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ЗмістBenign and malignant ovarian tumors
Ovarian tumors classification
I. Epithelial tumors
II. Sex cord stromal tumors
Unblastomatic unproliferative ovarian tumors
Corpus luteum cyst
Blastomatic proliferative ovarian tumors
Papillary serous cystadenomas
Special forms of ovarian tumors
Thecoma (Theca cell tumor)
Benign cystic teratoma (Dermoid cyst)
Ovarian cysts and cystadenomas' complications
Malignant ovarian neoplasms
TNM Stages of Primary Carcinoma of the Ovary
Topic: Benign tumours of the female reproductive organs. Gynecological aspect of diseases of the mammary gland.
3.2 To be able to:
1. Diagnose benign tumours of the external genitals, uterine and adnexa.
2. Make up a proper plan of examination to diagnose benign uterine tumours.
3. Make up a proper plan of examination to diagnose benign ovarian tumours.
4. Prepare a set of instruments to perform diagnostic scrapping of the uterine wall.
5. Make a target biopsy of the uterine cervix.
6. Perform speculum examination, vaginal examination, make the initial diagnostics.
8. Make up an individual plan of treatment.
3.3 Master the practical skills = a III.
1. Speculum examination of the uterine cervix.
2. Take smears for the cytological examination.
3. Bimanual gynecological examination.
4. Perform differentation diagnostics of intramural band submucous uterine myoma, cyst and cystoma.
5. Determine indications for surgical treatment in patients with ovarian tumours and their complications (torture of tumour peduncle, rupture and malignization).
Ovarian tumors are very common among all gynecologic diseases. The mortality rate is high because no effective screening devices are available for early detection.
According to pathogenic theory of ovarian tumors, gonadotropic ovarian hyperstimulation is the leading factor in the development of ovarian tumors. This theory should be recommended for pathogenetical explainatum of malignant ovarian tumors diagnosis and treatment.
The risk factors associated with ovarian carcinoma are:
All ovarian tumors should be divided into two main groups:
Clinical manifestations of ovarian tumors are various and usually uncertain. It depends on tumor's type and character, and also on the spread of the process in the case of malignant tumor.
Only histologic signs can give a possibility to distinguish benign and malignant ovarian tumor. From the prognostic or survival standpoint, however tumor grade remains the most important factor for all the ovarian tumors.
Histologic classification of ovarian tumors is presented below. ^
D. Clear cell
F. Mixed epithelial
There are benign and malignant tumors in each of these groups of neoplasms
A. Granulosastromal cell
B. Endodermal sinus tumor
C. Embryonal carcinoma
G. Mixed forms
A. Only blastoma (without any forms);
B. Mixed with disgerminoma and other forms of germ cell tumors.
VI. Soft tissue tumors not specific to the ovary.
VII. Unclassified tumors.
VIII. Secondary (metabolic) tumors.
VIII. Tumor-like conditions:
A. Pregnancy luteoma
B. Ovarian stroma hyperplasia and hyperkeratosis
C. Considerable ovarian edema
D. Functional follicle cyst and luteal cyst
E. Multiple luteal follicle cysts and (or) luteal cysts
G. Superficial epithelial cysts-inclusions
H. Simple cysts
I. Inflammatory processes
J. Paraovarian cysts
Ovarian cyst is the cavity of mature or atretic follicle that become distended with pale, straw-colored fluid as a result of its retention and excessive secretion. They are usually localized in ovaries (corpus luteum cyst, follicle cyst, theca luteal cyst, dermoid cyst) and in its adnexa (paraovarian cyst).
Follicle ovarian cyst is a single tumor with a thin membrane of mobile consistency with a straw-colored fluid. Its formation is a result of fluid retention in atretic follicles. Follicle cyst may be found in women of any age more often after inflammatory processes. True ovarian blastomatic process is absent in such tumor. Cyst membrane is not a new created tissue, it's a result of the excessive extension of follicle membrane. Although these cysts may attain a size from 8 to 10 cm in diameter, spontaneous resolution usually occurs within the weeks. It has been growing inside of abdominal cavity.
Clinic. The main symptom is the low abdominal pain, rarely menstrual cycle impairment or uterine bleeding as a result of hyperstimulation from exogenous gonadotropins is observed. Signs of acute abdomen are present in the case of ovarian cyst torsion. Bimanual examination reveals ovarian enlargement up to 10 cm. It is mobile, cystic, unilateral mass. Sometimes inflammatory processes in uterine adnexa are present. Follicle cysts rarely produce any symptoms and diagnosis is often made during monitoring.
Treatment. Observation for 2-3 menstrual cycles is necessary. If a spontaneous resolution doesn't occur, surgical intervention — ovarian resection or oophorectomy — should be recommended. It is very necessary because before surgical intervention it is difficult to make a differential diagnosis of ovarian cyst and serous cystadenoma. Total hysterectomy should be performed in climacteric and postmenopausal women.
Additional therapy is not recommended after operation.
