A tumor of a solid structure on the epididymis on the right. Malignant ovarian tumors. Mature cystic teratoma

Tumors and tumor-like formations of the ovaries are a pathology that occurs in medical practice with great frequency. According to studies, tumors and tumor-like neoplasms of the ovaries have been diagnosed up to 25 percent more often over the past decade. Most of them are benign, however, the number of women with malignant tumors increases every year. Most often, an ordinary cyst is diagnosed, which, if not treated in a timely manner, tends to develop into a cancerous body. Due to the histological and anatomical structure of the appendages, they are more often susceptible to the appearance of various formations. The reasons for such pathological changes today remain not fully understood, so disagreements among scientists on this issue continue to exist.

Etiology of the disease

Tumor-like formations of the ovary can appear from various sources. They are formed due to the pathological growth of the epithelium of the appendages, failures in the development of the egg at one or another stage of maturation, disturbances in the formation of theca tissues, granulosa and leyding cells, nonspecific connective tissues, nerves, vessels and other elements of the appendages. Tumors and tumor-like formations appear in women of all ages, however, patients between 30 and 60 years of age are more susceptible to the disease. In fifty percent of cases it is found in postmenopausal women. Whether it is a cyst or another type of formation, its development begins much earlier than diagnosis.

The risk group includes a list of patients with early or late onset of menstruation, late onset of menopause and disrupted menstrual cycle. A mass formation of the left ovary, like the right one, can lead to a decrease in reproductive functions and the inability to conceive and bear a child. Chronic diseases of the pelvic organs can complicate the situation. In recent years, scientists have paid special attention to the study of genetic and epidemiological factors that influence the formation of the ovary. According to the data obtained, this pathology is significantly influenced by a woman’s habits and lifestyle, the environment, and the quality of food and water.

Types of neoplasms

Most often, pathological processes in the appendages are a cyst of one type or another. However, if a mass is found on the ovary, but not a regular cyst, it could be a wide range of different diseases. They are usually divided into several groups, which combine pathologies of a benign, malignant or borderline nature. There are the following types of neoplasms in the appendages:

• sex cord stromal tumors;
• epithelial neoplasms;
• germinal;
• rarely forming tumors;
• tumor processes.

According to statistical data, most often patients experience:

1. Tumor pathologies of the stroma and surface epithelium. These include simple serous, papillary and papillary-serous cystadenomas, as well as mucinous (pseudomucinous cystadenomas) and endometrioid neoplasms (Brennen tumor and carcinomas).
2. Stromal neoplasms and sex cord tumors. This category includes granulosastromal cell pathologies such as granulosa cell diseases, fibromas and thecomas, and androblastomas.
3. Neoplasms of the germ cell type, such as teratomas.

This is just a small list of tumor pathologies that are encountered in modern gynecological practice. Each of these varieties can be benign or malignant. There are also borderline stages of the disease, when the formed pathological body is characterized by potentially low malignancy.

Benign neoplasms

Most often, ovarian formation is benign in nature and is characterized by cellular growth. The largest percentage falls on epithelial neoplasms on the ovary. Such pathologies are also called cystadenomas or cystomas. They are formed due to the growth of the outer shell of the appendages. These include the following types of cystadenomas:

• mucinous;
• papillary;
• endometrioid;
• serous.

Cyst and cystoma are pathologies that are often confused. Such fluid formations are most often asymptomatic, however, some types of them cause constant nagging pain in the lower abdomen and enlargement of the abdominal cavity. Similar sensations are caused by mucinous cystadenoma of a solid structure. The cavity of such a tumor quickly fills with a thick mucous substance and reaches a large size.

Note: Benign tumors also include oogenic tumors, which are formed from oocytes. The most complex neoplasm of this type is considered to be a teratoma, which is formed from an egg containing genetic material. Its interior may be filled with mature tissues and even rudimentary organs, including hair, fatty tissues, and the rudiments of bones and teeth. It is not a very voluminous formation of the ovary, but it is formed very rarely on both sides.

Another common benign pathology of the appendages is thecoma. It is formed from cells that produce estrogen and most often appears during the postmenopausal period. Although thecoma, due to the production of female hormones, increases libido, improves the appearance and well-being of women during menopause, it must be eliminated in time. Otherwise, hyperplasia and even endometrial cancer may develop.

Virilizing tumors are also benign. They are formed from elements of the appendages, which are similar in composition to the cells of the male gonads. As a result, the right or left ovary, it is presented with a solid structure. A woman with pathology is faced with virilization processes, including cessation of menstruation, atrophy of the mammary glands, enlargement of the clitoris and other male-type changes.

Brenner's tumor is quite rare. Such structures are small in size, so they are very difficult to detect using ultrasound. In most cases, they are diagnosed during surgery, the purpose of which is histological examination of the tissues of the appendages. A cyst is also considered benign. As a rule, it does not require treatment, however, if a solid ovarian tumor is detected, drug therapy or surgical treatment may be required. Rare diseases also include ovarian fibroma, which is formed from connective tissue. By its nature, it is a hormonally inactive thecoma. Most often, such fibromas occur during menopause. They have a respectable size and can grow up to 15 centimeters. This pathology is accompanied by disorders of the cycle and generative function. It is possible to develop fibroma and cyst in the same appendage.

Important! Almost any type of benign neoplasm in the ovary can eventually develop into a malignant tumor. Therefore, it is recommended to undergo regular examinations with a gynecologist and carefully monitor the development of any pathological phenomenon in the appendages.

