Ovarian cysts and tumours

Many ovarian tumours are cystic, but some cysts are not tumours and some tumours are not cysts. Their classification is complex, so here is a simplified scheme. First the cysts you may meet. Benign: (1) Functional cysts of the follicles and corpus luteum. (2) Benign serous or mucinous cystadenomas. (3) Dermoid cysts (teratomas or hamartomas). (4) Unclassified benign cysts (simple cysts). Malignant: (1) Malignant serous or mucinous cystadenocarcinomas. (2) Metastatic carcinomas (from the gut, or breast) (3) Burkitt's lymphoma. (4) Other rarer tumours. ''Pseudocysts' are postinflammatory collections of fluid between adhesions in the pelvis (6.6), and are not true ovarian cysts; but the distinction is not always easy, even at operation.

An ovarian cyst can be of any size, from a pingpong ball to larger than a full-term pregnancy, and may: (1) Present as a mass, or as abdominal distension, which may be massive. If so, the patient may be in poor health, or she may be fairly well. (2) Be found accidentally during a pelvic examination done for some other purpose, such as family planning. (3) Cause abdominal pain due to torsion (see below).

Ask your clinic staff to refer any patient with an ovarian cyst larger than a small orange. If it is not too large, removing it should not be too difficult, provided it has not stuck to surrounding structures. Don't try to biopsy it; instead, remove it entirely, and send a sample for section.

Large cysts are more likely to be malignant than small ones. But huge cysts (larger than a full term pregnancy) are usually benign, or only of low-grade malignancy. They are more common in places where there are few doctors removing small ones, which is why they are relatively common in the developing world. Solid ovarian tumours are more likely to be malignant, and to have spread by the time you see them.

Most large cysts are mucinous or serous cystadenomas; some are cystadenocarcinomas. Try to remove a cyst without spilling the fluid, because if you do, you may spread a malignant tumour and harm the patient greatly. If a tumour has not spread through the wall of a cyst, its removal intact without spilling will usually cure her. Aspirating a cyst before you try to remove it: (1) Makes it easier to remove. (2) Requires a smaller incision lower in the abdomen. (3) May make dissection of adhesions easier. (4) Is likely to cause some spillage. Not aspirating a cyst either causes no spillage, or, if it bursts or you cut into it, a much worse spillage than if you had aspirated it first. Should you aspirate or not? Opinions vary; much depends on how skilled you are. As you will see below, we advise you not to aspirate, if you can avoid it. Even large cysts are not too difficult to remove intact[md]if you make an incision which is large enough (see below).

Most ovarian cysts have few adhesions. If adhesions are dense you may be dealing with: (1) Old PID. (2) A malignant cyst in which the growth is already spreading into the peritoneum. (3) Previous peritonitis that has left adhesions which have stuck the cyst to the peritoneum. (4) A cyst which has previously undergone torsion.

Don't be put off by the difficulties we describe below: some are rare and others only occur with really huge cysts of 20 kg or more. Cysts of the size of a full-term pregnancy or a bit larger commonly cause no trouble. Don't operate unnecessarily, adhesions and infertility may follow. Try to avoid removing both ovaries for bilateral benign tumours (usually dermoids). Remember that operating on a pseudocyst, or a cyst in the broad ligament, is particularly dangerous.

IF YOU ARE INEXPERIENCED, ONLY OPERATE FOR SUSPECTED ACUTE COMPLICATIONS (torsion) Fig. 20-6 OVARIAN TUMOURS. A, a pseudomucinous cystadeoncarcinoma shown in cross-section on the right. B, a solid primary carcinoma. C, the same carcinoma in cross-section. Adapted from a drawing by Frank Netter with the kind permission of CIBA-GEIGY Ltd, Basle (Switzerland).

OVARIAN CYSTS EXAMINATION bimanually reveals a round, solid or cystic mass, which is dull to percussion and separate from the uterus.

THE DIFFERENTIAL DIAGNOSIS varies according to the way in which a cyst presents, but there is considerable overlap. Torsion (see below), is more likely to be confused with an inflammatory lesion.

Any presentation of an ovarian cyst may be confused with: (1) Pregnancy. (2) A distended bladder, which may contain up to 5 litres of urine. (3) Pseudocysts. (4) Hydrosalpinx. (5) Fibroids. (6) A chronic ectopic pregnancy (haematocele). (7) A broad ligament cyst arising from the Wolffian ducts. (8) An appendix mass, or a small-gut mass. (9) Mesenteric cysts. (10) An enlarged spleen with a long pedicle. (11) Hydronephros.