The evidence of corpus luteum cyst is 2-5% among all the ovarian tumors.
Corpus luteum cyst is an unilateral cystic enlargement which exceeds 8 cm in diameter. Grossly, the cyst protrudes from the contour of the ovary and the wall appears convoluted and thick. The cyst is filled with yellow fluid or blood. It may be found at the age from 16 to 55 years old.
Clinic. Symptoms are related to large size or complications of torsion, rupture or hemorrhage. The main complaint of the patient is abdominal pain as a result of concomitant inflammatory processes of uterine adnexa. Special clinical signs are absent. Bimanual examination reveals unilateral ovarian enlargement with tuberculosis uneven consistency. During pregnancy the corpus luteum becomes truly cystic with growth and continued function. At the absence of pregnancy, the corpus luteum normally collapses and is eventually replaced by hyaline connective tissue.
Treatment More commonly luteum cysts produce no symptoms and undergo absorption or regression. It is necessary to make observation for 2-3 reproductive cycles. Surgical intervention should be recommended in the case if corpus luteum cyst regression doesn't occur.
^ cysts belong to retential ovarian cysts. These cysts are almost bilateral and the enlargement may exceed up to 15 cm. They should be present during pregnancy, hydatidiform mole or choriocarcinoma. They are growing very quickly. They can dissolve after the main disease treatment — hydatidiform mole or choriocarcinoma.
Parovarian cyst is formed as a result of fluid retention in ovarian adnexa which has been situated in the broad ligament. It arises at the age of 20-40 years old because only in reproductive period ovarian epoephoron is well developed and it undergoes atrophic changes in climacteric women. Children can have parovarion cyst very rarely. Intraligamentous cysts may be small or may reach 8-10 cm or more in diameter. They are thin-walled and unilocular with solid consistency, they have smooth surface with vessels which are situated outside, it is filled with fluid (fig. 164).
Fig.164. Parovarian cyst of enormous size:
1 — cyst; 2 — right fallopian tube uterus; 4 — left ovary llopian tube
Clinic. Pain in the lower abdomen and sacral region may be present. Symptoms of adjacent organs compression are present if the tumor reaches large sizes. Symptoms of acute abdomen are common in the case of parovarian pedicle cyst torsion. At bimanual examination pelvic mass with smooth surface and elastic consistency which is palpated near uterus is found. It is painless and immobile.
Treatment. Surgical removal of parovarian cyst. It is very necessary to store the ovarian function. Puncture of the cyst should be indicated in some cases.
Thus, retential cysts are more often found in young women. After exception of true ovarian tumor such diagnosis is made in climacteric women. Ultrasonography and laparoscopy should be prescribed for diagnostics.
Patients with ovarian cysts should undergo careful monitoring. Retential cysts of small sizes may undergo spontaneous regression under the effects of anti-inflammatory drags. Thus, they may be treated within 4-6 weeks. One should remember that interm diagnosis and treatment of retential cysts is the prevention to ovarian cancer. True ovarian tumor is revealed in one out of four women with the diagnosis of retential cyst. That's why, these patients require interm surgical intervention.
Serous cystadenoma (fig. 165) is unilocular unilateral benign cystic neoplasm derived from the surface epithelium of the ovary and lined by epithelium that resembles the mucosa of the oviduct (fig. 166). It contains clear yellow fluid. The benign serous cystadenoma is usually between 5-15 cm in diameter. Occasionally it fills the entire abdomen. Tumor growing may lead to the enlargement of abdomen, adjacent organs function impairment. No symptoms are specific for this tumor. Rarely, patient may complain on dull abdominal pain. Reproductive
Fig.165. Serous ovarian cystadenoma. (Laparoscopy)
cycle is normal. The symptoms of peritoneal irritation are present in the case of pedicle torsion. These tumors are revealed during monitoring.
Fig.166. Serous cystadenoma. (Laparoscopy)
Pelvic examination reveals mobile, painless and unilateral tumor with smooth external surface. Ultrasonography and laparoscopy may confirm the diagnosis.
Treatment is surgical because of the relatively high rate of malignancy. In the patients after the childbearing age (after 40 years old) treatment should consist of bilateral salpingoophorectomy and hysterectomy not only because of chance of future malignancy, but because of the increased risk of similar occurrence in the contralateral ovary. In the younger patients with smaller tumors an attempt can be made to perform an ovarian cystectomy to try to minimize the amount of ovarian tissue removed. For large, unilateral serous tumors in young patients, unilateral oophorectomy with preservation of the contralateral ovary is indicated to maintain fertility.
The papillary projections of ovarian cystadenomas may grow inside (fig. 167) and outside of the tumor capsule. There are also mixed tumors when these projections are placed into internal and external surfaces of the tumor. Papillary projections may involve peritoneum in the case of malignant degeneration. These tumors are multilocular, they rarely reach large sizes, have a short pedicle. They may be situated intraligamentously. The tumor contains serous or sometimes serous-hemorrhaged fluid. Tumor may coexist with ascites.
