Ovarian tumor, benign

Ovarian tumor, benign

OVERVIEW:

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 a tumor from cysts, infectious lesions, ectopic pregnancy, and endometriomas. The tumors are often clinically silent until well developed; they may be solid, cystic, or mixed; and they may be functional (producing sex steroids as with arrhenoblastomas and gynandroblastomas) or nonfunctional.

System(s) affected: reproductive, endocrine/metabolic
Genetics: N/A
Incidence/Prevalence in USA: N/A
Predominant age:
• All ages
• Concern for malignancy greater in premenarchal girls and postmenopausal women
Predominant sex: Female only

SIGNS AND SYMPTOMS:

• Usually asymptomatic
• Pain related to torsion, endometriosis, or rupture
• Increased abdominal girth
• Bowel pressure or bladder pressure sensations
• Menstrual irregularities
• Hirsutism or sexual precocity
• Early satiety
• Dyspepsia/bloating

CAUSES:

• Endometriosis with localized, repeated ovarian hemorrhage
• Physiologic cysts
• Tumorigenesis with genetics as yet poorly defined

RISK FACTORS:

As yet poorly characterized for benign tumors. Cigarette smoking increases the relative risk for developing functional ovarian cysts twofold.

DIAGNOSIS

DIFFERENTIAL DIAGNOSIS:

• Ovarian malignancies
• Endometrioma
• Uterine leiomyoma
• Appendicular cysts
• Diverticulitis or bowel abscess
• Pelvic inflammatory disease with tubo-ovarian abscess
• Distended urinary bladder
• Ectopic pregnancy
• Hydrosalpinx
• Functional cysts (follicular and corpus luteum cysts)
• Polycystic ovaries

LABORATORY:

• CBC
• Pregnancy test
• Urinalysis
• Endometrial biopsy or dilatation/curettage if mass accompanied by menstrual abnormality
• Pap smear
• ESR
• Guaiac stool testing
• Serum tumor markers as indicated
• Cancer antigen (CA) 125
• Alpha fetoprotein
• Chorionic gonadotropin (beta-hCG)
• Serum LDH
• Serum estrogens and androgens

Drugs that may alter lab results: N/A
Disorders that may alter lab results:
• CA 125
• Endometriosis
• Peritonitis
• Pelvic inflammatory disease (PID)
• Meigs' syndrome
• Uterine fibroids
• Hepatitis
• Pancreatitis
• Systemic lupus erythematosus
• Diverticulitis
• Beta-hCG
• Pregnancy
• Hydatidiform mole
• LDH
• Liver disease, drug-induced hepatotoxicity
• AFP
• Hepatocellular carcinoma
• Hepatic cirrhosis
• Acute or chronic hepatitis

PATHOLOGICAL FINDINGS:

• Follicular (fluid distention of atretic follicle) and corpus luteum cysts (corpus luteum hematoma)
• Endometrioma
• Pregnancy luteoma (composed of hyperplastic stromal theca-lutein cells)
• Serous and mucinous cystadenomas and mixed serous/mucinous cystadenomas
• Granulosa cell tumors
• Benign connective tissue tumors (thecomas, fibromas, Brenner tumors)
• Cystic teratoma (dermoid cyst)
• Germinal inclusion cyst (regarded by some as the precursor for epithelial ovarian cancer)

SPECIAL TESTS:

• Pelvic exam is the most important
• Careful history and physical exam

IMAGING:

• Cystoscopy if there is hematuria in the absence of infection or if IVP reveals intravesical surface irregularity
• Cystometry if urinary symptoms not explained by extrinsic compression
• Transabdominal or transvaginal ultrasonography may differentiate tumors from other pelvic lesions and identify features that place the patient at greater risk for malignancy (solid component, papillations, multiple septations, ascites, bilaterality, fixed and irregular, rapidly enlarging, accompanied by cul-de-sac nodules). Color flow Doppler evaluation may also be helpful.
• Abdominopelvic CT scan with contrast
• Barium enema, colonoscopy, or IVP as indicated

DIAGNOSTIC PROCEDURES:

• Exploratory laparoscopy or laparotomy

TREATMENT

APPROPRIATE HEALTH CARE:

Inpatient if surgery necessary

GENERAL MEASURES:

N/A

SURGICAL MEASURES:

• Cystectomy or wedge resection for cyst with benign features
• Surgical removal of tumor to establish diagnosis when:
• Premenopausal cysts greater than 5 cm that persist more than 6-8 wks
• Mass that is solid
• Mass greater than 10 cm
• Mass in a premenarchal or postmenopausal female
• Suspicion of torsion or rupture
• Postmenopausal cysts
• Cysts with worrisome ultrasound features (e.g., papillations)

ACTIVITY:

As tolerated

DIET:

No special diet

PATIENT EDUCATION:

A variety of excellent patient education materials (e.g., Ovarian Cyst) can be downloaded from the AAFP (http://www.aafp.org/afp) and ACOG (http://www.acog.com) internet sites.

MEDICATIONS

DRUG(S) OF CHOICE:

In premenopausal patients with cystic lesions less than 10 cm in diameter, simple observation for 4-6 wks is acceptable. There is no evidence that use of a contraceptive pill is more effective than time alone in facilitating ovarian cyst resorption. If the cyst remains unchanged after 4-6 wks of observation, then surgical exploration is indicated.

Contraindications: Those established for OCPs (e.g., hypercoagulable state or history of DVT, ischemic heart disease, history of CVA, hypertension, hepatic adenoma).
Precautions: Refer to manufacturer's profile of each drug
Significant possible interactions: Refer to manufacturer's profile of each drug

ALTERNATIVE DRUGS:

N/A

FOLLOW UP

PATIENT MONITORING:

• Most require only yearly exams
• Varies by diagnosis

PREVENTION/AVOIDANCE:

Although oral contraceptives do not appear to increase rates of cyst resorption, they do decrease risk for forming new ovarian cysts

POSSIBLE COMPLICATIONS:

Complications of untreated dermoid and mucinous cysts may include pseudomyxoma peritonei

EXPECTED COURSE AND PROGNOSIS:

Complete cure

MISCELLANEOUS

ASSOCIATED CONDITIONS:

N/A

AGE-RELATED FACTORS:

Pediatric: Malignancy must be ruled out in premenarchal patients
Geriatric: Because incidence of malignancy increases with age, postmenopausal patients warrant comprehensive evaluation and follow-up.
Others: N/A

PREGNANCY:

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

SYNONYMS:

N/A

ICD-9-CM:

220 Benign neoplasm of the ovary

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Medical Diagnosis » O » Ovarian tumor, benign