The struma of the ovary is a germ cell tumor. It is considered a type of teratoma (a special tumor during intrauterine development). It accounts for up to 1.4% of all primary teratogenic formations (according to histology). The origin of the pathology is not fully understood; it is assumed that impaired fetal development at the embryonic stages plays a major role.
According to histology, several clinical variants of neoplasia are distinguished: non-infiltrative and diffuse nodular. When examining the structure of the neoplasm (morphological assessment), it is discovered that its structure corresponds to a highly differentiated mature teratoma or teratoblastoma. Depending on the degree of differentiation of cells (the certainty of their functional purpose; cancer is always poorly differentiated), we can talk about benignity or malignancy.
The peak incidence occurs at 50-60 years of age. The growth of the neoplasm is slow, stable, if we are talking about a benign variant.
Malignancy is observed in every 10-20 cases (5-10% of the total mass); in some clinical situations, the pathology is combined with other types of cancer (carcinoma, carcinoid, etc.). Teratogenic neoplasm requires planned treatment and follow-up. Malignant forms - urgent treatment.
Structure
Histology is required to determine morphological characteristics. The structure is homogeneous, the neoplasm has an unusual shape, attached to the ovary with a stalk. Neoplasia predominantly consists of thyroid tissue (thyroid cells). Ovarian struma and thyrotoxicosis go hand in hand: in fact, another thyroid gland begins to function in the body. But the degree of activity of this pseudo-organ varies: only in 6% of clinical cases is a sufficient amount of hormones produced for thyrotoxicosis.
Homogeneous teratomas of the type in question account for 50% of all neoplasias. They are called monodermal, that is, consisting of one type of tissue. In particular, thyroid. There are options when epithelium is found in the neoplasm - this is a completely different type of tumor.
Reasons for development
Oncologists still do not know enough about the etiology of the process. According to the main theory, even during the period of intrauterine development, a pathological spread of elements of the thyroid gland into the ovary occurs (so-called heterotropy).
The speed and aggressiveness of the development of the disease and the severity of thyrotoxicosis are influenced by a number of factors:
- Genetic predisposition. If there was a woman in the family with the diagnosis in question, the likelihood of the scenario repeating in future generations increases.
- Inflammation of paired reproductive organs (adnexitis). It can trigger a pathological mechanism and accelerate the growth of neoplasm.
- . Pathological proliferation of cells of the functional layer of the mucous lining of the uterus beyond the normal anatomical position.
- Early/late onset of the menstrual cycle. Associated with changes in the balance of progesterone and estrogen in the body. The problem begins to brew during puberty (sexual development of the body).
- Various cyclical changes.
- Hormonal imbalance with early or late onset.
- Primary or secondary infertility.
- Histology of the formation itself (the greater the degree of atypia of cellular elements, the more aggressive the disease is).
Clinical picture
Symptoms of ovarian struma vary widely, it all depends on the size of the neoplasm and its type. You should pay attention to the following manifestations:
- Pain in the lower abdomen that is not associated with the menstrual cycle is of a pressing, pulling nature, radiating to the lower back. The symptom is due to good innervation of the organs, creating a mass effect.
- Ascites (accumulation of fluid in the abdominal cavity).
- Discomfortable sensations, a feeling of heaviness in the abdomen and groin area.
- Signs of thyrotoxicosis: increased body temperature, increased blood pressure, formation of exophthalmos (bulging of the eyes), impaired neck relief, weakness, insomnia. A history of thyrotoxicosis worsens the overall prognosis and quality of life. Symptoms are relieved as part of comprehensive treatment.
- Changes in the nature of the menstrual cycle according to different types. There are: algodismenorrhea (painful menstruation), hyperpolymenorrhea (main symptom: prolongation of the natural cycle by several days).
There may be no symptoms of the disease. In this case, they speak of its latent course, most characteristic of the early stage of neoplasia. Later, the clinical picture expands and new symptoms are added.
Malignant struma of the ovary appears more clearly. Characteristic manifestations of an acute abdomen (severe pain, forced positioning of the body) associated with impaired local circulation due to torsion of the tumor stalk. Diffuse nodular struma grows into the walls of surrounding organs, which also explains the pain syndrome. There are also more rare symptoms: increased intestinal gas formation, dysuria, uterine bleeding, acyclic discharge from the genital tract. Fortunately, the proportion of malignant variants of the neoplasm is small; malignancy almost never occurs with timely therapy.
Diagnostics
Diagnosis of diffuse nodular struma and benign formation is the same. If a combination of symptoms occurs, you should seek medical help. Even if the suspicions are unfounded. A specialized specialist is a gynecologist or gynecological oncologist.
At the beginning of the diagnosis, an oral survey is carried out regarding complaints. The doctor collects anamnesis. Palpation allows you to assess the structure and size of the neoplasm, gynecological examination using mirrors - the nature of the growth of neoplasia, the degree of germination into the surrounding anatomical structures.
Determination of specific tumor markers (AFP, hCG, LDH) is mandatory. The hormonal activity of the struma is detected using a blood test for T3, T4.
Diagnostics involves determining the degree of malignancy of the neoplasm: a biopsy and morphological examination of a sample of collected tissue in the laboratory (histology) are indicated. Pathomorphological obtaining of biomaterial is possible (during surgery).
Ultrasound, chest x-ray, and electrocardiography are prescribed as auxiliary diagnostic methods.
Staging of malignant struma of the ovary is carried out on the basis of clinical data and histology. According to indications, the doctor can send the patient to a CT scan, MRI with gadolinium contrast enhancement (to determine the extent of the neoplastic process), urography, and cystoscopy.
An informative way to make a diagnosis is. Typical echo signs are determined. Ovarian scintigraphy will also be a good help. Since the altered tissue consists of thyroid cells, it will behave like the thyroid gland when the radioactive isotope accumulates. However, in any case, histology cannot be avoided: this is the main way to determine the microscopic structure of the tumor structure.
The scope of diagnosis is determined by the attending physician. If you have thyrotoxicosis, you will need to consult an endocrinologist.
Therapy
Treatment of ovarian struma is carried out according to an individual plan. It all depends on the patient’s age, type of formation, and its size. Therapy is prescribed immediately after neoplasia is detected to exclude malignancy.
