MINISTRY OF PUBLIC HEALTH OF UKRAINE
NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY,
VINNYTSYA
Approved at a meeting
of the department of
obstetrics and gynecology №1
Head of the Department
______________ prof. Chaika H.
« 27 »
08
METHODICAL INSTRUCTIONS
for practical lesson
Educational discipline
Моdule №
Topic № 9
Course
Faculty
Gynecology
1
Benign tumors of the female genital organs.
Benign ovarian tumors (cysts and cystomas).
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Medicine
2020
2
Approved at the meeting of the Department of Obstetrics and Gynecology
№1. Protocol №1 dated August 27, 2020.
Compiler: Associate Professor Malinina O.B
Actuality of the topic
Benign ovarian tumors account for 75-80% of all ovarian tumors.
Benign ovarian tumors include concepts such as cysts and cysts of the ovaries.
Ovarian cysts are tumor-like formations characterized by fluid accumulation among
normal ovarian tissue surrounded by a clear capsule. These include: ovarian
follicular cyst, corpus luteum cyst, paraovarian cyst. Cystoma is a real tumor of the
ovary, which has all the characteristics of tumor growth (benign).
Educational purpose
Name of the previous discipline
Acquired skills
Normal anatomy
Apply knowledge of the structure of the
female genitals, mammary glands.
Histology
Morphological structure of female
genitals, mammary glands.
Normal physiology
Physiology of the menstrual cycle,
physiology of hormonal aspects of breast
function.
Pathological anatomy
Morphological structure of all types of
benign tumors of the female genitals and
mammary glands.
Pathological physiology
Pathophysiological changes of the
hormonal cycle, the impact on cyclic changes
in breast tissue.
Operative surgery
The main types of operations on the
female genitals and breast.
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Pharmacology
Pharmacokinetics of drugs used to
correct the menstrual cycle, hormonal drugs,
hemostatic drugs, anti-inflammatory drugs.
Student must know:
1). Determination of the main etiological and pathogenetic factors of
background, precancerous diseases and malignant tumors of the female genital
organs and breast.
2). Classifications of background, precancerous diseases and malignant
neoplasms of the female genital organs and breast.
3). Stages of drawing up a plan of examinations, be able to analyze the data
of laboratory and instrumental examinations for background, precancerous diseases
and cancer of the female genital organs and breast.
4). Methods of differential diagnosis, justification and formulation of
preliminary diagnosis.
5). Tactics of management of patients (principles of surgical interventions,
conservative treatment, rehabilitation measures) at background, precancerous
diseases and malignant new growths of female genitals and a mammary gland.
Student should be able:
1). Conduct gynecological examination (in mirrors, bimanual, rectal,
rectovaginal).
2). Collect a special gynecological history, evaluate the results of laboratory
tests (general and biochemical tests of blood, urine, coagulogram, etc.).
3). To collect material from the vagina, cervix, cervical canal and urethra.
4). Evaluate the results of colpocytological examination.
5). Evaluate the results of cytological, histological and bacteriological
examinations.
6). Evaluate the results of X-ray examinations of female genitals.
7). Evaluate the results of ultrasound.
8). To make the plan of inspection of the patient at various nosological types
of gynecologic pathology.
Content of the topic
Benign ovarian tumors account for 75-80% of all ovarian tumors.
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Benign ovarian tumors include concepts such as cysts and cysts of the ovaries.
Ovarian cysts are tumor-like formations characterized by fluid accumulation among
normal ovarian tissue surrounded by a clear capsule. These include: ovarian
follicular cyst, corpus luteum cyst, paraovarian cyst. Cystoma is a real tumor of the
ovary, which has all the characteristics of tumor growth (benign).
In none of the organs is there such a histological variety of tumors as in the
ovary. According to the International Histological Classification compiled by WHO
experts (1973), ovarian tumors are divided into eight groups. Given its complexity
for perception not only by students but also by general practitioners, SK Serov
(1978) proposed a more simplified version of this classification.
I. EPITHELIAL TUMORS
A. Serous, mucinous, endometrioid, mesonephroid (clear cell), mixed;
and). benign - cystadenoma, adenofibroma, superficial papilloma;
b). borderline - intermediate forms of cystaden and adenofibrom;
in). malignant - adenocarcinoma, cystadenocarcinoma, papillary carcinoma.
