Benign Gynecologic TumorsDr. Ulfah Wijaya K, M.Ked(OG), SpOG

1. Benign Vulva and Vagina Tumors2. Benign Ovarian Tumors3. Benign Uterus and Cervix Tumors

Benign Vulva and Vagina tumors

VulvaEpidermoid and sebaceous cysts can be difficult to differentiate. Management involves excision of the cyst. Cysts may also arise from the duct of the Bartholins gland that lies in subcutaneus tissue below the lower third of the labium majorum. Incision and marsupialization of the abscess and antibiotic therapy give excellent results. The pus from the abscess should be sent for culture in media suitable for the detection of gonococcal infection.

Vulva Epidermoid cyst

Vulva Sebaceous cyst

Vulva Bartholins cyst

VulvaBartholins cyst

VulvaCondyloma acuminata

CA are small papules that are sometimes sessile and often polypoid. These are due to infection by the HPV and may be seen over the whole perineal region. Treatment :Trichloroacetic acidPodophyllin less effective & more toxic but may also be usedOccasionally electrodiathermy is required to remove these warts.

VulvaCondyloma acuminata

Vagina

Tumors in the vagina are uncommon, The commonest are Condyloma acuminata (warts)

VaginaCondyloma acuminata (warts)

Benign ovarian tumors

Understanding the pathophysiologyPathology of benign ovarian tumorsPhysiological cysts Follicular cyst Luteal cyst

Benign germ cell tumors Dermoid cyst Mature teratoma

Understanding the pathophysiology (cont.)

Pathology of benign ovarian tumors Benign epithelial tumours Serous cystadenoma Mucinous cystadenoma Endometrioid cystadenoma Brenner tumour Clear cell tumour

Benign sex cord stromal tumours Granulosa cell tumour Theca cell tumour Fibroma Sertoli-Leydig cell tumour

Physiological cysts Follicular cyst: The commonest benign ovarian tumor and is most often found incidentally It results from the non-rupture of a dominant follicle or the failure of atresia in a non-dominant follicle Can persist for several menstrual cycles and may achieve a diameter of up to 10 cm Occasionally, they may continue to produce oestrogen, causing menstrual disturbances and endometrial hyperplasia.

Physiological cysts Follicular cyst:

Physiological cysts Follicular cyst:

Physiological cysts Follicular cyst:

Physiological cysts Luteal cyst: Less common than follicular cysts More likely to present with intraperitoneal bleeding They may also rupture, usually happens on days 20-26 of the cycle. Corpora lutea are not called luteal cysts unless they are more than 3 cm in diameter.

Benign germ cell tumors Dermoid cyst:The benign dermoid cyst is the only benign germ cell tumor that is common. It results from differentiation into embryonic tissues. Usually a unilocular cyst < 15 cm in diameter, in which ectodermal structures are predominant.Thus it is often lined with epithelium like the epidermis and contains skin appendages, teeth, sebaceous material, hair and nervous tissue. Endodermal derivatives include thyroid, bronchus and intestine Mesoderm may be represented by bone, cartilage and smooth muscle.

Benign germ cell tumors Mature (solid) teratoma:

These rare tumors contain mature tissues just like the dermoid cyst, but there are few cystic areas. They must be differentiated from immature teratomas, which are malignant.

Benign epihtelial tumours Serous cystadenoma: The most common BET and is bilateral in about 10 per cent of cases Usually a unilocular cyst with papilliferos processes on the inner surface and occasionally on the outer surface. The cyst fluid is thin and serous They are seldom as large as mucinous tumours.

Benign epihtelial tumours Mucinous cystadenoma:They are typically large, unilateral, multilocular cysts with a smooth inner surface; A recent specimen at the Hammersmith Hospital (London) weighed over 14 kg.The cyst fluid is generally thick and glutinous

Benign epihtelial tumours Mucinous cystadenoma:

Benign epihtelial tumours Endometrioid cystadenoma:Difficult to differentiate from ovarian endometriosis. They may be associated with pelvic pain and deep dyspareunia due to adhesions They present a typical appearance on transvaginal sonography with an absence of pupillae and typical ground glass contents of unclotted blood.

Benign epihtelial tumours Brenner Tumours:

These account for only 1-2 % of all ovarian tumours, and are bilateral in 10-15 % of cases. They probably arise from Wolffian metaplasia of the surface epithelium. Although some can be large, the majority is < 2 cm in diameter Some secrete oestrogens and abnormal vaginal bleeding is a common presentation.

Benign epihtelial tumours Brenner Tumours:

Benign epihtelial tumours Brenner Tumours:

Benign epihtelial tumours Clear cell (mesonephroid) tumours These arise from serosal cells showing little differentiation, and are only rarely benign The typical histological appearance is of clear or hobnail cells arranged in mixed patterns

Benign sex cord stromal tumours Granulosa cell tumour

These are all malignant tumors but are mentioned here because they are generally confined to the ovary when they present and so have a good prognosis. They do grow very slowly and recurrences are often seen 10-20 years later. They are largely solid in most cases. Some produce oestrogens and most appear to secret inhibin.