If benignity is confirmed, resection of the ovary with total excision of pathological areas is indicated (how the operation is performed, we). The surgical treatment of struma is gentle: the neoplasm is well demarcated, and its complete removal is possible.
Scheme of ovarian resection with excision of the pathological area
With diffuse nodular struma, when the tumor grows infiltratively, removal of the entire affected organ is required. This is the only treatment option. In severe cases, total excision of the uterus and ovaries is necessary. Usually such a crippling procedure is prescribed to patients in the older age group, but sometimes there is no other choice.
When determining tactics for treating ovarian struma in young women, the doctor strives to maintain a balance: to preserve reproductive function as much as possible, while at the same time ensuring the optimal volume of removal of altered structures.
In the treatment of malignant ovarian struma, radiotherapy and chemotherapy are used. But with caution: if the dosage of the drug or radiation is incorrectly selected, the neoplasm cells develop resistance, ceasing to respond to the harmful effects. In this case, the chances of cure are reduced, and death is likely.
Signs of thyrotoxicosis are relieved by intravenous or oral administration of iodine preparations: sodium iodide or potassium iodide.
Forecast
For life - conditionally favorable.
For maintaining ability to work - favorable. When signs of thyrotoxicosis occur, it worsens.
From the point of view of preserving reproductive function, it depends on the volume of surgical intervention and the type of formation (diffuse nodular ones have a worse outcome).
Malignant neoplasm has an unfavorable prognosis in case of late detection or early administration of chemotherapy.
Thyroid tissue can be found in ovarian tumors (called struma ovary). M.F. Glazunov classified these neoplasms as germ cell tumors of the ovaries, teratomas. Unlike extragenital teratomas, germ cell tumors, according to M.
F. Glazunov, are not the result of an embryonic malformation and are associated with the ability of the germ cell under pathological conditions to grow and differentiate in its own directions, undergoing or not undergoing malignancy. The vast majority of these tumors are in a state of complete differentiation and consist of various mature tissues. In rare cases, ovarian teratoma can be represented only by thyroid tissue - colloidal struma of the ovary. Thus, the struma of the ovary has nothing to do with the embryogenesis of the thyroid gland.
Ovarian struma is observed very rarely. According to the literature, it accounts for 2.7% of all ovarian teratomas. In turn, teratomas make up 10-12% of ovarian tumors.
The clinical picture of these neoplasms usually does not differ from the picture of other benign ovarian tumors, and then only a morphologist can determine the thyroid nature of the tumor. However, thyroid tissue can begin to actively function and give a clear picture of thyrotoxicosis. According to the literature, approximately 5-6% of ovarian struma is accompanied by
are given by the phenomena of hyperfunction. Ovarian struma may be the cause of relapse of thyrotoxicosis after surgical treatment of toxic goiter.
Thyroid tissue in an ovarian teratoma can be a source of development of a malignant tumor.
We observed 5 patients with carcinomas that developed from the ovarian struma. In one of these observations, generalization of the tumor process with seeding of the peritoneum and metastases to the lungs was the cause of the patient’s death.
In all cases, the diagnosis was made only after surgery and morphological examination of the removed tumor, since the clinical picture of these tumors does not have specific features. Understanding the essence of the process and its pathogenesis in these tumors is of great practical importance, as it determines the choice of rational treatment tactics. The fact is that a mandatory component of modern combined treatment of malignant ovarian tumors is polychemotherapy. Meanwhile, carcinomas from the ovarian struma are predominantly highly differentiated tumors that are completely insensitive to chemotherapy. In this regard, the accepted treatment regimens for malignant ovarian tumors are not effective in such cases.
We observed another very rare localization of malignant teratoma from thyroid tissue.
Patient U., 73 years old, was consulted by us at the Leningrad City Oncology Clinic in January 1989. In November 1988, in one of the Leningrad hospitals, he underwent a right nephrectomy for a kidney tumor. Morphological conclusion: metastasis of papillary thyroid cancer. When examining the patient, no clinical data in favor of a thyroid tumor were found. Microscopic specimens of the removed tumor were reviewed (E.D. Neustadt), and a picture of papillary thyroid cancer was revealed. Clinical and morphological data allowed us to conclude that this was a malignant tumor that developed from a mature kidney teratoma, built from thyroid tissue.
In this observation, the correct interpretation of the essence of the process was directly related to the choice of treatment tactics and made it possible to reasonably refrain from postoperative chemotherapy.
Very often, women hear from their doctor about the presence of ovarian tumors. This horrifies many patients, as they believe that all tumors are cancerous. However, there are many benign tumors, the prognosis of which is often very favorable.
Causes of benign ovarian tumors
In gynecological practice, benign ovarian tumors are an extremely pressing problem. They are sometimes found even in little girls before the onset of puberty.
Currently, doctors cannot reliably say what exact reason can lead to the appearance of this type of neoplasm.
- Possible factors include:
- hormonal changes;
- viral infections;
- previous surgical interventions;
- abortions;
consequences of childbirth.
Stressful conditions can greatly affect the functionality of the ovaries. During emotionally difficult periods, eggs sometimes stop maturing, which eliminates the possibility of getting pregnant. This process is natural from a biological point of view, since the body tries to prevent the conception of a child during an unfavorable period.
Video: ovarian tumors - should you be afraid of the diagnosis?
Types of benign neoplasms
- There are many types of benign ovarian tumors. Neoplasms can grow from tissues of different origins, so they have different external signs from each other. There are three groups of tumors:
- epithelial;
- stromal;
germinogenic.
This type of neoplasm is formed due to the proliferation of epithelial tissues of the ovary (those that form the surface of the organ).
Such tumors are detected most often, in approximately 80% of all cases. The age of women is usually 45–50 years.
- Among epithelial ovarian tumors there are:
- serous cystadenoma;
- mucinous cystadenoma;
- endometrioid growths;
- clear cell tumors;
mixed epithelial neoplasms.
