Epithelial tumors (cystadenomas). Benign epithelial ovarian tumors

Tumors and tumor-like formations of the ovaries- an extremely common pathology. According to various authors, the frequency of ovarian tumors over the past 10 years has increased from 6-11% to 19-25% of all tumors of the genital organs. Most ovarian tumors are benign, accounting for 75-87% of all true ovarian tumors. A significant part of ovarian cystic formations are tumor-like retention formations (70.9%).

The anatomical and histological structure of the ovaries determines the morphological diversity of tumors. The size and weight of the ovaries depend on the volume and number of follicles contained and normally range from 3.0x1.5 x 0.6 to 5.0x3.0x1.5 cm and, accordingly, 5-8 g.

The most important structural and functional part of the ovary is the follicular apparatus. Follicles have a connective tissue membrane (theca), consisting of thecaintern and thecaexterna. The inside of the follicle is lined with follicular epithelium, from which the granular and granulosa membranes are formed. The latter is associated with the maturation of the egg. Together with the theca tissue, it participates in the production of estrogenic hormones. The interstitial tissue of the cortex contains hilus cells that secrete androgens. The medulla is richly supplied with blood vessels and nerves. Throughout a woman's life, age-related changes in the ovaries occur. In old age, the formation of Graafian vesicles stops, the corpus luteum does not develop, the theca tissue decreases, fibrosis and diffuse sclerosis of the ovaries occur.

The weight of the ovary with such changes usually does not exceed 2 g. The follicles do not disappear immediately, only 4-5 years after the cessation of menstruation.

What causes tumors and tumor-like formations of the ovaries

The histogenesis of ovarian tumors, including benign ones, is not fully understood, which explains the disagreement about the origin of a particular tumor. Ovarian tumors have very diverse clinical and morphological manifestations.

The integumentary epithelium of the ovaries, eggs at different stages of maturation, granulosa cells, theca tissue, Leydig cells, elements of the male part of the ovary, rudimentary embryonic structures, tissue dystopias, nonspecific connective tissue, vessels, nerves - all these components can be sources of a wide variety of tumors.

A woman’s age plays a certain role in the development of ovarian tumors. Most ovarian tumors develop between the ages of 31 and 60 years, most often over 40 years, and 50% are postmenopausal patients. Tumor growth begins long before it is detected. Every 3rd patient is observed for a mass formation in the uterine appendages from several months to 4-5 years and is unsuccessfully treated for the supposed inflammation of the uterine appendages. Previous diseases and premorbid background are of great importance due to the disruption of reflex relationships in the hypothalamic-pituitary-ovarian system.

Risk factors for the occurrence of ovarian tumors determine ways to prevent this disease.

Risk factors for ovarian tumors: early or late menarche, late (after 50 years) onset of menopause, menstrual irregularities. Reduced reproductive function of a woman, infertility, and miscarriage are also associated with the risk of ovarian tumors. Chronic inflammatory diseases of the uterine appendages can form the premorbid background of the tumor process.

In recent years, the role of epidemiological and genetic factors in the etiology of ovarian tumors has been studied. The environment, nutrition, habits, and customs have a certain significance.

Pathogenesis (what happens?) during Tumors and tumor-like formations of the ovaries

Modern gynecological oncology uses the international classification of ovarian tumors, based on the microscopic characteristics of tumors taking into account the clinical course of the disease. Tumors of each nosological group are divided into benign, borderline and malignant.

1. Epithelial tumors (cystadenomas)

• A. Serous tumors
  • 1. Benign:
    • b) superficial papilloma;
  • • a) cystadenoma and papillary cystadenoma;
    • b) superficial papilloma;
    • c) adenofibroma and cystadenofibroma.
  • 3. Malignant:
    • a) adenocarcinoma, papillary adenocarcinoma and cystadenocarcinoma;
    • b) superficial papillary carcinoma;
    • c) malignant adenofibroma and cystadenofibroma.
• B. Mucinous tumors
  • 1. Benign:
    • a) cystadenoma;
  • 2. Borderline (potentially low malignancy):
    • a) cystadenoma;
    • b) adenofibroma and cystadenofibroma.
  • 3. Malignant:
    • a) adenocarcinoma and cystadenocarcinoma;
    • b) malignant adenofibroma and cystadenofibroma.
• B. Endometrioid tumors
  • 1. Benign:
    • a) adenoma and cystadenoma;
    • b) adenofibroma and cystadenofibroma.
  • 2. Borderline (potentially low malignancy):
    • a) adenoma and cystadenoma.
  • 3. Malignant:
    • a) carcinoma:
    • b) adenocarcinoma;
    • c) adenoacanthoma;
    • d) malignant adenofibroma and cystadenofibroma.
    • e) endometrioid stromal sarcoma.
• D. Clear cell tumors
  • 1. Benign:
    • a) adenofibroma.
  • 2. Borderline (potentially low malignancy).
  • 3. Malignant:
    • a) carcinoma and adenocarcinoma.
• D. Brenner tumors
  • 1. Benign.
  • 2. Borderline.
  • 3. Malignant.
• E. Mixed epithelial tumors
  • 1. Benign.
  • 2. Borderline (borderline malignancy).
  • 3. Malignant.
• G. Undifferentiated carcinomas
• 3. Unclassified epithelial tumors

1. Tumors of the sex cord stroma.

• A. Granulosostromal cell tumors
  • 1. Granulosa cell tumor.
  • 2. Tecom-fibromas group:
    • a) tecoma;
    • b) fibroma;
    • c) unclassifiable.
  • B. Androblastomas

Tumors from Sertoli and Leydig cells.

• 1. Highly differentiated:
  • a) Sertoli cell tumor;
  • b) tumors from Sertoli cells with accumulation of lipids (Lessen);
  • c) tumors from Sertoli and Leydig cells;
  • d) Leydig cell tumors, hilus cell tumors.
• 2. Intermediate (transitional differentiation).
• 3. Poorly differentiated (sarcomatoid).
• 4. With heterological elements.

• B. Gynandroblastoma
• D. Unclassified sex cord stromal tumors

3. Germ cell tumors

• A. Dysgerminoma
• B. Tumor of the epidermal sinus
• B. Chorionepithelioma
• D. Embryonic carcinoma
• D. Teratomas:
  • 1 Immature.
  • 2. Mature:
    • a) solid;
    • b) cystic: dermoid cyst, dermoid cyst with malignancy.
  • 3. Monodermal (highly specialized):
    • a) struma of the ovary;
    • b) carcinoid;
    • c) ovarian struma and carcinoid;
    • d) others.
• E. Mixed germ cell tumors
  • 1. Gonadoblastoma.
  • 2. Tumors not specific to the ovaries.
  • 3. Unclassified tumors.
• IV. Secondary (metastatic) tumors
• V. Tumor-like processes.
  • A. Luteoma of pregnancy.
  • B. Hyperplasia of the ovarian stroma and hyperthecosis.
  • B. Massive swelling of the ovary.
  • D. Single follicular cyst and corpus luteum cyst.
  • D. Multiple follicular cysts (polycystic ovaries).
  • E. Multiple follicular cysts and/or corpus luteum.
  • G. Endometriosis.
  • 3. Superficial epithelial inclusion cysts
  • I. Simple cysts.
  • K. Inflammatory processes.
  • L. Paraovarian cysts.
  • I. Epithelial benign ovarian tumors

The largest group of benign epithelial ovarian tumors are cystadenomas. The former term “cystoma” has been replaced by the synonym “cystadenoma”. Depending on the structure of the epithelial lining and internal contents, cystadenomas are divided into serous and mucinous.

Among epithelial ovarian tumors, which make up 90% of all ovarian tumors, serous tumors occur in 70% of patients.

Serous neoplasms are divided into simple serous (smooth-walled) and papillary (papillary).

Simple serous cystadenoma(smooth-walled cilioepithelial cystadenoma, serous cyst) is a true benign ovarian tumor. Serous cystadenoma is covered with low cubic epithelium, under which there is a connective tissue stroma. The inner surface is lined with ciliated epithelium, reminiscent of a tubal epithelium, capable of proliferation.

Microscopically, a well-differentiated tubal-type epithelium is determined, which can become indifferent, flattened-cubic in formations stretched with contents. The epithelium in some areas may lose cilia, and in some places even be absent; sometimes the epithelium undergoes atrophy and desquamation. In such situations, morphologically smooth-walled serous cystadenomas are difficult to distinguish from functional cysts. In appearance, such a cystadenoma resembles a cyst and is called serous. Macroscopically, the surface of the tumor is smooth, the tumor is located on the side of the uterus or in the posterior fornix. More often the tumor is unilateral, single-chamber, ovoid in shape, with a tight-elastic consistency. Cystadenoma does not reach large sizes, is mobile, painless. Typically, the tumor contents are a clear, straw-colored serous fluid. Cystadenoma turns into cancer extremely rarely.

Papillary (rough papillary) serous cystadenoma- a morphological type of benign serous cystadenomas, observed less frequently than smooth-walled serous cystadenomas. Accounts for 7-8% of all ovarian tumors and 35% of all cystadenomas.

This is a single or multi-chamber cystic neoplasm; on the inner surface there are single or numerous dense papillary vegetations on a wide base, whitish in color.

The structural basis of the papillae is small cell fibrous tissue with a small number of epithelial cells, often with signs of hyalinosis. The integumentary epithelium is similar to the epithelium of smooth-walled cilioepithelial cystadenomas. Rough papillae are an important diagnostic feature, since similar structures are found in serous cystadenomas and are never observed in non-neoplastic ovarian cysts. Rough papillary growths with a high degree of probability make it possible to exclude the possibility of malignant tumor growth even during an external examination of the surgical material. Degenerative changes in the wall can be combined with the appearance of layered petrificates (psammotic bodies).

Papillary serous cystadenoma has the greatest clinical significance due to its pronounced malignant potential and high incidence of cancer development. The incidence of malignancy can reach 50%.

Unlike rough papillary cystadenoma, papillary serous cystadenoma includes papillae of soft consistency, often merging with each other and located unevenly on the walls of individual chambers. The papillae can form large nodes that invert tumors. Multiple papillae can fill the entire tumor capsule, sometimes growing through the capsule to the outer surface. The tumor takes on a “cauliflower” appearance, raising suspicion of malignant growth.

Papillary cystadenomas can spread over a long distance, disseminate throughout the peritoneum, and lead to ascites, more often with bilateral tumor localization. The occurrence of ascites is associated with the growth of papillae along the surface of the tumor and along the peritoneum and due to a violation of the resorptive ability of the peritoneum of the utero-rectal space. Everting papillary cystadenomas are much more often bilateral and the course of the disease is more severe. With this form, ascites is 2 times more common. All this allows us to consider an everting papillary tumor to be clinically more severe than an inverting one.

The most serious complication of papillary cystadenoma is its malignancy - transition to cancer. Papillary cystadenomas are often bilateral, with an intraligamentous location.

The tumor has limited mobility, has a short stalk or grows intraligamentously.

Superficial serous papilloma (papillomatosis)- a rare type of serous tumor with papillary growths on the surface of the ovary. The neoplasm is often bilateral and develops from the surface epithelium. Superficial papilloma does not spread beyond the ovaries and has true papillary growths. One of the variants of papillomatosis is cluster-shaped papillomatosis (Klein tumor), when the ovary resembles a bunch of grapes.

Serous adenofibroma (cystadenofibroma) is relatively rare, often one-sided, round or ovoid in shape, up to 10 cm in diameter, dense in consistency. On a section, the tissue of the node is grayish-white in color, dense, fibrous structure with small cavities. Rough papillary growths are possible. Upon microscopic examination, the epithelial lining of glandular structures is practically no different from the lining of other cilioepithelial neoplasms.

Borderline serous tumor has a more adequate name - a serous tumor, potentially malignant. Morphological types of serous tumors include all of the above forms of serous tumors, since they arise, as a rule, from benign ones.

Borderline papillary cystadenoma has more abundant papillary growths with the formation of extensive fields. Microscopically, nuclear atypia and increased mitotic activity are determined. The main diagnostic criterion is the absence of invasion into the stroma, but deep intussusceptions can be detected without invasion of the basement membrane and without pronounced signs of atypia and proliferation.