Diagnostic methods

Both benign and malignant structures in the appendages often occur without any symptoms. To prevent complications or the formation of cancerous tumors, it is recommended to visit a doctor at least once a year. If neoplasms or discomfort in the lower abdomen are detected, disruptions in the menstrual cycle or other complaints arise, it is worth undergoing gynecological examinations once every period prescribed by a specialist. In most cases, ultrasound diagnostics is sufficient to diagnose tumor processes in the ovaries. Formations with different structures have different echogenicity. There are anechoic or hyperechoic structures. This may be an ordinary cyst or a dangerous neoplasm that requires treatment. If the doctor doubts the nature of the tumor, additional studies are prescribed.

Important! Transvaginal ultrasound is often combined with Doppler ultrasound, which makes it possible to distinguish a tumor from avascular cysts. Malignant bodies mainly have blood vessels, while benign bodies have only a cavity filled with fluid.

If necessary, the patient is prescribed magnetic resonance imaging or CT. Such methods make it possible to more accurately determine the nature of the formation in the ovary, make a diagnosis and determine the required volume of surgical treatment. Today, modern methods for detecting markers indicating the development of cancer cells are increasingly being used. Such tumor markers make it possible not only to identify already existing malignant processes, but also to determine in advance the likelihood of the degeneration of benign tissues into cancerous lesions.

2. DIAGNOSTICS

2.1. MORPHOLOGICAL AND CLINICAL PICTURE

2.1.1. MORPHOLOGICAL CLASSIFICATION

The morphological classification of ovarian tumors developed by WHO and the International Federation of Obstetricians and Gynecologists (FIGO) is presented in Table. 2. All ovarian tumors can be divided into epithelial (80-90%) and non-epithelial. In turn, nonepithelial tumors include stromal cell, lipid cell, germ cell tumors and gonadoblastoma. In addition, the ovaries are often the site of metastases of cancer of the gastrointestinal tract, breast, and uterus (secondary or metastatic tumors). A separate group consists of tumor-like formations of the ovaries, such as functional cysts (follicular and luteal), and inflammatory processes.

2.1.2. EPITHELIAL TUMORS

In the nomenclature of epithelial tumors, in addition to indicating the histotype (serous, mucinous, endometrioid, mesonephroid, Brenner tumor, mixed), the type of tumor is determined (benign, borderline - low-grade - and malignant).

At benign tumors, epithelial proliferation occurs without signs of atypia and destruction of the basement membrane. Benign epithelial tumors have the appearance of cystic smooth-walled formations (cystadenomas), the contents of which are determined by the histotype. The sizes of cysts, especially mucinous ones, sometimes reach large sizes, more than 20-30 cm. The age of patients can be different, but mostly about 40 years. In elderly and senile women, a rare Brenner tumor of fibroepithelial structure is detected.

At borderline tumor (low grade) epithelial proliferation is noted with the formation of papillary structures, the presence of cellular and nuclear atypia with high mitotic activity, but there is no invasion into the stroma.

The proportion of borderline tumors among ovarian malignancies ranges from 5% to 15%. The average age of women with borderline tumors is 40 years, which is 20 years younger than patients with ovarian carcinomas. Low-grade tumors, first described by Taylor in 1929, have a relatively benign course, being limited to the ovary only. However, it must be remembered that peritoneal implants may be found in 10%. Most borderline tumors are serous or mucinous histotypes. Serous borderline tumors quite often affect both ovaries, according to various sources, from 38 to 75%. Mucinous borderline tumors can reach significant sizes and are associated with pseudomyxoma peritonei. Borderline Brenner tumors and endometrioid tumors are extremely rare.

Malignant epithelial ovarian tumors (adenocarcinomas) characterized by histotype and degree of cellular differentiation. The histological type of ovarian carcinomas does not have such a significant prognostic value compared to the degree of cellular differentiation of the tumor, which is especially important for the early stages of the disease. Broders proposed to evaluate the degree of tumor differentiation by the proportion of poorly differentiated cells. Tumors with a content of poorly differentiated elements of no more than 25% are classified as high degree of differentiation (G1), medium degree (G2) - from 26 to 50%, low degree (G3) - from 51 to 75%, undifferentiated (G4) - from 76 to 100%. In disseminated ovarian cancer, the greatest prognostic significance is the degree of clinical spread of the tumor process, i.e., the stage of the disease (see section 1.3 and 3.2.1.1). The average age of ovarian cancer patients is 60 years.

In the early stage of the disease, benign, borderline and malignant epithelial tumors do not have pathognomonic symptoms. Clinical symptoms may include pain in the lower abdomen and lower back, dyspepsia or dysuria. When the cyst stem is twisted, acute pain occurs. Menstrual irregularities are relatively rare. These tumors do not have hormonal activity. Most patients with ovarian cancer (up to 70%) already have stages III or IV of the disease at the time of diagnosis. Complaints of general weakness, loss of appetite, abdominal enlargement due to ascites, hydrothorax appear with an already widespread malignant process.

