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The primitive germ cells, originally thought to be derived from germinal epithelium of the gonad, originate in the dorsal part of the epithelial lining of the hindgut. These specialized cells are easily identified in the hindgut by their larger size and paler-staining cytoplasm. They possess the propensity for ameboid motility, and they subsequently migrate to the posterior portion of the gonad and invade the mesenchymal portion. The germ cells differ from somatic cells in size, shape, cytoplasmic structure, and nuclear arrangement. They have almost 30 times as much cell body as nucleus; the nucleus is vesicular and has a distinctive chromatin arrangement with several nucleoli.
The first stage in the organ development takes place in the formation of primary cell cords from the local mesenchyme after migration of the germ cells. Later, additional aggregates of cells form from the surface epithelium and fuse with the locally produced primary sex cords. It is possible that the second set of cells retain totipotential reactivity to estrogen and progesterone in the adult ovary, accounting for the celomic metaplasia theory of the origin of endometriosis.
The next step in the development of the ovary is the partitioning of the germinal cords into islands, each containing two or more germinal cells. This segmentation is brought about by proliferation of nonspecific mesenchymal stroma and is completed when each oocyte is a potentially functional unit surrounded by a single layer of prospective granulosa cells. As the granulosa cells proliferate, the egg cell is displaced eccentrically. Cellular proliferation is followed by liquefaction, with formation of a cavity. This follicular structure is the graafian follicle.
Approximately 12 to 15 graafian follicles may be found in the fetal ovary during week 36 of gestation. The hilus, from which the connective tissue and vascular channels radiate, represents the portion of the gonadal anlage that is not separated by the development of the lateral clefts and is therefore in direct continuity with the mesonephric ridge. From this area, a network of connective tissue arises that penetrates the gonad and is completely developed in the 180-mm fetus. These fibers form a coarse mesh in the medullary region but are much finer in the cortex. Under the surface epithelium, another layer of coarse connective tissue develops and extends parallel to the ovarian surface; this eventually becomes the tunica albuginea.
The human ovary undergoes multiple changes in size, shape, and position during the lifetime of a woman. In addition to extensive histologic changes brought about by various endocrine stimuli, ovarian asymmetry is common; the right ovary is usually larger than the left. Independent fragments of ovary may exist as a result of complete segmentation during embryonic development. Segments may be found retroperitoneally that may produce estrogen and progesterone after bilateral oophorectomy. A portion of the left ovary can often be left in the mesentery of the sigmoid after bilateral salpingo-oophorectomy, where it resides as an independent focus.
In the newborn, the ovary is a delicate structure that is 1.5 cm long, 0.5 cm wide, and 1.5 to 3.5 mm thick. It weighs 0.3 to 0.4 g and is shaped like a three-sided prism with rounded edges. The surface of the ovary is pinkish white and smooth, and it glistens. Occasionally, small cystic structures can be seen throughout the surface epithelium. The ovary gradually enlarges in size and changes shape and position between birth and puberty. The ovary becomes almond
The onset of puberty brings many changes in the histologic anatomy of the ovary that significantly alter the gross anatomic appearance. At this stage, the organ is 2.5 to 5 cm long, 1.5 to 3.0 cm wide, and 0.6 to 1.5 cm thick. The upper, rounded pole of the ovary is embraced by the fimbria of the oviduct and is attached to the suspensory ligament. The lower, more pointed pole is attached to the uterus by a fibromuscular cord, the uteroovarian ligament. Blood vessels and nerves enter and leave the ovary by way of the hilus through the mesovarium. The ovary normally resides in the triangular fossa formed by diverging folds of peritoneum covering the iliac vessels. It is bound laterally by the iliac veins and ureter and anteriorly by the round ligament. The vertical position of the ovary is maintained by the infundibulopelvic ligament, aided by the mesovarium and the uteroovarian ligament. The normal ovarian cortex is usually tense and elastic. When cut, fluid escapes from follicles and cysts, exposing a pink, moist surface. Follicular cysts have smooth, thin-walled cavities and are 3 to 5 cm in diameter.
The arterial supply of the ovary is derived from an anastomosis of the ovarian and uterine vessels. The ovarian artery arises from the aorta and is enmeshed with its venous counterpart in the infundibulopelvic ligament. As it reaches the broad ligament, it divides, giving off a branch to the oviduct. The main ovarian trunk runs in the folds of the broad ligament and mesovarium, and it divides again to give off multiple branches that enter the hilus of the ovary. At this point, each artery is subdivided into two medullary branches that traverse the entire ovary. Each medullary artery runs in a straight-line fashion to the opposite pole of the ovary, giving off cortical branches during its course. The cortical vessels divide into arterioles, each of which supplies a group of follicles. There is a free anastomosis between cortical arterioles, and at the cortical margin, the arterioles anastomose with the venules.
The venous drainage is similar to the arterial arrangement, the veins emerging at the hilus as two major vessels. These represent the uterine and ovarian venous systems, and during pregnancy or extreme venous congestion, a pampiniform plexus is evident. At the time of cesarean section, these venous channels are enormously distended and tear easily.
The nerve supply arises from a sympathetic plexus intimately enmeshed with the ovarian vessels in the infundibulopelvic ligament. Its fibers are derived from branches of the renal and aortic plexuses and from the celiac and mesenteric ganglia. Nonmedullated nerve trunks accompany the arterial trunks. They then divide into terminal plexuses that surround the arterioles and extend to the follicles.
During pregnancy, the ovaries are lifted out of the true pelvis by the enlarging uterus, and during the early weeks of gestation, the corpus luteum of pregnancy is large and protrudes above the ovarian surface. At the time of cesarean section, the ovaries are usually of normal size but are covered with a pink, irregular frosting that is attached to or part of the surface epithelium. This pink, irregular frosting represents a pseudodecidual reaction in totipotential mesenchyme caused by the prolonged and continuous stimulation of chorionic estrogen and progesterone. During the puerperium, the ovary diminishes in size, and the pseudodecidual reaction disappears. The cystic follicles undergo atresia, and some time may elapse before gonadotropic function brings about follicular maturation and ovulation.
After menopause, the ovary undergoes rapid regressive changes. It becomes smaller, and the surface becomes wrinkled, frequently resembling the gyri and sulci of the cerebrum. The color fades from gray to almost white. Perhaps the most striking change is in the size of the organ; it may be only 2 by 1.5 cm or less. In many postmenopausal or senescent patients, the ovary is so small that it cannot be palpated on pelvic examination.
The microscopic anatomy of the ovary is quite dynamic. In proximity to the medulla of the ovary is a zone of growing follicles, and in the newborn and infant, well-developed graafian and atretic follicles are seen. During infancy, growth of follicles and stroma is rapid; this rate of differentiation then tapers off until the time of pubescence, when rapid development again occurs. The number of ova in the newborn ovary is estimated to be between 50,000 and 400,000. In the average female lifetime, not more than 300 to 400 proceed through ovulation and are released with the potential for fertilization.