Mucinous cystadenoma (pseudomucinous cystadenoma) ranks second in frequency after cilioepithelial tumors and accounts for 1/3 of benign ovarian tumors. This is a benign epithelial tumor of the ovary.

The former term “pseudomucinous tumor” has been replaced by the synonym “mucinous cystadenoma”. The tumor is detected at all periods of life, more often in the postmenopausal period. The tumor is covered with low cubic epithelium. The underlying stroma in the wall of mucinous cystadenomas is formed by fibrous tissue of varying cellular density, the inner surface is lined with high prismatic epithelium with light cytoplasm, which in general is very similar to the epithelium of the cervical glands.

Mucinous cystadenomas are almost always multilocular. The chambers are made of jelly-like content, which is mucin in the form of small droplets; mucus contains glycoproteins and heteroglycans. True mucinous cystadenomas do not have papillary structures. The size of mucinous cystadenoma is usually significant; there are also giant ones, with a diameter of 30-50 cm. The outer and inner surfaces of the walls are smooth. The walls of a large tumor are thinned and can even become visible due to significant stretching. The contents of the chambers are mucous or jelly-like, yellowish, less often brown, hemorrhagic.

Mucinous adenofibromas and cystadenofibromas- very rare types of mucinous tumors. Their structure is similar to serous adenofibromas of the ovary, they differ only in the mucinous epithelium.

Borderline mucinous cystadenoma is potentially malignant.

Mucinous tumors of this type have the form of cysts and in appearance do not differ significantly from simple cystadenomas. Borderline mucinous cystadenomas are large multilocular formations with a smooth internal surface and a focally flattened capsule. The epithelium lining borderline cystadenomas is characterized by polymorphism and hyperchromatosis, as well as increased mitotic activity of the nuclei. Borderline mucinous cystadenoma differs from mucinous carcinoma in the absence of invasion of the tumor epithelium.

Pseudomyxoma of the ovary and peritoneum. This is a rare type of mucinous tumor arising from mucinous cystadenomas, cystadenocarcinomas, and also from diverticula of the appendix. The development of pseudomyxoma is associated either with a rupture of the wall of a mucinous ovarian tumor, or with germination and penetration of the entire thickness of the wall of the tumor chamber without a visible rupture. In most cases, the disease occurs in women over 50 years of age. There are no characteristic symptoms; the disease is almost not diagnosed before surgery. In fact, one should not talk about a high-quality or benign variant of pseudomyxomas, since they are always secondary (of infiltrative or implantation origin).

Brenner's tumor(fibroepithelioma, mucoid fibroepithelioma) was first described in 1907 by Franz Brenner. It is a fibroepithelial tumor consisting of ovarian stroma.

Recently, the origin of the tumor from the integumentary coelomic epithelium of the ovary and from the hilus has been increasingly substantiated. In the region of the gate, they arise according to the location of the network and epoophoron. Benign Brenner tumor accounts for about 2% of all ovarian tumors. It occurs both in early childhood and over the age of 50 years. The tumor has a solid structure in the form of a dense node, the cut surface is grayish-white with small cysts.

The microscopic appearance of Brenner's tumor is represented by epithelial nests surrounded by strands of spindle cells. Cellular atypia and mitoses are absent. Brenner's tumor is often combined with other ovarian tumors, especially mucinous cystadenomas and cystic teratomas.

Epithelial components tend to undergo metaplastic changes. The possibility of developing proliferative forms of Brenner tumor cannot be ruled out.

The size of the tumor ranges from microscopic to the size of an adult’s head. The tumor is one-sided, often left-sided, round or oval in shape, with a smooth outer surface. The capsule is usually absent. The tumor often resembles ovarian fibroma in appearance and consistency.

Mostly the tumor is benign and is discovered accidentally during surgery.

It is possible that proliferative forms of Brenner tumor may develop, which may become a transitional stage to malignancy.

Proliferating Brenner tumor(borderline Brenner tumor) is extremely rare and has a cystic structure with papillomatous structures. Macroscopically, there can be both cystic and cystic-solid structures. On the section, the cystic part of the tumor is represented by multiple chambers with liquid or mucous contents. The inner surface can be smooth or with tissue resembling papillary growths, loose in places.

Mixed epithelial tumors can be benign, borderline or malignant. Mixed epithelial tumors account for about 10% of all epithelial ovarian tumors. Two-component forms predominate; three-component forms are identified much less frequently. Most mixed tumors have a combination of serous and mucinous epithelial structures.

The macroscopic picture of mixed tumors is determined by the predominant tumor components. Mixed tumors are multilocular formations with different contents. There are serous, mucinous contents, less often areas of a solid structure, sometimes resembling fibroma or papillary growths.

Symptoms of Tumors and tumor-like formations of the ovaries

Benign ovarian tumors, regardless of their structure and clinical manifestations, have many similar features. Ovarian tumors often occur asymptomatically in women over 40-45 years of age. There are no specifically reliable clinical symptoms of any tumor. However, a more thorough questioning of the patient can reveal dull, aching pain of varying severity in the lower abdomen, lumbar and groin areas.

The pain often radiates to the lower extremities and the lumbosacral region and may be accompanied by dysuric phenomena, apparently caused by the pressure of the tumor on the bladder and an enlarged abdomen. Paroxysmal or acute pain is caused by torsion of the tumor stalk (partial or complete) or perforation of the tumor capsule. As a rule, pain is not associated with the menstrual cycle. They arise due to irritation and inflammation of the serous membranes, spasm of the smooth muscles of hollow organs, irritation of the nerve endings and plexuses of the vascular system of the pelvic organs, as well as due to tension of the tumor capsule, disruption of the blood supply to the tumor wall. Pain sensations depend on the individual characteristics of the central nervous system.

With papillary serous cystadenomas, pain occurs earlier than with other forms of ovarian tumors. Apparently, this is due to the anatomical features of papillary ovarian tumors (intraligamentary location, bilateral process, papillary growths and adhesions in the pelvis).

With papillary cystadenomas, usually bilateral, ascites is possible. The occurrence of ascites is associated with the growth of papillae along the surface of the tumor and the peritoneum and due to a violation of the resorptive ability of the peritoneum of the utero-intestinal space. With everting papillary serous cystadenomas (the papillae are located on the outer surface of the capsule), the course of the disease is more severe, and bilateral ovarian damage is much more common. With this form, ascites develops 2 times more often. All this allows us to consider an everting papillary tumor to be clinically more severe than an inverting tumor (location of the papillae on the inner surface of the capsule). The most serious complication of papillary cystadenoma remains malignancy.

With large tumors (mucinous), there is a feeling of heaviness in the lower abdomen, it enlarges, and the function of neighboring organs is disrupted in the form of constipation and dysuria. Nonspecific symptoms - weakness, increased fatigue, shortness of breath are less common. Most patients have various extra-genital diseases that can cause nonspecific symptoms. Reproductive function is impaired in every 5th examined woman (primary or secondary infertility).

The second most common complaint is menstrual irregularities. Menstrual dysfunction is possible from the moment of menarche or occurs later.

Recognizing pseudomyxoma before surgery is extremely difficult. There are no characteristic clinical signs on the basis of which a diagnosis could be made. The main complaint of patients is pain in the lower abdomen, often dull, less often paroxysmal.

The disease often begins gradually under the guise of chronic, recurrent appendicitis or an abdominal tumor of undetermined localization. Often patients consult a doctor due to rapid enlargement of the abdomen. The abdomen is round, spherical, its shape does not change when the patient’s body position changes. During percussion, there is a dullness of the percussion sound throughout the abdomen; palpation reveals doughiness, a characteristic “colloidal” crackle or “crunch”, since colloidal masses with pseudomyxoma do not overflow, as with ascites. Diffuse reactive peritonitis forms an extensive adhesive process, often disrupting the functions of the abdominal organs. Patients complain of loss of appetite, flatulence, and dyspepsia. The formation of intestinal fistulas, the appearance of edema, the development of cachexia, an increase in body temperature, and a change in the blood formula are possible. Death occurs due to increasing intoxication and cardiovascular failure.

The clinical picture of mixed epithelial tumors does not differ significantly from single-component epithelial tumors.

Diagnostics of tumors and tumor-like formations of the ovaries

Despite technological advances, diagnostic thinking based on clinical examination remains important. Establishing a diagnosis begins with clarifying complaints, collecting anamnesis and bimanual gynecological and rectovaginal examinations. With a two-manual gynecological examination, it is possible to identify a tumor and determine its size, consistency, mobility, sensitivity, location in relation to the pelvic organs, and the nature of the tumor surface. It is possible to detect only a tumor that has reached a certain size when it increases the volume of the ovary. For small tumor sizes and/or giant tumors and atypical location of the tumor, bimanual examination is not very informative. It is especially difficult to diagnose ovarian tumors in obese women and in patients with adhesions in the abdominal cavity after laparotomies. It is not always possible to judge the nature of the tumor process based on palpation data. Bimanual examination gives only a general idea of ​​the pathological formation in the pelvis. A rectovaginal examination helps to exclude malignancy, during which it is possible to determine the absence of “spikes” in the posterior fornix, overhang of the fornix with ascites, and germination of the rectal mucosa.

During a two-manual vaginal-abdominal examination in patients with simple serous cystadenoma in the area of ​​the uterine appendages, a volumetric formation is determined posterior or lateral to the uterus, round, often ovoid in shape, tight-elastic consistency, with a smooth surface, with a diameter of 5 to 15 cm, painless, mobile on palpation .

Papillary cystadenomas are often bilateral, located on the side or posterior to the uterus, with a smooth and/or uneven (lumpy) surface, round or ovoid in shape, tight-elastic consistency, mobile or limitedly mobile, sensitive or painless on palpation. The diameter of the neoplasms ranges from 7 to 15 cm.

During a two-hand gynecological examination, mucinous cystadenoma is determined posterior to the uterus, has a lumpy surface, uneven, often tight-elastic consistency, round shape, limited mobility, diameter from 9 to 20 cm or more, sensitive to palpation. The mucinous tumor is often large (giant cystadenoma - 30 cm or more), occupying the entire pelvis and abdominal cavity. Gynecological examination is difficult; the body of the uterus and collateral appendages are difficult to differentiate.

During a two-manual vaginal-abdominal examination in patients with a verified diagnosis of a Brenner tumor, a space-occupying formation of an ovoid or, more often, round shape, dense consistency, with a smooth surface, 5-7 cm in diameter, mobile, painless, is determined lateral and posterior to the uterus. Brenner's tumor often resembles subserous uterine fibroids.

Ultrasound occupies one of the leading places among methods for diagnosing pelvic tumors due to its relative simplicity, accessibility, non-invasiveness and high information content.

Echographically, a smooth-walled serous cystadenoma has a diameter of 6-8 cm, a round shape, the thickness of the capsule is usually 0.1-0.2 cm. The inner surface of the tumor wall is smooth, the contents of the cystadenoma are homogeneous and anechoic, septa can be visualized, often single. Sometimes a finely dispersed suspension is detected, which is easily displaced by percussion of the formation. The tumor is usually located posterior and to the side of the uterus.

Papillary serous cystadenomas have papillary growths unevenly located on the inner surface of the capsule in the form of parietal structures of varying sizes and increased echogenicity. Multiple very small papillae give the wall a rough or spongy appearance. Sometimes lime is deposited in the papillae, which has increased echogenicity on scanograms. In some tumors, papillary growths fill the entire cavity, creating the appearance of a solid area. Papillae can grow onto the outer surface of the tumor. The thickness of the capsule of papillary serous cystadenoma is 0.2-0.3 cm.

Papillary serous cystadenomas are defined as bilateral round, less often oval formations with a diameter of 7-12 cm, single-chamber and/or double-chamber. They are located lateral or posterior to the uterus, sometimes thin linear septa are visualized.

