Topic: Backgrounds and precancerous diseases of female genital organs.
Malignant formations of genital organs. Trophoblast diseases.
1. Topicality: Malignancies of the cervix are almost always carcinomas, and a
summary of the more common histologic types are shown in the following
box. Approximately 80% to 85% of these tumors are squamous cell
carcinomas and from 15% to 20% are adenocarcinomas. The incidence of
adenocarcinomas has increased in most developing countries, particularly
among younger women. Carcinoma of the cervix is closely associated with
early and frequent sexual contact and cervical viral infection, particularly
human papillomavirus (HPV), (Intraepithelial Neoplasia of the Lower
Genital Tract).
2. Number of hours: 4.
3. Educational objectives: to acquaint the students with
frequency, structure, risk factors of development of
backgrounds and precancerous diseases of female genital
organs. Malignant formations of genital organs. Trophoblast
diseases. Discuss clinical manifestation, methods of
diagnostics and treatment backgrounds and precancerous
diseases of female genital organs. Malignant formations of
genital organs. Trophoblast diseases.
To know: a=II
1. Classification of backgrounds and precancerous diseases of
female genital organs.
2. Complications of backgrounds and precancerous diseases of
female genital organs.
3. Peculiarities of examination and treatment of backgrounds and
precancerous diseases of female genital organs..
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.
Summary:
Malignant Diseases of the Cervix : Microinvasive and Invasive Carcinoma:
Diagnosis and Management
KEY TERMS AND DEFINITIONS
Adenoma
Malignum
A virulent adenocarcinoma of the cervix that histologically
consists of glands that appear well differentiated (minimal
deviation adenocarcinoma).
Barrel-Shaped
Cervix
A cervix containing a large carcinoma, generally of
endocervical origin, that has replaced much of the cervix,
causing its diameter to widen (usually > 4 cm).
Brachytherapy
A form of radiation therapy in which the source is placed
close to the tumor. The application may be in the form of
needles implanted into the tumor (interstitial therapy) or into
the vagina or cervical canal (internal therapy). For cervical
tumors, an intracervical tandem and vaginal ovoids
(colpostats) are usually used.
Endophytic
A term used to describe a tumor that begins in the
endocervical canal.
Exophytic
A term used to describe a cervical tumor that grows on the
outside surface primarily of the cervix (portio).
Extrafascial
Hysterectomy
An operation that develops the pubocervical fascia to allow
total removal of the cervix and uterus (class I hysterectomy).
Fletcher-Suit
Applicator
A system that delivers brachytherapy to cervical carcinomas
by use of a tandem in the cervical canal and ovoids
(colpostats) in the vagina.
Glassy
Carcinoma
Microinvasive
Carcinoma
Cell
A virulent adenosquamous carcinoma that occurs in the cervix
and metastasizes early in the course of the disease.
A small (stage IA) carcinoma detected by microscopic
examination with little or no risk of spread to regional lymph
nodes (see text for detailed discussion).
Modified Radical An operation that removes the uterus and cervix and some
paracervical tissues but does not dissect the ureters distal to
Hysterectomy
the uterine artery (class II hysterectomy).
Pelvic
Exenteration
An extensive pelvic operation usually employed to treat a
central pelvic recurrence of cervical carcinoma after
radiation. A total exenteration involves removal of the
bladder, uterus, cervix, and rectum. An anterior exenteration
spares the rectum, whereas a posterior exenteration spares
the bladder.
Persistent Tumor The identification of invasive disease at the site of primary
therapy less than 6 months after therapy.
Point A
A term used in radiation therapy of carcinoma of the cervix to
identify a point 2 cm above the external os of the cervix and 2
cm lateral to the cervical canal.
Point B
A term used in the radiation treatment of carcinoma of the
cervix to identify a point 3 cm lateral to point A or 5 cm from
the cervical canal.
Radical
Hysterectomy
An operation that removes the uterus, upper third of the
vagina, cervix, and paracervical-parametrial tissues. The
pelvic ureters are dissected to the uterovesical junction. It is
usually combined with a pelvic lymph node dissection (class
III hysterectomy).