The number of primordial follicles diminishes from birth, and there is no evidence that formation of new follicles occurs after birth. During pubescence, the follicles of the hilus develop first. There is first an increase in the size of the follicular cells as they become cuboidal with an increase in cytoplasm. There is also a natural increase in the number of cells until three or four layers surround the ovum. Eventually, the follicular cells become multilayered, and a fluid, the liquor folliculi, accumulates eccentrically. The precise cause of this fluid is unknown in the human but is presumed to be a combination of cell secretion, cell degeneration, and vascular transudate.
In follicles smaller than 0.3 mm, the ovum is centrally placed, but in follicles 0.4 mm or larger, a vesicular form appears, and the ovum is placed eccentrically. The follicle cells, known as granulosa cells, are arranged around the ovum in a covering 8 to 12 rows thick. The mound of granulosa cells containing the ovum that projects into the cavity of the follicle is known as the cumulus oophorus. As the growth of
The early primordial follicle is devoid of a connective tissue covering, but the fully developed follicle has an inner layer, the theca interna, and an outer layer, the theca externa. The origin of the theca interna cells is unsolved, but characteristic fat-laden or spiral cells appear between its fibrils. There is some evidence that these cells contain steroid substances, which probably are precursors in the production of estrogen and progesterone. The theca externa contains only coarse fibers that intertwine around the follicle and form a thick capsule.
The mature ovary does not differ appreciably from the description of the ovary at pubescence except for changes associated with ovulation. The surface epithelium retains only a single layer of cuboidal cells, but there are furrows and folds due to cicatrization in areas of previous ovulation. Occasionally, the surface epithelium dips into the cortical area and may become pinched off, providing an etiologic mechanism for cyst formation. The tunica albuginea lies subjacent to the surface epithelium and is composed of interlacing, coarse fibers with minimal cellularity.
The exact mechanism by which ovulation is initiated in the human is unknown, although studies using animals suggest that ovulation is associated with significantly increased intrafollicular pressure. Follicular rupture is associated with an escape of the liquor and a collapse of the walls, with extrusion of the ovum and discus proligerus into the fimbria of the oviduct or into the peritoneal cavity. It is possible for ovulation to occur without release of the ovum. Ovarian pregnancies and certain cases of idiopathic infertility may be explained on this basis. After rupture, there is hemorrhage into the theca interna, and the stigma is sealed by a blood clot from the thecal vessels and by a central coagulum in the cavity. Examination at this stage reveals active mitoses in the granulosa and theca cell layers, and the structure is rapidly converted into the corpus luteum.
Many investigators recognize four stages in the development of the corpus luteum: proliferation, vascularization, complete development, and regression. During the proliferative stage, granulosa cells and theca cells show active mitotic activity, and there is rapid growth. The theca cells enlarge even more than the granulosa cells, and deposits of lipid are seen in the cytoplasm. This stage lasts about 4 days and results in the formation of an epithelial gland with secretory activity.
The stage of vascularization is characterized by the appearance of a raspberry-like protuberance on the ovarian surface. The dark red peripheral area surrounds a jelly-like core that is gray or pink, and the entire structure is friable and vascular. The endothelial capillaries extend through the entire granulosa layer to the central coagulum. Connective tissue cells begin to invade the coagulum, and these cells and the fibrin deposits account for the healing of the stigma.
The stage of full development is evidenced by a moderate increase in size of the total structure, firmness of the central core, and a scalloped border that becomes brown or yellow. Liquefaction of the central coagulum may give rise to cyst formation. At this stage, the granulosa cells have a characteristic pale, clear cytoplasm, and the number of theca cells are diminished.
The stage of regression, beginning about day 26 of a normal cycle, proceeds rapidly. The core becomes fibrotic, the granulosa layer diminishes, and the cells become granular and vacuolated. The theca cells are loosely arranged in groups, with dark nuclei and pale cytoplasm. There is progressive fibrosis and hyalinization of the core, atrophy of the lutein layers, and crenation of the hyalinized connective tissue. The resultant scar, known as a corpus albicans, requires about 70 days to develop.
All primordial follicles do not reach maturity. It is evident that most undergo a degenerative process known as atresia. This process has been observed in the ovaries of newborn infants and young children. The zona pellucida first becomes hyalinized and crenated. The germinal vesicle then demonstrates chromatin lysis, and the ovum is invaded by round cells. After degeneration of the ovum, the follicular epithelium begins to show specific necrobiotic changes. In a well-developed follicle, there is resorption of the liquor folliculi and folding of the peripheral layers. The granulosa and the theca layers are replaced by fibrous connective tissue that is later hyalinized. The scar may persist for long periods and is known as a corpus atreticum. Large follicles may not undergo complete regression, and if the liquor is not completely absorbed, a cystic process may develop. This is demonstrated in the sclerocystic ovarian syndrome in which cyclic ovulation does not occur.
The most common enlargements of the ovary are those arising from physiologic cystic proliferation of the normal follicular apparatus of the ovary; these
The benign true neoplasms of the ovary arise from normal constituents of the ovary or from congenital rests or heterotopic implants. The tumors developing from structures of the ovary are mostly cystic tumors, which arise from the surface (i.e., germinal) epithelium; the hormone-producing tumors, which arise from the specialized stroma of the ovarian cortex; the rare tumors also found in sites other than the ovary, which arise from the nonspecialized connective tissue of the ovary; and the benign and malignant teratomas, which arise from the germ cells. Tumors arising from congenital rests or heterotopic implants include adrenal tumors, hilus-cell tumors, and mesonephric and metanephric rest tumors.
The classifications of tumors or enlargements of the ovary have evolved because of a need to understand the origin and function of these lesions and their clinical significance. As more is learned about the physiology and metabolism of the ovary, it becomes apparent that all of the classifications have serious shortcomings. Nonetheless, some form of organization is necessary to permit an orderly discussion of the varieties of benign ovarian enlargements, and the following outline serves this purpose:
Functional cysts
Follicle cyst
Corpus luteum cyst
Theca lutein cyst
Hyperplasia
Germinal inclusion cyst
Hyperthecosis
Luteoma
Polycystic ovary
Endometrial cysts
True neoplasms
Common surface epithelial neoplasms
Serous cystadenoma
Mucinous cystadenoma
Cystadenofibroma
Brenner tumor
Sex cord-mesenchymal (i.e., gonadal stromal)
tumors
Theca cell tumor
Hilus cell tumor
Nonintrinsic connective tissue tumors
Fibroma
Rare tumors
Germ cell tumors
Mature teratoma
Cystic teratoma (i.e., dermoid)
Struma ovarii
Carcinoid tumor
Gonadoblastoma
Adrenal rest tumor.
Figure 51-1 Follicle cysts of the ovary.
Mature or atretic follicles that become distended with pale, straw-colored fluid are frequently found in the ovary. Enlargement of atretic follicles to the point of producing grossly visible cystic changes is common during infancy and childhood and rarely may enlarge one or both ovaries. After puberty, grossly cystic follicles are less common but still constitute the most frequently seen cystic enlargement of the ovary.