Serous cystadenoma
- This type is the most common and is found in 70% of patients with ovarian tumors. Cystadenoma can reach quite large sizes; on the outside it is covered with a dense and elastic membrane, under which there is a capsule with liquid contents (serous fluid). This type of tumor has the following features:
- does not grow into neighboring tissues, only pushes them apart or compresses them;
- cells grow slowly;
does not metastasize.
Depending on how the cyst wall is built, serous cystadenoma is divided into two types:
Serous cystadenomas usually form on one of the ovaries. If neoplasms appear on two organs at once, there is a high probability of a malignant process.
Symptoms of cystadenoma may not appear for a long time until the tumor grows to a large size or its base is torsioned.
Sometimes patients may complain of aching pain, constipation, and frequent urge to urinate. A bulge may appear on the side of the tumor on the abdomen, which is especially noticeable in thin girls.
- If the tumor ruptures, the patient’s well-being begins to deteriorate sharply. Blood pressure may rise or, conversely, drop sharply. The body temperature becomes very high, all signs of intoxication appear. In this case, emergency surgery is required.
- To identify serous cystadenoma, ultrasound diagnostics is used, which shows a large round formation with one or more cavities filled with homogeneous fluid. In the case of the papillary form, small papillary outgrowths are sometimes noticeable. Additional diagnostic methods are:
- CT or MRI. These studies are necessary to clarify the location and nature of the formation.
Blood analysis. To identify either the inflammatory process or blood loss. For young women, doctors try to preserve the integrity of the ovary, but during menopause they sometimes resort to removing not only it, but also the fallopian tubes and uterus if there is a suspicion of cancerous degeneration.
Video: Ultrasound of serous papillary cystadenoma of the ovary
This tumor grows from cubic epithelium, which is located deeper than the superficial lining of the organ. The structure of such cystadenoma is usually multilocular.
Mucinous cystadenoma can reach gigantic sizes. In some patients, a tumor weighing fifteen kilograms was removed.
Inside the chambers there is mucosis - a secretion of heterogeneous composition with suspension and sediment. It looks like a thick, opaque gray mucus. The walls of this tumor are smooth and dense; it often affects the ovaries on both sides at once, which increases the risk of malignant degeneration.
According to statistical studies and observations, mucinous cystadenoma of the ovary is more common in women after 30 years of age. In a short period of time, it not only takes on enormous dimensions within the ovary, but also gradually spreads to neighboring organs. Approximately 5% of women with mucinous cystadenoma develop oncological tumors against its background.
When diagnosing mucinous cystadenoma, chambers with partitions between them are clearly visualized
Symptoms manifest themselves as the tumor enlarges, which begins to interfere with the functioning of internal organs. Characteristic signs of a mucinous cyst include:
- nagging unpleasant sensations of pain in the pubic area;
- significant increase in abdominal volume;
- constant urge to urinate;
- feeling of incomplete bowel movement;
- frequent constipation.
The most difficult and unpleasant thing about mucinous cystadenoma is the impossibility of timely detection. Therefore, at the slightest discomfort, you should not hesitate and contact a specialist.
Diagnosis is carried out using ultrasound, and doctors successfully distinguish this cystadenoma from other formations due to inclusions and sediment in the internal fluid.
Treatment is only surgical. In some cases, the goal is to preserve the woman’s reproductive function. Then only the tumor itself is removed. But in adulthood, or at least with a slight suspicion of malignancy, the uterus and fallopian tubes are excised along with the ovaries.
Video: Ultrasound of mucinous cystadenoma
This type of epithelial tumor is one of the rarest and is associated with great difficulties in diagnosis. It is because of this that some experts believe that such a variety does not exist.
The spread of endometrial cells (the inner layer of the uterus) to neighboring organs occurs against the background of mechanical trauma and with a decrease in immune defense.
Endometrioid tumors can form anywhere in the female body, but most often the problem occurs in the appendage area.
- Tumor-like neoplasms of the ovaries have the following symptoms:
- relatively small sizes (from 0.5 to 10 cm);
- thick outer capsule;
- presence of blood in the contents;
the presence of dense adhesions on the outer surface.
- In most cases, when endometriosis forms in the ovary, a woman experiences the following symptoms:
- constant nagging pain in the lower abdomen;
- increased pain before menstruation;
- irradiation of pain to the lumbar region, perineum or rectum;
- problems with the intestines that arise from adhesive disease (tendency to constipation);
chills with increased temperature during menstruation.
The main symptom is pain. He will force the woman to see a specialist. At the first examination, the gynecologist will pay attention to the presence of a neoplasm in the area of the uterine appendages that is painful on palpation. The most common method for diagnosing this type of tumor is laparoscopy.
This procedure is performed under anesthesia, the patient is given a small incision through which a tube with a camera is inserted. If necessary, the tumor is removed immediately.
When performing an ultrasound, an endometrioid tumor looks like a very thick capsule, consisting of two layers and does not shift under mechanical influence. The main criterion for diagnosis is the absence of cytogenic stroma (connective tissue containing blood vessels and nerve fibers). If it is present, doctors diagnose endometriosis.
An endometrioid tumor is an accumulation of menstrual blood in the membrane of endometrial cells.
Treatment can be either conservative, consisting of taking medications, or surgical, in which the tumor itself and, if necessary, the affected ovary are removed.
With endometrioid tumor of the ovary, women often complain of pain in the lower abdomen
Brenner's tumor Brenner's tumor is considered an extremely rare disease.
It is usually detected during surgical operations performed to treat various gynecological pathologies.
Most often, Brenner's tumor is a unilateral neoplasm and is found in women after forty years of age.
The walls of this tumor are usually smooth, less often nodular. On a section it has a whitish tint, a small number of vessels, and sometimes areas of necrosis. The main danger is the fact that the disease is often asymptomatic. Pain and other unpleasant sensations appear when the tumor reaches very large volumes and begins to interfere with the functioning of other internal organs.
Since a malignant tumor can develop in advanced stages, it is very important to begin timely treatment. It happens exclusively operationally. In most cases, doctors resort to removing the tumor along with the ovary.
Without timely treatment, the disease progresses, which leads to death, because in the later stages even surgical intervention does not give adequate results, especially if the tumor is borderline in nature.
Benign clear cell tumors
Another name for this type of epithelial tumor is mesonephroma. Most often, the ovary is damaged on only one side.