Recurrent Tumor The identification of invasive disease 6 months or more after
therapy.
Stage I: Tumor confined to the cervix
Stage IA: Microinvasion (preclinical)
Stage IB: All other cases confined to the cervix
Stage IIA: Tumor spread to the upper two thirds of the vagina
Summary
Stages
Carcinoma.
of
of Stage IIB: Tumor spread to paracervical tissue but not to the
pelvic walls
Stage IIIA: Tumor spread to the lower third of the vagina
Stage IIIB: Tumor spread to the pelvic wall or obstruction of
either ureter by tumor
Stage IV: Tumor spread to the mucosa of the bladder or
rectum or outside the pelvis.
Teletherapy
A form of radiation with placement of the radioactive source
at a distance from the patient (external therapy). It is usually
used to treat the pelvis and occasionally the paraaortic nodes
in patients with cervical carcinoma.
Verrucous
A wart-appearing, well-differentiated squamous malignancy
that rarely metastasizes.
Carcinoma
Malignancies of the cervix are almost always carcinomas, and a summary of
the more common histologic types are shown in the following box. Approximately
80% to 85% of these tumors are squamous cell carcinomas and from 15% to 20%
are adenocarcinomas. The incidence of adenocarcinomas has increased in most
developing countries, particularly among younger women. Carcinoma of the cervix
is closely associated with early and frequent sexual contact and cervical viral
infection, particularly human papillomavirus (HPV), (Intraepithelial Neoplasia of
the Lower Genital Tract). According to the American Cancer Society, the
frequency of cervical cancer has been steadily decreasing, in part because of the
effect of widespread screening for premalignant cervical changes by cervical
cytology (Pap smear). Approximately 9710 new cases of cervical cancer will be
diagnosed in the United States in 2006, making it the third most frequent
malignancy of the lower female genital tract after endometrial and ovarian
carcinomas. Approximately 3700 deaths annually result from cervical cancer,
which is less than the approximately 15,310 for ovarian cancer. The incidence of
cervical carcinoma in the United States is higher among the Hispanic/Latin
population (15%) compared with whites (8.7) and African Americans (11.1).
However, the mortality rate from cervical cancer is the highest among African
Americans compared with other races. This is partially because African Americans
tend to have their cancers diagnosed at a late stage. Invasive cervical cancers are
diagnosed at a localized stage in 56% of white women and 48% of African
American women. This chapter details the various types of cervical carcinomas
and consider their natural history, methods of diagnosis and evaluation, and the
details of therapy. Primary sarcomas and melanomas of the cervix are extremely
rare and are not considered separately ( Fig. 29-1 ).
Summary of Major Categories of Cervical Carcinoma
Squamous Cell Carcinomas
Large cell (keratinizing or nonkeratinizing)
Small cell
Verrucous
Adenocarcinomas
Typical (endocervical)
Endometrioid
Clear cell
Adenoid cystic (basaloid cylindroma)
Adenoma malignum (minimal deviation adenocarcinoma)
Mixed Carcinomas
Adenosquamous
Glassy cell
KEY POINTS
•
Carcinomas of the cervix are predominantly squamous cell carcinomas
(85% to 90%), and approximately 10% to 15% are adenocarcinomas.
•
Squamous cell carcinomas appear to have a viral and venereal
association, particularly with HPV. In the United States, squamous cell
carcinoma is more frequent in blacks than in whites.
•
Cervical carcinoma is the third most frequent malignancy of the lower
female genital tract, after endometrial and ovarian cancer, and the second
most frequent cause of death, after ovarian cancer.
•
The definitive diagnosis of microinvasive carcinoma is established only
by means of cervical conization, not biopsy. The margins of the cone
should be free of neoplastic epithelium before conservative therapy is
undertaken
•
Microinvasive carcinoma of the cervix can be effectively treated by total
hysterectomy, with a 5-year survival rate of almost 100%, but recurrent
neoplasia can develop after 5 years. However, a precise and reliable
definition of microinvasion is controversial.
•
Prognosis in squamous cell cancer of the cervix is related to tumor stage
and lesion volume (size), depth of invasion, and spread to lymph nodes.
