endocervix or that of intestinal cells
• Mucinous cyst adenoma


  • Quite common, account for about 20-25% of all ovarian tumors
  • Bilateral in about 10% cases
  • Risk of malignancy is about 5-10%
  • Wall is smooth, lobulated with whitish or bluish-white hue, may be thin and translucent
  • Content is thick, viscid, mucin-a glycoprotein with high content of neutral polysaccharides
  • Multilocular on cut section

  
• Microscopic appearance of mucinous cyst adenoma


  Lined by a single layer of tall columnar epithelium with dark staining basal nucleus but without any cilia, epithelial characteristics are like those of endocervix
• Serous cyst adenoma

  • Quite common, accounts for about 40% of ovarian tumors
  • Bilateral in about 40%
  • Risk of malignancy is about 40%
  • Cysts are not as big as mucinous type, more chance of proliferation of lining epithelium to form papillary projection, intracystic hemorrhage is more likely

  
• Serous cyst adenoma

  • Wall is smooth, shiny and grayish white, may have exuberant papillary projection
  • Content fluid is clear, rich in serum proteins—albumin and globulin
  • May be multilocular on cut section
  • Lined by a single layer of cubical epithelium, papillary structures consist of broad dense fibrous stroma covered by single or multiple layers of columnar epithelium, may have ciliated, secretory and peg cells resembling tubal epithelium
  • Psammoma bodies may be present (15%)
• Endometrioid tumors


  Rare (5%), consists of epithelial cells resembling those endometrium
• Clear cell (mesonephroid) tumors

  Contain cells with abundant glycogen and are called hobnail cells, nuclei of the cells protrude into the glandular lumen, occur in women 40-70 years of age and are highly aggressive

  
• Psammoma bodies


  Tiny, spherical, laminated calcified structures which are most often found in areas of cellular degeneration
• Presence of psammoma bodies per se does not denote malignancy
• Psammoma bodies are not present in slow growing tumors

  
• Important features of a serous cyst adenoma

  • Epithelial ovarian tumor
  • Common (40%) ovarian tumor
  • Bilateral in up to 20%
  • May be multilocular or unilocular
  • Surface papillary projections are often present
  • Psammoma bodies may be present (15%)
  • Histology: Columnar epithelial cells single/multiple layers
  • Risk of malignancy up to 40%

  
• Endometrioid tumors are rare (5%) and consists of epithelial cells resembling those endometrium
• Endometroid carcinomas (malignant variety) may occur
• Clear cell (mesonephroid) tumors

  Contain cells with abundant glycogen and are called hobnail cells. The nuclei of the cells protrude into the glandular lumen. They occur in women 40–70 years of age and are highly aggressive.

  
• Fig. 21.4: Cut section showing mucinous cyst adenoma. Multilocularity of the tumor is seen. Cyst wall is thick and there was intracystic hemorrhage.

  
• Fig. 21.5: Microphotograph showing the lining epithelium of mucinous cyst adenoma. The epithelium does not invade the wall and the serosa is intact.
• Fig. 21.6: Diagrammatic picture showing a single layer of tall columnar epithelial cells with basal nuclei. These cells secrete mucin—mucinous cyst adenoma.
• Brenner tumor


  Accounts for 2–3% of all ovarian tumors, 8–10% are bilateral and usually seen in women above the age of 40. Majority are solid and are less than 2 cm in diameter. It usually arises from squamous metaplasia of surface epithelium. Histologically islands of transitional epithelium (Walthard nests) in a compact fibrous stroma are seen. The cells look like 'coffee bean' as the nuclei have longitudinal grooves. They are usually benign in nature. Estrogen is secreted by the tumor and the woman may present with abnormal vaginal bleeding.

  
• Treatment choice for Brenner tumor

  • Unilateral oophorectomy in a young woman
  • Total hysterectomy and bilateral salpingo-oophorectomy in elderly women

  
• Dermoid cyst (mature Teratoma)


  Arises from a single germ cell arrested after the first meiotic division. Karyotype in majority is 46XX.
• Dermoid cyst constitutes about 97% of teratomata. Its incidence is about 30–40% amongst ovarian tumors.
• The tumor is bilateral in about 15–20%. It constitutes about 20–40% of all ovarian tumors in pregnancy.

  
• Complications of dermoid cyst

  • Torsion (15–20%)
  • Rupture (1%)
  • Malignancy (1–2%)