Cystadenofibroma, or serous adenofibroma, of the ovary has a dense structure, a whitish or pinkish tint inside. In some cases, the inside may consist of papillary projections, which is why doctors sometimes mistake this tumor for cancer. It usually develops only on one side, has a round shape and rarely grows more than ten centimeters.
Patients practically do not complain of unpleasant symptoms until the tumor reaches a large size. Diagnosis requires ultrasound, MRI and histological analysis to distinguish this tumor from others.
Treatment is only surgical. Removal of adenofibroma can be performed laparoscopically or conventionally, depending on the size of the formation.
In women of childbearing age, they try to remove only the tumor, without affecting the ovary
Mixed epithelial tumors
Mixed epithelial tumors are characterized by a combination of serous and mucinous epithelial structures. During diagnosis, the doctor may identify several or one chamber filled with various types of fluids. This can be either a homogeneous serous or mucinous environment containing various inclusions and sediment. Sometimes papillary projections are found.
As with many other epithelial tumors, treatment involves only surgical removal of the tumor with possible excision of the ovary.
Sex cord stromal tumors
These types of neoplasms are hormonally active, that is, they themselves produce hormones. There are feminizing (producing female sex hormones) and masculinizing (producing male hormones) tumors.
Tecoma
This species is feminizing, most often appears on one of the ovaries and reaches a size of up to 15 centimeters. The thecoma consists of stromal cells and secretes a certain amount of estrogen. It is because of this that women experience dramatic rejuvenation, the skin becomes more elastic, and the number of wrinkles is reduced. However, this may cause disruption of the menstrual cycle and the appearance of severe uterine bleeding.
The consistency of the tumor is very elastic and elastic. There is no pain on palpation, and the tumor itself is mobile. Sizes and shapes may vary, and once cut, the thecoma reveals either a liquid or a gel-like structure. In rare cases, this type of tumor can become cancerous.
The patient may exhibit the following signs of pathology:
- menstrual irregularities in young women, as the neoplasm produces a sex hormone;
- unnatural softness of the ovary, which is revealed by palpation;
- secondary infertility;
- skin smoothing;
- swelling of the mammary glands, as during menstruation;
- the appearance of uterine bleeding after menopause.
Benign thecoma does not respond to conservative treatment. Once the diagnosis is made, the patient is prescribed surgical removal of the tumor. As in other cases, doctors try to preserve the integrity of the ovaries in young girls, but in women over fifty, the appendages are usually completely removed.
During laparoscopy, very small incisions are made into which surgical instruments, a video camera and a gas supply tube are inserted.
Granulosa cell tumor of the ovary
This type is feminizing and usually appears in children. This is due to early puberty, which in fact turns out to be false, since the girl does not ovulate. But at the same time, rare bleeding is detected, secondary sexual characteristics begin to appear, and the uterus increases in size.
These neoplasms are formed from cells located in the follicles. Depending on which groups of cells became the basis of the tumor, it can produce various hormones.
Granulosa cell tumors that form in adults typically synthesize estrogens. This is manifested by the following symptoms:
- enlargement and tenderness of the mammary glands;
- increased libido;
- increased amount of vaginal secretion;
- improvement of skin condition - increased turgor and elasticity, which gives a woman a youthful appearance.
Some patients suffer from problems with urination and defecation, and flatulence. In rare cases, tumors in adult women produce androgens, which leads to male-pattern hair growth.
Instrumental methods are used for diagnosis:
Laboratory tests include:
- clinical blood test, which pays attention to ESR (phenomena of acute inflammation), hemoglobin (manifestations of anemia), leukocyte formula;
- blood and urine tests for hormone levels (estrogens or androgens).
Treatment consists of removing the tumor. Upon closer examination, a rather dense capsule with many chambers is visible. Sometimes hemorrhages and necrotic areas are observed.
Androblastoma
This is a very rare tumor that produces male hormones. Most often it is discovered at an early age.
Teenage girls may experience the following symptoms:
- menstrual irregularities - absence of menstruation;
- small size of the mammary glands;
- acne;
- excess greasiness of skin and hair;
- rough voice;
- clitoral hypertrophy;
- hirsutism - hair growth above the upper lip, on the chin, abdomen, and in excess on the legs.
In the absence of treatment, the formation of the skeleton will also occur according to the male type - broad shoulders, narrow pelvis.
Androblastoma provokes hirsutism - the appearance in women of secondary sexual characteristics characteristic of men
The diagnosis is established on the basis of clinical signs, gynecological examination, and ultrasound examination. A blood test for hormone levels is required. In patients with androblastoma, elevated levels of testosterone and a decrease in luteinizing and follicle-stimulating hormones are detected.
Treatment of androblastoma can only be surgical. Most often, the tumor is removed along with the ovary on one side. For older women, excision of all appendages may be indicated.
Fibroma
This type of tumor is very common and occurs in approximately 10% of all ovarian tumors. It can appear in childhood, but is most often recorded during menopause.
Unlike previous tumors of the sex cord stroma, fibroids do not secrete hormones. The first symptoms appear when the tumor has reached a significant size.
A woman may be bothered by aching, nagging pain in the lower abdomen or lower back. They are not related to the menstrual cycle. The pain is caused by stretching of the fibroid capsule and compression of the pelvic nerve plexuses. Sometimes patients are bothered by a feeling of heaviness in the abdomen, constipation, and urinary problems. Such signs occur when the tumor presses on the intestines or bladder.
If salt deposition occurs, the fibroma becomes hard to the touch. When the tumor ruptures and its contents enter the abdominal cavity, patients experience ascites. This causes shortness of breath, increased temperature, and increased heart rate.
As a result of fibroid rupture, fluid accumulates in the woman’s abdominal cavity and ascites develops.
Ultrasound, computed tomography and gynecological examination can be used for diagnosis. Treatment for fibroids is only surgical. Depending on the woman’s age and her desire to have children, the doctor performs either laparoscopic removal of the tumor or a more serious abdominal surgery with excision of all appendages.
Germ cell tumors of the ovary
These types of ovarian neoplasms develop from primordial germ cells, which tend to develop into any type of cell.