2.1.3. NONEPITHELIAL TUMORS

Stromal cell (sex cord stromal tumors): granulosa cell, thecoma, fibroma, androblastoma, gynandroblastoma

Granulosa cell tumors are relatively rare and account for 2-5% of all ovarian tumors. The most likely source of development of these tumors is granulosis of the primordial ovarian follicles. Granulosa-like cells form various structures, including follicular, trabecular and diffuse (sarcomatoid). The cytoplasm of cells has a high lipid content. Tumors with a low degree of malignancy do not have signs of infiltrative growth and have a favorable clinical course. Malignant granulosa cell tumors contain a large number of polymorphic and anaplastic cells with pronounced mitotic activity and invasive tumor growth. Macroscopically, granulosa cell tumors are solid, cystic-solid formations, yellow in section; in malignant ones, numerous foci of necrosis with hemorrhagic contents can be observed. Granulosa cell tumors of the ovary are hormonally active. Depending on the age of the patient, the hormonal activity of the tumor manifests itself differently: in children (juvenile form), premature puberty is observed, and in women of childbearing age, menopause or metrorrhagia is observed. Some elderly patients look younger than their age. Manifestations of hyperestrogenism are expressed in the estrogenic type of colpocytological reaction, endometrial hyperplasia and even the development of endometrial cancer in postmenopause. In the malignant course of a granulosa cell tumor, the clinical manifestations of hormonal activity decrease due to a decrease in cell differentiation. Tumor relapses can occur 5-30 years after tumor removal, mainly in the area of ​​the serous integument of the abdominal organs and the omentum. Some researchers propose to determine the level of inhibin as a tumor marker of granulosa cell tumors (see tumor markers).

Tecoma - It is a lipid-rich stromal tumor that consists of cells resembling the theca cells of the inner lining of follicles. Macroscopically, thecomas have a solid structure, in a capsule. On the section, the tumor is yellowish-orange in color; with a malignant course, numerous foci of necrosis and hemorrhage are found. Thecomas, like granulosa cell tumors, belong to the group of estrogen-producing neoplasms. However, thecomas, unlike granulosa cell tumors, primarily affect older postmenopausal women.

Fibroids - benign tumors consisting of fibroblasts with varying degrees of maturity, producing abundant amounts of collagen. Macroscopically, the tumor has a dense fibrous structure, pearlescent color, in the capsule, there may be foci of calcification. Fibroids do not have hormonal activity and primarily affect older women, in whom the tumor may be accompanied by polyserositis (Meigs syndrome).

Androblastomas (Sertoli-Leydig tumors) belong to hormonally active tumors with an virilizing (virilizing) effect. The tumors consist of Sertoli-Leydig cells of varying degrees of maturity and repeat in an imperfect form the stages of development of testicular tissue. It is recommended to indicate the degree of morphological differentiation. Well-differentiated tumors of a tubular structure imitate an adenoma of the embryonic seminiferous tubules and are less common than other variants, having the least hormonal activity. In tumors of intermediate (transitional) differentiation, along with tubules, there are immature cells. The hormonal effect of these tumors can be either virilizing or mixed. In poorly differentiated androblastomas, there are no tubes; an abundance of spindle-shaped cells of a sarcomatous structure is observed. The virilization syndrome is most pronounced in this type of tumor. Macroscopically, tumors of a solid structure are up to 10 cm in diameter; on a section they are grayish-yellow or reddish-brown. Tumor nodes are usually solitary and unilateral, and the contralateral ovary is often atrophic. Androblastomas are less common than other stromal tumors and primarily affect young women 25-30 years old and children. Clinical manifestations of hormonal activity of androblastomas in typical cases consist of defeminization and masculinization. The disease usually begins with amenorrhea, followed by atrophy of the mammary glands, hypertrophy of the clitoris, and lack of libido. Later, the figure loses its feminine outline, and male-type hair growth is noted. Most androblastomas are benign, and after their removal, the female appearance of the patient is restored. Hypandroblastoma - a rare tumor in which the structures of androblastoma and granulosa cell tumor are represented.

Lnid cell tumors belong to the category of casuistry. The histogenesis of these tumors has not been established. Tumor cells resemble luteal cells and adrenal cortex cells. Tumors can be hormonally active with a virilizing effect.

Germ cell tumors. Unlike epithelial tumors, which develop from the coelomic epithelium, the origin of germ cell tumors is assumed to be from primary germ cells that migrate into the gonadal tubercle by the 6th week of embryogenesis. The frequency of germ cell tumors does not exceed 5% among malignant ovarian tumors. Patients with germ cell tumors are predominantly young and children. All tumors can be divided into three large groups: benign, mainly represented by dermoid cysts; malignant, arising from the elements of the dermoid cyst, and initially malignant germ cell tumors. Dermoid cysts, which make up 1/4-1/3 of all benign ovarian tumors, are more often detected in young women, but can affect children and older women. Malignant tumors developing from elements of a dermoid cyst are predominantly represented by squamous cell carcinoma, which accounts for 2-3% of ovarian carcinomas, and the age of patients is the same as for carcinomas (adenocarcinomas) developing from the integumentary epithelium of the ovaries. Primary malignant germ cell tumors, the proportion of which in the incidence of ovarian cancer ranges from 2% to 3%, are almost always detected in young women, reaching a peak age of 20 years. Germ cell tumors are not hormonally active. The main symptom of the disease is pain in the lower abdomen, often acute due to torsion of the affected ovary by a solid tumor; vaginal bleeding is much less common. Due to the manifestation of acute pain syndrome, germ cell malignant tumors, unlike adenocarcinomas, are detected mainly in stage I of the disease. Tumor markers for some malignant germ cell tumors are alpha-fetoprotein and human chorionic gonadotropin (see. tumor markers). Clinically important is the division of primary malignant germ cell tumors into dysgerminomas And nondysgerminomas, which, in turn, are divided into yolk sac tumors, embryonal carcinoma, choriocarcinoma, teratoma of varying degrees of maturity.