Fig.167. Papillary ovarian cystoma
No characteristic symptoms are specific for this tumor. Frequently, it is revealed during monitoring. The diagnosis is based on the results of bimanual examination, ultrasonography and laparoscopy.
Bimanual examination reveals immobile painless lobulated tumor which is situated near uterus. Frequently it resembles the subserosal uterine fibroid. These tumors have high frequency of malignant change.
Treatment is surgical and it is the same as in case of serous cystadenomas.
Mucinous cystadenoma is a benign epithelial tumor which may be present in women of different age. It may reach large sizes, sometimes it is multilocular, with round or oval form. The cut surface shows the individual cysts or lobules of various sizes that contain sticky slimy or viscid material of yellow or brown color (fig. 168).
Clinic. No symptoms are specific for this tumor even in case of large sizes. Pain in the lower part of the abdomen and back region may be present in case of intraligamentous location. Symptoms of adjacent organs compression are present if a tumor is huge. Ascites is rare. Bimanual research reveals elastic tumor with lobular surface in the adnexal region. Laparoscopy and ultrasonography can be used for diagnostics.
The usual treatment for the obviously benign mucinous cystadenoma is unilateral oophorectomy. In older women after 45 bilateral oophorectomy and hysterectomy are preferable. Total hysterectomy with bilateral salpingoopho-rectomy are indicated in case of coexisting cervical pathology.
Pseudomyxoma is one of the kinds of mucinous cystadenoma. The incidence of these tumors is low. The tumor is multilocular and has a thin wall. It can be ruptured spontaneously or during the pelvic exam. Pseudomyxoma peritoneal is the complication that may result if the contents of mucinous cyst is spilled into the peritoneal cavity by rupture, extension or at surgery. Sticky slimy material which is spilled into the peritoneal cavity doesn't absorb. Diffuse implants develop into all the peritoneal surfaces with tremendous accumulation of mucinous material within the peritoneal cavity. It supports the chronic inflammatory process in the pelvis, thus chronic pelvic pain is a true result of this. Diffuse implants develop on all the peritoneal surfaces with the tremendous accumulation of mucinous material within the peritoneal cavity.
Clinic. Pain is the main characteristic sign of pseudomyxoma. The clinical course is usually progressive malnutrition and emaciation. The palpation of the abdomen is painful.
Pelvic exam reveals elastic tumor, frequently of large sizes which is situated near uterus. The diagnosis is proved during operation.
Treatment is surgical. The fluid is difficult to remove because of its viscosity. Repeated chemotherapy may be required in postoperative period.
Cystadenofibroma is a benign tumor which is developed from ovarian stroma. It has round or oval form, it is firm and unilateral and may reach the sizes of fetal head. The age distribution is 40-50 years old. It has asymptomatic duration or sometimes it is accompanied by ascitis. Hydrothorax and anemia may be present in rare cases (Meigs Syndrome).
Androblastoma which is usually masculinizing tumor is reported to produce masculinization. It occurs very rarely and its duration is also malignant. Androblastoma is unilateral tumor with smooth or lobular surface. It has small sizes and pedicle and it is mobile.
Clinic. Breast, uterine and female external genitalia atrophy are the characteristic signs. Uterine and ovarian hyporplasia, endometrial atrophy are common. Amenorrhea and all masculinizing features are present. The combination of masculinizing and feminizing symptoms is possible.
Diagnosis. Ultrasonography, laparoscopy and ovarian biopsy play an important role at confirmation of diagnosis.
Treatment is surgical — removal of the tumor.
In the majority of cases prognosis is favorable.
Thecoma belongs to the feminizing tumors. It occurs at all ages but is common after 40 years old and later. The evidence indicates that thecomas arise from the ovarian cortical stroma. Theca cell tumors are unilateral and in most cases they are not malignant. Their sizes may vary from small to those of fetal head. The external surface is firm, ovoid or round, smooth, and gray, occasionally streaked with yellow. Symptoms are related to estrogen production. When the granulosa cell tumor occurs in the pediatric age group, it may contribute to signs and symptoms of precocious puberty and vaginal bleeding. In women of reproductive age group such symptoms as impairment of menstrual function, infertility and pregnancy loss are common. Menopause bleeding, enlarged sizes of uterus and breasts, increasing libido are present in these patients. Ascites may be present in favorable and unfavorable duration of disease. Malignant degeneration of tumor is frequently common in young patient.
Diagnosis is based on clinic, bimanual research, ultrasonography, laparoscopy and hysteroscopy.
Treatment is surgical.
Prognosis is good in favorable duration and it is unfavorable during the malignant course.
Folliculoma is a hormonal active tumor which produces estrogenic components and may be manifested in patients through feminizing characteristics. It varies from microscopic inclusions to 40-50 cm in diameters, they are yellow-colored. Folliculoma may have good as well as malignant potential. It is always unilateral with lobular surface. They occur at all ages but are common in women older than 40. Uterine fibromyoma and uterine cancer can coexist with folliculoma.
