Ovarian Tumor, Benign

Reviewed 06/2017
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Subject: Ovarian Tumor, Benign

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BASICS

DESCRIPTION

  • The ovaries are a source of many tumor types (benign, malignant, low malignant potential) 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 females

  • 50% of women without regular cycles

  • Predominant age: Premenarchal girls have a 6–11% risk of cancer in an ovarian tumor, and postmenopausal women have a 29–35% risk. A high percentage of ovarian tumors are malignant in girls <15 years of age.

ETIOLOGY

  • Endometriosis with localized, repeated ovarian hemorrhage

  • Physiologic cysts

  • Tumorigenesis, with genetics as yet poorly defined

RISK FACTORS

  • Cigarette smoking doubles the relative risk for developing functional ovarian cysts.

  • Possible contributory factors are early menarche, obesity, infertility, and hypothyroidism.

  • Tamoxifen increases risk of ovarian cyst formation (15–30%) (1).

  • Risks for ovarian cancer include age >60 years; early menarche; late menopause; nulligravidity infertility; endometriosis; polycystic ovarian syndrome; family history of ovarian, breast, or colon cancer; a personal history of breast/colon cancer; or BRCA mutation.

  • Risk for ovarian cancer is decreased in women who have used oral contraceptive pills (OCPs), are multiparous, have a history of a tubal ligation, or who have breastfed.

GENERAL PREVENTION

  • OCPs do not appear to increase rates of cyst resolution, they do decrease the risk for forming new ovarian cysts (1).

  • 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 (2).

DIAGNOSIS

  • A careful history is important.

  • Usually asymptomatic

  • Pain is related to torsion, endometriosis, or rupture.

HISTORY

  • Early satiety

  • Dyspepsia/bloating

  • Increased abdominal girth

  • Bowel pressure or bladder pressure sensations

  • Menstrual irregularities

  • Dyspareunia

  • Hormonal status (OCPs, hormone replacement therapy [HRT] or fertility drugs)

PHYSICAL EXAM

  • Severe acne

  • Examine lymph nodes for enlargement.

  • Chest auscultation can reveal a pleural effusion.

  • Abdominal exam may identify ascites, masses, or increased abdominal girth.

  • Hirsutism/sexual precocity

  • Pelvic exam

  • Rectovaginal exam

  • Virilization

DIFFERENTIAL DIAGNOSIS

  • Ovarian malignancies

  • Ovarian tumor of low malignant potential (Borderline tumor)

  • Endometrioma

  • Serous cystadenoma

  • Mucinous cystadenoma

  • Teratoma

  • Hemorrhagic cyst

  • Granulosa cell tumor

  • Theca Lutein cyst

  • Diverticulitis/bowel abscess

  • Pelvic inflammatory disease (PID) with tubo-ovarian abscess

  • Ectopic pregnancy

  • Hydrosalpinx

  • Paraovarian cyst

  • Peritoneal inclusion cysts

  • Functional cysts (follicular and corpus luteum cysts)

  • Polycystic ovaries

  • Ovarian fibroma

  • Neoplasm metastatic to ovary

TESTS

INITIAL TESTS

  • Serum β-human chorionic gonadotropin (β-hCG)

  • CBC for WBCs is helpful if PID or ovarian torsion is suspected.

  • Urinalysis

  • Serum estrogens and androgens if signs of androgen excess (although only as part of polycystic ovarian [PCO] workup)

  • Serum tumor markers may be considered but often confuse rather than help to resolve diagnosis; choose carefully (3)[B].

    • 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 ultrasound, a CA-125 level >200 U is concerning. In a postmenopausal patient, cancer must be ruled out and a CA-125 >35 U is concerning (value is lab dependent) (4)[B].

    • α-Fetoprotein and hCG can be ordered for suspected germ cell tumor.

    • Inhibin A and Inhibin B for suspected granulosa cell tumor

    • Lactate dehydrogenase (LDH) and α-fetoprotein (AFP) for suspected germ cell tumors

  • Human epididymis protein 4 (HE4) may offer superior specificity compared to CA-125 for the differentiation of benign and malignant adnexal masses in premenopausal women (2)[B].

