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Summary
BENIGN AND MALIGNANT OVARIAN TUMORS
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:
• women with impairment of ovarian function
• women with postmenopausal bleeding
• women that have been monitored for a long period of time with the diagnosis of uterine
fibromyoma, chronic inflammatory processes of uterine adnexa, benign ovarian tumors
• women that have had surgical intervention in pre- or postmenopause with keeping ovaries (or
their resection)
All ovarian tumors should be divided into two main groups:
• blastomatic unproliferative tumors (ovarian cysts)
• blastomatic proliferative tumors (ovarian cystadenomas)
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.
Follicle 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.
Parovarian cyst
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).
cycle is normal. The symptoms of peritoneal irritation are present in the case of
pedicle torsion. These tumors are revealed during monitoring.
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
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
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
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).
SPECIAL FORMS OF OVARIAN TUMORS
Androblastoma (arrhenoblastoma)
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.
(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.
Brenner tumor
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:
• for a long period of time they are asymptomatic, they are growing into direction of
abdominal cavity. Pain is a common symptom in case when the tumor is growing
intraligamentously (fig. 173)
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
• the signs of adjacent organs compression are present during tumor' growing
• the tumors are palpated as a rule in the lateral sides of the uterus
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.
Tla — cancer is limited by one ovary Tib — cancer is limited by two ovaries
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
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
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.
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.
Bowen's disease
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.
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 (VULVAR CANCER)
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.
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.
References:
1. Obstetrics – edited by Professor I.B. Ventskivska, Kyiv “Medicine”, 2008.
2. Gynecology – Stephan Khmil - Ternopil, 2003.
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.