Among germ cell tumors, it predominates dysgerminoma. The tumor develops from germ cells that have not undergone differentiation. Its histological structure is similar testicular seminoma. The microscopic structure has a characteristic pattern resembling an “end pavement”, since the tumor consists of a uniform type of rounded light cells located diffusely. Macroscopically, the tumor has a solid structure, is located in a capsule, can reach large sizes, and is white on a section. The tumor does not have hormonal activity. Dysgerminomas are more benign than other germ cell tumors. Most patients with dysgerminomas have a localized tumor process affecting one ovary, but it is possible to affect both (up to 10%). The main route of metastasis by dysgerminomas is lymphogenous, in rare cases - hematogenous.

Other germ cell tumors. Non-dysgerminomas, with the exception of mature teratomas, are malignant tumors with a poor prognosis, in contrast to dysgerminomas. Alpha-fetoprotein (AFP) and human chorionic gonadotropin (CG) are nondysgermin tumor markers (see tumor markers).

Teratomas. Tumors develop from elements of one or all three germ layers (ecto-, meso- and endoderm). Mature (benign) teratomas histologically consist of mature tissue structures and organs of the embryo (skin, teeth, thyroid gland, intestinal tube, cartilage, etc.). Mature teratomas are divided into solid and cystic. Cystic mature teratomas include dermoid cysts, which include the epidermis and its appendages. Struma and carcinoid are identical to thyroid tissue and intestinal carcinoids. Malignant transformation of elements of a dermoid cyst is possible. Immature (malignant) teratomas contain immature embryonic structures of varying degrees of maturity (G1,2,3).

Gonadoblastomas belong to rare tumors. Histologically, the tumor resembles an embryonic testicle in the early stages of fetal development. Gonadobastoma is usually combined with dysgerminoma. Tumors have been described in girls and young women. Clinically, the tumor may manifest as precocious puberty or masculinization. Gonadoblastoma is classified as a malignant tumor due to possible early metastasis.

2.2. DIAGNOSTIC METHODS

As noted earlier, most ovarian tumors have an epithelial structure, benign and malignant variants of which do not give pathognomonic clinical symptoms at the initial stages of the disease. Pain occurs even when the cysts are quite large in size, and even in the presence of dissemination of metastases of malignant epithelial tumors (cancer) in the abdominal cavity, the clinical picture of the disease is blurred, expressed in “discomfort” from the gastrointestinal tract, an increase in abdominal volume due to ascites. Almost 70% of patients with ovarian cancer at the time of diagnosis have stages III or IV of the disease, while in patients with non-epithelial tumors (stromal cell, germ cell) in 70% of cases stage I of the disease is diagnosed. Unlike epithelial. ovarian tumors, germ cell tumors have a solid structure, so pain occurs in the initial stages of tumor development due to tension in the suspensory ligament or its torsion. Tumors developing from the sex cord stroma are hormone-producing, and the symptoms of the disease may be a manifestation of overproduction of estrogens or androgens. Granulosa cell tumors of the ovaries in premenarchal girls stimulate early puberty, in women of reproductive age they lead to amenorrhea, and in postmenopausal women they cause postmenopausal uterine bleeding. Androgenic ovarian tumors (Sertoli-Leydig tumors) are accompanied by virilization (see section 2.1.2).

Clinical recto-vaginal examination of the pelvis often allows identification of an ovarian neoplasm. Since the 1970s, the introduction of ultrasound technology has ushered in a new era in the diagnosis of ovarian tumors. Ultrasound examination of the pelvis has become a routine method in examining a woman with suspected ovarian tumor. For small tumors in the pelvis, transvaginal echography is most informative; for formations larger than 6-7 cm, the role of transabdominal echography increases. When ultrasound scanning of healthy women of reproductive age, the ovary has a heterogeneous structure with a developed follicular apparatus, up to 3-4 cm in cross section. An increase in the size of the ovaries in women of reproductive age can be caused by tumor-like formations, follicular or luteal cysts. The functional nature of these formations is evidenced by their spontaneous regression over several menstrual cycles or when oral contraceptives are prescribed for two to three months. In postmenopausal women, the ovaries have a homogeneous hypoechoic structure, and their size does not exceed 2 cm. Ultrasound examination of women of this age can identify small (from 1.5 to 3 cm) smooth-walled ovarian cysts. To exclude the malignancy of these cysts, it is recommended to determine the concentration of CA-125 in the blood; if its values ​​are normal, dynamic monitoring of elderly and senile patients is possible. In cases of elevated CA-125 levels, immediate surgical intervention is indicated. In young women, the tumor marker CA-125 is not so specific and its concentration may change throughout the menstrual cycle and in non-oncological diseases (see below tumor markers).

In the differential diagnosis of benign and malignant tumors, A. G. Vesnin et al. suggests taking into account a number of clinical and echographic signs. Cystadenomas (serous, mucinous), as a rule, occur only on one side and are small in size, but mucinous cysts can be gigantic and occupy the entire abdominal cavity. Cysts have thick smooth walls, a homogeneous echo-negative structure (in mucinous ones - with a hyperechoic suspension). Benign serous-papillary cysts are additionally characterized by single hyperechoic zones with clear contours in the capsule area, which corresponds to rough-papillary formations. Endometrioid cysts are often unilateral single-chamber formations with a capsule unevenly thickened due to parietal accumulations of blood clots; the contents of the cysts are of a heterogeneous structure with many echo-positive inclusions. When diagnosing endometriotic cysts, it is necessary to take into account the rather characteristic clinical picture of endometriosis.