B. Brenner's tumor.
a). benign;
b). border;
с). malignant.
II. TUMORS OF THE STROKE OF SEXUAL WEIGHT.
A. Granulosa-thecacellular tumors: granulosa-cellular, tecom-fibroma group,
non-classified tumors.
B. Androblastomas, tumors of Sertoli and Leydig cells (differentiated,
intermediate, poorly differentiated).
B. Ginandroblastoma.
G. Tumors that are not classified.
III. LIPID-CELL TUMORS.
IV. HERMINOGENIC TUMORS.
A. Dysgerminoma.
B. Tumor of the endodermal sinus.
B. Embryonic carcinoma.
R. Polyembrinoma.
D. Chorionepithelioma.
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E. Teratomas (mature, immature).
J. Mixed germinogenic tumors.
V. GONADOBLASTOMA.
VI. SOFT TISSUE TUMORS (non-specific for ovaries).
VII. TUMORS THAT ARE NOT CLASSIFIED.
VIII. SECONDARY (METASTATIC) TUMORS.
IX. TUMOR-LIKE AND PRE-TUMOR PROCESSES: luteoma of
pregnancy, hypertecosis, follicular cysts, corpus luteum cyst, endometriosis,
inflammatory processes, paraovarian cysts.
3.3.1. Ovarian epithelial tumors consist of one or more types of stromal
epithelium in various combinations.
3.3.1.1. Serous epithelial cyst of the ovaries. Serous tumor cells produce
serous fluid or mucin. Serous tumors are single- or multichambered, large in size.
Their walls are dense, the contents are transparent, light, the inner surface of the
capsule is smooth.
At vaginal research the smooth-walled mobile formation of the rounded or
ovoid form laterally or behind from a uterus is defined.
Papillary serous cystadenomas, which are characterized by the presence of
papillary growths on the inner surface of the cyst capsule, are quite common. They
are often bilateral. The main complaints of patients with this pathology are: pain in
the lower abdomen, torsion of the leg of the tumor - acute, there are dysuric
disorders, increase in abdominal volume, infertility.
The diagnosis is established on the basis of the clinical course of the disease,
bimanual and ultrasound data.
3.3.1.2. Mucinous or pseudomucinous tumors. These are cysts whose
epithelial component is similar to the epithelium of the cervical canal. These are
multi-chambered rounded or oval-shaped tumor-like formations with an uneven
surface. They contain a viscous turbid liquid, often unilateral. The size varies from
small size to a giant tumor.
Clinically manifested by pain, locks, a feeling of heaviness in the lower
abdomen, dysuric disorders, abdominal enlargement. The most common complaint
is dull, numb, pain in the lower abdomen, sometimes paroxysmal, acute.
At vaginal research the thick-walled tumor of a rigid elastic consistence
laterally or behind a uterus is palpated, the tumor surface is uneven due to
multichamber. Rarely affected both ovaries, usually have a well-defined leg, and
therefore, there is a torsion.
Pseudomyxoma is a type of mucinous ovarian tumor.
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3.3.1.3. Endometrioid tumors. Derived from the remnants of the Mullerian
epithelium. It is a single- or multi-chambered tumor containing a chocolate-colored
thick liquid. The inner surface of the capsule is covered with endometrioid
epithelium, which functions cyclically, like the epithelium of the uterine cavity.
More often it is a unilateral tumor, although there is a bilateral localization. The main
complaint is pain in the lower abdomen, mostly during or after menstruation.
3.3.1.4. Mesonephroid clear cell tumors are rare.
3.3.1.5. Brenner's tumor is a rare tumor that consists of epithelial components
located in the form of inclusions among the connective tissue of the ovaries. The
tumor has an oval or round shape, smooth outer surface and small size.
3.3.2. Tumors of the stroma of the genital tract. This is a group of hormoneproducing and hormone-dependent tumors. Hormonally active ovarian tumors are
tumors that originate from hormonally active structures of the "female" and "male"
part of the gonad, secreting respectively estrogen and androgens, causing
respectively the development of feminizing or virilizing symptoms. Their
occurrence is associated with the presence of embryonic residues and hormonal
imbalance in the body. Unlike all other ovarian tumors, hormone-producing tumors
are characterized by a clinically pronounced picture of the disease.