Clinic. Symptoms depend on the level of hyperestrogenemia and on the women age. The girls have the signs of precocious puberty. In reproductive age group women amenorrhea, acyclic bleeding, and later menopausal uterine bleeding may be present. Combination of feminizing syndrome with infertility and menstrual function impairment testifies the presence of hormonal active tumor.
Diagnosis is based on the ultrasonography results, laparoscopy, histologic examination of tissue.
Treatment is surgical. In malignant duration of the disease total hysterectomy with omentum major incision should be performed. Chemotherapy is prescribed in III-IV stages of cancer.
Fig.169. Dermoid cyst: a — dermoid cyst; b — dermoid cyst on sectioning
Dermoid cysts are almost always ovarian tumors. The tumors may occur at any age. Dermoids are bilateral and have 5-10 cm in diameter. At operation, the tumors are found to be round with smooth, glistening, grey 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. 169 a, b). In 30% to 50% of cases cysts contain the formed teeth. Slow growing, without any symptoms, as a rule, is a characteristic feature of the tumor. Moreover, a dermoid cyst often has a long cruz. At pelvic examination it allows to palpate the cyst in the abdomen or anterior to the uterus.
Clinic. No symptoms are common for small sizes tumors. Pain is present in case of large tumors. Ultrasonography, laparoscopy are used for diagnosis.
Treatment is surgical. It consists of excision of the cyst, conserving the remaining portion of the ovary.
Prognosis is favorable. In 0,4-1, 7% of patients malignant degeneration of tumor is present.
The Brenner tumor is a fibroepithelial tumor with gross characteristics similar to those of fibroma. It constitutes approximately l%-2% of all the ovarian tumors and is rarely malignant. Brenner tumors have been reported in patients older than 50. Frequently a tumor is unilateral, its shape, sizes and consistency are similar to fibroma (fig. 170). 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 (fig. 171).
Clinic. A few Brenner tumors are associated with postmenopausal bleeding, and it is suggested that some may contain hormonally active stroma. Bimanual examination, ultrasonography and laparoscopy are diagnostics.
Treatment consists in simple excision or oophorectopmy.
Diagnosis of benign ovarian tumors.
General and pelvic examination should be performed. Differential diagnosis should be made with uterine fibromyoma (fig. 172), endometriosis, inflammatory tuboovarian tumors and moving kidney.
Additional methods of investigation such as uterine probbing, culdoscopy, cystoscopy, urography, X-ray examination, ultrasonography and laparoscopy should be performed.
Thus, benign ovarian tumors have some common peculiarities of clinical course, such as:
in the majority of cases cysts and cystadenomas are mobile as a result of pedicle presence. The anatomical and surgical pedicles are distinguished. The anatomical pedicle is composed of the infundibulopelvic ligament, the
Fig.172. Ovarian cystoma. Determination of correlation between a tumor and adnexa in bimanual research by Vebl'
ovarian ligament and mesoovarium. Surgical ligament composes of all of these structures and fallopian tube with its nerves vessels. During tumor removal the clamps should be put on the surgical pedicle below the place of torsion
Malignant degeneration. It is most commonly found in serous and papillary cystadenomas, frequently — in mucinous cystadenomas and very rare in dermoid ovarian cysts. It is very difficult to reveal the moment of tumor' malignant degeneration, that's why it is very important to remove the tumor at early stages.
Torsion. If the torsion is incomplete, the result is congression and enlarr gement of the neoplasm and thrombosis of the vessels. If the torsion is complete and obstructs the arterial blood supply, a gangrenous necrosis can appear as a result. 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. Immediate surgery is necessary to remove the compromised tissue.
Purulention. High temperature, symptoms of peritoneal irritation, abdominal pain are common. Immediate surgery is recommended.
Rupture. In the result of hemorrhage or torsion ovarian cyst may rupture and spill its contents into the abdominal cavity resulting in intensification of the symptoms. Rupture of suspected neoplasm should initiate immediate laparotomy for a prudent removal of the neoplasm
All ovarian tumors warrant surgical removal because of their potential for malignancy, but it is very difficult to reveal this tumor at early stages.
Most of the malignant neoplasms that arise in the ovary fall into three categories: primary cancer (neoplasms derived from the ovarian surface epithelium, i.e. epithelial tumors), secondary (neoplasms derived from papillary or pseudomucinous cystadenomas), metastatic (intestinal and breasts' metastasis).
Ovarian cancer is the fourth most common of all cancers of women having the frequency of 15-20%. The risk increases with age. More often it occurs in women at the age of 45-50. Rarely it is found in women of ealier age. There is considerable worldwide variation in the incidence of the ovarian cancer. There is a higher incidence of ovarian cancer in Sweden 15,1 per 100.00 women, Estonia — 14,2 per 100.00 of population, in Ukraine — 7,3 per 100.000 women.
