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Subject: Ovarian Tumor, Benign
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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
Because incidence of malignancy increases with age, postmenopausal patients warrant comprehensive evaluation and follow-up.
Malignancy must be ruled out in premenarchal patients. Early neonatal cysts are rare.
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.
Endometriosis with localized, repeated ovarian hemorrhage
Tumorigenesis, with genetics as yet poorly defined
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.
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).
A careful history is important.
Pain is related to torsion, endometriosis, or rupture.
Increased abdominal girth
Bowel pressure or bladder pressure sensations
Hormonal status (OCPs, hormone replacement therapy [HRT] or fertility drugs)
Examine lymph nodes for enlargement.
Chest auscultation can reveal a pleural effusion.
Abdominal exam may identify ascites, masses, or increased abdominal girth.
Ovarian tumor of low malignant potential (Borderline tumor)
Granulosa cell tumor
Theca Lutein cyst
Pelvic inflammatory disease (PID) with tubo-ovarian abscess
Peritoneal inclusion cysts
Functional cysts (follicular and corpus luteum cysts)
Neoplasm metastatic to ovary
Serum β-human chorionic gonadotropin (β-hCG)
CBC for WBCs is helpful if PID or ovarian torsion is suspected.
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].
Exploratory laparoscopy or laparotomy
Aspiration of cyst fluid (contraindicated in postmenopausal women)
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.
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.
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].
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].
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
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.
Most require only yearly exams.
Varies by diagnosis
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]
D27.9 Benign neoplasm of unspecified ovary
D27.0 Benign neoplasm of right ovary
D27.1 Benign neoplasm of left ovary
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)
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.