3.3.2.1. Granulocytic tumor. Sometimes mostly unilateral rarely reaches large
sizes. The source of its growth is granulosa follicles and cerebral cords. Clinical
manifestations are due to the hormonal activity of the tumor, which causes changes
in the appearance of the patient, due to the production of tumor cells by estrogenic
hormones. Girls have premature puberty, enlargement of the mammary glands, the
appearance of secondary sexual characteristics. In menopausal women,
menstruation resumes, often - metrorrhagia. In childbearing age, frequent bleeding,
sometimes amenorrhea, infertility, frequent miscarriages. Older patients look
younger than their years. Along with the signs of hyperestrogenism there is an
increase in skin turgor, swelling of the mammary glands. The ovaries may be slightly
enlarged.
3.3.2.2. Tecoma .. Develops from the cells of the inner shell of the follicle or
from the ovarian stroma. Its clinical manifestations are approximately the same as
in granulosa cell tumor and are due to increased estrogen production. At vaginal
research the slightly increased uterus and formation of an ovary of a dense
consistence, mobile, painless, unilateral is defined.
3.3.2.3. Fibroma .. Develops from the ovarian stroma - a unilateral tumor of
solid structure. It has a slow growth, dense consistency, may be asymptomatic. At
vaginal research the ovarian fibroma is located behind or on the side of a uterus.
Ultrasound helps in diagnosis.
3.3.2.4. Androblastoma. It develops from the elements of the male gonad. The
clinical course is dominated by signs of defeminization and masculinization of the
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female body. The disease in most cases begins with amenorrhea, a gradual decline
in libido, male pattern hair growth, slow alopecia, flattening of the mammary glands,
coarsening of the voice. At inspection the tumor in the field of appendages of a
uterus, painless, elastic consistence, mobile, as a rule, unilateral is defined.
3.3.2.5. Ginandroblastoma. This is a combined tumor, in which on the one
hand there are structures characteristic of granulosa cell tumor, on the other - typical
tubules covered with cells such as sustenocytes. The clinic of this tumor may be
characterized by a small estrogenization.
3.3.3. Lipid cell tumors. These are rare tumors from the dystopian cortical
layer of the adrenal glands - hypernephroma, luteoma. Clinically manifested by
defeminization, masculinization, the presence of Cushing's syndrome, infertility,
anovulation, amenorrhea, hair growth on the upper lip and chin.
3.3.4. Germinogenic tumors. Arise from the elements of undifferentiated
gonads due to genetic disorders and malformations.
3.3.4.1. Dysgerminoma. This is the most common tumor. Some experts
attribute it to benign, but this tumor is fast growing and gives early lymphogenic
metastases. The tumor has no hormonal activity. The main symptom of the disease
is pain in the lower abdomen.
3.3.4.2. Endodermal sinus tumor and embryonic carcinomas. These are rare
tumors with a high degree of malignancy. They metastasize lymphogenically,
hematogenously and implantation.
3.3.4.3. Teratoma. Is a derivative of embryonic leaves. Sometimes cystic and
solid. Most mature ovarian teratomas are cystic, which include dermoid cysts. This
is a single-chamber formation with a smooth surface.
Immature teratoma is a malignant tumor.
Clinically manifested by abdominal pain. Menstrual function is not disturbed.
3.3.4.5. Gonadoblastoma. It is a homologue of different stages of development
of the gonad. The tumor is very rare, occurs in patients with gonadal dysgenesis.
Clinical manifestations - symptoms of verification. The tumor is often unilateral.
3.3.6. Tumors of soft tissues, non-specific for the ovaries. These tumors are
diagnosed according to the histological classification of soft tissue tumors.
3.3.7. Unclassified tumors. This group includes tumors that cannot be
classified as those types of tumors that are mentioned above.
3.3.8. Secondary (metastatic) tumors. They make up 20% of all ovarian
tumors, arise as a result of metastasis of malignant tumors of different localization
by lymphogenic, hematogenous and implantation-transperitoneal way.
3.3.9. Tumor-like formations of the ovaries.
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These include ovarian cysts that occur as a result of fluid accumulation in the
anterior cavity, without epithelial lining. The result of these formations can be:
reverse development, transformation into a real tumor, twisting of the tumor leg.