Older patients tend to have a worse prognosis, and HPV-positive younger
patients have a better prognosis.
•
The prognosis of adenocarcinoma of the cervix is related to tumor stage,
size, grade, and depth of invasion. Large adenocarcinomas tend to be
poorly differentiated.
•
Metastases to regional pelvic nodes in stage I squamous carcinomas
correlate with lesion size, depth of invasion, presence of capillary
lymphatic space involvement, and correlate inversely with patient age.
•
Cervical carcinomas are locally invasive tumors that spread primarily to
the pelvic tissues and then to the pelvic and paraaortic lymph nodes. Less
frequently, hematogenous spread to the liver, lung, and bone occurs.
•
The risk of the spread of cervical carcinoma to pelvic nodes is
approximately 15% for stage I, 29% for stage II, and 47% for stage III.
For the paraaortic nodes, percentages are 6% for stage I, 19% for stage II,
and 33% for stage III.
•
Stage IB carcinomas of the cervix may be treated equally effectively by
radical hysterectomy and pelvic node dissection or radiation. The 5-year
survival rate is approximately 80%. If lymph nodes are free of tumor, the
5-year survival rate is approximately 90%, and if the nodes contain metastatic tumor, the rate is 50%. Improved overall survival rates have been
reported for patients with tumors less than 4 cm in diameter treated by
preliminary brachytherapy followed by radical hysterectomy.
•
During radical hysterectomy, the ureter should never be grasped with
surgical instruments to avoid damaging the periureteral blood supply.
•
Surgery is often used for treating stage IB and early stage IIA carcinomas
of the cervix, particularly for smaller tumors and for younger patients to
preserve their ovarian function. Surgery produces less scarring and
vaginal fibrosis than does irradiation and is preferred for women with a
pelvic mass, pelvic infection, or history of conditions such as
inflammatory bowel disease, which increase the risk for radiation
complications.
•
High-stage tumors are treated by chemoradiation. Current programs
usually use cisplatin 40 mg/m2 weekly during external treatment and with
brachytherapy.
•
Urinary fistulas follow radical hysterectomy in approximately 1% of
cases.
•
Most cancers of the cervix are treated by radiation therapy (teletherapy
and brachytherapy). Radiation doses vary with tumor size and stage but
approximate 50 to 65 Gy at point B and 85 Gy at point A. Current
practice is to combine radiation with simultaneous chemotherapy to
optimize the results.
•
Improved cure rates of cervical cancers are obtained with increased
doses, which also lead to an increased frequency of complications. Large
increments in dose may increase complications without increasing cure
rates.
•
Complications following radiation are related to dose and volume of
tissue treated and include radiation inflammation of the bladder or bowel,
which may lead to pain, bleeding, or, infrequently, fistula formation. The
normal cervix is resistant to radiation, and the dose can be as high as 200
to 250 Gy over 2 months. The bladder and rectum can be injured at
average doses in the range of 65 to 75 Gy. Overall, the rate of moderate
to severe radiation complications for treatment of all stages is
approximately 10%.
•
Radiation complications of the intestine are more frequent than bladder
complications. Bowel complications tend to occur within the first 2 years
after treatment, whereas bladder complications can occur up to 20 years
after treatment.
•
Worldwide 5-year survival rates reported for patients with carcinomas of
the cervix are as follows: stage Ia, 95%; stage Ib, 80%; stage II, 70%;
stage III, 50%; and stage IV, 20% with radiation therapy alone.
•
Pregnancy does not adversely affect the survival rate for women with
carcinoma of the cervix, stage for stage.
•
Approximately one third of patients treated for cervical carcinoma
develop tumor recurrence, and approximately half of these recurrences
are located in the pelvis and most occur within 2 years.
•
Patients whose recurrences occur more than 3 years after primary therapy
have a better prognosis than those with earlier recurrence.
•
Pelvic exenteration in carefully selected patients with central pelvic
recurrence can lead to a 5-year survival rate of 50% or better.