Dermoid cysts
Another name is mature ovarian teratoma. This type of germ cell tumor is surrounded by a very dense and elastic membrane. When making an incision, a mucous substance with all sorts of formations is discovered, such as hair, bone structures, teeth, and neuromuscular fibers.
This tumor can appear at any age.
Inside the teratoma, you can find hair, teeth, bones that develop from germ cells, like the tumor itself
- While the teratoma is small, patients rarely show any symptoms. However, as it grows, very severe pain can appear, sometimes women even lose consciousness because of it. The dense structure of the tumor compresses all nearby organs, impairing their blood supply. In this case, a woman may experience:
- periodic discomfort and heaviness in the lower abdomen;
- urinary disturbance;
- bowel dysfunction (constipation or diarrhea);
- weakness, fatigue, weight loss;
If torsion of the teratoma leg occurs, then within a short period of time patients begin to feel very severe pain, similar in symptoms to appendicitis. Body temperature may rise sharply, pain radiates to the lower extremities and rectum.
For diagnosis, a gynecological examination and ultrasound are often sufficient, in which a large tumor with various structures inside will be clearly visible.
Treatment for teratoma is exclusively surgical, since this type of neoplasm is not amenable to drug therapy.
For small sizes, minimally invasive laparoscopy is possible; in other cases, surgery is prescribed with a large incision on the side of the abdomen.
Video: ovarian teratoma
Struma ovary This type of germ cell tumor consists of thyroid cells.
Its formation occurs due to embryonic developmental defects, in which the cells of this organ enter the ovaries.
Cells intended to form the thyroid gland, due to fetal malformations, can enter the ovaries, subsequently triggering the development of struma
Most often, the struma appears only on one side and is benign.
Palpation reveals an uneven and dense formation, which is very mobile and rests on a small stalk. Patients report menstrual irregularities and pain in the lower abdomen. Also, a blood test reveals elevated levels of thyroid hormones.
For diagnosis, ultrasound and histological examination are prescribed, after which mandatory removal of the struma is carried out.
Gonadoblastoma Gonadoblastoma is an extremely rare disease that develops from primordial germ cells.
During genetic testing, patients are found to have chromosomal abnormalities. The diagnosis is made based on these tests, ultrasound and after a gynecological examination.
In women, there is a lack of menstruation and pathological development of the reproductive organs. Gonadoblastoma is often combined with certain types of malignant tumors, which often lead to metastasis. In especially severe cases, a person has a male appearance, but at the same time female genital organs.
A woman with gonadoblastoma has a completely male appearance and suffers from incurable infertility
There are many types of benign ovarian tumors. The prognosis of treatment largely depends on the timeliness of visiting a doctor. In most cases, it is possible to completely get rid of tumors without further consequences for the body. For almost any diagnosis, removal of the tumor is prescribed, and from a certain age, excision of the appendages.
Shared
Tumors are a very common phenomenon in modern society. The pathological process can affect any organ: the brain, lungs, stomach, pancreas, prostate or thyroid gland. There are tumors that are more common than others, while others are rare. Among them, formations originating from immature tissues of the embryonic period stand out. Such formations in women include ovarian teratoma.
The embryonic period is a very unique stage in human development. All organs and tissues come from a single cell - the zygote, which contains half the genetic information from the mother and father. After a fairly short period of time, the organism is already a rudiment of an embryo. Initially, all cells are divided into three germ layers - ectoderm, mesoderm, endoderm.
The first will later form the skin, many endocrine glands, the nervous system and the brain. The mesoderm will give rise to connective tissue and its various types: bone, cartilage, tendon. The endoderm will become the source of the development of the intestinal tube, from which the digestive tract, liver and pancreas will subsequently form. The internal genital organs of both sexes originate from a single rudiment. Women will subsequently develop a uterus, tubes and ovaries.
Teratoma is a tumor that forms from immature embryonic tissues localized in the ovary.
Teratoma refers to dermoid cysts of the ovary
Synonyms for the disease: dysgerminoma, dermoid cyst, dermoid, germ cell tumor.
The disease occurs both at a young age and among women who have entered the period of natural decline of reproductive function.
The incidence of ovarian teratoma is one case per 40 thousand newborns.
Teratoma can be localized not only in ovarian tissues. Similar formations have been recorded in the kidneys, sacrococcygeal region, nervous system, abdominal cavity, testicles and other rarer areas.
Classification
Causes and development factors
Dermoid cysts by their nature are teratogenic tumors. The main reason for its development is the disruption of the processes of formation of mature tissues from the rudiments of the embryo. All cells in the human body have the same set of hereditary information. For the formation of various tissues, the process of creating the epigenome, which is a collection of active genes, is extremely important.
However, the formation of the epigenome is not everything. Tissues distribute their future functions, experiencing the chemical influence of various substances released by their “neighbors”. Only the combination of these factors will allow all organs and systems to form correctly.
Organogenesis occurs most intensively in the first half of pregnancy
The development of the child in the womb occurs throughout the forty weeks of pregnancy. However, this process occurs most intensively during the first trimester. Any negative factor acting on the fetus can cause a malformation - an anomaly of the anatomical structure, and is therefore called teratogenic.
- Many chemicals and physical agents can have an effect:
- infections (bacterial, viral);
- toxic substances;
- medications;
radiation exposure.
The impact of the above factors is the main cause of disruption of the formation of tissues and organs.
The “grandmother syndrome” stands apart. Egg precursors are formed in the early stages of intrauterine development. A girl born after an adverse effect has defective reproductive cells. A fetus formed from such an egg may suffer from various abnormalities. Teratoblastoma is a malignant tumor of extremely immature embryonic tissue.
Like other similar formations, this form of teratoma is prone to uncontrolled growth, damage to neighboring organs, lymph nodes and the formation of secondary foci - metastases. First of all, the uterus, tubes, bladder, rectum, peritoneum and greater omentum are involved in the process.
Teratoblastoma primarily affects the pelvic organs
Symptoms of the disease In many cases, dermoid cysts can be asymptomatic, especially if they are small in size.
Often, a teratoma is an accidental finding.