Follicle cysts are the result of failure of ovulation, with continued growth of the follicle. They are usually multiple and occur in both ovaries (Fig. 51-1) . The average size of follicle cysts is 2 cm, and they only occasionally attain a diameter larger than 3 cm.
Follicle cysts causing marked enlargement of the ovaries are rare complications of hyperstimulation from exogenous gonadotropins used to induce ovulation. They do not always alter the external surface of the ovary but may produce yellow blebs on the surface. When cut, they are seen to be thin walled and filled with a clean serous fluid. Microscopically, the cystic space is lined by a layer of granulosa and underlying theca cells, occasionally flattened or obliterated by the intracystic pressure (Fig. 51-2) .
Follicle cysts rarely produce symptoms unless they
Figure 51-2 Microscopic
section of the wall of a follicle cyst, shows the lining granulosa cells.
A diagnosis is often made at the operating table, and treatment consists of nothing but puncture of the cyst or excision of the cyst if it is large or hemorrhagic.
Although these cysts may attain a size of 8 to 9 cm in diameter, spontaneous resolution usually occurs within 8 weeks (Fig. 51-3) (Figure Not Available) . Some clinicians feel that the use of oral contraceptive medications during the 8-week period assists resolution, ostensibly by reducing follicle-stimulating hormone secretion. Persistence of a large cystic structure beyond this waiting period requires further diagnostic procedures, including possible laparoscopy and laparotomy for cyst removal.
The corpus luteum that develops after ovulation is normally a cystic structure, albeit small and often only potentially cystic. During pregnancy, with growth and
Figure 51-3 (Figure Not Available) Management of a premenopausal woman with an adnexal mass. (From DiSaia PJ, Creasman WT. Clinical gynecologic oncology. 4th ed. St.
Louis: CV Mosby, 1993.)
Cystic enlargement rarely exceeds 4 cm in diameter but has been observed to be as large as 11 cm. Grossly, the cyst protrudes from the contour of the ovary, and the wall appears convoluted, with yellow-orange areas alternating with the usual gray surface. If the cyst is filled with blood, a dark red or purple discoloration is seen. Microscopically, all elements of the corpus luteum are present in the cyst wall. Depending on the age of the cyst and the degree of intracystic pressure, luteinized granulosa and theca cells may be easily recognizable or may be distorted. The center of the cyst contains blood, serous coagulum, and some connective tissue organization.
Symptoms are related to large size or complications
Spontaneous regression of these cysts in a manner similar to follicle cysts, usually occurs within 8 weeks. Hallatt described 173 women (Table 51-1) (Table Not Available) with hemoperitoneum from a ruptured corpus luteum demonstrating a right-sided predominance and frequent onset during intercourse.
If the symptoms warrant operation, treatment usually consists of excision of the cyst and conservation of the remainder of the ovary.
Theca lutein cysts are the least common of the three types of functional ovarian cysts. During pregnancy, atretic follicles are numerous in the ovaries. Occasionally, they undergo cystic enlargement. Bilateral ovarian enlargement due to multiple theca lutein cysts occurs in 50% to 60% of women with hydatidiform mole, 5% to 10% of women with choriocarcinoma, and a few women who have multiple gestations. Cyst formation is best explained as a response to the increased production of chorionic gonadotropin.
The cysts are almost always bilateral, and the enlargement may exceed 15 cm. The external surface
Theca lutein cysts rarely produce symptoms of their own and are usually found incidentally in a patient with hydatidiform mole (Fig. 51-5) . The finding of bilaterally enlarged ovaries offers strong support to the diagnosis of hydatidiform mole. These cysts may undergo the same complications as other ovarian enlargements. Despite the occasional enormous size of theca lutein cysts, they are physiologic and should be removed only if dictated by the nature of the intrauterine pathology. After evacuation of a hydatidiform mole or termination of a pregnancy, complete regression of the cysts and return of the ovary to normal size may be anticipated.
Figure 51-4 Microscopic section of the wall of a theca lutein cyst shows vertically arranged
luteinized theca cells. There is slight fibrosis of the central lining.
Figure 51-5 Bilateral theca cysts associated with a hydatidiform mole.
Bilateral polycystic enlargement of the ovaries is found in adolescent girls and young women with a complex of symptoms and endocrine abnormalities related to anovulation (Fig. 51-6) . These ovaries are enlarged, tense, and oval. The external surface is smooth and white, sometimes revealing subcapsular cysts. The tunica is thick, tough, and white. The ovarian cortex is represented by a thick fibrous capsule surrounding ovarian stroma containing multiple follicle cysts (Fig. 51-7) . Microscopically, the follicle cysts demonstrate prominent hyperplasia of the theca interna cells, which are frequently luteinized (Fig. 51-8) . Atretic follicles are numerous, with similar hyperplasia and luteinization of theca cells surrounding the lumen. Primordial follicles are not present in the
Figure 51-6 An x-ray gynegram of an adolescent patient demonstrates bilateral
polycystic enlargement of ovaries.
These ovarian changes may result from a specific type of ovarian insufficiency without clearly demonstrable causes outside of the ovary. In 1935, Stein and Leventhal reported seven cases of a possible syndrome consisting of bilateral polycystic ovarian enlargement, amenorrhea or irregular menses, and infertility, often with masculinization. Similar cystic ovarian enlargement is not uncommon in patients with various types of adrenal hyperplasia and has been observed with pituitary and hypothalamic tumors, increased intracranial pressure, adrenal tumors, and chronic inflammatory disease of the pelvis. Similar changes have been observed in ovaries containing small, masculinizing mesenchymomas. The ovaries of prepubertal girls between 10 and 15 years of age are morphologically similar to the polycystic ovaries just described. All of these observations suggest that the microscopic morphology of the polycystic ovary is specific only of anovulation. The similarity between the morphology of the polycystic ovary in the abnormal postpubertal woman and that in the normal prepubertal girl and certain clinical findings in the postpubertal women suggest that the clinical syndrome of the polycystic ovary is related to acyclic hypothalamic activity and failure to initiate regular ovulation at puberty.
For many years, there has been interest in polycystic ovary disease and its variations, and there have been efforts to explain the altered ovarian physiology. As a result of this enthusiasm, the polycystic ovary syndrome has become more elusive and hard to define. If we eliminate the nonovarian causes of anovulation and related symptoms of amenorrhea, infertility,
Figure 51-7 Gross appearance of the cut surfaces of bilateral polycystic
ovaries.
Characteristically, these young patients, who may still be in adolescence or slightly beyond, have never developed regular ovulatory cycles. A few have never menstruated, but most have had irregular menstrual periods that have gradually become more abnormal. In some cases, this menstrual abnormality is first manifested by excessive or prolonged bleeding due to endometrial hyperplasia. Eventually, the periods may become infrequent, scanty, or absent. Infertility exists and is commonly the most serious problem among the patients who are married. There may be hirsutism but rarely true masculinization. Obesity is sometimes a factor. Ovarian enlargement, although common, may be absent or unilateral. This may be demonstrated by pelvic examination, ultrasonography,
Figure 51-8 Polycystic ovary. Microscopic section of a follicle cyst with
an inner lining of granulosa cells and an outer zone of hyperplastic luteinized
theca cells. The theca cells are large with abundant, pale cytoplasm. There
is a Call-Exner body in the granulosa layer.