3.3.9.1. The most common are follicular cysts of the ovaries. The
accumulation of fluid occurs due to its transudation from blood vessels, the follicular
epithelium does not participate in the accumulation of fluid. A follicular cyst is a
single-chamber, thin-walled cystic formation with light transparent contents.
Patients complain of lower abdominal pain, menstrual irregularities. The size of a
follicular cyst seldom exceeds 8-10 see
3.3.9.2. Cysts of the corpus luteum. The reason for their formation may be
inflammatory changes in the ovaries. In size, consistency, shape and clinical
manifestations, they are similar to follicular cysts.
3.3.9.3. Paraovarian cyst. It usually arises from the embryonic remnant of the
wolf's canal. Is a retention entity. The ovary does not participate in its formation. Its
capsule is thin-walled, the contents are transparent, the size is small. It develops
asymptomatically and, as a rule, is an accidental finding at professional examination.
The main methods of diagnosis of ovarian tumors: clinical methods (history,
complaints, rectovaginal examination); Ultrasound; CT; MRI; determination of
tumor markers (CA-125); examination of the gastrointestinal tract (fibrocolono-,
fibrogastroscopy); cytological method of examination of effusion in cavities, etc.
The main method of treatment of all real ovarian tumors is surgery. The scope
of the operation depends on: the type of tumor (pathomorphology), the woman's age,
the prevalence of the process (endometrioid ovarian tumors).
Theoretical questions for the lesson
1.What is an ovarian cyst?
2. What is an ovarian cyst?
3. Classification of ovarian cysts.
4. Epithelial tumors of the ovary: types, clinical manifestations.
5. Hormone-producing and hormone-dependent ovarian tumors: types,
clinical manifestations.
6. Germinogenic ovarian tumors: types, clinical manifestations.
7. What is a lipid cell tumor.
8. What is a secondary ovarian tumor.
Practical tasks performed in class
1. The main methods of diagnosing ovarian tumors.
2. The main methods of treatment of ovarian tumors.
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3. What do you know about tumor-like formations of the ovaries, clinic,
tactics of management of patients?
Materials for self-control
1. A 16-year-old patient was admitted to the clinic with complaints of no
menstruation from the age of 13. Menarche from 11 years, regular. From the age of
13 menstruation stopped, there were moderate signs of hirsutism. The mammary
glands are hypoplastic. As a result of examinations (clinical, laboratory, hormonal,
gynecological, ultrasound, radiological) was found a tumor in the left ovary 9 x 6
cm, 17-CS - 10.9 mg / day, Turkish saddle is normal. Your diagnosis, tactics of
treatment of the patient.
A. * Androblastoma, surgical treatment.
B. Granulocytic tumor, surgical treatment.
S. Androblastoma, observation.
D. Congenital hermophraditism, observation.
2. A 32-year-old patient was admitted to the clinic with complaints of
increased abdominal volume, heaviness in the lower abdomen, intermittent pain,
more on the left. The abdomen has increased over the past 2-3 months. Last
professional examination 6 months. back - a tumor of the left ovary 5 cm in diameter.
An additional examination was offered, which the patient refused. Menstrual
function is not impaired, 1 normal birth. At clinical, laboratory, gynecological,
ultrasound examination, a tumor of the left ovary measuring 30 x 45 cm, mobile,
dense-elastic consistency, moderately painful, according to ultrasound - uneven
intensity, a solid formation of the type "colorful pattern". What can be assumed
diagnosis, treatment tactics.
A. * Ovarian dysgerminoma, surgical treatment.
B. Cystic formation of the ovary with torsion of the leg, surgical treatment.
C. Granulocytic tumor, surgical treatment.
D. Androblastoma, surgical treatment.
3. A 23-year-old patient complained of moderate lower abdominal pain, which
occurs periodically, is aching, has long been a concern. I had not seen a doctor
before. At clinical, laboratory, gynecologic research, the tumor of the right ovary in
the sizes of 5 x 6 cm is found, mobile is a little painful, there are no other pathological
changes. According to ultrasound, a tumor with a dense capsule with a solid-liquid
component, with a predominance of solid, which emphasizes the presence of
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hyperechoic areas by type of bone or cartilage. A woman's menstrual function is not
impaired. Your probable diagnosis, treatment tactics.