Benign sex cord stromal tumours Theca cell tumour: Almost all are benign, solid and unilateral, typically presenting in the sixth decade. Many produce oestrogens in sufficient quantity to have systemic effects such as precocious puberty, postmenopausal bleeding, endometrial hyperplasia and endometrial cancer.

Benign sex cord stromal tumours Fibroma: These unusual tumors are most frequent around 50 years of age. Most are derived from stromal cells and are similar to thecomas. They are hard, mobile and lobulated with a glistening white surface. Less than 10 % are bilateral.

Benign sex cord stromal tumours Sertoli-Leydig cell tumour:

Rare, less than 0,2 % of ovarian tumors. Difficult to distinguish from other ovarian tumors because of the variety of cells and architecture seen Many produce androgens and signs of virilization are seen in three-quarters of patients. They are usually small and unilateral

SymptomsPresentation of benign ovarian tumours: Asymptomatic (found incidentally) Pain (torsion, rupture, hemorrhage or infection) Abdominal swelling Pressure effects (GI or urinary symptoms) Menstrual disturbances (may be coincidence) Hormonal effects (androgen >> hirsutism & acne) Abnormal cervical smear

Torsion

Abdominal swelling

Differential diagnosisPain: Ectopic pregnancy Spontaneous abortion PID Appendicitis Meckels diverticulum Diverticulitis

Abdominal Swelling:Pregnant uterusFibroid uterusFull bladderDistended bowelOvarian malignancyColorectal carcinoma

Differential diagnosis (cont)Pressure effects:Urinary tract infectionConstipationHormonal effects:All other causes of menstrual irregularities, precocious puberty and postmenopausal bleeding

Investigation Gynecological history General history and examination Abdominal examination Bimanual examination Ultrasound Ultrasound-guided diagnostic ovarian cyst aspiration Radiological investigation Blood test and serum markers

Management

The management will depend upon the severity of the symptoms, the age of the patient and therefore the risk of malignancy and her desire for further children.

Criteria for observation of an asymptomatic ovarian tumors

Unilateral tumor Unilocular cyst without solid elements Premenopausal women-tumor 3-10 cm Postmenopausal women-tumor 2-6 cm Normal Ca125 No free fluid or masses suggesting omental cake or matted bowel loops.

Benign uterus and cervix tumors

Benign disease of the cervix and body of the uterus is extremely common. Cervical ectropion, fibroids and adenomyosis cause symptoms that women present with in almost every gynecological out-patients clinic.

Epithelium: the uterine cervixCervical ectropion

The presence of a large area of columnar epithelium on the ectocervix can be associated with excessive mucus secretion, leading to a complaint of vaginal discharge.

Management: discontinuing the oral contraceptive pill or alternatively ablative treatment under local anesthesia using a thermal probe.

Epithelium: the uterine cervixNabothian folliclesWithin the transformation zone of the ectocervix the exposed columnar epithelium undergoes squamous metaplasia.

Glands contained within columnar epithelium may become roofed over with squamous cells, resulting in the formation of small (2-3 mm) mucus-filled cysts visible on the ectocervix.

Nabothian follicles are occasionally identified coincidentally during TVU scanning.

No pathological significant no require treatment.

EndometriumEndometrial polyps

These typically occur in women aged over 40 years.

EndometriumEndometrial polyps

MyometriumUterine fibroidsA fibroid is a benign tumour of uterine smooth muscle, termed a leiomyoma.

Etiology unknown but growth is oestrogen dependent

The gross appearance is of a firm, whorled tumor located adjacent to and bulging into endometrial cavity (submucous fibroid), centrally within the myometrium (intramural fibroid), at the outer border of the myometrium (subserosal fibroid) or attached to the uterus by a narrow pedicle containing blood vessels (pedunculated fibroid)

Uterine fibroids

Uterine fibroids

Uterine fibroids Clinical features

Risk factors: NulliparityObesityA positive family historyAfrican racial origin

Uterine fibroids Clinical features (cont)

Common presenting complaints are menstrual disturbance and pressure symptoms, especially urinary frequency Menorrhagia submucous fibroids distorting the endometrial cavity and increasing the surface area are truly causal. Subfertility mechanical distortion or occlusion of the fallopian tubes submucous fibroids may prevent implantation of a fertilized ovum. Abdominal exam. might indicate the presence of a firm mass arising from the pelvis.

Uterine fibroids Differential Diagnosis

PregnancyOvarian tumorLeiomyosarcomas

Uterine fibroids Investigation

A Hb concentration will help to indicate anemia if there is clinically significant menorrhagia.USG is useful to distinguish a uterine from an ovarian mass.

Uterine fibroidsTreatment

Concervative management is appropriate where asymptomatic fibroids are detected incidentally.Repeat clinical exam. or ultrasound after a 6-12 month interval. Ovarian suppression using a GnRH agonist A bulky fibroid uterus causes pressure symptoms, the options are myomectomy with uterine conservation, or hysterectomy.

Adenomyosis

Condition in which functioning endometrial tissue has penetrated the myometrium by direct spread from the uterine lining.

AdenomyosisManagementSymptoms and enlargement

Negative No treatment Positive Hysterectomy

Hysterectomy is usually the preferred treatment since adenomyosis does not respond well to hormonal treatment