Mucinous cystadenoma has multiple septa 2-3 mm thick, often in separate areas of the cystic cavities. Suspension is visualized only in relatively large formations. Mucinous cystadenoma is often large, up to 30 cm in diameter, almost always multilocular, located mainly on the side and behind the uterus, round or ovoid in shape. In the cavity there is a fine, non-displaceable suspension of medium or high echogenicity. The contents of some chambers may be uniform.

Brenner's tumor, mixed, undifferentiated tumors give a nonspecific image in the form of formations of a heterogeneous solid or cystic-solid structure.

Color Doppler mapping (CDC) helps to more accurately differentiate benign and malignant ovarian tumors. Based on the blood flow velocity curves in the ovarian artery, the pulsation index and the resistance index, tumor malignancy can be suspected, especially in the early stages, since malignant tumors have active vascularization, and the absence of vascularization zones is more typical for benign neoplasms.

With color Doppler ultrasound, benign epithelial ovarian tumors are characterized by moderate vascularization in the capsule, septa and echogenic inclusions. The resistance index does not exceed 0.4.

Recently, X-ray computed tomography (XCT) and magnetic resonance imaging (MRI) have been used to diagnose ovarian tumors.

Endoscopic research methods (laparoscopy) are widely used for the diagnosis and treatment of ovarian tumors. Although laparoscopy does not always make it possible to determine the internal structure and nature of the formation, it can be used to diagnose small ovarian tumors that do not lead to volumetric transformation of the ovaries, “non-palpable ovaries.”

The endoscopic picture of a simple serous cystadenoma reflects a volumetric formation of a round or ovoid shape with a smooth shiny surface of a whitish color with a diameter of 5 to 10 cm. A simple serous cystadenoma often resembles a follicular cyst, but unlike a retention formation, its color ranges from whitish-gray to bluish, which, apparently due to the uneven thickness of the capsule. A vascular pattern is determined on the surface of the capsule. The contents of serous cystadenoma are transparent, with a yellowish tint.

Papillary cystadenoma is defined at surgery as an ovoid or round tumor with a dense, opaque whitish capsule. On the outer surface of papillary cystadenoma there are papillary growths. The papillae can be single in the form of “plaques” protruding above the surface, or in the form of clusters and located in various parts of the ovary. With pronounced dissemination of papillary growths, the tumor resembles “cauliflower”. In this regard, it is necessary to inspect the entire capsule. Papillary cystadenoma can be bilateral, in advanced cases it is accompanied by ascites. Intraligamentary location and distribution of papillae throughout the peritoneum are possible. The contents of papillary cystadenoma are transparent, sometimes acquiring a brown or dirty yellow color.

The endoscopic picture of mucinous cystadenoma is often characterized by a large size. The surface of mucinous cystadenoma is uneven, the structure is multilocular. The boundaries between the cameras are visible. The tumor is irregular in shape, with a dense, opaque capsule, whitish in color, sometimes with a bluish tint. Bright, branching, unevenly thickened large vessels are clearly visible on the capsule. The inner surface of the tumor is smooth, the contents are jelly-like (pseudomucin).

Laparoscopic intraoperative diagnosis of ovarian tumors is of great value. The accuracy of laparoscopic diagnosis of tumors is 96.5%. The use of laparoscopic access is not indicated in patients with ovarian tumors, so it is necessary to exclude a malignant process before surgery. If malignant growth is detected during laparoscopy, it is advisable to proceed to laparotomy. During laparoscopic removal of a cystadenoma with malignant degeneration, disruption of the integrity of the tumor capsule and contamination of the peritoneum may occur; difficulties may also arise during omentectomy (removal of the omentum).

In the diagnosis of malignant ovarian tumors, a large place is given to the determination of biological substances specific to these tumors by biochemical and immunological methods. Of greatest interest are the numerous tumor-associated markers - tumor-associated antigens (CA-125, CA-19.9, CA-72.4).

The concentration of these antigens in the blood allows us to judge the processes in the ovary. CA-125 is found in 78 - 100% of patients with ovarian cancer, especially in serous tumors. Its level exceeds the norm (35 IU/ml) only in 1% of women without ovarian tumor pathology and in 6% of patients with benign tumors. Tumor markers are used for dynamic monitoring of patients with malignant ovarian tumors (before, during and after treatment).

In case of bilateral ovarian damage, to exclude a metastatic tumor (Krukenberg), an X-ray examination of the gastrointestinal tract should be performed, and, if necessary, endoscopic methods (gastroscopy, colonoscopy) should be used.

The prevalence of the process is clarified by urological examination (cystoscopy, excretory urography). In exceptional cases, lymph and angiography are used.

Additional research methods in patients with space-occupying ovarian formations allow not only to determine the surgical approach, but also to form an opinion about the nature of the space-occupying formation, which determines the choice of surgical treatment method (laparoscopy - laparotomy).

Treatment of Tumors and Tumor-like Formations of the Ovaries

The scope and access of surgical intervention depend on the patient’s age, the size and malignancy of the formation, as well as on concomitant diseases.

The extent of surgical treatment helps determine an urgent histological examination. With simple serous cystadenoma at a young age, it is permissible to remove the tumor, leaving healthy ovarian tissue. In older women, the uterine appendages are removed from the affected side. For simple serous cystadenoma of the borderline type in women of reproductive age, the tumor is removed from the affected side with a biopsy of the collateral ovary and omentectomy.

In premenopausal patients, supravaginal uterine amputation and/or hysterectomy and omentectomy are performed.

Papillary cystadenoma, due to the severity of proliferative processes, requires more radical surgery. If one ovary is affected, if the papillary growths are located only on the inner surface of the capsule, in a young woman it is permissible to remove the appendages of the affected side and biopsy the other ovary. If both ovaries are affected, supravaginal amputation of the uterus with both appendages is performed.

If papillary growths are found on the surface of the capsule, supravaginal amputation of the uterus with appendages or extirpation of the uterus and removal of the omentum is performed at any age.

Laparoscopic access can be used in patients of reproductive age with unilateral ovarian lesions without tumor capsule germination using an evacuating bag-container.

For borderline papillary cystadenoma of unilateral localization in young patients interested in preserving reproductive function, removal of the uterine appendages of the affected side, resection of the other ovary and omentectomy are acceptable.

In perimenopausal patients, extirpation of the uterus with appendages on both sides is performed and the omentum is removed.

Surgical treatment of mucinous cystadenoma: removal of the appendages of the affected ovary in patients of reproductive age.

In the pre- and postmenopausal period, it is necessary to remove the appendages on both sides along with the uterus.

Small mucinous cystadenomas can be removed by surgical laparoscopy using an evacuation pouch.

For large tumors, it is necessary to first evacuate the contents with an electric suction through a small hole.

Regardless of the morphological affiliation of the tumor, before the end of the operation it is necessary to cut it and examine the internal surface of the tumor.

Inspection of the abdominal organs (appendix, stomach, intestines, liver), examination and palpation of the omentum, para-aortic lymph nodes, as with tumors of all types, are also indicated.

The prognosis is favorable.

For pseudomyxoma, immediate radical surgery is indicated - resection of the omentum and parietal peritoneum with implants, as well as freeing the abdominal cavity from gelatinous masses. The scope of surgical intervention is determined by the patient’s condition and the involvement of the abdominal organs in the process. Despite the fact that it is almost completely impossible to free the abdominal cavity from gelatinous masses, recovery can sometimes occur after surgery. Even in advanced cases of the disease, one should try to operate, since without surgical intervention the patients are doomed.

The prognosis for pseudomyxoma is unfavorable. Frequent relapses are possible, in which repeated surgery is indicated. Despite the morphological benignity of the tumor, patients die from progressive exhaustion, since it is not possible to completely free the abdominal cavity from the erupted gelatinous masses.

Treatment of Brenner's tumor is surgical. In young patients, removal of the uterine appendages of the affected side is indicated. In perimenopause, supravaginal amputation of the uterus and appendages is performed. In case of a proliferating tumor, supravaginal amputation of the uterus with appendages and total removal of the omentum are indicated.

Which doctors should you contact if you have Tumors and tumor-like formations of the ovaries

Gynecologist

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Papilloma– benign tumor-like formation of the skin and mucous membranes of viral etiology. It looks like a papilla on a narrow base (pedicle), soft or dense consistency, from light to dark brown. Localization of papillomas on the skin leads to the formation of a cosmetic defect, in the larynx - breathing and voice disturbances, on the mucous membrane of internal organs - ulcerations and bleeding. Relapses of the disease are possible, the most dangerous complication being malignant degeneration. Removal of papillomas can be carried out by electrocoagulation, cryodestruction, surgical excision, radio wave method or laser exposure.

General information

is a disease that affects epithelial cells and skin. The cause of papillomas is the human papillomavirus, which belongs to the Papoviridae family, the Papillomavirus group. Among HPV, viruses with high and low oncogenic risk are distinguished. The oncogenicity of papillomas is explained by the ability of the virus to integrate its DNA into the genome of human cells.

Mechanism of human papillomavirus infection

When HPV enters the human body, it initially infects the basal cells of the epithelium. Microtraumas, abrasions, cracks and other damage to the skin contribute to the penetration of the papilloma virus into the body. For a long time, the virus can reproduce initially without manifesting itself clinically (chronic carriage). If the virus multiplies in the superficial layers of the skin, then over time, even with chronic carriage of the papilloma virus, cell hyperplasia is observed.

Since the human papillomavirus is unstable in the external environment, infection occurs through direct contact. Promiscuous sexual intercourse leads to infection; smoking, pregnancy, endometriosis, vitamin deficiency, immunodeficiencies are predisposing factors for infection to occur when interacting with the virus. The risk of infection increases with frequent contact with bare human skin, for example during massage.

Clinical manifestations of papillomas

HPV 13, 32 cause local epithelial hyperplasia, which is characterized by the appearance of small papillary neoplasms on the oral mucosa and on the red border of the lips, which slightly rise above the skin and tend to merge.

One of the rare papillomas is Lewandowsky-Lutz papillomas (epidermodysplasia verrucous). Mostly children and adolescents are affected. Sometimes epidermodysplasia verruciformis is familial. Clinically it looks like multiple red-brownish spotted papillomas on the hands and feet. If papillomas are located in areas of the skin that are most susceptible to ultraviolet radiation, then in 30% of cases they become malignant and degenerate into malignant tumors with germination into neighboring tissues.

HPV, which is the causative agent of genital warts, can have a low, medium and high risk of oncological degeneration, therefore, when diagnosing genital warts, you should always undergo a PCR examination. The incubation period ranges from several weeks to several months. Since in some cases the changes are minimal, these papillomas go unnoticed. The main route of transmission is sexual. The risk group includes people with immunodeficiencies and frequently changing sexual partners. Externally they look like pink or pale gray pigmented pointed growths on a stalk.

In most cases, there is pain, burning, itching, irritation when touched and rubbed by underwear, and they are often injured and bleed. They are localized in the vestibule of the vagina, on the labia minora; less commonly, genital warts are found in the vagina and on the cervix. In men, the opening of the urethra is affected. The affected area depends on sexual behavior; in individuals who practice anal intercourse, genital warts are found in the perineal area and in the perianal area. In some cases, genital warts are diagnosed on the oral mucosa and on the red border of the lips, which is again associated with the characteristics of sexual life.

Juvenile laryngeal papillomas are rarely recorded and are caused by HPV 6.11; Mostly children under five years of age are affected. Infection occurs during childbirth, when a woman in labor has papillomas in the vagina and the child, while passing through the birth canal, takes a premature breath. The disease is characterized by papilloma growths on the vocal cords, which leads to difficulty in air circulation and speech impairment.

Diagnosis of papillomas

Diagnosis of papillomas is carried out by a dermatologist or venereologist. Due to the large number of types of virus, it has its own characteristics. An accurate diagnosis based on visual examination can only be made in the classic case of genital warts, but this does not provide accurate information about the type of virus and its oncogenicity. Therefore, if the papillomatous nature of the neoplasms is suspected, they resort to PCR diagnostics of viral DNA.