A. * Dermoid ovarian cyst or mature ovarian teratoma, surgical treatment.
B. Secondary ovarian tumor, surgical treatment.
C. Dysgerminoma, observation.
D. Cyst of the corpus luteum, observation.
4. A 30-year-old patient complained of pain in the lower abdomen of aching
nature, moderate intensity, disturbing for 2-3 weeks. The last menstruation 6 weeks
ago, normal, timely. At the time of examination there is a delay of menstruation for
2 weeks. The pregnancy test is negative. As a result of clinical, laboratory,
gynecological and ultrasound examinations, a cyst of the left ovary 6 cm in diameter,
smooth-walled, moderately painful, dense-elastic consistency, mobile. Your
diagnosis, treatment tactics.
A. * Follicular cyst of the ovary, ultrasound monitoring is recommended in
the dynamics, if necessary - hormonal treatment.
B. Serous ovarian cyst, surgical treatment.
C. Paraovarian cyst of the ovary with torsion of the leg, observation.
D. Secondary ovarian tumor, surgical treatment.
5. The patient is 45 years old, was admitted to the clinic with signs of acute
abdomen. I fell ill the day before, after intense exercise. During the night the pain
intensified, the abdomen swelled, the body temperature rose to 38o C, the gases did
not go away, there were no chairs, the stomach was tense. Laboratory,
gynecological, clinical and ultrasound examinations revealed a formation behind the
uterus, 8 cm in diameter, limited mobility, painful. According to ultrasound, the
uterus and uterine appendages are not changed, the uterus is a thin, smooth formation
with a clear capsule. According to laboratory tests - signs of inflammation. Your
diagnosis, treatment tactics.
A. * Torsion of the paraovational cyst, surgical treatment.
B. Tumor of the rectum, consultation with a surgeon.
C. Acute appendicitis, surgical treatment.
D. Necrosis of the uterine fibroids, surgical treatment.
6. The child is 11 months old. appeared bloody discharge from the vagina,
enlarged breasts. The girl was examined clinically, laboratory, gynecologically,
ultrasound, examination of the skull bones, examined for blood hormones.
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Examinations in the area of the right ovary revealed a solid formation of 45 x 60
mm. No other pathological changes were found. Your diagnosis, treatment tactics.
A. * Granulocytic tumor of the right ovary, subject to surgical treatment.
B. Granulocellular tumor of the right ovary, observation is recommended.
C. Congenital pathology of development, observation.
D. Embryonic carcinoma, surgical treatment.
References
BASIC
1. Vdovichenko YP, Tatarchuk TF etc. Gynecology of children and
adolescents. Kyiv: Medicine. – 2012. 110-130p.
2. Gynecology: Textbook. for obstetricians - gynecologists, interns, students.
higher honey. textbook lock education of III-IV levels. Golota V.Ya., Benyuk VO Kyiv, "Polygraph Book", 2004. – 450-480 p.
3. Gynecology: a guide for doctors / VK Likhachev. - Vinnytsia: Nova Kniga,
2018. - 688 with https://nk.in.ua/pdf/1579r.pdf 3-5p.
4. Gynecology: a textbook / ed. GM Savelyeva, VG Breusenko. - 4th ed.,
Reworked. and ext. - Moscow: GEOTAR-Media, 2020. – 420-430 p..
5. Gynecology: a national guide / ed. GM Savelieva, GT Sukhikh, VN Serov,
VE Radzinsky, IB Manukhin. - 2nd ed., Reworked. and ext. - M .: GEOTAR-Media,
2020. – 678-690 p.
ADDITIONAL
1. Abdullaev RY, Vdovichenko YP, Mukhomor AI. Ultrasound diagnostics
in reproductive gynecology. Textbook Kharkiv: New word, 2013. - 147 p .: ill.
Recommended by the Ministry of Health of Ukraine dated 04.06.2013 (protocol №2)
2. Gynecology: a textbook (edited by BM Ventskovsky, GK Stepankovskaya,
ME Yarotsky) .- K .: VSV Medicine, 2012.- 352 p.
3. Methodical instructions for teachers on the organization of the educational
process in gynecology at the medical faculty - Ventskivsky BM 2010
4. Hirsch HA, Kezer O., Ikle FA. Operative gynecology. Translated from
English by Kulakov VI 2005.-649 p.
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