Etiology. Ovarian tumors belong to hormonal active tumors. Epidemiolog and experimental investigations of ovarian cancer reveal impairment of menstru; function in these tumors.
The certain epidemiologic factors associated with the development of ovarii cancer include low parity, decreased fertility and delayed childbearing. All < these factors lead to hormonal disbalance in the organism.
Recently, demonstration of the genetic inheritance of ovarian cancer h; revealed an important information regarding the possible etiology of the diseas
The relationship between the benign ovarian neoplasm and its maligna] counterpart is clinically important. If the benign counterpart is found in the patie: the removal of both ovaries is necessary, because of the possibility of futu: malignant transformation in the remaining ovary. The decision concerning tl removal of one or both ovaries, however, must be individual and is based on tl age, type of tumor, and future risks. Some investigators have suggested that bilateral oophorectomy in the patients over 40 years should be performed, gives a possibility to decrease the ovarian cancer development. There is connection between breast cancer and ovarian tumors. The incidence of ovaric cancer in these women is in 10 times higher than in healthy women. There dependence between endometrial hyperplastic processes and ovarian cancer.
One should remember that unblastomatic unproliferative processes (follicl luteal cysts) are the results of pituitary and ovarian hormones disbalance. Tl observation that patients with breast cancer have a two fold increase in the ri: of developing of ovarian cancer supports the concept that hormones play s important role in the cause of ovarian cancer.
Malignant ovarian neoplasms are usually categorized according to the orig of the cell and are similar to their deign counterparts:
There are malignant tumors with inside and outside growing. Mixed tumo are also common.
Epithelial cell ovarian carcinoma may reach both small and large sizes, thi are typically multiloculated and often have external excrescencies on otherwi smooth capsular surface. The walls of malignant cysts have different thicknes and, as a rule, have papillary injections on the inner surface (fig. 176). Epitheli tumors haven't cysts, they are soft. They are small in sizes, with smooth surfa and grow in the direction of the adjacent organs.
Sometimes the metastatic cancer can appear in the ovaries. The ter Krukenberg tumor (fig. 174) describes the ovarian tumor that is metastatic fro other sites such as the gastrointestinal tract (80% from stomach, remainder frocolon, breast, and endometrium). Most of these tumors are characterized as infiltrative, mucinous carcinoma of predominantly signet-ring cell type and as bilateral and associated with the widespread metastatic disease.
Ways of spread of ovarian cancer. Ovarian cancer can spread by means of several pathways. The neoplasm can directly invade adjacent organs such as the small intestine, rectosigmoid, colon, peritoneum, omentum, uterus, fallopian tubes, and broad ligament. Spread can occur by means of the peritoneal fluid and malignant cells can be implanted throughout the pelvis and abdominal cavity, including the omentum, posterior cul-de-sac, infundibulopelvic ligaments, paracolic gutters, right diaphragm and capsule of the liver. Ascites can often develop wit1! peritoneal metasteses.
Dissemination may also occur through lymphatics to the uterine tube, uterus, pelvic and paraaortic lymph nodes (fig. 175). Metastases occasionally are detected in distal sites such as the supraclavicular or inguinal lymph nodes.
The least common way of spread is hematogenous dissemination. Hematogenous metastases occur in the liver parenchyma, skin, and lungs.
Clinic. Early diagnosis of ovarian cancer is difficult, because symptoms are often absent or vague until the neoplasm has attained a large size and metastasized. Even large tumors usually produce nonspecific symptoms. Early symptoms include vague sensations of pelvic or abdominal discomfort, urinary frequency, and alterations in gastrointestinal function. When the neoplasm attains a diameter of about 15 cm, it rises into abdominal cavity, which leads to feelings of abdominal fullness or distension and early safety. Abdominal enlargement can also be secondary to ascites. General weakness, weight loss, continuos dull pain in the lower part of abdomen are common. In 15% of patients they experience abnormal vaginal bleeding.
Hemorrhage into the tumor or torsion of the ovary containing neoplasm can produce sudden pain and other symptoms of acute abdomen.
The physical findings in patients with ovarian neoplasms in early stages are similar to benign ovarian cystadenomas. Usually, they are of small sizes, painless, movable, with firm consistency. They are palpated on the back from the uterus. The tumor may be palpated by means of rectal examination. One can feel the mass within the cul-de-sac. The tumor may be fixed because it can fill the available space in the pelvis or because the pedicle is very short (it looks like uterine myoma). The tumor reaches large sizes and rises out of the pelvis. It is palpated in the abdomen. The surface of tumor is nodular. There may be irregularities or even solid portions. It is immobile. There is a high temperature as a result of products' disintegration absorption in the case of tumor destruction. Anemia, leukocytosis and increased ESR are common symptoms in early stages of tumor. If the tumor reaches large sizes the symptoms of intestinal obstruction may be present. The dyspnoe may be present at ascites. Bilaterality or fixation arouse the suspicion of malignancy.