Presenting as an acute abdomen (torsion, see below). (1) Appendicitis or an appendix mass (12.1). (2) Acute ectopic pregnancy (16.6). (3) Degeneration, bleeding, or infection in a fibroid (20.6). (4) A mass due to PID (6.6). See also 10.2.

Presenting as an abdominal mass or distension. (1) Ascites (she is dull to percussion in her flanks, rather than in the centre of her abdomen). (2) Obesity (fat is usually generalized). (3) Distension with gas in a false pregnancy.

CAUTION ! (1) Be quite sure she is not pregnant. (2) Always catheterize her before you try to diagnose an intra-abdominal cyst[md]it may subside dramatically!

THE MANAGEMENT [s7]OF AN OVARIAN CYST If you are inexperienced, refer her. If she is pregnant see below under ''Difficulties'. If you cannot refer her, proceed as follows.

If a cyst is [lt]5[nd]10 cm in diameter, it is usually a functional (follicular or luteal) cyst, and may be associated with fibroids and dysfunctional uterine bleeding (DUB, 20.2). 5 cm is the size of a small orange. Don't include her normal ovary in the measurement. The simple rule is that a cyst like this need not come out. Review her in 6[nd]8 weeks, and only operate if the cyst persists. Most functional cysts will have disappeared. If you find such a cyst at laparotomy for some other condition, leave it. If you must interfere, aspirate it.

If she is [lt]15 (before the menarche), many cysts are benign, but there is an increased risk of malignancy, which is sometimes low-grade. At operation the decision to remove her ovaries is particularly difficult. Only remove large ([mt]10 cm), solid ovarian tumours, and be sure to send them for histology.

If she is 15 to 35 years old, and the cyst is [mt]5 cm, it is probably a dermoid, especially if it is firm. An X-ray may show bone or a tooth. Remove it; to do so you may have to remove the whole ovary. If it is bilateral (15%), try to leave some ovarian tissue.

If she is 30 to 55 and it is large, it is likely to be a cystadenoma, which may be bilateral (20%). The contents may be serous, and there may be papilliferous growths inside its wall (less likely to be malignant), or outside (more likely to be malignant). If it is very large, its contents are likely to be mucinous. Malignant change is unusual. If however the mucin spills into her peritoneum, dense adhesions (myxoma peritonei) may form. Remove these cysts: they may undergo torsion, or occasionally rupture spontaneously.

If she is past her menopause, the risk of malignancy is increased. Be prepared to do a hysterectomy, when you remove the cyst.

If you can remove a serous cystadenoma intact, before there has been any spread, as shown by peritoneal deposits and ascites, her prognosis is very good. If there is peritoneal spread, the cyst will probably be adherent to the surrounding structures, and her prognosis is poor. If you are not an expert, don't try to remove ovarian carcinomas which have spread to the peritoneal surface.

If she presents with a palpable mass, ascites, or oedema of her legs (due to lymphatic obstruction from peritoneal deposits), consider the possibility of a solid adeno- or undifferentiated carcinoma of the ovary, which characteristically presents like this. It is often bilateral, and by the time she reaches laparotomy, it will probably have spread widely. Her prognosis is poor, but rare cases do occasionally regress spontaneously.

If there is peritoneal spread, remove the primary if this is not too difficult; but it will not cure her. There is little to be gained by removing her uterus.

If the tumour is solid, remember the unusual possibility that it may be a fibroma, which is benign, but can cause ascites (Meig's syndrome). Remove it.

If you are in an endemic area and she is between 10 and 25, remember Burkitt's lymphoma (32.3), which is often bilateral.

INDICATIONS FOR SURGERY. The treatment or prevention of complications: torsion, bleeding, or infection. (2) Suspected malignancy. (3) Discomfort due to size.

CAUTION ! Infertility is not an indication.

ANAESTHESIA. (1) General anaesthesia. (2) Subarachnoid anaesthesia.

Fig. Fig. 20-7 MORE OVARIAN TUMOURS. A, a papillary serous cystadenoma. B, the same in cross-section. C, a very large ovarian cyst showing dilated veins on the abdominal wall. A, and B, adapted from drawings by Frank Netter with the kind permission of CIBA-GEIGY Ltd, Basle (Switzerland). C, after James Young.