PCR diagnostics allows not only to confirm the presence of human papillomavirus in the body and determine its type, but also to diagnose how many viruses are present in the body at the time of the analysis. This has diagnostic significance, since, knowing the percentage of the virus and its type, it is possible to determine the approximate timing of infection and identify contact persons for the purpose of examination and prescribing preventive therapy. PCR diagnostics also provides information about whether papillomas have a chronic course or are the result of a one-time decrease in immunity. Thanks to such data, adequate therapy can be prescribed.

If the only method of treatment is removal of papillomas, then in parallel with surgery, a biopsy is performed for cytological examination. Histological examination of papillomas tissue gives more accurate results, since both the cells and the correct arrangement of their layers and the structural features of the tissue are subject to examination. This gives reliable results about the degree of changes in the body and the likelihood of malignancy, since long-term and untreated papillomas more often lead to cancer than timely detected HPV with a high degree of cancer risk.

As a rule, PCR diagnostics are of a screening nature and, if the analysis confirms the presence of the virus, then additional research is carried out.

Treatment of papillomas

The treatment regimen for papillomas is selected individually in each specific case. If HPV is detected during diagnosis, but there are no clinical manifestations yet, then preventive therapy with cytostatics is prescribed. It is quite effective and allows you to “put to sleep” the virus for several years. Patients who are carriers of HPV are recommended to periodically undergo PCR examinations and use barrier contraceptives so as not to expose their partner to the risk of contracting the human papillomavirus.

Inosine pranobex is a drug for the treatment of papillomas from the group of antiviral drugs that suppresses the reproduction of viruses. It is one of the most preferred because it has immunomodulatory properties. Indications for use are diagnosed papillomas with a combination of other viral infections, such as cytomegalovirus infections, measles and mumps viruses. The presence of herpes virus, chronic viral hepatitis and immunodeficiency also requires the inclusion of Isoprinosine in the treatment regimen. Since therapy for papillomas is long-term, inosine pranobex should be taken only under the supervision of a physician, since monitoring of laboratory parameters is necessary. The use of immunomodulators and courses of vitamins are indicated for all patients with HPV.

If there are manifestations of HPV on the skin and mucous membranes, then, depending on the location and symptoms, they resort to cryodestruction of papillomas, electrocoagulation or laser removal of papillomas. It is possible to use another modern method of surgical treatment - removal of papillomas using radio waves. If the papilloma has signs of malignancy, then excision of the affected area with a scalpel is carried out, capturing healthy tissue.

It should be borne in mind that removal of papillomas does not lead to complete recovery, since today there are no drugs that have a detrimental effect on HPV. Therefore, patients with previously diagnosed papillomas need to undergo periodic examinations and courses of antiviral therapy.

Since HPV is mainly transmitted sexually, the only way to prevent papillomas is a barrier method of contraception. When planning a pregnancy, it is necessary to diagnose and, if necessary, treat the virus in order to reduce the likelihood of infection of the child during childbirth and in the first years of life.

Papillary cystadenoma of the ovary is a benign neoplasm filled with fluid, localized on the surface of the epithelium of the appendage, the size of which ranges from several mm to 30-35 cm.

A papillary ovarian cyst is a type of neoplasm. If it is small in size, then there is no clinical picture. As the tumor grows, pain in the lower abdomen and other symptoms appear. Diagnosis of pathology is carried out by ultrasound and laparoscopy. The rupture or death of the cyst is accompanied by the development of intra-abdominal bleeding and inflammation of the peritoneum. Timely treatment of pathology helps prevent the occurrence of life-threatening complications, as well as the degeneration of a benign neoplasm into a malignant tumor.

1. Smooth-walled (simple), as a rule, is formed on one appendage and is single-chamber. In rare cases, multilocular tumors with watery exudate occur. The size of the neoplasm is 4-15 cm. It is most often detected in women over 50 years of age. During pregnancy, a smooth-walled cyst, the size of which is no more than 3 cm, does not affect the gestation of the fetus.

2. Papillary (papillary) cystadenoma is the next stage in the development of a smooth-walled tumor, since the papillae form only a few years after the appearance of a simple cyst. Papillary cystadenoma can be localized on both ovaries and is divided into several types:

• everting, in which the growths are on the outside of the capsule;
• inverting, characterized by the presence of papillae in the middle part of the tumor;
• mixed, when growths are localized inside and outside the neoplasm.

Papillary outgrowths located on the cystadenoma often enlarge and spread to the peritoneum, but this does not indicate the development of a malignant process. In most patients, the size of papillary neoplasms in diameter does not exceed 10 cm.

3. Serous papillary cystadenoma degenerates into an oncological tumor in 50% of cases. Serous papillary cysts can be single- or multi-chamber. There is liquid inside them. Sometimes the tumor grows, affecting neighboring organs, which leads to malfunctions of the intestines and urinary tract.

– a malignant tumor that can occur in several chambers of cystadenomas. It is formed due to malignancy of the epithelium of ovarian cysts and usually occurs in women aged 40-60 years. It should be remembered that timely consultation with a doctor is the primary prevention of oncological processes.

Superficial serous papilloma (ovarian papillomatosis) is a type of serous neoplasm with papillary growths on the outer part of the appendage. As a rule, such a tumor is bilateral, develops from the integumentary epithelium, does not extend beyond the boundaries of the ovaries and is characterized by true papillary growths.

4. in origin it is considered close to a serous neoplasm, but, unlike it, it is filled with mucous fluid. This tumor has chambers and septa, and is detected during an ultrasound examination. Most often it affects both ovaries at once and measures up to 30 cm, which necessitates its surgical excision.

Causes of papillary tumors

The factors contributing to the formation have not been sufficiently studied, however, the leading role is given to hormonal disorders and the presence of functional ovarian cysts, which usually spontaneously resolve within a year from the moment of appearance, but if this does not happen, they are transformed into cystadenomas.

Other reasons why serous papillary cystadenoma appears are:

Signs of neoplasm

Small papillary cystadenoma does not make itself felt and is most often discovered by chance (during a planned procedure). You should consult a doctor if your menstrual cycle is disrupted or if you experience pain of any intensity in the lower abdomen.

As the tumor progresses, the following symptoms are noted:

• nagging pain in the lower abdomen and lumbar region (from the side of the tumor);
• bleeding from the genital tract not caused by menstruation;
• disruptions of the menstrual cycle;
• pain during active movements and/or during sexual intercourse;
• nausea and vomiting that occurs periodically;
• painful sensations when performing an act of defecation or urination;
• sometimes - ascites.

Large papillary cystadenomas often compress neighboring organs, resulting in a woman experiencing an increased urge to urinate, discomfort in the intestines, constipation, swelling of the legs, and nausea. A neoplasm that measures 6-10 cm or more can cause an increase in the size of the abdomen and its asymmetry.

Serous cystadenomas usually do not affect the menstrual cycle. Large tumors pressing on the ovary and/or reproductive organ affect the characteristics of menstruation, which become abundant or, on the contrary, scanty, as well as painful.

Diagnosis of papillary cystadenoma

To identify a tumor, the following methods are used:

• examination on a gynecological chair (by bimanual palpation of the uterine appendages);
• ultrasound examination of the pelvic organs;
• a blood test for oncological markers makes it possible to detect the degeneration of cystadenoma in time and is usually performed before surgical excision of the tumor, which allows the doctor to decide on the tactics of the operation;
• or it is advisable to perform a CT scan to clarify the location and type of tumor;
• A general blood test makes it possible to detect the inflammatory process;
• a pregnancy test is performed to exclude ectopic pregnancy;
• color Doppler sonography, which makes it possible to distinguish a benign neoplasm from an oncological tumor.

Treatment of pathology

A functional cyst usually resolves or decreases in size 1-3 months after its appearance, so it is monitored. If the patient has been diagnosed with another type of tumor that is progressing, then surgical intervention is prescribed at the discretion of the doctor.
Simple serous papillary cystadenoma, the size of which does not exceed 3 cm, is usually excised by carrying out (husking). Larger tumors often have a dense capsule formed from adjacent compressed tissues. For this reason, it is advisable to remove it along with the affected appendage.

The operation is routinely performed in the presence of papillary cystadenoma larger than 6 cm, which has existed for 4-6 months. Smaller neoplasms are subject to excision within the time frame established by the gynecologist based on the results of dynamic observation.

Emergency surgical procedures are performed when there is suspected torsion of the pedicle or rupture of the cyst capsule. Elective surgery is usually done by.
Papillary cystadenoma in half of the cases transforms into serous ovarian carcinoma (the patient is then diagnosed with cystocarcinoma). The degree of malignancy of the neoplasm is determined based on the results of histological examination. Ovarian carcinoma must be removed along with the ovary and sometimes the reproductive organ.

When choosing the type of operation, the patient’s age, the need to preserve reproductive function, and the size of the tumor should be taken into account. Young women are shown surgical intervention to preserve healthy tissue of the appendage and prevent the development of infertility. For patients who have entered menopause, radical surgical interventions are recommended to prevent the recurrence of the tumor.

A simple cystadenoma of small size only requires dynamic observation, since the likelihood of its malignant transformation is extremely low. In contrast, a papillary ovarian cyst often degenerates into a cancerous tumor and grows quite quickly in size, therefore it is subject to surgical excision by laparotomy or laparoscopy.

If the neoplasm is of impressive size, then it is often necessary to remove the ovary along with it. The woman's second appendage remains intact, so her chances of pregnancy remain intact. During menopause, it is advisable to remove the entire ovary, along with the tumor.

Laparoscopy is the preferred method of surgical intervention for women of reproductive age, as in most cases it makes it possible to preserve reproductive function by ensuring the integrity of the ovary and uterus. Complications after it are very rare, and the recovery period does not last long.

It is carried out if the doctor doubts the benignity of the process. During this operation, an incision is made on the abdominal wall, which, if necessary, allows you to expand the boundaries of the manipulations performed.

Treatment of papillary cystadenoma should be aimed at its removal. The decision on the scale of the operation is made by the specialist, based on the patient’s age and other factors.

A. Cysts
According to our classification, cysts include retention (non-blastomatous) tumors arising from the follicle or corpus luteum. The prototype of a retention follicle tumor is the so-called small cystic degeneration of the ovary.

A simple follicle cyst is formed during the growth and stretching of one of the follicles; it is thin-walled, single-chamber, contains a yellowish liquid and does not exceed the size of a tangerine.

Follicular cysts are somewhat larger and may be multilocular. In both varieties, the inner surface is covered with a single or double row layer of granulosa cells. Follicular multilocular cysts are also called simple serous cysts.

The second group of ovarian tumors are corpus luteum cysts; they can be divided into three subgroups: luteal, with hydatidiform mole and chorionepithelioma, and the so-called “chocolate” (endometriosis).

Luteal cysts on a section contain a yellowish layer in their walls, and sometimes a reddish-brown one. These cysts are formed from the corpus luteum or atretic follicle. In both cases, the yellowish layer of thecallutein cells is equally well expressed.
Luteal cysts in hydatidiform mole or chorionepithelioma are very interesting tumors that form in approximately half of cases of hydatidiform mole or chorionepithelioma. These cysts are bilateral and can reach the size of a fist. They are capable of self-resorption within one to two months after the elimination of hydatidiform mole; therefore they should not be operated on. The contents of these cysts are mostly liquid, yellowish or brownish in color.

“Chocolate” or “tar” cysts of the corpus luteum, usually bilateral, small in size, contain a thick, dark brown liquid. These tumors are usually surrounded by adhesions. Most modern authors believe that “chocolate” cysts represent endometriosis (adenomyosis) of the ovary, and they believe that endometrial particles during menstruation are transported through the tubes from the uterine cavity and implanted on the surface of the ovary. In such endometroid tissue, the phases of the menstrual cycle may change with the release of blood; As a result of the organization of bloody clots, adhesions are formed around the ovary. These cysts can cause pain during menstruation; during bimanual examination they are characterized by low mobility.

B. Cystoma
Cystoma, as mentioned above, we divide into pseudomucinous and seropapillary.
Pseudomucinous cystomas or cystomas account for 2/3 of ovarian tumors. The sources of development of pseudomucinous cystoma are Waltgard's strands, the epithelium of the Müllerian duct, and sometimes the ectopic rudiment of the cervix. According to some authors, the epithelium covering the walls of mucinous cysts is similar to the epithelium covering the cervical canal or intestinal epithelium.