- A large tumor size may cause the following symptoms:
- pain in the lower abdomen;
- frequent urination;
- loose stools;
constipation
Teratoblastoma, as a malignant tumor, is characterized by the following features:
Menstrual function in many cases may not be impaired. An existing teratoma often does not interfere with the normal course of pregnancy and childbirth.
Clinical aspects of teratoma - video
Diagnostic methods
To establish a correct diagnosis, the following measures must be taken:
- gynecological examination: allows you to approximately determine the location and size of the formation;
- rectal examination: necessary to exclude damage to the rectum by malignant immature teratoma;
- Ultrasound examination of the pelvic organs: carried out to establish the exact location of the tumor, its size, as well as concomitant pathology of the uterus and appendages;
Ultrasound diagnostics allows tumor localization
- color Doppler mapping: allows you to determine the speed of blood flow through the tumor vessels;
- ultrasound examination of the abdominal organs: necessary to search for secondary foci of immature teratoma;
- X-ray of the chest organs: carried out to search for metastases of teratoblastoma;
- computer (or magnetic resonance) tomography: allows you to evaluate the structure of the abdominal pelvic organs;
Computed tomography allows you to evaluate the anatomical structure of the tumor and neighboring organs
- laparoscopy: performed under anesthesia through several punctures under video control, the procedure allows you to visually assess the condition of the organs and take tumor material for examination;
- biopsy: involves examining the tumor material after appropriate preparation under a microscope in order to determine the nature of the formation.
Microscopic examination will definitively determine the type of tumor
Treatment methods
Treatment of teratoma is carried out under the guidance of a gynecologist. Surgical intervention is the method of choice when making a diagnosis. The extent of the operation depends on the morphological type of the tumor.
In the presence of a mature teratoma and the patient’s young age, excision of the tumor within healthy tissue while preserving the organ is permissible. During the postmenopausal period, supravaginal amputation of the uterus and appendages is used. In some cases, preservation of reproductive organs is acceptable. Teratoblastoma is subject to surgical intervention involving supravaginal amputation of the uterus and appendages and removal of the greater omentum. In some cases, the operation is performed laparoscopically, which can significantly speed up the rehabilitation process. The intervention is carried out regardless of the day of the menstrual cycle.
Surgical intervention for teratoma - photo gallery
Cyst resection is a gentle organ-preserving procedure
Rehabilitation
The duration of the recovery period after surgery depends on the method of execution and the volume of the operation. The period of incapacity for work is determined by the doctor individually.
Complications and prognosis
The prognosis for treatment of mature teratoma is usually favorable. After the intervention, a woman is able to become pregnant and give birth naturally. Teratoblastoma is characterized by a malignant course with the formation of secondary tumor foci. The following complications develop:
- accumulation of fluid in the abdominal cavity;
- accumulation of fluid in the pleural cavity;
- breathing problems;
- death.
Thyrotoxicosis syndrome with trophoblastic tumors, ovarian struma (struma ovarii), hydatidiform mole, choriocarcinoma (chorionepithelioma), T4- and T3-secreting ovarian teratoma, ovarian struma
Version: MedElement Disease Directory
Thyrotoxicosis with ectopia of thyroid tissue (E05.3)
Endocrinology
general information
Short description
This subheading describes the syndrome of thyrotoxicosis, which develops in some cases in patients with trophoblastic tumors (hydatidiform mole and chorionepithelioma) and ovarian struma. After removal of the tumor, the clinical manifestations of thyrotoxicosis completely disappear.
Hydatidiform mole and chorionepithelioma secrete large amounts of human chorionic gonadotropin Human chorionic gonadotropin is a hormone produced by the placenta that stimulates the production of progesterone; in medicine, detection of human chorionic gonadotropin is one of the main methods for early pregnancy establishment
(HG). This hormone is a weak stimulator of TSH on thyrocytes. When the concentration of hCG exceeds 300,000 U/l (which is several times higher than the concentration of hCG in normal pregnancy), thyrotoxicosis may occur.
There are two forms of trophoblastic disease - hydatidiform mole and chorionepithelioma.
Hydatidiform mole develops during pregnancy and is characterized by swelling of all or part of the chorionic villi (complete or partial hydatidiform mole), hyperplasia Hyperplasia is an increase in the number of cells, intracellular structures, intercellular fibrous formations due to enhanced organ function or as a result of pathological tissue neoplasm.
trophoblast. With a complete hydatidiform mole, the embryo is not detected, the uterus is filled with chorion villi that have changed in the form of bubbles; with partial hydatidiform mole, altered villi and an embryo are detected in the uterus, which usually dies in the early stages of development.
Chorionepithelioma(syn. choriocarcinoma) - originating from trophoblast cells Trophoblast is the outer layer of cells in mammalian embryos that appears at the blastocyst stage; provides contact between the embryo and the mother’s body; participates in the implantation of the embryo into the uterine wall and the formation of the placenta
malignant tumor. More often it is localized in the uterus. In most cases, chorionepithelioma develops from hydatidiform mole cells, less often from trophoblast cells Trophoblast is the outer layer of cells in mammalian embryos that appears at the blastocyst stage; provides contact between the embryo and the mother’s body; participates in the implantation of the embryo into the uterine wall and the formation of the placenta
remaining in the uterus after abortion or childbirth; the source of tumor development can also be teratoma cells Teratoma is a tumor-like formation that occurs as a result of a violation of tissue formation in the embryonic period of development; consists of one or more mature tissues; can grow and develop in parallel with the growth of the organism
. Primary localization of chorionepithelioma outside the uterus (for example, in the fallopian tube during implantation of the fertilized egg, ovaries) is rarely observed.
Chorionepithelioma is a soft spongy nodule formed by cytotrophoblast, along the periphery of which a rim of syncytium is defined Syncytium is a network-like structure consisting of cells in contact with each other by cytoplasmic processes
with extensive hemorrhagic areas. When the uterus is damaged, the tumor nodes protrude into the uterine cavity, but can also be located in its thickness and grow into the peritoneum. Tumor cells have the ability to lyse (destroy) surrounding tissues and blood vessels. Characteristic is early, predominantly hematogenous, metastasis to the vagina, lungs, brain, bones.