CYSTECTOMY [s7]FOR SMALLER OVARIAN CYSTS INCISION. Make a median or paramedian incision, big enough to allow you insert your hand, and to remove the cyst intact. Feel its whole surface for adhesions[md]if you find them see below. Search for secondaries in the rest of her peritoneal cavity, over the surface of her liver, and under her right diaphragm. You may need both hands.

When the cyst is free of adhesions, deliver it through the abdominal wound, and hand it to your assistant, taking care not to pull on its pedicle, which may be so thin that it easily tears, causing the proximal end to slip into her pelvis and bleed.

CAUTION ! Before you remove the cyst, examine her other ovary.

If her other ovary is also cystic, and she is relatively young, try to do an ovarian cystectomy (see below), unless there is a suspicion of malignancy. Suspect malignancy on the combination of these factors: (1) she is over 40 years, (2) the tumour is solid or lobulated, (3) there are papillary excrescences on its surface (especially) or inside it, (4) she has ascites, (5) there are secondaries on the surface of her peritoneum, (6) the cyst is fixed and immobile.

If she has a bilateral, papilliferous, or obviously malignant ovarian tumour, what you should do depends on your skills, and how far the tumour has spread: (1) If there is no peritoneal spread, and you can do a total hysterectomy with the removal of both ovaries, do so. Otherwise, do a bilateral oophorectomy (removal of the cyst with the ovary). (2) If there is little or no spread, do a bilateral oophorectomy. It will remove the bulk of the tumour, but it will not cure her, so the benefit will be minimal. (3) If there is wide peritoneal spread, merely biopsy a deposit on her parietal peritoneum.

The pedicle of an ovarian cyst consists of: (1) the infundibulopelvic ligament and ovarian vessels, (2) the ovarian ligament, (3) a portion of the broad ligament, and (4) frequently the Fallopian tube. If it is wide (often it is not), clamp it with several clamps, taking a bite of not more than 2.5 cm in each of them. Cut through the pedicle at some distance from each clamp; it will be less likely to slip off if you do this.

Transfix the pedicle in each clamp with double ''1' or ''2' catgut sutures, or ''O' or ''1' multifilament, taking care to avoid the plexus of veins as you insert the needle. Some surgeons advise that, if a pedicle is very broad, you should apply a chain of 3 to 4 or more ligatures. Finally, ask your assistant to hold the clamps, and pass a further ligature round the entire pedicle. This will tie any veins which may have escaped the other ligatures.

Swab the stump, and, if bleeding has been controlled, cut the ligatures short. Remove the cyst from the operation site, and ask an unscrubbed assistant to open it. If it looks malignant and she is [mt]40, remove her other ovary also, and if you can, her uterus too. If she is younger, wait for histological confirmation of malignancy, and refer for more radical surgery later if necessary.

CYSTECTOMY [s7]FOR A VERY LARGE CYST POSITION. She may develop the supine hypotensive syndrome (A 16.6), if she lies on her back, so lay her with a sandbag under one buttock.

INCISION. Make a paramedian or median incision. If you hope to remove the cyst intact, make it at least 5 cm longer than the diameter of the cyst.

If you are not sure if you can remove the cyst intact, make the incision at least 25 cm long and examine the cyst, separating such adhesions as you can see, without too forceful traction on the wound. If you cannot dissect further in safety, enlarge the incision to see the outline of the cyst and any adhesions. Aspirating fluid (see above) may help you do deliver it through the abdominal wall, but seldom helps in dissecting adhesions. A flabby cyst has an edge which is difficult to define, so that vital structures, such as the ureter, are more easily cut. If you do decide to aspirate fluid, use a syringe and needle, don't aspirate more than is necessary, and don't contaminate the operation site with the fluid you have aspirated!

NOTE: (1) The size of an incision makes almost no difference to the probability of operative shock. (2) A large one will not affect her adversely, except to increase the incidence of postoperative pain, and slightly increase the risk of wound breakdown. (3) A wound which is too small is dangerous because you cannot dissect safely, and you are obliged to exert excessive traction. This will kill cells in the edges of the incision, and increase the risk of subsequent wound sepsis, and possible breakdown[md]see Section 9.2.