M. F. Glazunov distinguishes three types of pseudomucinous cysts: secerating pseudomucinous, proliferating pseudomucinous and cancers from pseudomucinous cystoma.

Secerated pseudomucinous cystomas are covered with high differentiated mucus-forming epithelium, which is goblet-shaped tall cylindrical cells with a basally located nucleus.

V, M. Mikhailov proved the presence of ciliated cells among ordinary mucus-forming cells. Massey found cells in the epithelial layer identical to Kulchitsky’s cells in the intestine.

Proliferating pseudomucinous cystomas are transitional tumors to cancer arising from pseudomucinous cystomas. Both types of pseudomucinous cysts are multilocular tumors, usually unilateral; they can reach large sizes. It is pseudomucinous cystomas that include giant tumors that cause cachexia, described by K. F. Slavyansky. The tumors are filled with mucous contents, which include pseudomucin. This content is more or less homogeneous and translucent in large chambers, and in smaller ones it is thickened, similar to rubber glue, brownish or greenish in color, which depends on the admixture of blood or leukocytes.

The outer surface of proliferating pseudomucinous cysts is smooth; on the inner surface of the chambers there are areas of proliferation, villi or papillae. The papillary formations that fill the cavity of the chambers are similar to the sawtooth cervical glands during pregnancy; some of them are subject to necrobiosis. However, mitoses are not found in the cells of these growths. Proliferating pseudomucinous cystomas are bilateral in half of the cases. In rare cases, a rupture of its wall occurs with an outpouring of mucous contents into the peritoneal cavity, which forms a new tumor there (“pseudomyxoma peritonei”); the latter increases due to constant replenishment from the cystoma rupture. This content causes irritation of the peritoneum, adhesive peritonitis with a clinically “malignant course”. In pseudomucinous cystomas, cancer develops in 6-8% of cases. The maximum incidence of cancer is observed between the ages of 21 and 50 years. We will talk about this disease when considering ovarian cancer.

Seropapillary cystoma (serous cystadenoma). The integumentary epithelium of the tumor is single-row cylindrical cells. It is characterized by its diversity.

A characteristic feature of this cystoma is the ability to proliferate and form papillary growths covered with varieties of epithelium of the Müllerian ducts. The number of papillary growths can be very different: in some cases there are two or three growths, similar to cauliflower, in others - the entire cystoma cavity is filled with papillary growths; Papillary growths can also appear on the outer surface of the cystoma, as well as seed the abdominal cavity. The tendency to proliferate may lie in hormonal influences. Seropapillary cystoma is not a malignant tumor, but is an undoubted precancerous process.

Seropapillary cystoma is often a bilateral tumor, multilocular; may develop interconnectively. The tumor is most often observed at the age of 30-35 years; it rarely occurs in childhood and during menopause.

Seropapillary cystoma can cause menstrual irregularities. However, its most common symptom is pain. An important clinical feature of this cystoma is also frequent adhesions in the abdominal cavity (in more than 50% of patients). There is a significant incidence of ascites; sometimes unilateral or bilateral hydrothorax appears simultaneously with ascites.

A characteristic feature of seropapillary cysts is the content of calcareous stones of various shapes and sizes in the stroma of the papillae. Seropapillary cystomas, as mentioned above, may have papillary growths on the outer surface. The symptom of germination of the papillae onto the outer surface of the seropapillary cystoma, and then often the subsequent seeding of the peritoneum, is usually accompanied by a transient symptom of an “acute abdomen” and a subsequent rapid increase in ascites.

Papillomatous growths can be very diverse. M. F. Glazunov divides such papillomatous forms of ovarian cysts into the following subgroups: 1) micropapillomatosis, 2) papillomatosis, 3) cluster papillomatosis and cluster polycystic ovary disease.

In the first two subgroups there are warty growths on the outer surface of the ovary of varying sizes. With small papillae, the surface of the ovary becomes velvety or warty; such an ovary is called warty - micropapillomatosis.

Ovarian papillomatosis, according to some authors, is formed when the wall is torn and subsequently everted. The papillae are larger, than in the first group, growths such as villi. Ovarian papillomatosis is also called superficial papilloma, “hairy papilloma” or “Cossack cap”.

Cluster papillomatosis is swelling of the papillae, which look like bunches of grapes or elements of a hydatidiform mole. The inner surface of the papillae is smooth. Often, edematous villi break off and float freely in the ascitic fluid. With cluster-shaped polycystic ovaries (racemose, cluster-shaped papilloma) there is a similarity with a bunch of grapes; the conglomerate protrudes freely into the peritoneal cavity without being bound by a common membrane. Macroscopically, many bubbles are detected, ranging in size from a pea to a child’s head, sitting on a thin stalk. The bubbles are filled with a clear liquid. The process of formation of polycystic pampiniform disease is unclear. It is believed that this process is a consequence of cystic expansion of multiple microcysts of the ovarian cortex. The percentage of malignant transformation reaches 60.

B.Germ cell neoplasms and tumors
The previous idea that dermoid cysts arise from the ectoderm, and teratomas from the three germ layers, is rejected by modern authors. Wilms proved that each dermoid contains derivatives of all three germ layers. Therefore, a strict distinction between dermoids and teratomas turned out to be unnecessary, and currently only the term teratoma is used (according to Wilms, embryoma). Recognizing teratoma as an embryonic malformation of the male and female gonads, M. F. Glazunov classifies them as germ cell tumors and ovarian neoplasms. These tumors come in varying degrees and maturity, and they may contain differentiation products of all three germ layers, or two, or even one. He divides these tumors into the following five subgroups: 1) mature and maturing teratomas (dermoids); 2) cancers and sarcomas from teratoma; 3) teratoblastoma; 4) chorionepitheliomas; 5) dysgerminomas.

Mature teratomas, or dermoids, dermoid cysts, follow in frequency the seeddomucinous cystoma. The right ovary is affected somewhat more often than the left. 85% of dermoids are unilateral; bilateral - 15%. In the vast majority of cases, ovarian dermoid is a solitary tumor. Multiple dermoids are described as very rare. We had to see seven dermoids in one ovary and four in the other. The shape of the dermoid is round, oval or kidney-shaped. The surface is smooth and shiny. The removed tumor at room temperature shrinks as the fat hardens and becomes wrinkled. The color of the tumor wall is whitish or yellowish, the consistency is in some places densely elastic, in others dense or doughy. On a section, a dermoid cyst is a leathery sac that usually contains a single-chamber cavity filled with a yellowish fat-like mass and hair. After removing the contents of the dermoid, a mound, or body, of various sizes is found in it. In this mound you can find various parts of the body (fingers, limbs, parts of organs - the brain, intestinal tube, rudiments of the eyes). Repin found an ugly homunculus in a dermoid cyst. Frequent finds are teeth and often the rudiments of the jaw. Organs of the caudal part of the body are much less common than the cranial part. Tumors from immature teratomas are observed much more often than from mature ones.

Rarely, cancers and sarcomas can arise from dermoid cysts; The most common occurrence is squamous cell carcinoma.

Teratomas, or teratoblastomas (they are also called embryonal teratomas, mesateriomas, mixed tumors, carcinosarcoma), in contrast to dermoids, are malignant and do not have a cystic nature. On section they have the appearance of a solid tumor of an organ-like structure and only in places contain small cystic cavities. Teratoblastomas are rare, mainly occurring under the age of 30 and especially common in childhood and adolescence, when they are often misdiagnosed as cervical cancer. Macroscopically, teratoblastoma is a lumpy tumor, often fused with surrounding organs; its size reaches the size of a child’s or adult’s head. Microscopically, a derivative of all three germ layers, located at various stages of embryonic differentiation, is found in the tumor. Teratoblastoma is characterized by very rapid growth and metastases. Ascites is often observed with teratomas.

Chorionepithelioma of the ovary is observed very rarely. M. F. Glazunov believes that the development of chorionepithelioma in the ovary can occur due to ovarian pregnancy or in connection with parthenogenetic (reproduction without fertilization) fragmentation of egg cells. The second factor should be considered more reliable, since the occurrence of chorionepitheliomas is observed in girls and young women (as well as in men in the testicles).

Possessing very rapid growth, chorionepitheliomas reach very large sizes and often metastasize. The Tsondek-Aschheim reaction for these tumors is positive. The histological structure of metastases can give a picture of teratoblastoma in some nodes, and chorionepithelioma in others.

Dysgerminoma, after the work of R. Meyer, is a malignant tumor that occurs in the female or male gonad. From 1911 to 1930 it was called seminoma of the ovary. Rarer synonyms of dysgerminoma are: endothelioma, alveolar round cell sarcoma, solid large cell carcinoma, etc. Ovarian dysgerminoma is much less common than testicular dysgerminoma and is observed at a much younger age and in girls. Ovarian dysgerminoma occurs in combination with genital hypoplasia, as well as in individuals with signs of pseudohermaphroditism. Dysgerminoma sometimes causes menstrual irregularities and amenorrhea. With this disease, signs of intersexuality are often observed; however, these signs quickly disappear after removal of the tumor. The Tsondek-Aschheim reaction is usually positive.

Dysgerminoma affects only one ovary in 2/3 of cases. It has a round or kidney-shaped shape, often surrounded by adhesions, its color is gray or mottled from hemorrhages and necrosis; the consistency is dense. The microscopic structure is identical to testicular dysgerminoma. The arrangement of cellular elements, due to their close proximity to each other, resembles an “end pavement”. The cells are large, well contoured, folded into cords or alveoli, contain glycogen, and are often separated by narrow layers of argyrophilic fibers. Multinucleated giant cells are often found. Dysgerminomas are highly sensitive to X-rays.

D. Connective tissue tumors
Ovarian connective tissue tumors are a rather rare group, comprising 2 to 4% of all ovarian tumors. There are two forms of these tumors: 1) benign forms - ovarian fibroma and Brenner tumor and 2) malignant form - ovarian sarcoma.

The origin of ovarian fibroids is more complex than previously thought. M.F. Glazunov believes that it comes from the ovarian parenchyma and is a thecoma that is not hormonally active. Ovarian fibroids occur between the ages of 20 and 50 years. The tumor is predominantly one-sided, whitish in color when cut. In case of ovarian fibroids, attention should be paid to ascites. It was assumed that ascites occurs due to irritation of the peritoneum by a dense massive tumor, but there are cases when, with ascites, the tumor was very small and could not produce mechanical irritation of the peritoneum.

In most cases, the microscopic appearance of ovarian fibromas is varied, but sometimes a fascicular structure can be discerned, especially in areas rich in cells. The shape of the cells is most often spindle-shaped. In edematous forms of fibromas, the cells acquire a stellate shape, there are no mitoses, and the fibrous substance in fibromas is represented exclusively by argyrophilic fibers. Macroscopically indistinguishable from fibromas are Brenner tumors and sometimes ovarian sarcoma.

Brenner's tumor is a benign neoplasm consisting of tissue resembling ovarian fibroma and interspersed with islets or cysts of an epithelial nature. These epithelial inclusions, the genesis of which is unclear, are a characteristic feature of Brenner tumors. Previously, due to the presence of these inclusions, Brenner's tumor was called adenofibroma, colloid adenofibroma; it was also mistaken for cancer. The term "Brenner tumor" was introduced by R. Meyer. Brenner's tumor is rare - five to six times less common than fibroma. It is almost always unilateral and most often occurs between the ages of 30 and 40. It does not occur in childhood. Brenner's tumor does not give any obvious symptoms of hyperestrogenism, but in some cases a menstrual cycle disorder develops in the form of amenorrhea, cyclic or acyclic bleeding. The shape of the tumor is round-oval, sometimes slightly lumpy, and the consistency is very dense. On a section, it is similar to a fibroma; epithelial inclusions cannot always be distinguished without a magnifying glass. Some authors speak about the homogeneity of the epithelium of the Brenner tumor and pseudomucinous ovarian cysts.