•
Chemotherapy of recurrent squamous cell carcinoma of the cervix does
not produce long-term cures, but response rates of approximately 50%
(partial and complete) have been obtained with multiple-agent regimens
that contain cisplatin.
•
Leg pain following the distribution of the sciatic nerve or unilateral leg
swelling is often an indication of pelvic recurrence of carcinoma of the
cervix.
Gestational Trophoblastic Disease : Hydatidiform Mole, Nonmetastatic and
Metastatic Gestational Trophoblastic Tumor: Diagnosis and Management
KEY TERMS AND DEFINITIONS
Impregnation of an inactive egg by a paternal haploid
sperm that duplicates its chromosomes to provide a
Androgenesis
diploid complement. This results in a complete mole.
Choriocarcinoma
A morphologic term applied to a highly malignant type of
trophoblastic neoplasia in which both the cytotrophoblast
and syncytiotrophoblast grow in a malignant fashion.
Complete Mole
A molar pregnancy with swelling of all placental villi.
Fetal tissues are absent.
Disease that results from the abnormal proliferation of
Gestational
trophoblast associated with pregnancy. The disease is
Trophoblastic Disease
considered persistent or recurrent if it remains active or
(GTD)
returns after therapeutic intervention.
Hydatidiform Mole
A placental abnormality involving swollen placental villi
and trophoblastic hyperplasia with loss of fetal blood
vessels. There are two types: partial and complete.
Invasive Mole
A variant of hydatidiform mole in which the hydropic villi
invade the myometrium or blood vessels. It may spread to
extrauterine sites.
Partial Mole
A molar pregnancy with some normal and some swollen
villi plus fetal, cord, and/or amniotic membrane elements.
A rare type of GTD arising in the uterus that secretes
Placental-Site
human placental lactogen and human chorionic
Trophoblastic Tumor
gonadotrophin (HCG).
Gestational trophoblastic disease (GTD) refers to the spectrum of
abnormalities of the trophoblast associated with pregnancy. These neoplasias have
been known for hundreds of years, and they specifically secrete HCG. The
availability of extremely sensitive and specific assays to measure HCG allows
prediction of the clinical status of the disease as well as monitoring of treatment.
The initial use of methotrexate in 1956 by Li and associates to successfully treat
malignant trophoblastic disease completely altered the prognosis of patients with
these tumors and represented a milestone in the cure of human tumors by
chemotherapeutic agents.
KEY POINTS
•
Persistent abnormal bleeding following normal pregnancy, abortion, or
ectopic pregnancy should lead to a consideration of the diagnosis of
GTD. The finding of pulmonary nodules on chest radiograph after normal
pregnancy suggests GTD. The HCG is elevated in these situations.
•
A young woman with an unknown primary neoplasm or poorly explained
hyperthyroidism should have her serum HCG tested.
•
Approximately half the cases of GTD follow molar pregnancy, one fourth
follow normal pregnancy, and one fourth follow abortion or ectopic
pregnancy.
•
The major risk factors for molar pregnancy include maternal age (older
than 40 and younger than 20 years) and a history of molar pregnancy.
There appears to be an increased frequency of these diseases in Southeast
Asia and Mexico.
•
The risk of hydatidiform mole is approximately 0.75 to 1.0 per 1000
pregnancies in the United States.
•
The risk of developing a second molar pregnancy after a primary mole is
approximately 20 to 40 times greater than the initial risk.
•
The monitoring of trophoblastic disease and its follow-up is
accomplished by the measurement of β-HCG.
•
Complete moles are of paternal origin, are diploid, and carry a 20% risk
of GTD sequelae.
•
Partial moles are of maternal and paternal origin, are triploid, and rarely
are followed by GTD, but require the same follow-up for potential
malignant sequelae as a complete mole.
•
The diagnosis of a molar pregnancy can be established with
ultrasonography and may coexist with a normal pregnancy.
•
Hydatidiform moles are effectively and safely evacuated from the uterus
using suction curettage.
•
Medical complications of hydatidiform mole include anemia, toxemia,
hyperthyroidism, hyperemesis gravidarum, cardiac failure, and rarely
pulmonary insufficiency.