Benign germ cell tumors are represented by mature teratomas, most often in the form of dermoid cysts. The echographic picture of the latter is represented by unilateral cysts with heterogeneous internal contents, which include fatty elements, calcifications, and bone tissue. A typical echographic criterion is the presence of the so-called. “bump”, which is a hyperechoic formation of a round shape. The remaining germ cell tumors (found predominantly in children) have a homogeneous hyperechoic structure due to the solid structure of the formation. If echo-negative inclusions are detected in them, indicating necrosis, one can think about the high malignancy of the tumor process.

Ovarian cancer (malignant epithelial tumors) in the early stages of the disease, namely IA and IB, is echographically a cystic formation with single papillary formations with unclear contours, while in stages 1C and II extensive papillary growths are already visualized with a violation of the integrity of the cyst capsule and A small amount of fluid (ascites) is detected in the retrouterine space. In the differential diagnosis of benignity and malignancy of a tumor process, a number of authors recommend studying blood flow in the tumor area using color Doppler sonography. According to Kurjak et al. , certain Doppler structures and a decrease in the resistance (less than 0.6) and pulsation (less than 1.0) indices may indicate the malignancy of the process. However, this section of the echographic diagnosis of ovarian tumors requires further clarification of the thresholds of its sensitivity and specificity.

Generalized stages of ovarian cancer (III and IV) are echographically characterized by the presence of an irregularly shaped tumor conglomerate of a cystic-solid structure with blurred boundaries and growths along the outer contour. Ascites is detected in 70-80% of cases. It is possible to establish tumor growth into the uterus, metastases in the tissue of the Douglas space in the form of solid hypoechoic nodes, damage to the greater omentum, regional lymph nodes, and peritoneum. Echographically, metastases in the liver have the appearance of single or multiple hypo- or isoechoic foci, surrounded by an anechoic rim; sizes vary from 0.5 to 10 cm or more; foci of necrosis are observed in the center of large nodes. The use of color Doppler imaging provides additional opportunities for detecting liver metastases. To do this, study the vascular pattern of the liver, evaluate the location of the vessels and their number per 1 cm. Two options for the ultrasound picture of metastases are described: hypervascular and hypovascular. It is much more difficult to diagnose small metastatic nodes (less than 0.5 cm) in the greater omentum and along the pelvic peritoneum, especially with intestinal loops swollen with gas and obesity [Z]. Detection of metastases in the retroperitoneal lymph nodes is also difficult due to the adhesive-infiltrative process. In table Figure 3 shows the echo-graphic parameters of ovarian cancer depending on the degree of spread of the tumor process.

When identifying echographic signs of malignancy of the tumor process in the ovaries and beyond, it is necessary to differentiate the primary and secondary lesions of the ovaries. Secondary (metastatic) ovarian tumors are characterized by bilateral involvement of solid tumors with clear bumpy contours, small sizes, not fused to the uterus, rarely accompanied by ascites. In table 4 presents echographic criteria for the differential diagnosis of primary and metastatic ovarian cancer.

The advantages of the ultrasound method in the diagnosis of ovarian tumors are its high information content (sensitivity, specificity and accuracy reach 80-90%), simplicity, speed, harmlessness, painlessness, the possibility of objective documentation and repeated use.

The next stage of in-depth diagnosis of malignant ovarian tumors can be called x-ray computed tomography in cases where echography does not provide a clear idea of ​​the extent of tumor damage. The method is based on mathematical processing of data on the absorption capacity of tissues in relation to X-rays with obtaining a transverse image of tissues, a “Pirogov slice”. Thanks to serial studies with high probability (sensitivity 80-85%), it is possible to detect metastases in the liver, greater omentum, intestinal mesentery, and retroperitoneal lymph nodes. However, differential diagnosis of tumor and purulent-inflammatory processes in the pelvis is often difficult. The negative side of the method is the high radiation exposure for the patient and the high cost of the study.

Magnetic resonance imaging is a more advanced method of radiodiagnosis for assessing the extent of spread of a malignant tumor process. The method is based on the selective absorption of electromagnetic radiation by various tissues. Unlike computed tomography, images can be obtained in various projections, which is important for detecting tumor growth into neighboring organs - the rectum, bladder. Another advantage of the method compared to computed tomography is lower radiation exposure, but the high cost of the equipment also remains a limitation to its use.

Great importance in the diagnosis of malignant ovarian tumors is given to the search tumor markers- specific biological substances produced by the tumor, which could be determined by biochemical or immunological methods. Currently, two groups of tumor markers are best known: oncofetal antigens (alpha-fetoprotein and human chorionic gonadotropin) and tumor-associated antigens (CA-125, CA-19-9 and CA-72-4).

Determination of oncofetal antigens (AFT and hCG) in the blood of young patients with tumor formations of a solid structure in the ovaries indicates the presence of a germ cell tumor. High levels of APT and hCG indicate a poor prognosis of the disease, most likely the presence of non-dysgerminomas. Determining the level of oncofetal antigens during treatment and after its completion makes it possible to judge the effectiveness of therapy. In recent years, reports have appeared on the importance of inhibin as a tumor marker for estrogen-producing granulosa cell tumors, which requires further study.