Diagnosis. Pelvic examination is the main one in diagnostics of ovarian cancer neoplasms. Physical findings in patients are absent if a tumor is of small sizes. Bilateral tumors may be palpated on the sides of the pelvis, sometimes in the back of the uterus. Malignant ovarian tumors are similarly irregular with nodular surface and have the firm consistency. Ultrasonography should determine tumor location, its internal surface. Ultrasonography is especially useful for uncertain physical findings in case of obesity.
Percutaneous fine-needle aspiration is an accurate method of diagnosing of the variety of tumors. It should not be used for the initial diagnosis of the ovarian tumor, because the neoplasm should be treated by surgical excision. There is some risk that a cystic neoplasm may rupture when aspirated.
Laparoscopy with diagnostic purposes should be indicated for the patients for revealing external peculiarities of the tumor, presence of dissemination and metastases. It is contrindicated for the patients that were previously operated, with excessive weight, with large tumors.
Sometimes diagnostic laparotomy is necessary in the evaluation of ovarian cancer. After skin incision a detailed inspection of pelvis and abdominal cavity must be held. Smears for cytologic evaluation and biopsy should be performed. The final diagnosis is made after cytologic and hystologic investigation.
Radiographic examination is valuable in the diagnosis of chest and abdominal cavity revealing. X-ray examination of stomach and intestine is obligatory for exception of metastatic ovarian cancer. Fibrogastroscopy and biopsy, pneumo-pelviog -aphy may be useful for diagnosis.
Lymphography is of value in the diagnosis of dysgerminoma when lymphogenic way of spread is the main one. In 30% of patients sacral metastases are present.
Treatment. All histologic types of ovarian carcinoma are threated in the same way. The standard surgical procedure for carcinoma of the ovary is total abdominal hysterectomy and bilateral salpingoophorectomy. A partial or complete omentectomy should be performed, and in the advanced disease, an attempt should be made to resect as much metastatic tumor as possible. The contralateral ovary and fallopian tube are removed unless the conservation of fertility is important. The contralateral ovary is resected because it has been shown to contain an occult metastasis or primary carcinoma in 5% of patients.
It is a radical method of treatment for the patients with ovarian carcinoma in the I-II stages. In the cases of advanced cancer (III-IV stages) the surgeon r^ust determine the appropriate treatment after exploring the patient's abdomen. Some patients have unrespectable cancer. In this case the surgeon should attempt to establish the diagnosis by excising the involved ovary. If this is not feasible, a biopsy should be obtained from the ovary or metastases. Several studies havе revealed that survival of the patients with stage III-IV ovarian cancer is improved. Radiation therapy is uneffective when there are large residual tumor masses, and treatment with many chemotherapeutic regimens is also the most successful when residual tumor volume is minimized. This type of surgery is referred to as cytore-ductive surgery.
^ — cancer is limited by one ovary Tib — cancer is limited by two ovaries
T2a — cancer involves fallopian tube and uterus, but not extend to pelvic tissue
T3a — implants tumor grossly limited to the true pelvis, abdominal implants
Fig.175. Ovarian cancer (scheme of ovarian cancer).
Fig.176. Bilateral papillary cystadenocarcinoma
The patient whose neoplasm has spread beyond the ovary is initially a :andidate for chemotherapy even if all tumor has been resected. Chemotherapy s usually advocated for women with all stages of disease. A variety of drugs are ictive against the ovarian cancer. Such of them as Methotrexate, Cyclophosphan, >arcolizine are emerhed as drugs for chemotherapy. Combination chemotherapy nay be more effective than single-agent chemotherapy in patients with bulky esidual tumor, but it is also more toxic. Combination of such agents as Cyclopho-iphane+Phtoruracil; Cyclophosphane+Methotrexate+Phtoruracil; Cyclophos-)hane+Adriablastine+Cisplatin should be prescribed. Tiotef and Cisplatin should )e administrated intraperitoneally.
There is no difference between single-agent and combination therapy in the ;ases of advanced cancer. You should remember that Cisplatin has Nephrotoxic effects, and Adryamicin and Phtoruracil have cardiotoxic effects.
Prognosis. The overall survival rate for stage IA is 90-98%; for stage IB — t is less than 68%, for stage II — 50%, for stage III — 10-15%. The overall survival rate for ovarian cancer at 5 years is 28-30%.
Dysgerminoma is the most common malignant germ cell tumor which is irising from undifferenting gonades that are present in the ovarian sinus.
Clinic. The tumor is common in the infantile patients of 30 years of age. 3atients generally can observe pelvic or abdominal mass, abdominal enlarge-nent or pain. The duration of symptoms ranges from 1 month to 2 years with a nedian of 4 months. The metastases are present in lungs.
Diagnosis is difficult and it is based on the results of clinical findings, laparo-scopy and histologic investigation results.
Treatment is surgical with the following radiation therapy and chemotherapy.
Ovarian teratoblastoma is a rare malignant tumor which is found in childhood in juvenile period.
Clinic. Pain in the lower part of the abdomen and general weakness are common. In the advanced cases ascites is present. Metastatses arise very quickly.