Some patients manifesting polycystic ovarian disease may have a related abnormality that is known as hyperthecosis. These patients may have striking hyperplasia and luteinization of the theca interna surrounding the cyst and atretic follicles. The cortical stroma itself may be hyperplastic and may have islands of luteinized cells. The cause of this change is unknown and may be another manifestation of polycystic ovarian disease.
Luteomas are hyperplastic nodules of large, pale, polyhedral lutein cells in the stroma in one or both ovaries. Such lesions may be discrete, as large as 3 cm, and yellow, brown, or white. They have been reported in perimenopausal and postmenopausal women in association with androgen manifestations. In this circumstance, they may be classified with the lipid-cell tumors.
Luteoma of pregnancy is a specific hyperplastic entity that develops during pregnancy and involutes after delivery. These lesions probably arise from hyperplasia of the luteinized theca cells of atretic follicles. The lesions are bilateral in as many as one half of the cases and may reach sizes as large as 20 cm. Approximately one fourth of patients have androgen manifestations. However, in most cases, the lesions are asymptomatic, incidental findings. The lesions regress rapidly after termination of pregnancy and should be removed only if the diagnosis is unknown or uncertain.
Serous inclusion cysts are nonfunctional and are commonly found in ovaries removed at hysterectomy with salpingo-oophorectomy. They probably result from repeated ovulation with trapping of surface epithelium in the cortex of the ovary, particularly in the epithelium that lines crypts. They may lie close to the surface or deep in the cortex, and they may be a few millimeters to several centimeters in diameter. Most of these cysts are small and microscopic, but they can be large, unilocular, and have a smooth, well-vascularized outer and inner surface. They contain watery fluid that may be clear, blood tinged, or grossly bloody. Large cysts should be differentiated from paraovarian cysts; the latter arise in the mesoarium. Many researchers think that these cysts are the source of benign and malignant epithelial tumors of the ovary. Tumor markers commonly associated with epithelial neoplasms of the ovary can be identified in the cells lining these cysts, supporting the concept that they may be an origin of epithelial neoplasms of the ovary.
Functional, ectopic endometrium can implant on the ovary and still retain its ability to bleed periodically with the proper hormonal stimulus. Alternate oozing and healing with each menstrual cycle results in the formation of endometrial cysts. Endometrial cysts vary in size from microscopic implants (i.e., "powder burns") to 10 to 12 cm in diameter. Dense adherence to neighboring structures is commonplace, making surgical excision without rupture rare. The cyst wall contains active endometrial tissue, and local bleeding occurs from these foci of tissue simultaneous with menses. Hemosiderin, pseudoxanthoma, and chronic inflammatory elements with fibrosis are often seen.
The symptoms associated with endometrial cysts include infertility, hypermenorrhea, dyspareunia, and dysmenorrhea. Dysmenorrhea is usually premenstrual or comenstrual and is of an aching crescendo or grinding type, with pain often referred to the sacrum or rectum.
Not all chocolate cysts are endometrial in origin. Bleeding into any cystic cavity later yields decomposed blood, creating the chocolate-colored material. Treatment of endometriomas is surgical resection of the cyst, leaving as much functional ovarian tissue as possible.
Distortion and adherence of the tube and ovary as a result of salpingitis or pelvic peritonitis can cause a restricted, inflammatory adnexal mass as large as 15 cm in diameter with cyst formation. Severe, persistent pelvic pain and tenderness are typical. Menorrhagia and hypermenorrhea may also occur. If the pain is unilateral, acute appendicitis, intrapelvic bleeding, and endometriosis must also be considered. The leukocyte count and erythrocyte sedimentation rates are moderately elevated, and the pregnancy test result should be negative. Antibiotics, analgesics, and sometimes local heat are helpful in alleviating the symptoms.
The serous cystadenoma and the mucinous cystadenoma are the most common benign ovarian neoplasms. Serous tumors constitute 15% to 25% of all
The serous cystadenoma (Fig. 51-9) is a unilocular, parvilocular, or multilocular cystic neoplasm derived from the surface epithelium of the ovary and lined by epithelium that resembles the mucosa of the oviduct. The external surface is smooth or lobulated, gray or blue-gray, and darker if there has been hemorrhage into the cyst. External papillary projections occur in 10% to 30% of tumors. They are firm, white, and broad based. Softness and friability suggest malignancy. The benign serous cystadenoma is usually between 5 and 15 cm in diameter; occasionally, it fills the entire abdomen. The cut surface reveals a single loculus or multiple loculi that have a smooth, gray lining and contain clear, yellow fluid. Most are unilocular and thin walled. Less common are those with multiple loculi and numerous thin septa. Papillary processes similar to those described on the external surface may be found. Finding solid portions should suggest malignancy. One or more of the loculi may contain blood.
Microscopically, the epithelial lining of a serous cystadenoma varies from simple cuboidal to tall columnar cells with elongated nuclei, resembling the epithelium of the oviduct (Fig. 51-10) . Cilia are observed in some cases. The stroma varies from an edematous to a densely fibrous type, and the amount of stromal tissue varies. The papillary processes are broad, fibrous, and covered by a single layer of epithelium (Fig. 51-11) . Occasionally, small calcific concretions, known as psammoma bodies, are found in the stroma adjacent to the epithelium. These deposits, if present in large numbers, may be visible on x-ray examination of the abdomen.
The microscopic evaluation of malignancy in this group of tumors may pose considerable difficulty. In some borderline tumors, piling up of epithelial cells and slight degrees of dedifferentiation make it impossible to differentiate a benign from a malignant process. In these cases, which are also referred to as tumors of low malignant potential, only the clinical course indicates the biologic nature of the tumor. The problem of borderline malignancy is discussed elsewhere.
Figure 51-9 Serous cystadenoma. The surface of the tumor is lobulated and glistening.
The tumor assumed the shape of the bony pelvis as it grew. The hydrosalpinx
is attached to the superior surface of the cyst.
Figure 51-10 Microscopic view of a papillary serous cystadenoma. The tumor did not enlarge
the ovary and was not visible externally. The papillary processes are blunt
and broad based and are lined by single layer of epithelium. This lesion
represents an early phase in the histogenesis of a serous tumor of the ovary.
Figure 51-11 Microscopic section of a papillary serous cystadenoma. The papillae are small
and delicate but are lined by a single layer of epithelium.
No symptoms are specific for this tumor. The diagnosis is commonly made after pelvic examination in a patient who is asymptomatic or has noticed gradual abdominal enlargement.