•
Patients are classified into low- or high-risk categories. Low-risk
categories receive single agent chemotherapy, usually methotrexate.
High-risk patients receive combination chemotherapy, usually EMA/CO.
•
Low-risk patients have a cure rate of greater than 90%.
•
Patients with high-risk metastatic GTD are successfully treated with
chemotherapy in more than 70% of the cases.
•
Patients treated for GTD should not become pregnant for approximately 6
to 12 months after treatment to allow accurate assessment of HCG levels.
•
Fertility rates and pregnancy outcomes are similar in patients treated for
GTD compared with the general population.
•
Patients treated with EMA/CO regimens have an increased rate of second
malignancies, particularly hematologic.
CHARACTERISTICS
Trophoblastic tissue normally shares certain characteristics with
malignancies, such as the ability to divide rapidly, to invade locally, and
occasionally to metastasize to distant sites such as the lung, yet these activities
usually cease at the end of preg-nancy, and the trophoblasts disappear. However, in
GTD, abnormal growth and development continue beyond the end of pregnancy.
Hydatidiform Mole
A hydatidiform mole has three morphologic characteristics: (1) a mass of
vesicles (distended villi) that appear as large, grapelike dilations; (2) a loss of fetal
blood vessels, which are either diminished or absent from the villi; and (3)
hyperplasia of the syncytiotrophoblast and cytotrophoblast.
The terms complete mole and partial mole have been used to describe the
variations of molar pregnancies. With a complete mole, all placental villi are
swollen, and the fetus, cord, and amniotic membranes are absent. With partial
molar pregnancy, only some chorionic villi are swollen, and fetal tissues are
present, such as amniotic membrane, cord, or even rarely a full-term fetus. The
fetus is usually chromosomally abnormal. With a partial mole, the trophoblastic
hyperplasia is limited to the syncytiotrophoblast.
The genetics of molar pregnancy has been extensively studied. In normal
pregnancy, half the chromosomes of the conceptus are paternal and the other half
are maternal, resulting in a diploid content. In complete mole, only paternal
chromosomes are believed to be present; there are 46 chromosomes and nearly
always 46,XX, although a few moles with 46,XY karyotype have been reported.
The development of complete mole appears to result from the fertilization of an
“empty egg,” one with an absent or inactive nucleus. The haploid paternal set of
chromosomes from the sperm impregnate the inactive egg. These paternal
chromosomes then duplicate to give the diploid number, a process known as
androgenesis, the development of an embryo due only to chromosomes from an Xbearing sperm ( Fig. 35-2 ). In the rare case of complete mole with an XY
chromosomal content, the empty egg appears to be fertilized by two haploid sperm,
one X and one Y.
Incomplete, or partial, moles are usually triploid and have 69 chromosomes
of both maternal and paternal origin. The most common mechanism for the origin
of partial mole is a haploid egg being fertilized by two sperm, resulting in three
sets of chromosomes. Alternatively, triploidy could result when an abnormal
diploid sperm fertilizes the haploid egg. It is also possible for an abnormal diploid
egg to be fertilized by a haploid sperm, but this latter mechanism usually results in
an abnormal conceptus with congenital abnormalities rather than a partial mole.
Partial mole is often difficult to diagnose and may present as a missed abortion in
the second trimester. Although these fetuses are usually abnormal, Watson et al.
noted that some partial moles have occurred with phenotypically normal fetuses. In
such cases, the uterus is small for dates. As noted by Lage and associates, a few
partial moles are diploid, and these very rare cases may be less sensitive to
chemotherapy than triploid moles if subsequent GTD develops.
Partial moles are rarely associated with the subsequent development of
GTD. Bagshawe and colleagues reported that neoplasia requiring chemotherapy
occurs in approximately one in 200 cases of partial mole compared with one in 12
with complete mole. However, Rice and coworkers noted 16 of 240 partial moles
(6.6%) had malignant sequelae, all of which responded to chemotherapy. Goldstein
and colleagues summarized a number of published reports that indicated that GTD
followed partial mole in 39 of 1125 (3.5%) cases. Despite rare subsequent
malignancy, patients with partial moles need the same follow-up as those with
complete moles.