  • Disorders that may alter lab results are the following:

    • CA-125: endometriosis, peritonitis, PID, Meigs syndrome, uterine fibroids, hepatitis, pancreatitis, systemic lupus erythematosus (SLE), diverticulitis

    • β-hCG: pregnancy, hydatidiform mole

    • α-Fetoprotein: hepatocellular carcinoma, hepatic cirrhosis, acute/chronic hepatitis

  • Transvaginal ultrasound is the best means to determine the architecture of an ovarian cyst or mass (5)[B].

  • 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; palpillations; multiple septations; ascites, bilaterality, fixed and irregular, rapidly enlarging, accompanied by cul-de-sac nodules).

  • Transabdominal ultrasonography can help identify ascites.

  • MRI can be helpful in better defining masses in women with low risk of ovarian cancer but who have an “indeterminant” mass on ultrasound. Usually not necessary, as decision for surgery can proceed without MRI if indicated; can add greatly to cost of care.

  • Abdominopelvic CT scan with contrast material, if MRI is unavailable, although ultrasound still far superior (6)

  • Mathematical models and calculators have been created to evaluate the risk of malignancy of ovarian tumors (7)[A].

DIAGNOSTIC PROCEDURES/SURGERY

  • Exploratory laparoscopy or laparotomy

  • Aspiration of cyst fluid (contraindicated in postmenopausal women)

INTERPRETATION

  • Ultrasound findings should include size and consistency of the mass such as cystic, solid, or mixed and if unilateral or bilateral.

  • Thin-walled sonolucent, unilocular cysts with regular borders are most likely benign.

  • Septations, mural nodules, papillary excresenses, or ascites are concerning for malignant etiology.

  • Endometriomas (extrauterine endometrial tissue) are often homogeneous appearing cysts with low-level echoes.

  • Cystic teratomas (dermoid cysts) are often hypoechoic with multiple small homogenous interfaces.

  • Follicular cysts are the most common ovarian cysts in the premenopausal nonpregnant female.

Pregnancy Considerations

  • Most cysts discovered during pregnancy are corpus luteum/follicular cysts.

  • The two most commonly encountered tumors during pregnancy are cystadenomas (serous/mucinous) and dermoid cysts.

 

TREATMENT

GENERAL MEASURES

  • In premenopausal patients cystic lesions <10 cm in diameter, simple observation for 4 to 6 weeks is acceptable.

  • Premenopausal women should have a repeat ultrasound ideally during their follicular phase (day 3 to 10 of cycle) (8)[C].

  • In premenopausal patients, simple and hemorrhagic cysts <3 cm are not suspicious and do not likely need follow-up (8)[C].

  • If a large cyst remains unchanged after 4 to 6 weeks of observation, then surgical exploration is indicated.

  • In postmenopausal patients cysts <1 cm are likely benign (8)[C].

MEDICATION

FIRST LINE

  • NSAIDs or opioids may be helpful for discomfort.

  • Oral contraceptives do not hasten the resolution of functional ovarian cysts. Most cysts resolve without treatment within a few cycles (9)[B].

SURGERY

  • Cystectomy/wedge resection for cyst with benign features

  • Surgical removal of tumor to establish diagnosis when:

    • Premenopausal cysts >5 cm that persist >12 weeks

    • Mass is solid.

    • Mass is >10 cm.

    • Mass in a premenarchal/postmenopausal female

    • Suspicion of torsion/rupture

    • Postmenopausal cysts

    • Cysts with worrisome features on ultrasound (e.g., papillations, septations)

    • For masses that are worrisome for cancer, consider referral to a gynecologist/oncologist for initial surgery.

  • Bilateral salpingo-oophorectomy may be appropriate in postmenopausal patients to reduce the risk of future pelvic surgery.

ONGOING CARE

FOLLOWUP RECOMMENDATIONS

MONITORING

  • Most require only yearly exams.