Treatment must be planned with knowledge of the frequency of bilateral involvement, the potential for malignancy, and the fact that papillary processes and hemorrhage suggest malignancy. In patients past the childbearing age, treatment should consist of bilateral salpingo-oophorectomy and hysterectomy. Conservatism is recommended for most other patients.
Mucinous cystadenomas are unilocular or multilocular cystic ovarian tumors occurring as often as serous cystadenomas. They constitute 16% to 30% of all benign ovarian neoplasms. Unlike the serous tumors, they are bilateral in only 5% to 7% of cases. Moreover, the incidence of similar tumors appearing later in the conserved, opposite ovary is extremely low. These tumors rarely become malignant. Mucinous cystadenomas occur most frequently during the third and fifth decades of life, and only occasionally (10%) after menopause. They may complicate pregnancy.
There are two theories of histogenesis. The most commonly accepted is an origin from the surface epithelium of the ovary with differentiation to the endocervical type of mullerian duct epithelium. The other theory holds that the epithelium is an intestinal type and arises from a monophyletic teratoma in which only one type of tissue persists. It is possible that the cysts arise in both fashions.
Mucinous tumors are often much larger than the serous cystadenomas and usually account for the legendary huge cysts that are reported (Fig. 51-12) (Figure Not Available) . They range from 1 to 50 cm in diameter, but most are between 15 and 30 cm in diameter. They usually are completely cystic and multilocular. The external surface is smooth, occasionally lobulated, pinkish gray, and without extracystic papillary growths (Fig. 51-13) and (Fig. 51-14) . The cut surface shows individual cysts or locules of various sizes that contain a sticky, slimy, or viscid material. The interlocular septa are very thin. Intracystic papillary processes are found in 10% to 25% of the cysts, and as is true for the serous tumor, they are even more common in the malignant variety.
Microscopically, the locules and cysts are lined by a typical tall, columnar, picket-fence-type of cell, with a basally situated nucleus and superficial accumulation of mucin within the cytoplasm (Fig. 51-15) . The cell resembles the secretory cell of the endocervix and intestine. Argentaffin cells also may be present. Dense connective tissue stroma is scant and forms a capsule.
The usual treatment for the obviously benign mucinous cystadenoma is unilateral oophorectomy. In older women, bilateral oophorectomy and hysterectomy are preferable.
Figure 51-12 (Figure Not Available) Patient with a huge, benign cystadenoma of the ovary. The cyst weighed 128
lb (58 kg); after removal, the patient weighed 126 lb (57 kg). There was
marked edema of the lower extremities. (Courtesy of J. W. Kelso)
Pseudomyxoma peritonei is a complication that may result if the contents of a mucinous cyst are spilled into the peritoneal cavity by rupture, extension, or at surgery. This is a good reason not to tap or aspirate ovarian cysts during surgery. Pseudomyxoma does not always develop with spillage, and pseudomyxoma peritonei has been reported in women with intact ovaries and ovarian cysts. The process is biologically malignant, although it is histologically benign. Diffuse implants develop on all the peritoneal surfaces, with tremendous accumulation of mucinous material within the peritoneal cavity. Rarely is there spread beyond the peritoneum or invasion of vital structures. Microscopic examination of the implants reveals the morphology of a benign mucinous tumor. The areas of epithelium are scant and hard to find. The clinical course is usually progressive malnutrition and emaciation. The fluid is difficult to remove because of its viscosity, and repeated laparotomies may be required.
Figure 51-13 Mucinous cystadenoma. The surface of the tumor is bosselated,
and a solid portion is in the lower pole.
The cystadenofibroma is a variant of the serous cystadenoma and is much less common. This tumor is partially cystic and partially solid. The age distribution
Figure 51-14 Mucinous cystadenoma coexisting with a cystic teratoma (i.e.,
dermoid). Coexistence of these two tumors supports the theory of the origin
of mucinous tumors from benign teratomas.
The external surface is gray or white, composed of multiloculated cystic areas and lobulated solid portions with broad papillae or deep sulci. The papillae are firm and nonfriable. The cut surface reveals numerous amber fluid-filled cysts within firm, glistening, grayish white lobules. Microscopically, the solid areas are composed of whorls of fibrous connective
Figure 51-15 Microscopic
appearance of the lining of a mucinous cystadenoma. The "picket-fence" epithelium
is characteristic of this tumor.
The Brenner tumor is a fibroepithelial tumor with gross characteristics similar to those of the fibroma. It constitutes approximately 1% to 2% of all ovarian tumors and is rarely malignant. Brenner tumors have been reported in patients 6 to 81 years of age; however, approximately one half of the patients are older than 50 years of age. One study indicates that approximately 13% of the tumors are bilateral, but rates as low as 5% have been given by others.
According to the most widely accepted theory of histogenesis, Brenner tumors arise from the Walthard cell rests, which are a modification and inclusion of the surface or germinal epithelium of the ovary. Brenner tumors and mucinous cystadenomas occasionally coexist. This is explained as metaplasia of the mucinous epithelium to the squamoid type or of the epithelial nests of the Brenner tumor to a mucinous type. The association of these two tumors is compatible with a theory of origin from the surface epithelium of the ovary. Coexistence of other genital tumors has been reported.
The tumors can be microscopic to 30 cm in diameter. The average tumor is between 10 and 15 cm in diameter. They are usually solid but may be partially cystic. The surface is smooth and grayish white, with irregular lobulation. The cut surface is grayish white and whorled. The cystic areas vary in size and contain clear serous fluid. Microscopically, the solid portion of the tumor consists of abundant fibrous connective tissue and typical nests of squamous-like epithelial cells with characteristic longitudinal grooving of the nucleus (Fig. 51-16) . Frequently, the centers of these nests become cystic. The cells lining the central cavity are cuboidal, low columnar, or occasionally typical of mucinous epithelium.
A few Brenner tumors have been associated with postmenopausal bleeding, and it has been suggested that some may contain hormonally active stroma. In common with the fibroma and thecoma, the Meigs syndrome of ascites and hydrothorax occurs with Brenner tumors. Treatment usually consists of simple excision or oophorectomy.
It is apparent that the morphology of gonadal stromal tumors (i.e., sex cord-mesenchymal tumors) is often amazingly similar and that tumors of each morphologic type may demonstrate clinical features of estrogen
Figure 51-16 Microscopic appearance of cell nests in a Brenner tumor. Beginning
cystic change is occurring in one of the cell nests.
Any attempt to limit the production of specific hormones to a specific cell or a specific tumor of the ovary is not realistic in the light of clinical findings or knowledge of steroid biosynthesis in the ovary. Any cell or tissue that is capable of steroid biosynthesis is capable of producing progesterone, estrogens, and androgens. The predominance depends on the rates of biosynthesis and the enzymes required for the various steps. It is postulated that all of these tumors arise from the mesenchymal ovarian stroma, which retains most of its embryonic multidifferentiating potential. This potential may be exploited in degree and direction by tumorigenic stimuli. Abnormal hormone production probably occurs as a result of subsequent imbalance of normal enzyme activity and disruption of the usual steroid metabolic pathways.
