The risk of epithelial tumors increases with age. Although serous cystadenomas are often considered the more common benign neoplasm, in one study, benign cystic teratomas represented 66% of benign tumors in women younger than 50 years of age; serous tumors accounted for only 20% (197). Serous tumors are generally benign; 5% to 10% have borderline malignant potential, and 20% to 25% are malignant. Serous cystadenomas are often multilocular, sometimes with papillary components (Fig. 14.22). The surface epithelial cells secrete serous ﬂuid, resulting in a watery cyst content. Psammoma bodies, which are areas of fine calcific granulation, may be scattered within the tumor and are visible on radiograph. A frozen section is necessary to distinguish between benign, borderline, and malignant serous tumors because this distinction cannot be made on gross examination alone. Mucinous ovarian tumors may grow to large dimensions. Benign mucinous tumors typically have a lobulated, smooth surface, are multilocular, and may be bilateral in up to 10% of cases. Mucoid material is present within the cystic loculations. Five to 10% of mucinous ovarian tumors are malignant. They may be difficult to distinguish histologically from metastatic gastrointestinal malignancies. Other benign ovarian tumors include fibromas (a focus of stromal cells), Brenner tumors (which appear grossly similar to fibromas and are frequently found incidentally), and mixed forms of tumors, such as the cystadenofibroma.
Figure 14.22 Serous cystadenoma.
Uterine, gastric, breast, and colorectal malignancies can metastasize to the ovaries and should be considered, although as with many malignancies, these tumors are more common in postmenopausal-aged women.
Masses that include the fallopian tube are related primarily to inﬂammatory causes in the reproductive age group. A tubo-ovarian abscess can be present in association with PID (see Chapter 18). In addition, a complex inﬂammatory mass consisting of bowel, tube, and ovary may be present without a large abscess cavity. Ectopic pregnancies can occur in the reproductive age group and must be excluded when a patient presents with pain, a positive pregnancy test, and an adnexal mass (see Chapter 20). Paraovarian cysts may be noted either on examination or on imaging studies. In many instances, a normal ipsilateral ovary can be visualized using ultrasonography. The frequency of malignancy in paraovarian tumors is quite low and may be more common in paraovarian masses larger than 5 cm (218).
Diagnosis A complete pelvic examination, including rectovaginal examination and Papanicolaou (Pap) test, should be performed. Estimations of the size of a mass should be presented in centimeters rather than in comparison to common objects or fruit (e.g., orange, grapefruit, tennis ball, golf ball). After pregnancy is excluded, one simple office technique that can help determine whether a mass is uterine or adnexal includes sounding and measuring the depth of the uterine cavity. Pelvic imaging can confirm the characteristics of the adnexal mass—whether solid or cystic or mixed echogenicity. Diagnosis of uterine leiomyomas usually is based on the characteristic finding of an irregularly enlarged uterus. The size and location of the usually multiple leiomyomas can be confirmed and documented with pelvic ultrasonography (Fig. 14.23). If the examination is adequate to confirm uterine leiomyoma and symptoms are absent, ultrasonography is not always necessary unless an ovarian mass cannot be excluded.