Of the tumor-associated antigens, CA-125 is the most studied. This tumor marker is a glycoprotein antigen produced by the cells of serous malignant ovarian tumors and detected using monoclonal antibodies. CA-125 is not strictly specific only for ovarian cancer; its level can be increased in liver cirrhosis, acute pancreatitis, endometriosis, uterine fibroids, and pregnancy. In young women, its concentration may also fluctuate during the menstrual cycle. However, the content of CA-125 above 35 U/ml is detected in almost 80% of patients with ovarian cancer: in 90% with advanced ovarian cancer and in 50% with early stages [b5]. This is much more common than in non-tumor pathological conditions (5-10%) or in healthy women (up to 1%). Therefore, CA-125 is the standard in examining a woman when tumor masses are detected in the pelvis, suspicious according to clinical and echographic studies for cancer. At the same time, the possibility of obtaining false-positive results among a healthy population of subjects does not allow the use of CA-125 as a tumor marker for screening programs for the early detection of ovarian cancer. Determining the level of CA-125 is of greatest importance in the dynamics of treatment for ovarian cancer and in further monitoring of patients to detect relapses of the disease.

The search for more sensitive and specific tumor markers for ovarian cancer continues. Macrophage colony-stimulating factor (M-CSF), measured in 70% of ovarian cancer patients, may be a complement to CA-125.

At the end of the examination of patients with suspected malignant ovarian tumor, an X-ray examination of the chest cavity is indicated to exclude metastatic pleurisy. X-ray or endoscopic examination of the gastrointestinal tract is recommended in the presence of appropriate symptoms to exclude gastric cancer with secondary damage to the ovaries or invasion of the rectosigmoid colon by an ovarian tumor.

All of the listed diagnostic methods may, with a greater or lesser degree of probability, indicate the benignity or malignancy of the tumor process. The final diagnosis can only be established through morphological examination. In the presence of ascites, smears from the sediment of centrifuged ascitic fluid obtained during laparocentesis or puncture of the posterior vaginal vault can be subjected to cytological examination. The detection of adenocarcinoma cells indicates a malignant process, but their absence does not exclude ovarian cancer. If doubts persist after an examination using the listed methods to make a final diagnosis, the question arises about the surgical procedure of laparoscopy or laparotomy.

2.3. SCREENING

Early diagnosis of ovarian cancer remains the main unresolved problem in gynecological oncology. Successful mass examinations of the population to identify early forms of cancer (screening) are aimed at reducing morbidity and mortality from them. Currently available diagnostic tests for ovarian cancer cannot be offered for routine screening programs. Any proposed screening aimed at identifying a malignant tumor must meet certain requirements proposed by WHO experts: 1) there must be a reliable screening test that registers the preclinical phase of the disease, 2) the development of the disease to the clinical phase must be long enough, 3) there must be opportunities for morphological verification of the disease, 4) examination methods must be acceptable to the population (available, sensitive and specific, should not cause complications), 4) a generally accepted strategy for treating identified patients is necessary, 5) treatment of the identified disease must be effective, 6) screening costs patients, including clarification of diagnosis and treatment, must be economically justified in relation to the overall costs of national health care.

Unfortunately, the proposed screening programs for detecting ovarian cancer do not meet most of the requirements formulated by WHO experts for routine screening in oncology. Firstly, the issues of the pathogenesis of the disease have not yet been resolved, namely, the issue of progression of a benign ovarian cyst into a borderline one, and that, in turn, into an invasive carcinoma remains unclear. Secondly, the proposed diagnostic tests are not strictly specific for detecting ovarian cancer, especially in the early stages, because they give a high percentage of false positive results. Thirdly, treatment tactics have not been definitively determined for varying degrees of tumor spread, and the results of treatment for ovarian cancer remain unsatisfactory.

The main of the three listed reasons why not a single screening option can be recommended for diagnosing ovarian cancer remains the lack of sensitivity and specificity of the three main diagnostic methods: palpation, vaginal ultrasound examination of the pelvis and determination of the concentration of CA-125 in the blood. Screening using these methods does not provide a definitive diagnosis, but helps identify patients at potentially high risk for ovarian cancer. If suspicion arises during screening, a surgical procedure, namely laparoscopy or laparotomy, is necessary to make a definitive diagnosis.

Although palpation (rectovaginal) remains a routine procedure in the diagnosis of ovarian cancer, it cannot be considered effective in modern screening programs to detect preclinical stages of the disease. The main emphasis in the proposed screenings is on determining the tumor marker and transvaginal ultrasound. At the same time, in addition to the case of ovarian cancer, an increase in the level of CA-125, as already noted, can be associated with cirrhosis, pancreatitis, endometriosis, uterine fibroids, and benign ovarian cysts. In a population-based study in Sweden, during an annual examination of 5550 women over 40 years of age, 175 had CA-125 elevations above 35 U/ml, which subsequently required dynamic determination of CA-125 once every 3 months. and transabdominal ultrasound examination once every 6 months. Six women were diagnosed with ovarian cancer. Transvaginal testing is more specific in screening for ovarian cancer, as evidenced by data from a study of 3,000 postmenopausal women in the United States. To reduce the number of false-positive results, simultaneous color Doppler testing continues to be studied to assess the status of ovarian blood flow, but the value of this method in large-scale screening remains unclear. In a population-based study in England, 22,000 volunteer women (excluding family history) participated in a screening test that included a CA-125 test followed by ultrasound if elevated above 30 U/mL. Women whose ovarian changes were detected by echography underwent laparotomy. 11 of them were diagnosed with ovarian cancer, but 8 patients already had stages III or IV of the disease. A meta-analysis of several uncontrolled screening programs involving more than 36,000 women showed that of the 29 cases of ovarian cancer detected by screening, only 12 patients had stage I. Despite the screening undertaken, for 17 patients with ovarian cancer, the prognosis of the disease will be extremely unfavorable, regardless of treatment methods. In the United States, the National Cancer Institute is currently conducting a prospective randomized trial comparing standard screening with annual CA-125 testing and transvaginal ultrasound to evaluate the effectiveness of screening for early detection of ovarian cancer. The study is planned for 10 years, examining 76,000 women aged 60 to 74 years. The European International Study, with its coordinating center in London, has planned a randomized trial that will compare the results of screening including transvaginal ultrasound followed by Doppler and CA-125 with standard clinical examination. The study will include 120,000 postmenopausal women.