In considering the clinical importance of this group of hormonally active tumors, it is impossible to stress too strongly the fallacy of emphasizing the histology rather than the metabolic activity of the tumor. However, histologic classification remains a handy means of considering the pathology of these tumors and is a necessity in deciding the malignant potential.
Most granulosa cell tumors contain various amounts of theca. However, there are tumors composed principally or entirely of theca cells (i.e., 12% of the feminizing mesenchymomas). Thecomas constitute about 2% of all ovarian tumors. They occur at all ages but are uncommon in women younger than 35 years of age. They are most often found in postmenopausal women.
The evidence indicates that thecomas arise from the ovarian cortical stroma. Transition from cortical stromal hyperplasia to thecoma has been observed, and cortical stromal hyperplasia frequently affects the opposite ovary.
Theca cell tumors are unilateral and almost never malignant; fewer than 20 cases of malignant thecoma have been reported. The encapsulated tumor may be so small that the external contour of the ovary is unaltered, or it may become as large as 15 to 20 cm in diameter. The external surface is firm, ovoid or round, smooth, and gray, occasionally streaked with yellow. The cut surface is firm, uniform, and gray, frequently showing yellow foci that represent luteinization with fat deposition (Fig. 51-17) . Microscopic examination reveals interlacing bands of plump, spindle-shaped theca cells with intervening zones of hyalinization (Fig. 51-18) . Fat stains frequently reveal the presence of fat within the cells. Some tumors show marked luteinization. Thecomas have been found
Figure 51-17 Thecoma
of the ovary. The cut surface is white streaked with yellow areas that represent
luteinization with fat deposition. Notice the hemorrhagic corpus luteum.
Symptoms are related to estrogen production. However, in 25% of cases, there has been no evidence of hormonal activity. Because the tumors are most common in the postmenopausal period, the most
Figure 51-18 Microscopic view of a thecoma.
The fat stain reveals fat within the cystoplasm of plump, spindle-shaped cells.
Figure 51-19 Patient
with marked masculinization resulting from a hilus cell tumor. The same appearance
may be associated with other masculinizing tumors of the ovary.
Treatment usually consists of removal of the involved ovary in young patients and bilateral salpingo-oophorectomy and hysterectomy in older patients.
Hilus cell tumors are extremely rare; approximately 50 have been described in the literature. The tumors are small and produce relatively little enlargement of the ovary. They have been discovered most often in menopausal women with hirsutism who have had menstrual abnormalities (e.g., oligomenorrhea, amenorrhea), infertility, enlargement of the clitoris, and related features of masculinization (Fig. 51-19) . Hilus cell tumors produce high levels of testosterone. Only one malignant tumor has been described.
Grossly, hilus cell tumors are circumscribed, solid, soft, and yellow or brown (Fig. 51-20) (Figure Not Available) . Microscopically, they consist of nonencapsulated sheets or cords of polyhedral cells similar to the normally occurring hilus cells of the adult ovary (Fig. 51-21) (Figure Not Available) . The cytoplasm contains lipochrome pigment and eosinophilic crystalloids.
Unilateral oophorectomy is recommended. It may be necessary to bisect the ovary to discover the tumor.
The ovarian fibroma is a connective tissue tumor composed of fibrocytes and some collagen. The fibroma occurs most frequently in middle-aged patients, at an average age of 48 years. These tumors probably arise from the nonintrinsic connective tissue of the ovarian cortical stroma, although they may represent the inactive end stage of thecomas. The frequency of bilaterality is between 2% and 10%.
The average size of ovarian fibromas is 6 cm, but 5% of the tumors are larger than 20 cm. At operation, the tumor is found to be firm or hard and smooth; the external and internal surfaces are grayish white and glistening (Fig. 51-22) . The cut surface is composed of homogeneous fibrous tissue but may contain cysts. Microscopically, the tumor consists of small, thin, spindle-shaped cells arranged in bundles, giving an overall fasciculated appearance. Small tumors usually are cellular; large tumors are more fibrous. Differentiation from thecoma may be difficult.
There are no specific symptoms other than the occasional finding of ascites and unusual finding of hydrothorax. The explanation of this occurrence with benign solid tumors is not clear and is of no special relevance. The effusion disappears after removal of the tumor. Simple removal of the tumor is adequate
Figure 51-20 (Figure Not Available) Uterus and ovary containing a hilus cell tumor. The ovary was not enlarged. (From Merrill JA. Ovarian hilus cells. Am J Obstet Gynecol 1959; 78:1258.)
Figure 51-21 (Figure Not Available) A microscopic
section from the edge of an ovarian hilus cell tumor demonstrates a lack of
encapsulation and nests of cells comprising growth. (From Merrill
JA. Ovarian hilus cells. Am J Obstet Gynecol 1959; 78:1258.)
Figure 51-22 The external surface of a fibroma
of the ovary is firm, smooth, and white.
Figure 51-23 Benign cystic teratoma of the ovary. The tumor
has been sectioned; sebaceous material and hair are apparent.
Benign cystic teratomas, also called dermoid cysts, are relatively common, probably derived from primordial germ cells, and composed of any combination of well-differentiated ectodermal, mesodermal, and
Figure 51-24 Microscopic section of a benign
cystic teratoma shows thyroid tissue, respiratory epithelium, salivary glands,
and cartilage. This section duplicates the structures of anterior part of
neck.
Dermoids are bilateral in approximately 12% of patients, and most are 5 to 10 cm in diameter. At operation, the tumors are found to be round, with a smooth, glistening, gray surface. At body temperature, they have the consistency of other tensely cystic tumors. Outside the body, they have a soft pultaceous consistency. On sectioning, they are usually unilocular and filled with thick sebaceous material and tangled masses of hair (Fig. 51-23) . There is often a solid portion at one pole of the cyst that contains the bulk of the cellular elements and the various dermal structures. In 30% to 50% of cases, the cysts contain formed teeth. Microscopically, a wide variety of tissues are found (Fig. 51-24) . Most common are tissues normally found above the diaphragm: skin, sweat glands, respiratory epithelium, cartilage, salivary glands, and nervous tissue. Ectodermal structures are almost always present, with mesodermal and entodermal structures occurring only slightly less frequently.
Because teeth are commonly in the cysts, x-ray films of the abdomen may aid in diagnosis. Moreover, a dermoid cyst often has a long pedicle, allowing it to be palpated in the abdomen or anterior to the uterus. The frequency of torsion is relatively great. Because the tumors occur in young patients, treatment
Struma ovarii is a unique benign cystic teratoma in which thyroid tissue constitutes most of or the entire cellular portion of the neoplasm. Externally, this tumor is not distinguishable from a dermoid cyst. On sectioning, loculi of typical colloid may be seen (Fig. 51-25) . The loculi are yellow-brown and of various sizes. Microscopically, well-differentiated thyroid tissue is seen.