Choriocarcinoma
Choriocarcinomas are malignancies that occur after or in association with
pregnancy, although the same histologic tumor can develop without pregnancy as a
primary neoplasm in the ovaries. The prognosis for primary gonadal
choriocarcinomas, which also occur in testes, is worse than for those associated
with gestation.
The diagnosis is made histologically, and the term is applied to the finding
of malignant cytotrophoblast and syncytiotrophoblast. Chorionic villi are absent.
These tumors tend to be hemorrhagic and necrotic. The latter is common because
these tumors frequently outgrow their blood supply. Metastases are common.
Most, but not all, gestational choriocarcinomas develop after molar
pregnancies. Trophoblastic tissue normally regresses within 2 to 3 weeks after
delivery, including cells that may have spread to the lung. The normal processes
leading to this regression are unknown, but the finding of trophoblastic cells in the
uterus more than 3 weeks after delivery should lead one to consider the possibility
of choriocarcinoma.
It is important to recognize that persistent or metastatic GTD has several histologic
patterns. The level of HCG determines tumor activity and guides therapeutic
intervention.
Placental-Site Trophoblastic Tumor
The term placental-site trophoblastic tumor (trophoblastic pseudotumor) was
introduced by Young and Scully to describe a rare tumor that consists of excessive
groups of mononucleate and multinucleate trophoblastic cells at the implantation
site accompanied by an inflammatory cell reaction. Immunohistochemical studies
have shown that the cells of these tumors tend to stain more for human placental
lactogen than for HCG, and both HCG and human placental lactogen should be
monitored. The tumor can lead to hemorrhage and uterine perforation. It tends to
be locally invasive, and most patients do not develop metastases. Hysterectomy is
the treatment of choice. Baergen and associates reported 55 of their own patients,
and an additional 180 cases from a literature review. In the results of the combined
studies, there were 186 treated with hysterectomy. Ninety-four also received
chemotherapy. In the combined patient population, there was an 80% to 86%
survival rate at 48 months.
Chemotherapy is usually administered for metastatic disease when it occurs,
but is less effective with these tumors than with other gestational trophoblastic
tumors, which is another reason for prompt operative treatment. EMA/CO
(etoposide, high-dose methotrexate with citrovorin (folinic acid) rescue,
actinomycin D, cyclophosphamide, and vincristine [Oncovin]) has been reported
on by Ajithkumar and colleagues for the treatment of metastatic placental-site
trophoblastic tumor, achieving a response rate of 71% and a complete response rate
of 38%.
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
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.
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 1520%. 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
Stage
characteristics
Tumor (T)
N,
Nodulus
M,
Metastasis
IA
Growth limited to one ovary, capsule intact T IA
NO
MO
IB
1С
NO
NO
MO
MO
NO
MO
II В
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
MO
ПС
Obvious parametrial involvement, T IIB
NO
MO
II A
III A
III В
III С
IV
T IIA or T IIB, ascites containing malignant cells
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
Any T with distant metastasis, T IV
Any T
NO
*
MO
NO
MO
NO
MO
Any N
Ml
N1
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
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.
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 magneto-laser 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 recto-vaginal fistulas. Hydro- and pyonephrosis, and later —
uraemia can develop on condition that the ureters are compressed.
One should differ carcinoma from decubitus, syphilitic and tuberculosis ulcers, condilomas,
endometriosis, chorioepithelioma, metastases of cervical and uterine cancer into vagina.
Lymphatic cancer spread is more common: from upper one-third into iliac and hypogastric
lymph modes; from middle one-third into the sacral ones; from the lower one-third into the
inguinal lymphatic nodes.
Final diagnosis is made after biopsy.
Treatment Carcinoma of the vagina is treated by the combined radiotherapy. X-ray or gamma-ray
telethepary with insertion of radioactive preparations into vagina are used.
5.4 Materials for Self- assessment:
A. Questions for self-assessment.
1.
2.
3.
4.
What is carcinoma?
What is choriocarcinoma?
What is gestational trophoblastic disease?
How are tumours classified?
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.