Struma of the ovary - a tumor that is similar in histological structure to the thyroid gland is classified as a mature teratoma. Usually unilateral, grows quickly, but remains benign. Clinically manifests itself in the form of thyrotoxicosis, combined with the presence of an ovarian tumor (fast-growing, dense consistency, with an uneven surface, relatively small in size, pedunculated).
Classification
Histological classification of trophoblastic neoplasia (FIGO, 2000)
1. Hydatidiform mole:
Complete hydatidiform mole;
Partial hydatidiform mole.
2. Invasive hydatidiform mole.
3. Choriocarcinoma.
4. Trophoblastic tumor of the placental bed.
5. Epithelioid trophoblastic tumor.
The histological form of a trophoblastic tumor has important prognostic significance.
Etiology and pathogenesis
Trophoblastic disease(TB) occurs due to disturbances in the development and growth of the trophoblast.
Presumably it can develop as a result of the following reasons:
- special properties of the egg;
- a virus that affects the trophoblast;
- increased hyaluronidase activity;
- immunological characteristics of sexual partners;
- chromosomal aberrations.
Hydatidiform mole develops during pregnancy and is characterized by swelling of all or part of the chorionic villi (complete or partial hydatidiform mole), trophoblast hyperplasia.
With a complete hydatidiform mole, the embryo is not detected, the uterus is filled with chorion villi that have changed in the form of bubbles, resembling a bunch of grapes (the diameter of the bubbles is from 1 mm to 1 cm or more).
With a partial hydatidiform mole, along with altered villi, an embryo is also found in the uterus, which usually dies in the early stages of development.
In some cases, the altered villi penetrate into the thickness of the myometrium and an invasive (destructive) hydatidiform mole or destructive chorioadenoma develops.
In the edematous growing villi of the chorion, large round cells with foamy cytoplasm (Kashchenko-Hoffbauer cells) are often detected microscopically. Almost half of patients with hydatidiform mole develop thecal lutein cysts in the ovaries, which is associated with hyperstimulation of ovarian corpus luteum cells by human chorionic gonadotropin produced by proliferating trophoblast cells.
Chorionepithelioma(syn. - choriocarcinoma) - a malignant tumor arising from trophoblast cells and most often localized in the uterus. In most cases, chorionepithelioma develops from hydatidiform mole cells, less often from trophoblast cells remaining in the uterus after abortion or childbirth. Teratoma cells can also be the source of tumor development.
Primary localization of chorionepithelioma outside the uterus (for example, in the fallopian tube during implantation of the fertilized egg, ovaries) is rarely observed.
Chorionepithelioma is a soft, spongy nodule formed by cytotrophoblast (polygonal glycogen-rich Langhans cells), along the periphery of which there is a rim of syncytium with extensive hemorrhagic areas.
When the uterus is damaged, the tumor nodes protrude into the uterine cavity, but can also be located in its thickness and grow into the peritoneum. Tumor cells are able to lyse surrounding tissues and blood vessels. Characteristic is early (mainly hematogenous) metastasis to the vagina, lungs, brain, bones.
Struma ovary- germ cell tumor of the ovary, which belongs to rare types of ovarian teratomas. Consists of thyroid tissue, develops due to various defects of embryonic development, resulting in heterotopia Heterotopy - the appearance in the process of embryogenesis of a particular structure (organ, tissue) in an unusual place
elements of the thyroid gland in the ovary.
The vast majority of these tumors are in a state of complete differentiation and consist of various mature tissues. In rare cases, ovarian teratoma can be represented only by thyroid tissue - colloidal struma of the ovary.
Thus, the struma of the ovary is not related to the embryogenesis of the thyroid gland.
Epidemiology
Prevalence of trophoblastoma:
- in European countries - 0.6-1.1 cases per 1000 pregnancies;
- in the USA - 1:1200 pregnancies;
- in Asian and Latin American countries - 1:200 pregnancies;
- in Japan - 2:1000 pregnancies.
The incidence of various forms of trophoblastic disease, according to one of the largest trophoblastic centers (Interregional Center - Sheffield, UK):
- complete hydatidiform mole - 72.2%;
- partial hydatidiform mole - 5%;
- choriocarcinoma - 17.5%;
- other forms - 5.3%.
Struma ovarianis mainly occurs in women aged 40-60 years, although it accounts for only 1.4% of the total number of cystic teratomas.
Ovarian struma is classified as one of those teratomas in which thyroid tissue predominates or constitutes a significant component of the tumor. However, in 20-30% of cases the tumor is represented only by thyroid tissue.
Only 5-6% of these tumors produce sufficient thyroid hormone to cause hyperthyroidism.
Approximately 5-10% of ovarian struma can transform into carcinoma.
Clinical picture
Symptoms, course
The clinical picture of thyrotoxicosis in trophoblastic tumors and ovarian struma has significant variability. As a rule, this is thyrotoxicosis of mild or moderate severity, and the degree of its severity depends on the level of thyroid hormones in the blood serum.
Increased function of the thyroid gland (TG) is due to the fact that trophoblastic tumors secrete a significant amount of human chorionic gonadotropin, which has an alpha subunit in common with TSH, and the structure of the beta subunit has great homology with the corresponding TSH subunit.
It is known that the thyroid-stimulating effect of human chorionic gonadotropin (HCG) is insignificant compared to TSH. Trophoblastic tumors secrete molecular variants of hCG, and some of them have quite high activity compared to hCG, which is secreted by the placenta during normal pregnancy.
Most women with trophoblastic tumors do not have clinical manifestations of thyrotoxicosis, despite a moderate increase in the level of thyroid hormones in the blood.
In other patients, thyrotoxicosis proceeds typically with the following: signs:
- weight loss;
- tachycardia Tachycardia - increased heart rate (more than 100 per minute)
;
- sweating;
- fatigue, muscle weakness;
- poor heat tolerance;
- irritability;
- tremor.
The thyroid gland is usually moderately enlarged or of normal size.
Ophthalmopathy Endocrine ophthalmopathy - 1) The general name for non-inflammatory pathological processes in the eye caused by dysfunction of the endocrine system; 2) Genetically determined independent autoimmune disease, accompanied by involvement of the eye and all orbital tissues in the pathological process and manifested by exophthalmos and ophthalmoplegia of varying degrees
, dermopathy, acropathy are absent.