About 5% of strumae produce symptoms or signs of thyrotoxicosis, and 10 patients have been reported with evidence of hyperthyroidism that was relieved by removal of the ovarian tumor. Rarely, thyrotoxicosis is unrelieved by thyroidectomy but finally is relieved after a struma ovarii is detected and removed. Equally rare are carcinoid tumors that may have symptoms of the carcinoid syndrome. These tumors are of low-grade malignancy.
Gonadoblastoma is the most common neoplasm of abnormal gonads, in which this lesion arises almost exclusively. Patients with gonadoblastoma are between 1 and 40 years of age and typically have congenitally abnormal gonads associated with sexual
Figure 51-25 Gross section of a struma ovarii in which locules of colloid are easily
identified.
Some patients with gonadoblastoma are virilized, and the tumors can synthesize androgens and estrogens. Steroid production appears to be independent of the presence of Leydig cells, because in some instances, the tumor may elaborate androgens in the absence of these cells.
Gonadoblastomas can be a few millimeters in diameter to large, solid masses, which may be soft, firm, or gritty, depending on the degree of calcification and the occurrence and extent of a germinomatous component. Dystrophic calcification is common and may be recognized in abdominal-appearing roentgenograms before surgery.
Gonadoblastoma is composed of a mixture of germ cells resembling dysgerminoma cells and gonadal stromal cells. The latter most closely resemble Sertoli cells. They surround individual germ cells or are aligned around the periphery of clusters of germ cells. Stromal cells also surround spaces containing eosinophilic material, creating a microfollicular pattern. Cells that are identical to luteinized ovarian stromal cells or testicular Leydig cells but do not contain crystals of Reinke are found in the stroma in two thirds of gonadoblastomas.
Approximately one half of gonadoblastomas are overgrown by germinoma. Rarely, endodermal sinus tumor, embryonal carcinoma, or choriocarcinoma develops in a gonadoblastoma instead of or in addition to a germinoma.
Any patient with gonadal dysgenesis and a Y chromosome runs a high risk of developing a germ cell tumor, particularly a gonadoblastoma. One third of gonadoblastomas are bilateral, and they may be small enough to be detectable only microscopically. If unresected, the gonadoblastoma tends to be overgrown by malignant elements; the median incidence of malignant germ cell tumors in patients with gonadal dysgenesis and a Y chromosome is 25%. Total abdominal hysterectomy and bilateral salpingo-oophorectomy are indicated for patients with gonadoblastoma, virtually all of whom have gonadal dysgenesis and an abnormal contralateral
The management of actual or suspected ovarian neoplasms is surgical. Surgery is indicated for the relief of symptoms, and when there are no symptoms, surgery is performed to exclude malignancy. It is not unrealistic to consider every ovarian neoplasm to be potentially malignant, although the likelihood of malignancy for all ovarian neoplasms is between 15% and 25% and is even greater among children and postmenopausal women. Therefore, the need for accurate diagnosis is clear. Occasionally, it is possible to differentiate benign from malignant tumors on the basis of history and physical examination, but usually an accurate diagnosis can be made only after gross and microscopic examination of the tumor.
Exploratory surgery is essential for all patients in whom an ovarian neoplasm is suspected. This concept should not be extended to include all patients with an enlargement of the ovary, because many ovarian enlargements represent extensions of the normal cystic response of the ovary to changing physiology. For deciding which patients need surgery, many gynecologists rely on the size of the ovarian enlargement. My colleagues and I consider ovarian enlargements larger than 7 cm in diameter as probably neoplastic and those smaller than this size as probably nonneoplastic; 7 cm is an easy size to visualize, because it is exactly the diameter of a new tennis ball. Other gynecologists draw the line at 6 or 5 cm. According to one study, 93% of ovarian cysts less than 5 cm in diameter were nonneoplastic.
Because the probability of malignancy is greater in solid than in cystic tumors, I prefer to operate on most patients with solid tumors, even those with lesions smaller than 7 cm. It is often of value to reexamine the patient and notice changes in the size of an ovarian enlargement. A patient found to have a mass about 7 cm in diameter should be reexamined in several weeks. Attention should be given to the phase of the ovarian cycle, because the enlargement of a corpus luteum before menstruation may not be apparent in the postmenstrual phase. If follow-up examination reveals gradual enlargement of a cystic mass, even though it is smaller than 7 cm, neoplastic growth should be suspected. If the tumor regresses in size or disappears, it is safe to assume the enlargement was functional and benign.
Oral contraceptives have been recommended to accelerate involution of nonneoplastic ovarian enlargement. Because most of these cysts are gonadotropin dependent, the inhibitory effect of ovarian steroids on the release of pituitary gonadotropins diminishes the stimulus to cyst formation and persistence. Spanos studied patients with unilateral cystic adnexal masses. Oral contraceptives were prescribed, and the masses disappeared in 72% of patients reexamined in 6 weeks. All patients with persistent masses were found to have neoplasms at laparotomy.
A plan of observation and follow-up is not applicable to the infant or young girl. In these patients, any enlargement mandates surgical exploration. The same is true for the postmenopausal woman. The probability of malignancy increases sharply after 50 years of age, and all ovarian enlargements larger than 5 cm in postmenopausal women should be investigated surgically.
Goldstein reported on 42 postmenopausal women with simple adnexal cysts smaller than 5 cm in diameter. All cysts were unilocular on ultrasound, and the patients had no evidence of ascites. Twenty-six of the patients underwent prompt surgical exploration. All lesions had benign histopathology. In 16 patients, serial sonographs were obtained every 3 to 6 months. Two of these patients subsequently underwent surgery because of increasing size of the lesion, and no malignancy was found in these two patients or in the remaining 14 patients who were followed 10 to 73 months. This study suggested that unilocular postmenopausal cysts that are smaller than 5 cm in diameter may be followed by ultrasound without surgical intervention with relative safety. These findings have been confirmed by other investigators.
When surgery is the treatment of choice, the type and extent needed can be determined only at the operating table on the basis of the pathologic findings considered in the light of the patient s age, general health, and desire for future childbearing. Treatment may consist of nothing; excision of the lesion, preserving the remainder of the ovary; unilateral removal of the adnexa; bilateral removal of the adnexa with hysterectomy; or more radical procedures. My colleagues and I are opposed to tapping large ovarian cysts to reduce their size to make removal less difficult. Even when the greatest caution is exercised, cells may be spilled into the peritoneal cavity and cause irritation and metastatic implantation.
If the lesion is thought to be benign, the opposite ovary and the uterus may be conserved if they are normal. Most physicians prefer to remove the opposite ovary and uterus in postmenopausal patients. A conservative approach is justified in the management of the questionable lesion if the patient is young and wants additional children. Simple cystectomy or oophorectomy is done, and further decisions regarding therapy are reached after the final pathologic interpretation of the specimen. If the patient is premenopausal or postmenopausal, questionable lesions should be treated by bilateral salpingo-oophorectomy and hysterectomy.