Ovarian sarcoma is a rare tumor that occurs at different ages, including children. In the past, authors, for example V.S. Gruzdev, described thecomas, dysgerminomas, and metastatic tumors under the guise of sarcomas. The former names of “endothelioma” and “perithelioma” are no longer used.

Sarcomas, according to their histological structure, occur in two forms: round cell and spindle cell.

Macroscopically, ovarian sarcomas differ from benign tumors in their soft consistency, brain-like character on the section, necrosis and hemorrhages. The softer the tumor is in consistency, the more malignant it is. The diagnosis of sarcoma in most cases is made only tentatively. With ascites, soft consistency of the tumor, adhesions with neighboring organs, rapid growth, ovarian sarcoma can be suspected.

D. Ovarian cancer
The incidence of ovarian cancer, according to the latest authors, is less than according to previous years. Cancer from ovarian cysts is the most common type of malignant epithelial ovarian tumors. We can say that all malignant ovarian tumors develop from benign tumors.

Ovarian cancer can develop primarily from the tissues of the ovary itself and secondarily, metastasizing to the ovary from a primary cancer tumor in some other organ. From a practical point of view, it is convenient to divide all types of ovarian cancer into three groups: 1) primary ovarian cancer, 2) cancer cystoma, 3) metastatic ovarian cancer.

Primary ovarian cancer. So-called primary ovarian cancer is rare and is a dense, solid tumor, mostly bilateral. This tumor can reach a significant size (up to the head of a newborn or the head of an adult), but retains the shape of the ovary. The size of the tumor of the right and left ovaries is always different, the surface of the tumors is slightly lumpy, yellowish in color on a section, of different consistency in certain areas, in some places there is decay or hemorrhage. The tumor can grow into the ovarian capsule and spread to the peritoneum and abdominal organs.

According to the histological structure, these cancers are adenocarcinoma. In some cases, similarities are found with pseudomucinous cysts.

Cancerous cystoma. The formation of cancer from seropapillary or pseudomucinous ovarian cysts constitutes the largest, one might say, the main group of malignant epithelial ovarian tumors. Most often, cancerous transformation occurs in gray-papillary (cilioepithelial, according to Glazunov) ovarian cystomas; Much less often the transition to cancer is observed with pseudomucinous cystomas. Initially, in both cases, cancer affects only individual areas, which at first can only be detected microscopically. But quite soon, as the malignant areas grow, they can be recognized macroscopically: they take on the appearance of a soft, brain-like mass.

During a microscopic examination of cancer-affected seropapillary ovarian cysts, the affected areas of the epithelium are distinguished by multilayered and pronounced polymorphism of cells.

In advanced cases, the structure of previously benign seropapillary cystomas is gradually lost, making it impossible to distinguish seropapillary cystoma cancer from pseudomucinous cystoma cancer.

The most vulnerable age group for this group of ovarian cancers is between 40 and 60 years. Cancerous cystomas under the age of 30 are very rare. Bilateral tumors occur in 50-70% of cases. Ascites is always observed, especially with tumor growth.

Metastatic ovarian cancer. Metastatic ovarian tumors are of great interest.

Krukenberg, describing a similar tumor, mistook it for the primary one, classifying it as connective tissue. A number of authors, including K.P. Ulezko-Stroganova, definitively proved that these tumors are epithelial and are metastases. Metastatic ovarian cancers do not produce any characteristic clinical symptoms. According to F.I. Pozharisky and T.A. Maikapar-Kholdina, in half of the cases they are observed before the age of 40 years, with about 20% occurring under the age of 30 years. Thus, metastatic ovarian cancer is diagnosed approximately several years earlier than cancer of those organs in which the primary focus is located, so it can be assumed that some neurohormonal influences play a role in its occurrence. Amenorrhea is often observed in younger patients. In the elderly, acyclic bleeding is common. According to most authors, the tumor is bilateral in 66-90%. Its size can reach the size of an adult’s head; the surface is sometimes smooth, sometimes bumpy. Ascites occurs in 60-70%; adhesions are observed less frequently than with other malignant ovarian tumors.

On a section of the tumor, you can see a homogeneous, dense or edematous mass, sometimes similar to the white matter of the brain; less often, a nodular form of the tumor is noted. The primary focus may be in the gallbladder, gastrointestinal tract, omentum, mammary gland, etc.

According to M.F. Glazunov, lung cancer also very often metastasizes to the ovaries.

Histological examination of metastatic ovarian cancer reveals a large number of different forms. It can be glandular, solid, small alveolar and diffuse.

Typical ovarian cancer is characterized by a tender, fibrous, edematous stroma, wide layers of which separate one group of tumor cells from another. In some parts of the tumors, you can find individual clusters of cancer cells floating in the edematous stroma and soaked in mucus. Signet ring-shaped ones can often be found among the cells. Metastatic cancers of the solid and scirrhous types are observed in the ovaries with cancer of the breast, bronchi and uterus.

The ways in which tumor cells enter the ovaries are different. M. F. Glazunov considers hematogenous to be the main route of metastasis. In isolated cases, retrograde lymphogenous, transperitoneal and transtubal pathways are observed.

E. Hormone-producing tumors
Hormone-producing tumors, according to the classification of M. F. Glazunov, include granulosa cell tumor, thecoma and arrhenoblastoma, the first two belonging to feminizing tumors, and arrhenoblastoma to feminizing tumors.

Granulosa cell tumor, or folliculoma, is a rare ovarian neoplasm, among the cellular elements of which there are cells reminiscent in their structure of follicular granulosis. The second feature of granulosa cell tumor is its general effect on the body, similar to the effect of estrogenic hormones. Granulosa cell tumor was identified as an independent nosological entity by R. Meyer. Until this time, the tumor was described as cancer, endothelioma, cylindroma, etc.

Folliculomas occur at different ages, including in children from the first month of life. However, the largest number of these tumors is observed at the age of 50-60 years.

Granulosa cell tumor at different ages gives different clinical symptoms, but always typical of hyperestrogenism. In girls, premature puberty occurs with the appearance of menstruation, development of the mammary glands, the appearance of pubic hair, enlargement of the clitoris and labia minora. During puberty, various disorders of the menstrual cycle such as menometrorrhagia, and sometimes amenorrhea, are observed. During menopause, characteristic symptoms are the resumption of menstrual bleeding, mucosal hyperplasia and an increase in the volume of the uterus, sometimes with the appearance of endometriosis in it. Folliculomas are often combined with uterine fibroids. Most granulosa cell tumors are benign; Malignant folliculomas are very rare. We will talk about them below.

Folliculomas are most often unilateral tumors (bilateral lesions occur in 6-7%). They have a dense elastic consistency with a smooth or, more often, lumpy surface. Their sizes are sometimes very significant, and their weight reaches several kilograms. Small tumors in the section have a solid structure, and large ones have a spongy or lobular structure. A typical microstructure for granulosa cell tumors is clusters of granulosa cells of various shapes and sizes. These cells have the ability to secrete, which often leads to the formation of pseudoglandular structures, as well as the ability to accumulate lipoids. The fibrous substance of the follicle contains many argyrophilic fibers. According to M.F. Glazunov, 25-30% of follicles are a combination of folliculoma and thecoma.

As for malignant follicles, their frequency, according to literature data, is 20-28%. On microscopic examination, the tumor, while maintaining the alveolar structure, consists of voluminous light cells with poorly distinguishable boundaries and a large vesicular nucleus, often in a state of mitosis.

Tekoma. Theca cell tumors of the ovaries were first described by Lefler and Prizel. A total of 335 cases of theca cell tumors have been described. Thecoma differs from folliculoma in its histological structure, similar to ovarian fibroids.

According to some authors, thecomas arise only from the theca cells of the follicle. However, M.F. Glazunov considers the source of origin of the tecom to be the stromatogenic elements of the ovary, i.e. those spindle-shaped cells that form its bulk. Thecomas are usually benign neoplasms; Only those that have estrogenic activity should be considered malignant thecomas.

Theca cell tumors can also occur in childhood, but most often thecomas occur at the age of 50-60 years. The tumor is mostly unilateral. Its size can reach the head of an adult. The surface is sometimes smooth, sometimes bumpy. The consistency is densely elastic, with a yellowish tint when cut. As a result of dystrophic processes in the tumor, cavities filled with semi-liquid contents are often observed.

Microscopic examination reveals spindle-shaped or polygonal cells with light protoplasm with the presence of vacuoles, the cell nuclei are round, elongated in places; fat droplets are found in the cells, as well as in the intercellular spaces. Silver staining reveals argyrophilic fibers located between the cellular elements. Tekoma is very rich in blood vessels.

With tecomas, yellowish or bloody ascitic fluid is often found in the abdominal cavity. Clinical signs correspond to estrogen saturation. Children develop symptoms of precocious puberty. During the childbearing period, menstrual cycle disorders appear in the form of cyclical and acyclic bleeding, and sometimes amenorrhea. The most definite clinical picture is observed in older women who are in menopause. Typically, such women complain that their “menstruation” has returned. When examining the genitals, one is struck by the absence of senile atrophic changes and the juiciness of the vaginal walls. In addition to the ovarian tumor, there is no age-related atrophy of the uterus; there is even some increase in it. A significant amount of estrogenic hormones is detected in the urine. For differential diagnosis, it is important to detect hormonal changes and the absence of malignant changes in scrapings from the uterine cavity.

Arrhenoblastoma. Arrhenoblastomas are very rare tumors: until recently, about 80 cases have been described in the world literature. Arrhenoblastoma belongs to tumors that have been little studied clinically, and especially histologically. The question of whether this tumor is benign or malignant has not yet been resolved. Most authors consider it benign. In the clinical symptomatology of arrhenoblastomas, two types of phenomena can be distinguished: one of them is defeminization (amenorrhea, flattening of the mammary glands, sterility); the second is masculinization - the development of hair according to the male type - on the face and body (hirsutism), changes in the contours of the body and face, deepening of the voice, changes in the larynx according to the male type, hypertrophy of the clitoris. After removal of the tumor, the symptoms of defeminization quickly disappear, but the symptoms of masculinization disappear slowly, and some of them (hypertrophy of the clitoris, Adam's apple) can remain for life.

The term arrhenoblastoma was proposed by R. Meyer. He suggested that these tumors arise from the embryonic rudiment of the male component of the female reproductive gland, namely from the pulpal tubes, the ovarian network and underdeveloped seminiferous tubules. Meyer divided arrhenoblastomas into three groups: testicular tubular adenoma, intermediate arrhenoblastoma, and undifferentiated arrhenoblastomas.

G. Other tumors
To this group we include tubo-ovarian cysts, intra- and pseudo-intraligamentary tumors and parovarian cysts.

Tuboovarian cysts, like hydrosalpinx, develop as a result of a chronic inflammatory process, including gonorrheal. If, during hydrosalpinx, a cystic formation of the ovary develops next to it and both tumors are welded together, then over time, resorption of the septum between the cavity of the tubar and ovarian tumor may occur, which leads to the formation of a tubo-osarial cyst. A tubo-ovarian tumor can also form as a result of gonococcus entering the ovary during ovulation, when the fimbriae cover the ovulating ovary, and then remain in this position due to the inflammatory process. These tumors have an elastic consistency and are thin-walled due to the presence of adhesions that are less mobile than ovarian cysts.

Intraligamentary tumors do not represent a separate nosological entity. Interligamentous tumors form in those rare cases when the onset of ovarian tumor growth occurs in the narrow space of the mesosalpinx duplication; gradually moving apart the layers of the peritoneum, the tumor turns out to be located interligamentously. Interligamentous location can be observed in both benign and malignant tumors. The clinical significance of interligamentous tumors lies in the difficulty of their removal and the special surgical technique.

Pseudo-intraligamentous location of the tumor is much more common. In these cases, it is not located interligamentally, but there is only fusion with the posterior leaf of the broad ligament. This pseudo-intraligamentous arrangement can be observed not only with ovarian neoplasms, but also with inflammatory saccular tumors such as sactosalpinx and tubo-ovarian inflammatory tumors.

