Download BENIGN AND MALIGNANT OVARIAN TUMORS

Topic: Benign tumours of the female reproductive organs.
Gynecological aspect of diseases of the mammary gland.
1. Topicality: Early and active detection of benign tumours and
precancer disorders of the female reproductive organs and
mammary glands, their timely and correct treatment –are the
guarantee to solve the problem of malignant diseases.
Annumerated causes make this topic rather important.
2. Number of hours: 4
3. Educational objectives: to acquaint the students with frequency,
structure, risk factors of development of benign formations of the
female reproductive organs and mammary gland. Discuss clinical
manifestation, methods of diagnostics and treatment of benign
tumours of the external genitals, ovaries, uterus and mammary
gland.
To know: a=II
1. Pathogenetical variants of development of uterine myoma.
2. Classification of uterine myoma.
3. The main clinical symptoms peculiar for uterine fibromyoma.
4. Examination methods to diagnose uterine myoma.
5. Conservative methods of treatment.
6. Indications for surgical treatment of myoma.
7. Methods of surgical treatment of myoma.
8. Classification of benign ovarian tumours.
9. Complications of ovarian tumours.
10.Peculiarities of examination and treatment of ovarian cystoma.
11.Gynecological preconditions 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).
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.
OVARIAN TUMORS CLASSIFICATION
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. I. Epithelial tumors:
A.
Serous
B.
Mucinous
C. Endometriod
D. Clear cell
E. Brenner
F. Mixed epithelial
G. Undifferentiated
H. Unclassified.
There are benign and malignant tumors in each of these groups of neoplasms
II. Sex cord stromal tumors:
A. Granulosastromal cell
B. Androblastoma
C. Gynandroblastoma
D. Unclassified
III. Lipid cell tumors
IV. Germ cell tumors:
A. Dysgerminoma
B. Endodermal sinus tumor
C. Embryonal carcinoma
D. Polyembryoma
E. Choriocarcinoma
F. Teratoma
G. Mixed forms
V. Gonadoblastoma:
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
F. Endometriosis
G. Superficial epithelial cysts-inclusions
H. Simple cysts
I. Inflammatory processes
J. Paraovarian cysts
UNBLASTOMATIC UNPROLIFERATIVE OVARIAN TUMORS
(ovarian cysts)
Ovarian cyst is the cavity of mature or atretic follicle that become distended with pale, strawcolored 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 cyst
Follicle ovarian cyst is a single tumor with a thin membrane of mobile consistency with a strawcolored 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.
Corpus luteum cyst
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.
Theca lutein 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
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.
BLASTOMATIC PROLIFERATIVE OVARIAN TUMORS
(ovarian cystadenomas)
Serous cystadenoma
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.
Papillary serous cystadenomas
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
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.
Thecoma (Theca cell tumor)
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
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.
Benign cystic teratoma (Dermoid cyst)
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. Dermoid cyst: a — dermoid
cyst; b — dermoid cyst on sectioning
(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
Ovarian cysts and cystadenomas' complications
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.
MALIGNANT OVARIAN NEOPLASMS
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:
• malignant epithelial cell tumors, which are the most common type, 46-48
• malignant germ cell tumors, 10-14%
• malignant stromal cell tumors, 4,7%
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.
TNM Stages of Primary Carcinoma of the Ovary
Tumor (T)
N,
Nodulus
M,
Metastasis
Growth limited to one ovary, capsule intact T IA
Growth limited to both ovaries, capsule intact, TIB
T IA or T IB with capsule ruptured, or with ascites,
TIC
Growth, involving one or both ovaries with uterus
and tubes extension, T IIA
-//- with extension to other pelvic tissues.
NO
NO
NO
MO
MO
MO
NO
MO
NO
MO
Obvious parametrial involvement, T IIB
T IIA or T IIB, ascites containing malignant cells
NO
Tumor grossly limited to the true pelvis with
histologically confirmed microscopic seeding of
abdominal peritoneal surfaces, T IIIA
-//- with histologically confirmed implants of abdominal peritoneal surface none exceeding 2 cm in
diameter, T IIIB
-//- abdominal implants > 2cm in diameter, and/or
positive retroperitoneal or inguinal nodes, T IIIC
NO
MO
NO
MO
NO
MO
Any N
Ml
N1
MO
Stage
characteristics
IA
IB
1С
II A
II В
ПС
III A
III В
III С
IV
Any T with distant metastasis, T IV
Any T
MO
*
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
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 Cyclophoiphane+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.
ADENOCARCINOMA OF THE FALLOPIAN
TUBE
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.
BENIGN AND MALIGNANT TUMORS
OF EXTERNAL GENITAL ORGANS
AND VAGINA
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 duct cyst
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.
The Gartner's duct cyst
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.
PRECANCEROUS DISEASES OF THE VULVA
To precancer diseases of the vulva belong:
leukoplakia
vulvar kraurosis
Bowen's disease
Paget's disease
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 magnetolaser therapy, gas and semiconductor apparates have been also used.
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)
Fig. 179. Histological picture in Paget disease
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, purulenthemorrhagic 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
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
Clinical manifestations. 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 rectovaginal 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.
5.4 Materials for Self- assessment:
A. Questions for self-assessment.
1. What is cystoma and true ovarian tumours?
2. What is ovarian cyst?
3. How are tumours and tumour- like formations of the ovaries classified?
4. What are the methods of diagnostics of ovarian tumours?
5. What are clinical signs in patients with ovarian tumours?
6. What are possible complications in patients with avarian tumours?
7. What is anatomical and surgical peduncle of ovarian tumour?
8. What are indications for surgical treatment in case of ovarian tumours?
9. What surgical methods are used for ovarian tumours?
10.What is uterine fibromyoma?
11.The causes of uterine fibromyoma, morphological changes in case of uterine
fibromuoma.
12.Methods to diagnose uterine fibromyoma (UF).
13.Clinical signs of UF.
14.Differentiation diagnostics of UF.
15.Complications of UF.
16.Indications forsurgical treatment.
17.Kinds of concervative operations.
18.Radical and half-radical operations.
19.Concervative therapy of UF.
20.Prevention of UF.
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?
C. Tests for self-assessment.
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
D. extraperitoneally
E. between uterine ligaments.
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. 201225.
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.