Due to the lack of sensitivity and specificity of available methods for diagnosing ovarian cancer, WHO experts currently do not recommend screening the entire population until completion of prospective randomized studies due to its low effectiveness. The decision was made on the basis that frequently observed false-positive results lead to unnecessary, expensive examinations and laparotomies, which can cause complications even with a fatal outcome. The small number of patients identified with the disease in the early stages cannot outweigh the possible risk of complications and the cost of these screenings. An exception may be patients with hereditary familial syndrome. Research is currently underway in the UK into the optimal screening strategy for hereditary ovarian cancer. The 5-year study is planned to include 3000 women aged 25-64 years with a moderate risk of ovarian cancer (see Table 1), who are recommended to undergo annual screening with transvaginal ultrasound and CA-125 determination. In addition to the proposed screening program for women with a hereditary predisposition to ovarian cancer, prophylactic oophorectomy after childbearing or after age 35 is recommended in the United States for these patients. The role of oophorectomy in women at high risk of developing hereditary ovarian cancer in the prevention of the disease remains controversial, since in these women, even after oophorectomy, the risk of developing peritoneal carcinoma of extragonadal origin remains high.

Ovarian neoplasms occupy second or third place in the structure of oncological

diseases of the female genital organs, but the mortality rate from them comes first and is about 49%.

Ovarian tumors occur in all age groups, from early childhood to senile, but generally the incidence begins to increase after 40 years.

Women at risk include:

With impaired ovarian function;

With postmenopausal bleeding;

Those who have been under clinical care for a long time for pathology of the uterus and its appendages;

Those who have undergone surgery on the internal genital organs with preservation or resection of one or both ovaries;

Those operated on for cancer of the breast, gastrointestinal tract and thyroid gland;

With a burdened heredity.

According to the 1973 WHO histological classification, ovarian tumors are divided into the following main groups:

Epithelial tumors;

Tumors of the sex cord stroma of embryonic gonads;

Tumors of germ cells;

Metastatic tumors;

Other (rare) tumors.

Benign forms (together with borderline ones) make up approximately 80%, malignant - 20%.

There are features of the distribution of different types of benign neoplasms in women of different age groups (Fig. 1). If among patients under 20 years of age the most common tumor is germ cell tumor (70%), then in patients over 70 years of age epithelial tumors occur in 85% of cases.

Epithelial tumors represent the largest group and make up about 70% of all ovarian tumors. They develop from the surface (coelomic) epithelium covering the ovary and the underlying stroma, especially in the so-called inclusion cysts that arise in places of mesothelium regeneration after ovulation due to invagination of the epithelium into the stroma. Epithelial tumors include serous, mucinous and other rare ones. Each of these neoplasms can be benign, borderline or malignant.

Serous (cilioepithelial) cystadenomas make up 40% of all benign ovarian tumors, being the most common neoplasms in women 30-50 years old. Tumors are so named because the epithelium lining the tumor capsule produces serous fluid. If the inner surface of the cystadenoma is smooth, the tumor is called smooth-walled cystadenoma; in cases where there is proliferation on the inner or outer surface - papillary cystadenoma. In 10-12% of cases, these tumors are bilateral, sometimes they can be located intraligamentally, which limits their mobility. The size of tumors can range from 5 to 30 cm, but usually do not exceed 15 cm.

Sonographic signs of serous (smooth-walled) cystadenoma:

A mobile formation located above the uterus;

Regular round shape;

The outer contour is smooth and clear;

Capsule thickness from 1 to 8 mm;

The formation is single-chamber (can be multi-chamber);

The inner surface is clear and smooth;

The contents are anechoic;

Arterial blood flow with a resistance index (RI) >0.5 is recorded in the capsule, as well as in the septa.

An important feature of the ultrasound image of smooth-walled cystadenoma is its almost complete identity with the follicular ovarian cyst. However, unlike a follicular cyst, a smooth-walled cystadenoma can reach a larger size and does not disappear during dynamic observation for 2-3 months. As reported

V.N. Demidov et al., in a third of cases, the internal structure of smooth-walled cystadenomas contained a finely dispersed, shifting suspension. Color Doppler mapping in 80% of cases reveals vessels in the tumor capsule, the IR in which with pulsed wave Doppler is >0.5.