Diagnosis is based on the histologic results.
Treatment is surgical with the following radiation therapy.
Adenocarcinoma of the fallopian tube is one of the rarest malignancies of the female genital tract. It may developed primarily (from uterine tube) secondary, or metastatically (from lesions arising in the adjacent organs such as uterus and ovaries). Primarily the disease affects the older women. The average age is 40-55 years that had chronic tubal inflammation for a long period of time. The process is always unilateral.
Adenocarcinoma of the fallopian tube has pappilary, glandular-papillarty, papillary-solid and solid structure. The process can quickly metastase inside the pelvis. Ascites is a rare associated finding. Distant metastases are relatively more important for tubal carcinoma than for ovarian carcinoma. More than 50% of the recurrences with tubal carcinoma appear outside the peritoneal cavity, although they usually associated with intraperitoneal metastases.
Clinic. Most patients with tubal carcinoma are asymptomatic, and diagnosis is made only after the patient has undergone surgical exploration for a pelvic mass. A few patients have symptoms such as vaginal bleeding or discharge, lower abdominal pain, abdominal distension and pressure. In many cases these symptoms are vague and nonspecific. Postmenopausal bleeding or discharge may be a symptom. The most common finding at examination is a pelvic or abdominal mass.
Diagnosis. Ultrasonography and laparoscopy, cytologic investigation of the uterine aspirate can prove the diagnosis.
Treatment is surgical. Total abdominal hysterectomy and bilateral salpingo-ophorectomy with the following radiation and chemotherapy are used.
OF EXTERNAL GENITAL ORGANS
Benign tumors of external genital organs (fibroma, myoma, lypoma, fibro-myoma, hydradenoma, myxoma, angiofibroblastoma) are found rarely in any age and are asymptomatic. Nodes of the tumor on pedicle or on the wide base reach considerable size, sometimes hang down between hips. Malignant transformation of the tumor is possible. Edema, hemorrhage, necrosis, secondary infection can develop due to violation of blood supply.
Fibroma is a rare tumor arising from connective tissue and smooth muscle elements of the vaginal wall. Depending on the arrangement of fibres, these tumors can be soft, solid and dermoid. A tumor is situated in the depth of labia major or under the vaginal mucosa. It grows slowly and gives no clinical symptoms until it reaches considerable size, that creats discomfort in walking and sexual intercourse. Only dermoid fibroma can become malignant.
Lipoma develops from adipose and connective tissue. It consists of mature adipose tissue, that is divided into lobules by partitions of connective tissue. It is localized in the region of pubis or labia major. The tumor is of soft consistency, it is round in shape, rather mobile and is not adhered with skin. It grows slowly.
Myxoma is formed from remnants of mesenchyme. It is localized in the region of pubis and labia major. It occurs more frequently in the aged women.
Hemangioma appears on the basis of congenital anomaly of skin vessels and mucosa of sexual organs. The capillary and cavernous hemangioma have been distinguished. It is localized in the region of labia major as a nodule of red or blue colour. It grows rapidly reaching considerable size, sometimes passing to vagina and cervix.
Papilloma is formed from the epithelium of labia major, has fibroepithelial structure. Macroscopically it is a single or plural tumor on the pedicle or wide base with granular surface. It should be differed from condyloma acuminata. Prognosis is usually favorable, but for some conditions malignization is possible.
Treatment of all the forms of benign tumors is surgical (tumor removal).
Bartholin gland cyst is formed in the result of blocking of its excretory duct. It is situated in the lower one-third of labia major. The formation has 2-4 cm in diameter, round or oval shape and elastic consistency. It is frequently complicated with suppuration, that is followed by symptoms of acute inflammation (pain, edema, hyperemia, infiltration of tissues, violation of general state of health, raising temperature).
Treatment is surgical — over the most prominent place the dissection of the skin 2-3 cm long is made, the gland is shelled off and removed by obtuse and sharp way. Hemostasis is performed and the stitches are put in.
Fig.177. The Gartner's duct cyst
The cyst of Gartner's duct has embrional origin. It is developed from the remnants of vestigial mesonephric duct. It is situated on the lateral wall of vagina, has up to 3-4 cm in diameter and dense or soft-elastic consistency. It is diagnosed during gynecological examination (fig 177). In some cases it should be differentiated from sarcoma of vagina, and in case of suburethral location of the cyst — from the diverticle of urethra.
Treatment is surgical. Vagina is opened by specula and its wall is incised in the place of the biggest prominence of the cyst that is shelled off.
To precancer diseases of the vulva belong:
pigmented spots, inclined to growth and ulceration
Treatment Replacement therapy, psychotherapy, sleeping-draughts, sedative remedies are prescribed. Baths with camomile decoction, prednisolon ointment, oxycort, ointment with anesthesin are prescribed locally. Treatment is not always effective. From non-medicinous methods magneto-laser therapy, gas and semiconductor apparates have been also used.