Remove the cyst by clamping its pedicle as above. Be careful not to pull it so hard that you tear this. Insert tension sutures (9.8), and apply an abdominal binder.

OVARIAN CYSTECTOMY This removes the cyst but leaves the tissue of her ovary. It is usually not difficult.

INDICATIONS. (1) She is less than 40, especially if her other ovary is also damaged. (2) The cyst is [mt]5 cm. If it is [lt]5 cm, it is probably functional, so leave it. (3) The cyst must be benign, a reasonable amount of normal ovarian tissue should be present. If her cystic ovary is her only remaining one, it is not important if its tube is intact or not. She needs its endocrine function, regardless of possible fertility. You may be able to shell out even quite large cysts, and retain some ovarian tissue.

METHOD. The cyst lies in the substance of her ovary and is covered by the ovarian capsule. Cut around the edge of the cyst, well away from the remaining mass of her normal ovary. Using scissors or fingers, dissect between the cyst and her ovarian tissue. Control bleeding with 2/0 chromic catgut, and close the outer layer of her ovary with continuous locking sutures.

SALPINGO[nd]OOPHORECTOMY INDICATIONS. Removing a tube and ovary is indicated when cystectomy, or ovarian cystectomy is not desirable, or not possible, because: (1) They have been damaged by torsion, bleeding, or infection. (2) There is a possibility of malignancy. (3) There are extensive adhesions between her tube and ovary. (5) If she is [mt]45[nd]50 a bilateral salpingo[nd]oophorectomy with hysterectomy is likely to be preferable.

METHOD. The tube and ovary receive their blood from two sources which anastomose with one another: (1) The ovarian vessels in the infundibulopelvic ligament (20-17), and (2) the ascending branches of the uterine vessels.

Carefully divide any adhesions between her ovary and broad ligament, approaching them from below and behind. Raise her tube and ovary, find her infundibulopelvic ligament, and identify her ureter, so that you can avoid it. Clamp, divide, and tie her ovarian vessels in her infundibulopelvic ligament. Clamp, divide, and tie her ovarian ligament. Clamp, divide, and tie her tube. Suture her round ligament over the raw area (optional).

CAUTION ! Be sure not to tie her ureter. This is not a problem if the structures are mobile. But if there are adhesions, and especially if her ovary and tube have stuck to the back of her broad ligament, be sure to mobilize them before you resect.

Fig. 20-8 REMOVING AN OVARIAN CYST. A, exploring the surface of the cyst. B, delivering the cyst without rupturing it. C, clamping and dividing the pedicle. D, transfixing the pedicle. E, tying the pedicle in halves. F, applying the encircling ligature. After ''Bonney's Gynaecological Surgery', Figs 4.29 to 4.34, Bailli[gr]ere Tindall, with kind permission.

DIFFICULTIES [s7]WITH OVARIAN CYSTS If she has severe, COLICKY LOWER ABDOMINAL PAIN, sometimes with vomiting, suspect TORSION OF AN OVARIAN CYST. Her pain if may come and go, as it twists and untwists. She may not know she has a mass in her abdomen; it may enlarge acutely as the veins in its pedicle become obstructed. For the differential diagnosis see Section 10.2. Rule out retention of urine preoperatively. Do a laparotomy, tie and transfix the pedicle, and excise the cyst.

If she is PREGNANT, you may meet any of these complications.

If the cyst is [lt]5 cm in diameter, it is probably a luteal cyst (very common, and usually disappears after 16[nd]18 weeks). Leave it and follow her up after delivery.

If it is [mt]5 cm, it is probably a cystadenoma, a dermoid, or a cystadenocarcinoma, and delivery may be difficult. Ovarian cystectomy or salpingo-oophorectomy are possible after the first trimester, and before the last few weeks of pregnancy. Don't remove it in early pregnancy, because abortion is more likely. Instead, remove it between the 16th and 24th week, even if you diagnose it earlier. If it is large, operate up to the 30th week.

If it causes pain, this may be due to torsion or haemorrhage. Remove it urgently at any stage of pregnancy.

If you diagnose it after the 30th week, allow her to deliver vaginally, unless it is very large ([mt]25[nd]30 cm). The ideal time to remove it is 4 to 6 weeks later.

If she goes into labour with an ovarian cyst and obstructs, see Section 18.4, and especially Fig. 18-5.

If you find an ovarian cyst at Caesarean section, remove it if it is [mt]5 cm. See Section 18.10.