Hydatidiform mole
The most characteristic clinical signs hydatidiform mole:
- a faster increase in the size of the uterus than during normal pregnancy (not corresponding to the delay in menstruation);
- cramping pain in the lower abdomen;
- uterine bleeding (bubble-shaped chorionic villi can be detected in the blood);
- toxicosis of pregnant women (often);
- invasive hydatidiform mole can metastasize to the external genitalia, vagina, as well as to the lungs and brain.
Chorionepithelioma
Clinical manifestations of uterine chorionepithelioma:
- bloody discharge from the genital tract that occurs after a hydatidiform mole or abortion, less often after childbirth (sometimes several years later);
- enlarged uterus;
- thecallutein cysts Theca lutein cyst - an ovarian cyst formed as a result of hyperstimulation of follicles by human chorionic gonadotropin, for example, with hydatidiform mole, chorionepithelioma
ovarian, anemia (50% of cases);
- intra-abdominal bleeding is possible when the tumor invades the serous membrane of the uterus.
With metastases, signs of damage to the relevant organs appear:
- metastases in the vagina look like dark red nodes and are detected upon examination; when blood vessels are destroyed, bloody discharge from the vagina is observed;
- with metastases to the lungs, shortness of breath, chest pain, cough with bloody sputum occur;
- with metastases to the brain, headache, vomiting, paresis and other neurological symptoms are observed;
- with bone metastases - pain in the affected area.
When chorionepithelioma is localized in the fallopian tube, severe pain in the lower abdomen is noted, and profuse intra-abdominal bleeding is possible due to the destruction of the serous covering of the fallopian tube.
Struma ovary manifested by pain in the lower abdomen and lower back, menstrual irregularities (usually hyperpolymenorrhea type Hyperpolymenorrhea - menstrual irregularity with heavy and prolonged (over 6-7 days) menstruation
and algodismenorrhea Algodysmenorrhea is a menstrual disorder, expressed in sharp cramping or aching pain in the lower abdomen, in the lumbar and sacral regions, accompanied by general malaise
).
In all of the above cases, symptoms of thyrotoxicosis are added against the background of a characteristic clinical picture.
Chorionepithelioma can occur in men and is localized in the testicle. In this case, the clinical manifestations of thyrotoxicosis are similar to those found in women. Gynecomastia often develops Gynecomastia - enlargement of the mammary glands in men
(also possible with diffuse toxic goiter).
Diagnostics
Hydatidiform mole
The diagnosis is made based on clinical symptoms, results of laboratory tests of urine and ultrasound scanning of the uterus.
Ultrasound reveals a typical cellular pattern of the uterus.
More rarely, radiography of the uterus (after the introduction of radiopaque substances into it) and transabdominal biopsy of the placenta are used.
Chorionepithelioma
The diagnosis is made based on:
- medical history;
- clinical manifestations;
- data from histological examination of tissues obtained by curettage of the uterine mucosa;
- detection (including using radiography) of metastases in other organs.
For early diagnosis of the disease, the determination of human chorionic gonadotronin in urine and blood is important.
The diagnostic value of cytological examination is limited due to the frequent necrosis of cellular elements in chorionepithelioma.
Nodules of chorionepithelioma due to their significant vascularization are clearly detected by pelvic angiography.
Metrosalpingography reveals an enlarged uterus, unevenness of its internal surface and filling defects. Ultrasound scanning is also informative, allowing to determine damage to the uterus and identify thecal lutein cysts of the ovaries. If uterine perforation is suspected, laparoscopy is performed.
Struma ovary
The diagnosis is established, as a rule, on the basis of anamnesis and pelvic ultrasound data.
Sonographic signs:
- the struma of the ovary on scanograms is depicted as a formation of various sizes of a fine-spongy structure of predominantly medium echogenicity (the spongy component is one of the components of a mature teratoma or mucinous cystadenoma);
- the dimensions of the spongy component range from 3.1x2.8x2.5 cm to 2.1x4.0x11.2 cm;
- the internal structure of the spongy component is heterogeneous - it contains single small (about 4 mm in diameter) hyperechoic inclusions or microcalcifications that leave behind an acoustic amplification effect ("comet tail").
During the diagnostic process, the absorption of radioactive iodine by the thyroid gland and ovaries is also examined, ovarian scintigraphy with 123I and computed tomography of the ovaries are performed.
Result histological examination- a fundamental indicator in making a diagnosis.
An ovarian struma is usually a unilateral tumor, although it is sometimes associated with a dermoid cyst in the opposite ovary. Macroscopically, the outer surface of the struma is smooth, the consistency of its tissue is elastic. The cut surface is brownish, brownish-red, sometimes with a pronounced green tint, and occasionally it contains cysts filled with colloid.
Under a microscope, the tumor contains foci of normal thyroid tissue, as well as areas with the structure of a goiter. Very often, cystic cavities are found, sometimes without lining.
Frequent hemorrhages, xanthomatosis Xanthomatosis is a pathological condition characterized by the deposition of cholesterol and (or) triglycerides in the skin or other organs and tissues due to impaired fat metabolism; usually manifested by the formation of xanthoma and xanthelasma
, sclerosis, calcium salt deposits, osteogenesis foci Osteogenesis is the process of bone tissue formation
.
Malignant struma of the ovary most often has a picture of papillary cancer.
Laboratory diagnostics
Hydatidiform mole
The main marker is an increased concentration of human chorionic gonadotropin (HCG).
The result of urine tests (even when diluted 50 or 100 times) gives a positive reaction to hCG.
The detection or increase in hCG titer after surgical treatment of hydatidiform mole indicates the development of chorionepithelioma.
Chorionepithelioma
The determination of hCG in urine and blood is important knowledge. In women who have previously given birth and had an abortion, a high-quality positive urine reaction to hCG is very important.
The diagnosis of chorionepithelioma is confirmed by the detection of trophoblastic β-globulin in the blood serum, especially in patients with low levels of hCG (for example, with severe tumor necrosis).
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