Bowen's disease is followed by appearing on the external genitals skin of flat or slightly rising above skin level spots with clear margins. Histologically the signs of hyperkeratosis and acanthosis are found.
Fig. 179. Histological picture in Paget disease
At Paget disease during gynecological examination on skin of vulva scarlet eczema-like spots with granular surface are found (fig. 179). Treatment is surgical. Vulvectomy is recommended.
Cancer of external genital organs is a malignant epithelial tumor, that appears in women during menopause and looks like infiltration, dense nodes or papilar formations. Ulceration is possible (fig. 180). Precancer diseases come before the appearing of neoplasm. Late puberty, early menopause and high fertility are typical for the patients with vulvar carcinoma. Frequently vulvar carcinoma is combined with obesity and diabetes mellitus.
Fig. 180. Cancer of clitoris
Exophytic, nodular, ulcerous and infiltrative forms of the tumor are distinguished.
Clinical manifestations. The main symptoms are itching, burning, pain, purulent-hemorrhagic discharge. Pain of tumors is usually localized in the region of clitoris. Hemorragic discharge can appear at tumor disintegration.
Final diagnosis is made basing on the histological research.
Metastasing happens into nodes of inguinal-femoral collector.
Treatment is, surgical. Vulvectomy and bilateral inguinal lymphadenectomy (Ducken's operation), combined treatment (vulvectomy and radiotherapy) are used. Radiotherapy is performed before the operation, and then after it they irradiate the regions of primary lesion and regional metastasing.
Regular medical check-up of patients must be made by the end of their life.
Carcinoma of the vagina can be primary and metastatic. More frequently women can have cancer in climacteric period and after menopause. Cancer can appear in the aged women with long-termed decubital ulcer due to its infecting and traumatizing (fig. 181). Exophytic (as cauliflower) or endophytic infiltrative growth is observed. Histologically carcinoma of the vagina is divided into the squamous cell keratinizing carcinoma, non-keratinizing and adenocarcinoma.
Fig.181. Carcinoma of the vagina
^ The purulent-hemorrhagic discharge, pain, disturbance of urination, signs of general intoxication are common unexpectable. Bleeding can occur at disintegration of the tumor. Nerves are pressed, ruined and patients feel pain if a tumor spreads to the underlying tissues, paravaginal cellular tissue. Neoplastic process can be spread on the adjacent organs like urinary bladder and rectum. Disintegration of the tumor can cause formation of bladder-vaginal and recto-vaginal fistulas. Hydro- and pyonephrosis, and later — uraemia can develop on condition that the ureters are compressed.
One should differ carcinoma from decubitus, syphilitic and tuberculosis ulcers, condilomas, endometriosis, chorioepithelioma, metastases of cervical and uterine cancer into vagina.
Lymphatic cancer spread is more common: from upper one-third into iliac and hypogastric lymph modes; from middle one-third into the sacral ones; from the lower one-third into the inguinal lymphatic nodes.
Final diagnosis is made after biopsy.
Treatment Carcinoma of the vagina is treated by the combined radiotherapy. X-ray or gamma-ray telethepary with insertion of radioactive preparations into vagina are used.
A. Questions for self-assessment.
B. Tasks for self-assessment.
1. A 25 year-old woman. Anamnesis: 1 labour, 1 abortion, regular menstrual cycle. Complaints: ache in the lower abdomen for 2 months. Vaginal examination: in the right side from the uterus – tumour- like formation 8 on 10 sm. USD: tumour- like formation within the right adnexa with clear borders. What is the diagnosis and plan of actions?
2. A 46- year-old woman is brought by an ambulance into gyneco9logical department complaining of sharp pain in the lower abdomen, more to the left, weakness, mucous discharge from the genitals. Anamnesis: 2 labours, 4 abortions, ovarian tumour was diagnosed 2 months ago, surgical treatment was recommended, but the woman refused. USD: left ovarian tumour 10 on 12 sm, in the minor pelvis and beyond it- free liquid. What is the diagnosis and plan of actions?
1. Uterine myoma belongs to the group of:
A. Tumours of the genital stroma.
B. Mesenchymal tumours.
C. Tumours of the cells of coelomic epithelium.
D. Tumours of the sexual cells (gonadocytes).
2. Most often uterine myoma is localized in:
A. uterine cervix
B. uterine body
C. uterine isthmus
E. between uterine ligaments.
1. Obstetrics – edited by Professor I.B. Ventskivska, Kyiv “Medicine”, 2008.
2. Gynecology – Stephan Khmil - Ternopil, 2003.
3. Danfor 3. Danforth’s Obstetrics and gynaecology. - Seventh edition.- 1994. - P. 201-225.
4. Basic Gynecology and Obstetrics. - Norman F. Gant, F. Gary Cunningham. -1993. -- P. 406-412.
5.Obstetrics and gynecology. - Pamela S.Miles, William F.Rayburn, J.Christopher Carey. - Springer-Verlag New York, 1994. - P. 62-64.
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