  • Varies by diagnosis

PATIENT TEACHING

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/journals/afp.html?cmpid=_van_188 and http://www.acog.org/

PROGNOSIS

Complete cure 

COMPLICATIONS

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

REFERENCES

Cusidó M, Fábregas R, Pere BS et al. Ovulation induction treatment and risk of borderline ovarian tumors. Gynecol Endocrinol.  2007;23(7):373–376.  [View Abstract]
Holcomb K, Vucetic Z, Miller MC et al. Human epididymis protein 4 offers superior specificity in the differentiation of benign and malignant adnexal masses in premenopausal women. Am J Obstet Gynecol.  2011;205(4):358.e1–358.e6.  [View Abstract]
Maggino T, Gadducci A, D’Addario V et al. Prospective multicenter study on CA 125 in postmenopausal pelvic masses. Gynecol Oncol.  1994;54(2):117–123.  [View Abstract]
National Institutes of Health Consensus Development Conference Statement. Ovarian cancer: screening, treatment, and follow-up. Gynecol Oncol.  1994;55(3 Pt 2):S4–S14.  [View Abstract]
Myers ER, Bastian LA, Havrilesky LJ et al. Management of Adnexal Mass. Evidence Report/Technology Assessment No.130. Rockville, MD: Agency for Healthcare Research and Quality; 2006.
Iyer VR, Lee SI. MRI, CT, and PET/CT for ovarian cancer detection and adnexal lesion characterization. AJR Am J Roentgenol.  2010;194(2):311–321.  [View Abstract]
Van Calster B, Van Hoorde K, Valentin L et al. Evaluating the risk of ovarian cancer before surgery using the ADNEX model to differentiate between benign, borderline, early and advanced stage invasive and secondary metastatic tumours: Prospective multicentre diagnostic study. BMJ.  2014;349:g5920.  [View Abstract]
Levine D, Brown DL, Andreotti RF et al. Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology.  2010;256(3):943–954.  [View Abstract]
Grimes DA, Jones LB, Lopez LM et al. Oral contraceptives for functional ovarian cysts. Cochrane Database Syst Rev.  2014;(4):CD006134.  [View Abstract]

ADDITIONAL READING

  • American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Management of adnexal masses. Obstet Gynecol.  2007;110(1):201–214.  [View Abstract]

  • Crayford TJ, Campbell S, Bourne TH et al. Benign ovarian cysts and ovarian cancer: a cohort study with implications for screening. Lancet.  2000;355(9209):1060–1063.  [View Abstract]

  • Givens V, Mitchell GE, Harraway-Smith C et al. Diagnosis and management of adnexal masses. Am Fam Physician.  2009;80(8):815–820.  [View Abstract]

  • 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(1):25–28.  [View Abstract]

  • Laberge PY, Levesque S. Short-term morbidity and long-term recurrence rate of ovarian dermoid cysts treated by laparoscopy versus laparotomy. J Obstet Gynecol Can.  2006;28(9):789–793.  [View Abstract]

  • Marchesini AC, Magrio FA, Berezowski AT et al. A critical analysis of Doppler velocimetry in the differential diagnosis of malignant and benign ovarian masses. J Womens Health (Larchmt).  2008;17(1):97–102.  [View Abstract]

CODES

ICD10

  • D27.9 Benign neoplasm of unspecified ovary

  • D27.0 Benign neoplasm of right ovary

  • D27.1 Benign neoplasm of left ovary

ICD9

220 Benign neoplasm of ovary 

SNOMED

  • 92260003 Benign neoplasm of ovary

  • 254865006 Fibroma of ovary

  • 119421006 Serous cystadenoma of ovary

  • 119422004 Mucinous cystadenoma of ovary

  • 10737281000119109 Mature cystic teratoma of right ovary (disorder)

  • 254873002 Benign germ cell tumor of ovary (disorder)

  • 119424003 mature cystic teratoma of ovary (disorder)

  • 10737321000119104 Mature cystic teratoma of left ovary (disorder)

PEARLS

  • In perimenopausal patients, follicles and simple cysts <3 cm are normal physiologic findings.

  • 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.

 
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