The parovarian cyst is not directly related to the ovary, but develops from the embryonic remnant of the Wolffian body and Wolffian duct, located between the layers of the mesosalpinx. These embryonic remains, shaped like a scallop or a series of flask-shaped bodies, can develop into a retention cyst, called a parovarian cyst. In the presence of a parovarian cyst, which is always located interligamentously, the ovary is determined separately from the tumor, and the tube is layered on top of the tumor. Parovarian cysts are spherical in shape, small in size, filled with serous fluid with a small amount of protein. The epithelium of the inner wall is smooth and almost never contains papillary growths.

Self-healing of parovarian cysts may occur when the cyst wall ruptures. These cysts can twist. The prognosis is favorable; No relapses are observed after surgical removal.

Papillary (rough papillary) serous cystadenoma- a morphological type of benign serous cystadenomas, observed less frequently than smooth-walled serous cystadenomas. Accounts for 7-8% of all ovarian tumors and 35% of all cystadenomas.
This is a single or multi-chamber cystic neoplasm; on the inner surface there are single or numerous dense papillary vegetations on a wide base, whitish in color.
The structural basis of the papillae is small cell fibrous tissue with a small number of epithelial cells, often with signs of hyalinosis. The integumentary epithelium is similar to the epithelium of smooth-walled cilioepithelial cystadenomas. Rough papillae are an important diagnostic feature, since similar structures are found in serous cystadenomas and are never observed in non-neoplastic ovarian cysts. Rough papillary growths with a high degree of probability make it possible to exclude the possibility of malignant tumor growth even during an external examination of the surgical material. Degenerative changes in the wall can be combined with the appearance of layered petrificates (psammotic bodies).
Papillary serous cystadenoma has the greatest clinical significance due to its pronounced malignant potential and high incidence of cancer development. The incidence of malignancy can reach 50%.
Unlike rough papillary cystadenoma, papillary serous cystadenoma includes papillae of soft consistency, often merging with each other and located unevenly on the walls of individual chambers. The papillae can form large nodes that invert tumors. Multiple papillae can fill the entire tumor capsule, sometimes growing through the capsule to the outer surface. The tumor takes on a “cauliflower” appearance, raising suspicion of malignant growth.
Papillary cystadenomas can spread over a long distance, disseminate throughout the peritoneum, and lead to ascites, more often with bilateral tumor localization. The occurrence of ascites is associated with the growth of papillae along the surface of the tumor and along the peritoneum and due to a violation of the resorptive ability of the peritoneum of the utero-rectal space. Everting papillary cystadenomas are much more often bilateral and the course of the disease is more severe. With this form, ascites is 2 times more common. All this allows us to consider an everting papillary tumor to be clinically more severe than an inverting one.
The most serious complication of papillary cystadenoma is its malignancy - transition to cancer. Papillary cystadenomas are often bilateral, with an intraligamentous location. The tumor has limited mobility, has a short stalk or grows intraligamentously.
Superficial serous papilloma (papillomatosis)- a rare type of serous tumor with papillary growths on the surface of the ovary. The neoplasm is often bilateral and develops from the surface epithelium. Superficial papilloma does not spread beyond the ovaries and has true papillary growths. One of the variants of papillomatosis is cluster-shaped papillomatosis (Klein tumor), when the ovary resembles a bunch of grapes.
Serous adenofibroma(cystadenofibroma) is relatively rare, often one-sided, round or ovoid in shape, up to 10 cm in diameter, with a dense consistency. On a section, the tissue of the node is grayish-white in color, dense, fibrous structure with small cavities. Rough papillary growths are possible. Upon microscopic examination, the epithelial lining of glandular structures is practically no different from the lining of other cilioepithelial neoplasms.
Borderline serous tumor has a more adequate name - a serous tumor, potentially malignant. Morphological types of serous tumors include all of the above forms of serous tumors, since they arise, as a rule, from benign ones.
Borderline papillary cystadenoma has more abundant papillary growths with the formation of extensive fields. Microscopically, nuclear atypia and increased mitotic activity are determined. The main diagnostic criterion is the absence of invasion into the stroma, but deep intussusceptions can be detected without invasion of the basement membrane and without pronounced signs of atypia and proliferation.
Mucinous cystadenoma (pseudomucinous cystadenoma) ranks second in frequency after cilioepithelial tumors and accounts for 1/3 of benign ovarian tumors. This is a benign epithelial tumor of the ovary.
The former term “pseudomucinous tumor” has been replaced by the synonym “mucinous cystadenoma”. The tumor is detected at all periods of life, more often in the postmenopausal period. The tumor is covered with low cubic epithelium. The underlying stroma in the wall of mucinous cystadenomas is formed by fibrous tissue of varying cellular density, the inner surface is lined with high prismatic epithelium with light cytoplasm, which in general is very similar to the epithelium of the cervical glands.
Mucinous cystadenomas almost always multi-chamber. The chambers are made of jelly-like content, which is mucin in the form of small droplets; mucus contains glycoproteins and heteroglycans. True mucinous cystadenomas do not have papillary structures. The size of mucinous cystadenoma is usually significant; there are also giant ones, with a diameter of 30-50 cm. The outer and inner surfaces of the walls are smooth. The walls of a large tumor are thinned and can even become visible due to significant stretching. The contents of the chambers are mucous or jelly-like, yellowish, less often brown, hemorrhagic.
Mucinous adenofibromas and cystadenofibromas are very rare types of mucinous tumors. Their structure is similar to serous adenofibromas of the ovary, they differ only in the mucinous epithelium.
Borderline mucinous cystadenoma potentially malignant. Mucinous tumors of this type have the form of cysts and in appearance do not differ significantly from simple cystadenomas. Borderline mucinous cystadenomas are large multilocular formations with a smooth internal surface and a focally sutured capsule. The epithelium lining borderline cystadenomas is characterized by polymorphism and hyperchromatosis, as well as increased mitotic activity of the nuclei. Borderline mucinous cystadenoma differs from mucinous carcinoma in the absence of invasion of the tumor epithelium.
Pseudomyxoma of the ovary and peritoneum. This is a rare type of mucinous tumor arising from mucinous cystadenomas, cystadenocarcinomas, and also from diverticula of the appendix. The development of pseudomyxoma is associated either with a rupture of the wall of a mucinous ovarian tumor, or with germination and penetration of the entire thickness of the wall of the tumor chamber without a visible rupture. In most cases, the disease occurs in women over 50 years of age. There are no characteristic symptoms; the disease is almost not diagnosed before surgery. In fact, one should not talk about a malignant or benign variant of pseudomyxomas, since they are always secondary (of infiltrative or implantation origin).
Brenner's tumor(fibroepithelioma, mucoid fibroepithelioma) was first described in 1907 by Franz Brenner. It is a fibroepithelial tumor consisting of ovarian stroma.
Recently, the origin of the tumor from the integumentary coelomic epithelium of the ovary and from the hilus has been increasingly substantiated. In the region of the gate, they arise according to the location of the network and epoophoron. Benign Brenner tumor accounts for about 2% of all ovarian tumors. It occurs both in early childhood and over the age of 50 years. The tumor has a solid structure in the form of a dense node, the cut surface is grayish-white with small cysts.
The microscopic appearance of Brenner's tumor is represented by epithelial nests surrounded by strands of spindle cells. Cellular atypia and mitoses are absent. Brenner's tumor is often combined with other ovarian tumors, especially mucinous cystadenomas and cystic teratomas.
Epithelial components tend to undergo metal-asthetic changes. The possibility of developing proliferative forms of Brenner tumor cannot be ruled out.
The size of the tumor ranges from microscopic to the size of an adult’s head. The tumor is one-sided, often left-sided, round or oval in shape, with a smooth outer surface. The capsule is usually absent. The tumor often resembles ovarian fibroma in appearance and consistency.
Mostly the tumor is benign and is discovered accidentally during surgery. It is possible that proliferative forms of Brenner tumor may develop, which may become a transitional stage to malignancy.
Proliferating Brenner tumor(borderline Brenner tumor) is extremely rare and has a cystic structure with papillomatous structures. Macroscopically, there can be both cystic and cystic-solid structures. On the section, the cystic part of the tumor is represented by multiple chambers with liquid or mucous contents. The inner surface can be smooth or with tissue resembling papillary growths, loose in places.
Mixed epithelial tumors can be benign, borderline and malignant. Mixed epithelial tumors account for about 10% of all epithelial ovarian tumors. Two-component forms predominate; three-component forms are identified much less frequently. Most mixed tumors have a combination of serous and mucinous epithelial structures.
The macroscopic picture of mixed tumors is determined by the predominant tumor components. Mixed tumors are multilocular formations with different contents. There are serous, mucinous contents, less often areas of a solid structure, sometimes resembling fibroma or papillary growths.
Clinic of epithelial ovarian tumors. Benign ovarian tumors, regardless of their structure and clinical manifestations, have many similar features. Ovarian tumors often occur asymptomatically in women over 40-45 years of age. There are no specifically reliable clinical symptoms of any tumor. However, a more thorough questioning of the patient can reveal dull, aching pain of varying severity in the lower abdomen, lumbar and groin areas.
The pain often radiates to the lower extremities and the lumbosacral region and may be accompanied by dysuric phenomena, apparently caused by the pressure of the tumor on the bladder and an enlarged abdomen. Paroxysmal or acute pain is caused by torsion of the tumor stalk (partial or complete) or perforation of the tumor capsule. As a rule, pain is not associated with the menstrual cycle. They arise due to irritation and inflammation of the serous membranes, spasm of the smooth muscles of hollow organs, irritation of the nerve endings and plexuses of the vascular system of the pelvic organs, as well as due to tension of the tumor capsule, disruption of the blood supply to the tumor wall. Pain sensations depend on the individual characteristics of the central nervous system.
At papillary serous cystadenomas pain occurs earlier than with other forms of ovarian tumors. Apparently, this is due to the anatomical features of papillary ovarian tumors (intraligamentary location, bilateral process, papillary growths and adhesions in the pelvis).
With papillary cystadenomas, often bilateral, ascites is possible. The occurrence of ascites is associated with the growth of papillae along the surface of the tumor and along the peritoneum and due to a violation of the resorptive ability of the peritoneum of the utero-rectal space. With everting papillary serous cystadenomas (the papillae are located on the outer surface of the capsule), the course of the disease is more severe, and bilateral ovarian damage is much more common. With this form, ascites develops 2 times more often. All this allows us to consider an everting papillary tumor to be clinically more severe than an inverting tumor (location of the papillae on the inner surface of the capsule). The most serious complication of papillary cystadenoma remains malignancy.
With large tumors (mucinous) there is often a feeling of heaviness in the lower abdomen, it enlarges, and the function of neighboring organs is disrupted in the form of constipation and dysuria. Nonspecific symptoms - weakness, increased fatigue, shortness of breath are less common. Most patients have various extragenital diseases that can cause nonspecific symptoms. Reproductive function is impaired in every 5th examined woman (primary or secondary infertility).
The second most common complaint is menstrual irregularities. Menstrual dysfunction is possible from the moment of menarche or occurs later.
Recognizing pseudomyxoma before surgery is extremely difficult. There are no characteristic clinical signs on the basis of which a diagnosis could be made. The main complaint of patients is pain in the lower abdomen, often dull, less often paroxysmal.
The disease often begins gradually under the guise of chronic, recurrent appendicitis or an abdominal tumor of undetermined localization. Often patients consult a doctor due to rapid enlargement of the abdomen. The abdomen is round, spherical, its shape does not change when the patient’s body position changes. During percussion, there is a dullness of the percussion sound throughout the abdomen; palpation reveals doughiness, a characteristic “colloidal” crackle or “crunch”, since colloidal masses with pseudomyxoma do not overflow, as with ascites. Diffuse reactive peritonitis forms an extensive adhesive process, often disrupting the functions of the abdominal organs. Patients complain of loss of appetite, flatulence, and dyspepsia. The formation of intestinal fistulas, the appearance of edema, the development of cachexia, an increase in body temperature, and a change in the blood formula are possible. Death occurs due to increasing intoxication and cardiovascular failure.
Clinic of mixed epithelial tumors It does not differ significantly from single-component epithelial tumors.
Diagnosis of epithelial ovarian tumors. Despite technological advances, diagnostic thinking based on clinical examination remains important. Establishing a diagnosis begins with clarifying complaints, collecting anamnesis and bimanual gynecological and rectovaginal examinations. With a two-manual gynecological examination, it is possible to identify a tumor and determine its size, consistency, mobility, sensitivity, location in relation to the pelvic organs, and the nature of the tumor surface. It is possible to detect only a tumor that has reached a certain size when it increases the volume of the ovary. For small tumor sizes and/or giant tumors and atypical location of the tumor, bimanual examination is not very informative. It is especially difficult to diagnose ovarian tumors in obese women and in patients with adhesions in the abdominal cavity after laparotomies. It is not always possible to judge the nature of the tumor process based on palpation data. Bimanual examination gives only a general idea of ​​the pathological formation in the pelvis. A rectovaginal examination helps to exclude malignancy, during which one can determine the absence of “spikes” in the posterior fornix, overhang of the fornix with ascites, and invasion of the rectal mucosa.
During a two-manual vaginal-abdominal examination in patients with simple serous cystadenoma in the area of ​​the uterine appendages, a volumetric formation is determined posterior or lateral to the uterus, round, often ovoid in shape, tight-elastic consistency, with a smooth surface, with a diameter of 5 to 15 cm, painless, mobile on palpation .
Papillary cystadenomas more often they are bilateral, located on the side or posterior to the uterus, with a smooth and/or uneven (lumpy) surface, round or ovoid in shape, tight-elastic consistency, mobile or limitedly mobile, sensitive or painless on palpation. The diameter of the neoplasms ranges from 7 to 15 cm.
During a two-manual gynecological examination, mucinous cystadenoma is determined posterior to the uterus, has a lumpy surface, uneven, often tight-elastic consistency, round shape, limited mobility, diameter from 9 to 20 cm or more, sensitive to palpation. The mucinous tumor is often large (giant cystadenoma - 30 cm or more), occupying the entire pelvis and abdominal cavity. Gynecological examination is difficult; the body of the uterus and collateral appendages are difficult to differentiate.
During a two-manual vaginal-abdominal examination in patients with a verified diagnosis of a Brenner tumor, a space-occupying formation of an ovoid or, more often, round shape, dense consistency, with a smooth surface, 5-7 cm in diameter, mobile, painless, is determined lateral and posterior to the uterus. Brenner's tumor often resembles subserous uterine fibroids.
Ultrasound occupies one of the leading places among methods for diagnosing pelvic tumors due to its relative simplicity, accessibility, non-invasiveness and high information content.
Sonographically smooth-walled serous cystadenoma has a diameter of 6-8 cm, a round shape, the thickness of the capsule is usually 0.1-0.2 cm. The inner surface of the tumor wall is smooth, the contents of cystadenomas are homogeneous and anechoic, septa can be visualized, often single. Sometimes a finely dispersed suspension is detected, which is easily displaced by percussion of the formation. The tumor is usually located posterior and to the side of the uterus (Fig. 10.1).