The decision to conserve the opposite ovary depends
Many of the benign tumors, cystic and solid, develop a tenuous pedicle that is triradiate: the infundibulopelvic ligament, the uteroovarian (i.e., suspensory)
Figure 51-26 (Figure Not Available) (A) Left ovarian cyst with a twisted
pedicle, including the uterine tube, ovarian ligament, and round ligament.
(B) Pedicle untwisted to show its anatomic
elements, the extent to which the round ligament is involved, and a hemorrhagic
infarct. (From Kelly HA. Operative gynecology. vol. 2. New York:
Appleton, 1903.)
If the torsion is incomplete, the result is congestion, enlargement of the neoplasm, and thrombosis of the vessels. If the torsion is complete and obstructs the arterial blood supply, gangrenous necrosis results. The symptoms may be gradual pain and tenderness in the region of the tumor or the abrupt onset of pain typical of an acute abdominal condition. The patient often describes the sudden onset of pain with coitus or a change in position. In other patients, partial torsion may occur with spontaneous reversal without significant vascular compromise, accounting for some patients who give a history of intermittent severe pain.
Torsion occurs somewhat more commonly in pregnant women and in children. In children, it is frequently confused with acute appendicitis. When complete torsion is suspected, immediate surgery is necessary to remove the compromised tissue. Considerable edema may exist, making it difficult to be conservative with a portion of the tissue, and complete removal is usually prudent.
Most clinicians advise clamping the infundibulopelvic ligament before untwisting the pedicle because of venous thrombi, which may be dislodged during untwisting. However, recent evidence suggests that untwisting is safe, especially when there appears to be an opportunity to perform a cystectomy. When a conservative operation that spares ovarian tissue is possible (e.g., partial torsion), the infundibulopelvic veins should be palpated to detect thrombi before a final decision.
As a result of hemorrhage or torsion, an ovarian cyst may rupture and spill its contents into the peritoneal cavity, resulting in intensification of the symptoms. Occasionally, a temporary reduction of the symptoms may occur if they have been the result of distention of the cyst. Rupture may also occur as a result of trauma, such as a fall, a blow to the abdomen, or intercourse. Rupture of small, thin-walled ovarian cysts is not rare after vigorous bimanual examination, particularly if this is done under anesthesia. If the cyst contains serous fluid, there may be few or no symptoms. If a benign cystic teratoma ruptures, the irritating sebaceous material produces an intense chemical peritonitis. Pseudomyxoma peritonei produces a specific diffuse accumulation of tenacious mucinous material throughout the abdomen.
Rupture of a suspected neoplasm should initiate immediate laparotomy for a prudent removal of the neoplasm. Unruptured neoplasms and laparotomy should be handled with caution to avoid rupture during the operative procedure. The adverse impact of spilling an encapsulated malignant neoplasm during surgery is unknown, but it is prudent to avoid a spill until the controversy is settled.
Most ovarian enlargements found in pregnancy are follicular or corpus luteum cysts and are no larger than 5 cm in diameter. Management of these enlargements in early pregnancy--commonly detected by the wide use of pelvic ultrasound in the first trimester--should be expectant, because more than 99% of these functional cysts disappear and become undetectable by week 18 of gestation. As the uterus begins to rise out of the pelvis at the end of the first trimester, ovarian enlargement is evaluated best by pelvic and abdominal ultrasound, because the ovaries often are not easily palpated. If the cyst remains unchanged or increases in size in the early second trimester, surgical removal should be seriously considered. Solid ovarian masses of any size or cystic enlargement more than 10 cm in diameter should also prompt surgical intervention. Laparotomy in the second trimester is associated with minimal or no increase in fetal wastage.
When an ovarian neoplasm is not detected during the first half of pregnancy, it often is not diagnosed until labor or delivery. An ovarian mass may obstruct the birth canal during labor, exploratory laparotomy is then indicated for delivery of the infant and management of the ovarian neoplasm. Allowing the labor to proceed while the ovarian neoplasm obstructs the birth canal can result in rupture of the ovarian mass, followed by hemorrhage, peritonitis, tumor dissemination, or shock. Torsion in the immediate postpartum period is particularly common for lesions that are allowed to persist into the third trimester.
Aimen, J, Edman C, Worley RJ, et al. Androgen and estrogen formation in women with ovarian hyperthecosis. Obstet Gynecol 1978; 51:1.
Barber HRK. Gynecological tumors in childhood and adolescence. Obstet Gynecol Surv 1973; 28:357.
Beck RP, Latour JPA. Review of 1019 benign ovarian neoplasms. Obstet Gynecol 1960; 16:478.
Blaustein AU. Surface cells and inclusion cysts in fetal ovaries. Gynecol Oncol 1981; 12:222.
Bourne T, Reynolds K, Campbell S. Ovarian cancer screening. Eur J Cancer 1991; 27:655.
Colgan TJ, Norris HJ. Ovarian epithelial tumors of low malignant potential. Int J Gynecol Pathol 1983; 1:367.
Creasman WT, DiSaia PJ. Screening in ovarian cancer. Am J Obstet Gynecol 1991; 165:7.
DiSaia PJ, Creasman WT. Clinical gynecologic oncology. 4th ed. St. Louis: CV Mosby, 1993.
Farber M, Tran TH, Millan VG, et al. Lipoid cell tumor of the ovary. Obstet Gynecol 1979; 54:576.
Garcia-Bunuel R, Berek JS, Woodruff JD. Luteomas of pregnancy. Obstet Gynecol 1975; 45:407.
Genatry R, Parmley T, Woodruff JD. Secondary malignancies in benign cystic teratomas. Gynecol Oncol 1979; 8:246.
Goldstein SR, et al. The postmenopausal cystic adnexal mass: the potential role of ultrasound and conservative management. Obstet Gynecol 1989; 73:8.
Hallatt JG, Steele CH, Synder M. Ruptured corpus luteum with hemoperitoneum: a study of 173 surgical cases. Am J Obstet Gynecol 1984; 149:6.
Kutsube Y, Berg JW, Silverberg SG. Epidemiologic pathology of ovarian tumors. Int J Gynecol Pathol 1982; 1:3.
Meigs JV. Pelvic tumors other than fibromas of the ovary with ascites and hydrothorax. Obstet Gynecol 1954; 3:471.
Novak ER, Long JH. Arrhenoblastoma of the ovary: a review of the ovarian tumor registry. Am J Obstet Gynecol 1965; 92:1082.
Spanos WJ. Preoperative hormonal therapy of cystic adrenal masses. Am J Obstet Gynecol 1973; 116:551.
Van Nagell JR, DePriest PD, Pals LE, et al. Ovarian cancer screening in asymptomatic postmenopausal women by transvaginal sonography. Cancer 1991; 68:458.
Weiner Z, Thaler I, Beck D, et al. Differentiating malignant from benign ovarian tumors with transvaginal color flow imaging. Obstet Gynecol 1992; 79:159.
Young RH, Scully RE. Ovarian sex cord-stromal tumors: recent progress. Int J Gynecol Pathol 1982; 1:101.
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