Clinical features:

1. Almost happen during the years between menarche and menopouse

2. No symptom or symptoms such as local discomfortable, menstral dysfuction, infertility, dysmenorrhea

3. Low abdominal pain, palpable abdominal mass, flank soreness 

Classifications of benign ovarian tumors

Functional cysts:

lFollicular cysts

lcorpus luteum cysts

lpolycystic ovarian dis.

Neoplastic lesions:

lserous adenomas

lmucinous adenomas

lmature teratomas

lEndometrioid adenofibroma

lBrenner tumors (fibroma ; transitional tumors) 

Diagnosis:

1. Pelvic exam. , rectal exam.

2. Sona ( transabdominal, transvaginal ) , Color Dopple sonography

3. Tumor markers: CA-125, CEA, AFP, β-HCG

4. KUB

5. CT-scan,  IVP, Low-GI, etc.

A. Follicle cysts:

Dominant follicle failing to rupture or an immature follicle failing to atresia.

translucent, thin-walled, filled with a watery, clear to strawcolored fluid. Normal size about 3 to 8 cm.

Most follicles disappeared spontaneously within 60 days without treatment.

B. Corpus luteum cysts:

Spontaneous and limited bleeding filled the corpus luteum cavity, we say hemorrhagic cystic corpus luteum

Spontaneous absorption without treament

 If rupture, intraperitoneal bleeding and peritoneal sign were found and surgical intervention is nessary

C. Polycystic ovarian dis.:

 Enlarged bilat. Ovaries, smooth, pearl-white surface and many small follicles beneath thicken fibrous cortex.

 Symptom: secondary amenorrhea, oligomenorrhea, infertility, and obesity or hersutium in 50% pts.

 Diagnosis by 17-ketosteroid, FSH, LH, basal body tempture.

 Treatment: clomiphene citrate 50-100 mg/day for 5-7 days cyclically or surgical intervention

D. Serous/ mucinous adenomas:

 Serous adenomas: unilobular, smooth lining surface, papillary projection on the inner surface cause cauliflower pattern

 Mucinous adenomas: huge, discrete septa or lobules containing clear, viscid fluid

 Surgical intervention:

solid mass at any age

cystic mass > 8 cm or size about 5 to 8 cm longer than 8wks.

Frozen pathology is necessary R/O malignancy

E. Mature teratomas:

Synonym: Dermoids, cystic teratomas

unilateral, 10-15 % are bilateral cystic content including bone, teeth, hair, and dermal tissues

 Surigcal intervention in any age for enucleation or oophrectomy

F. Meigs syndrome is a rare dis:

Three-combined signs : Fibroma, Ascites, Hydrothorax

If size larger than 6 cm , ascites found in 50% pts.

Both ascites and hydrothorax were resolved after fibroma was removed 

Pre-op evaluation:

1. sonography :

Transabdominal: large adnexal mass, size > 6 cm solid mass, irregular margin, combined ascites.

Transvaginal: bladder distension is not needed, cystic mass size < 6 cm, cul-de-sac mass.

® Color doppler: R/O malignancy, large mass, solid mass, irregular margin, combined ascites, bilateral adnexal mass.  If the resistance index < 0.4, malignancy is highly suspected.

2. Tumor marker:

CA-125: Normal < 35, if > 65 R/O endometrioma, malignant ovarian cancer

CEA: Normal 0-2.5 ng/ml, if elevated R/O adenocarcinoma

AFP: Normal value < 15 ng/ml, ↑R/O germ cell tumors

β-HCG: Normal value: O, ↑R/O malignant tumor or GTD dis except pregnancy

LDH: Non-specific markers, elevated in dysgerminoma

3. KUB for calcification of teratoma (bone, tooth)

4. CT scan: Large adnexal mass, bilateral, adnexal tumors, combined ascites to R/O liver, lymph node metastasis and displacement of ureter.

5. Low-GI : larger ovarian tumor compression cause GI symptoms

6. IVP : larger ovarian tumors compression cause urinary symptoms

7. Others evaluation are same as general Gyn. Pre-op

8. Pre-Op susvey須檢查pelvic mass是否為presacral tumor:

 PV PR時發現tumor在rectum下方。

 CT Scan發現rectum被tumor往前推。

® 若為presacral tumor則須照會直肛科，並大量備血。

Op indication:

1. 何時用laparotomy? 何時用laparoscope?

當mass被認為是benign(包括pre-op evaluation)，且非severe pelvic adhesion情況下，皆可用laparoscope op。

但demoid cyst最好以laparotomy徹底清除demoid cyst content，因demoid cyst content若破裂，容易造成chemical irrigation。

2. Functional cyst, size < 6 cm則可以follow up 3 minth若持續存在則可以考慮用laparoscope op。

3. 於pre-op evaluation R/O malignancy時，eg large solid mass, low resistance color doppler flow, bilateral mass, combined ascites則應以longiludinal incision larparotomy，且需要送frozen pathology以R/O malignancy。

4. Acute abdomen下的adnexal mass (rebounding pain, mass介於8-10cm左右)需R/O ovarian tumor torsion→immediate operation。

Post-op care:

1. Post-op evaluation in the night of operation

2. Check CBC , D/C , CD and flatus passage in coming morning

3. If frozen pathology was malignancy , refer to oncology for further tretment

4. Follow final pathological report in third or fourth day