Rice. 10.1
have papillary growths unevenly located on the inner surface of the capsule in the form of parietal structures of various sizes and increased echogenicity. Multiple very small papillae give the wall a rough or spongy appearance. Sometimes lime is deposited in the papillae, which has increased echogenicity on scanograms. In some tumors, papillary growths fill the entire cavity, creating the appearance of a solid area. Papillae can grow onto the outer surface of the tumor. The thickness of the capsule of papillary serous cystadenoma is 0.2-0.3 cm.
Papillary serous cystadenomas are defined as bilateral round, less often oval formations with a diameter of 7-12 cm, single-chamber and/or double-chamber. They are located lateral or posterior to the uterus, sometimes thin linear septa are visualized (Fig. 10.2).

Rice. 10.2
Mucinous cystadenoma has multiple septa 2-3 mm thick, often in certain areas of cystic cavities. Suspension is visualized only in relatively large formations. Mucinous cystadenoma is often large, up to 30 cm in diameter, almost always multilocular, located mainly on the side and behind the uterus, round or ovoid in shape. In the cavity there is a fine, non-displaceable suspension of medium or high echogenicity. The contents of some chambers may be homogeneous (Fig. 10.3).

Rice. 10.3
Brenner's tumor, mixed, undifferentiated tumors give a nonspecific image in the form of formations of a heterogeneous solid or cystic-solid structure.
Color Doppler mapping (CDC) helps to more accurately differentiate benign and malignant ovarian tumors. Based on the blood flow velocity curves in the ovarian artery, the pulsation index and the resistance index, tumor malignancy can be suspected, especially in the early stages, since malignant tumors have active vascularization, and the absence of vascularization zones is more typical for benign neoplasms.
With color Doppler ultrasound, benign epithelial ovarian tumors are characterized by moderate vascularization in the capsule, septa and echogenic inclusions. The resistance index does not exceed 0.4 (Fig. 10.4, 10.5, 10.6).

Rice. 10.4

Rice. 10.5

Rice. 10.6
Recently, X-ray computed tomography (XCT) and magnetic resonance imaging (MRI) have been used to diagnose ovarian tumors.
Endoscopic research methods (laparoscopy) widely used for the diagnosis and treatment of ovarian tumors. Although laparoscopy does not always make it possible to determine the internal structure and nature of the formation, it can be used to diagnose small ovarian tumors that do not lead to volumetric transformation of the ovaries, “non-palpable ovaries.”
The endoscopic picture of a simple serous cystadenoma (Fig. 10.7) reflects a volumetric formation of a round or ovoid shape with a smooth shiny surface of a whitish color with a diameter of 5 to 10 cm. A simple serous cystadenoma often resembles a follicular cyst, but unlike a retention formation, it has a whitish-gray color to bluish, which is apparently due to the uneven thickness of the capsule. A vascular pattern is determined on the surface of the capsule. The contents of serous cystadenoma are transparent, with a yellowish tint.

Rice. 10.7
Papillary cystadenoma at surgery it is determined (Fig. 10.8) as an ovoid or round tumor with a dense, opaque whitish capsule. On the outer surface of papillary cystadenoma there are papillary growths. The papillae can be single in the form of “plaques” protruding above the surface, or in the form of clusters and located in various parts of the ovary. With pronounced dissemination of papillary growths, the tumor resembles “cauliflower”. In this regard, it is necessary to inspect the entire capsule. Papillary cystadenoma can be bilateral, in advanced cases it is accompanied by ascites. Intraligamentary location and distribution of papillae throughout the peritoneum are possible. The contents of papillary cystadenoma are transparent, sometimes acquiring a brown or dirty yellow color.

Rice. 10.8
Endoscopic picture of mucinous cystadenoma often characterized by a large value. The surface of mucinous cystadenoma (Fig. 10.9) is uneven, the structure is multilocular. The boundaries between the cameras are visible. The tumor is irregular in shape, with a dense, opaque capsule, whitish in color, sometimes with a bluish tint. Bright, branching, unevenly thickened large vessels are clearly visible on the capsule. The inner surface of the tumor is smooth, the contents are jelly-like (pseudomucin).

Rice. 10.9
Laparoscopic intraoperative diagnosis of ovarian tumors is of great value. The accuracy of laparoscopic diagnosis of tumors is 96.5%. The use of laparoscopic access is not indicated in patients with ovarian tumors, so it is necessary to exclude a malignant process before surgery. If malignant growth is detected during laparoscopy, it is advisable to proceed to laparotomy. During laparoscopic removal of a cystadenoma with malignant degeneration, disruption of the integrity of the tumor capsule and contamination of the peritoneum may occur; difficulties may also arise during omentectomy (removal of the omentum).
In the diagnosis of malignant ovarian tumors, a large place is given to the determination of biological substances specific to these tumors by biochemical and immunological methods. Of greatest interest are the numerous tumor-associated markers - tumor-associated antigens (CA-125, CA-19.9, CA-72.4).
The concentration of these antigens in the blood allows us to judge the processes in the ovary. CA-125 is found in 78 - 100% of patients with ovarian cancer, especially in serous tumors. Its level exceeds the norm (35 IU/ml) only in 1% of women without ovarian tumor pathology and in 6% of patients with benign tumors. Tumor markers are used for dynamic monitoring of patients with malignant ovarian tumors (before, during and after treatment).
In case of bilateral ovarian damage, to exclude a metastatic tumor (Krukenberg), an X-ray examination of the gastrointestinal tract should be performed, and, if necessary, endoscopic methods (gastroscopy, colonoscopy) should be used.
The prevalence of the process is clarified by urological examination (cystoscopy, excretory urography). In exceptional cases, lymph and angiography are used.
Additional research methods in patients with space-occupying ovarian formations allow not only to determine the surgical approach, but also to form an opinion about the nature of the space-occupying formation, which determines the choice of surgical treatment method (laparoscopy - laparotomy).
Treatment of epithelial tumors operational. The scope and access of surgical intervention depend on the patient’s age, the size and malignancy of the formation, as well as on concomitant diseases.
The extent of surgical treatment helps determine an urgent histological examination. At simple serous cystadenoma at a young age, it is permissible to remove the tumor, leaving healthy ovarian tissue. In older women, the uterine appendages are removed from the affected side. At simple serous cystadenoma of borderline type in women of reproductive age, the tumor is removed from the affected side with a biopsy of the collateral ovary and omentectomy.
In premenopausal patients, supravaginal uterine amputation and/or hysterectomy and omentectomy are performed.
Papillary cystadenoma, due to the severity of proliferative processes, requires more radical surgery. If one ovary is affected, if the papillary growths are located only on the inner surface of the capsule, in a young woman it is permissible to remove the appendages of the affected side and biopsy the other ovary. If both ovaries are affected, supravaginal amputation of the uterus with both appendages is performed.
If papillary growths are found on the surface of the capsule, supravaginal amputation of the uterus with appendages or extirpation of the uterus and removal of the omentum is performed at any age.
Laparoscopic access can be used in patients of reproductive age with unilateral ovarian lesions without tumor capsule germination using an evacuating bag-container.
At border papillary cystadenoma of unilateral localization in young patients interested in preserving reproductive function, removal of the uterine appendages of the affected side, resection of the other ovary and omentectomy are acceptable.
In perimenopausal patients, extirpation of the uterus with appendages on both sides is performed and the omentum is removed.
Treatment of mucinous cystadenoma surgical: removal of the appendages of the affected ovary in patients of reproductive age. In the pre- and postmenopausal period, it is necessary to remove the appendages on both sides along with the uterus.
Small mucinous cystadenomas can be removed by surgical laparoscopy using an evacuation pouch.
For large tumors, it is necessary to first evacuate the contents with an electric suction through a small hole.
Regardless of the morphological affiliation of the tumor, before the end of the operation it is necessary to cut it and examine the internal surface of the tumor.
Inspection of the abdominal organs (appendix, stomach, intestines, liver), examination and palpation of the omentum, para-aortic lymph nodes, as with tumors of all types, are also indicated.
For pseudomyxoma, immediate radical surgery is indicated- resection of the omentum and parietal peritoneum with implants, as well as liberation of the abdominal cavity from gelatinous masses. The scope of surgical intervention is determined by the patient’s condition and the involvement of the abdominal organs in the process. Despite the fact that it is almost completely impossible to free the abdominal cavity from gelatinous masses, recovery can sometimes occur after surgery. Even in advanced cases of the disease, one should try to operate, since without surgical intervention the patients are doomed.
The prognosis for pseudomyxoma is unfavorable. Frequent relapses are possible, in which repeated surgery is indicated. Despite the morphological benignity of the tumor, patients die from progressive exhaustion, since it is not possible to completely free the abdominal cavity from the erupted gelatinous masses.
Treatment of Brenner's tumor is surgical. In young patients, removal of the uterine appendages of the affected side is indicated. In perimenopause, supravaginal amputation of the uterus and appendages is performed. In case of a proliferating tumor, supravaginal amputation of the uterus with appendages and total removal of the omentum are indicated.