If there are EXTENSIVE ADHESIONS, she may have a pseudocyst (postinflammatory cyst), and not a true ovarian one. Don't try to deliver the tumour until you have divided them, or you may lacerate her gut or tear large veins. Separate them using your hands, swabs, or scissors (not a scalpel!). Gently pass your hand between the cyst wall and the floor of her pelvis. Don't mistake her parietal peritoneum for the cyst wall. Don't tie off any colon when you tie off adhesions.

CAUTION ! It is safer to leave a little cyst wall on her gut or the bladder, than to remove a little gut or bladder with the cyst wall.

If you meet a collection of PSEUDOCYSTS, there may still be signs of inflammation. Aspirate as many collections of fluid as you can, close her abdomen, give her antibiotics, and hope they will not recur.

If the cyst is NOT FREELY MOBILE, but seems to be embedded in her broad ligament, it may be arising from the remains of her Wolffian duct. Removing it may be difficult. It may be: (1) stuck to her broad ligament, or (2) inside it. The distinction is usually unimportant. If it is inside the ligament: (1) be sure to avoid her ureter, which may run anywhere over the cyst. (2) Don't damage the venous plexuses in this region. Study her anatomy carefully before you start.

If the cyst does not shell out easily, and extends down close to her ureter, you would be wise to remove as much as you can, and leave the remains open to her peritoneal cavity (marsupialization).

If you can define the cyst clearly by finger dissection, and are able to push her ureter out of the way, you may be able to remove it completely. It is covered by peritoneum which you will have to dissect off. Divide her round ligament on the same side, to open up her broad ligament. Then dissect off her peritoneum posteriorly, until you reach her ovarian vessels in her infundibulopelvic ligament. Tie them. Then dissect anteriorly and medially, and divide her tube and ovarian ligament close to her uterus. Finally, slowly and carefully dissect the cyst from the posterior leaf of her broad ligament, so as to avoid her ureter.

If you find BILATERAL BENIGN CYSTS (common with dermoids), try to spare at least some ovarian tissue on one side.

If a cyst looks MALIGNANT, consider her age and her wish to have children.

If she is young and has no children, remove the tube and ovary which are involved, and send tissue for histology. If it is found to be malignant, it may be necessary to remove her uterus and other ovary.

If she is older and does have children, and particularly if you cannot follow her carefully, consider doing a bilateral salpingo[nd]oophorectomy together with a hysterectomy. This is a difficult operation and a difficult decision, so refer her if you can.

If her INFUNDIBULOPELVIC LIGAMENT IS GROSSLY THICKENED, so that her ovarian vessels are difficult to distinguish from her ureter, open up her peritoneal tissues lateral to them, and extend the incision towards her pelvic brim. Grasp her ovarian vessels and draw them medially. You will then see her ureter attached to her peritoneum, crossing her common iliac artery.

DIFFICULTIES [s7]WITH GIANT OVARIAN CYSTS If she develops CARDIAC FAILURE, which may be delayed for a day or two postoperatively (rare), the reasons for it are not clear. Don't overload her with fluid; if necessary, give her a diuretic.

If she develops RESPIRATORY FAILURE (rare), due to the paradoxical movement of her diaphragm, which is lax and overstretched, now that the the cyst has been removed, give her oxygen and sit her up. If necessary, do a tracheostomy and control her ventilation (A 16.1).

If her ABDOMEN DISTENDS postoperatively (unusual), it is probably due to ileus. Insert a nasogastric tube and give her intravenous fluids (10.13).

If her ABDOMEN IS ABNORMALLY LAX, apply an efficient binder postoperatively.

CAUTION ! Don't be tempted to resect any redundant abdominal wall. This will make the operation much more extensive, and open up more tissue planes. This is a cosmetic procedure; refer her for it later if necessary.

Fig. 20-9 PROLAPSE OF THE UTERUS. A, a cystocele and a rectocele. B, a third degree prolapse. C, and D, the same patient with procidentia; her fundus is outside her introitus. Ideally, all these patients need a vaginal hysterectomy and an anterior and posterior colporrhaphy. If you are unable to do this, you could do an anterior and posterior colporrhaphy on A, and a Le Fort's operation on the other two patients. Patient CD is also suitable for ventrisuspension. After Young James, ''A Textbook of Gynaecology', (5th edn 1939). A and C Black, permission requested.