Papillary cystadenomas have intraluminal parietal single or multiple inclusions (papillary growths), which are also found on the outer surface. On echography, vegetations can vary in size: from 2 mm to almost completely occupying the tumor cavity (Fig. 2). The internal contents are anechoic, but in some cases, according to A.N. Strizhakova et al., an echogenic suspension is visualized, the presence of which the authors regarded as a manifestation of hemorrhage. According to the WHO classification, papillary cystadenomas are classified as borderline tumors, and their malignancy rate reaches 50%. With color-coded techniques, blood flow is determined primarily in papillary growths, as well as in the capsule of the formation, in 89.2-98.6% of cases (Fig. 3). In benign forms of tumors, IR >0.4, but in borderline forms it may be<0,4.

Mucinous cystadenoma

Mucinous cystadenomas most often occur between the ages of 50 and 60 years and account for 10 to 20% of benign ovarian tumors. The internal contents of these neoplasms are represented by mucin (pseudomucin), which is a mucus-like substance and can crystallize into grains. Unlike serous cystadenomas, mucinous cystadenomas tend to grow rapidly and often reach large sizes. In 85% of cases, the average diameter of these tumors exceeds 15 cm. In approximately 10% of cases, mucinous cystadenomas affect both ovaries.

Sonographic signs of mucinous cystadenoma:

The shape is regular, round-oval;

The outer contours are smooth or lumpy;

The formation is multi-chambered, with multiple septa of varying thickness;

Contents with an echogenic suspension that moves when the sensor moves;

The capsule is of varying thickness; blood flow with an IR >0.4 is recorded in it (as well as in the septa).

During ultrasound examination, the internal contents have pronounced polymorphism, which is associated with a large number of septa of different thicknesses, parietal growths and a suspension of mucin, which does not precipitate during prolonged immobility of the patient. Mucin is visualized in the form of echogenic inclusions of point, linear or irregular shape. Chambers within the same tumor may have a suspension of different echogenicity (Fig. 4). With jerky movements of the sensor, it moves into the cavity of the neoplasm.

With color Doppler, vessels are detected in the capsule and septa with a fairly high frequency (Fig. 5), and with Doppler, IR >0.4. When the tumor capsule ruptures and the abdominal cavity is seeded, peritoneal myxoma occurs, which has echographic signs similar to the maternal tumor, and in most cases is accompanied by ascites. Sensitization of the patient to mucin plays an important role in the development of peritoneal myxoma. The risk of malignant transformation of mucinous cystadenoma is up to 17%.

Endometrioid epithelial tumor

Endometrioid epithelial tumor arises from terminal cysts localized in the ovaries, or from endometrioid heterotopias, which are implants of endometrioid-like tissue, which, in turn, can lead to the formation of all tumors of the endometrioid group: adenoma, adenocarcinoma, malignant adenofibroma, stromal sarcoma and mesodermal mixed tumor . In most cases there is a malignant course. In approximately half of the cases, both ovaries are affected, in 25% there is a combination with endometrial cancer. Echographically, the tumor is represented by a cystic formation with papillary growths and a heterogeneous internal structure with the presence of zones of reduced and medium echogenicity due to hemorrhagic and (or) necrotic masses (Fig. 6).

Uroepithelial tumor

Uroepithelial tumor (Brenner tumor) is rare, the incidence is from 0.6 to 2.6%) among all ovarian neoplasms, occurs mainly in elderly women (average age 63 years), in most cases has a benign course, combined with hyperplasia and cancer endometrium. Brenner's tumor can be found as part of other epithelial neoplasms. Most often, one ovary is affected, the average size of the tumor is 5-10 cm. On echography, the shape is regular, round-oval, the contours are clear, uneven, the structure is solid or cystic-solid with inclusions of high echogenicity.

Superficial papilloma

Superficial papilloma is also a rare tumor and echographically represents an irregularly shaped formation with unclear contours, a heterogeneous structure due to alternating areas of high and low echogenicity, as well as cystic cavities with papillary growths (Fig. 7).

Mixed and unclassified epithelial tumors have a nonspecific echographic image in the form of formations with a heterogeneous solid or cystic-solid structure.

Ovarian cancer

Ovarian cancer in the vast majority of cases arises from preexisting benign or borderline epithelial tumors, and primary cancer accounts for 4-5%.

There are serous, papillary and mucinous cystadenocarcinoma, superficial papillary carcinoma, malignant cystadenofibroma and other morphological types. In Russia, ovarian cancer consistently ranks third after cancer of the body and cervix, while mortality from it ranks first and amounts to 49%, and the average five-year survival rate of patients does not exceed 20-28%. Ovarian cancer occurs in women of all age groups, but the peak incidence is observed between 60 and 70 years, and in Moscow - 50 and 60 years. In approximately 80% of cases, the diagnosis is made in stages I-III. Such late detection of cancer is associated with a long asymptomatic course and a lack of oncological alertness among doctors. A malignant tumor is characterized by rapid growth, early, extensive metastasis and invasion into neighboring organs.

FIGO classification of ovarian cancer (without substages)):

Stage I - the tumor is limited to the ovary (ovaries);

Stage II - spread to nearby organs (uterus, fallopian tubes, etc.);

Stage III - spread beyond the pelvis and (or) metastases to the retroperitoneal lymph nodes;

Stage IV - distant metastases.

It should be noted that, starting from stage I, the tumor can grow into the capsule, which leads to the development of ascites. The aggressiveness of the course and, therefore, the prognosis of the disease is also influenced by the degree of differentiation of the tumor: Grade I - highly differentiated; Grade II - moderately differentiated and Grade III - poorly differentiated.

Sonographic signs of ovarian cancer:

Multi-chamber (single-chamber) formation;

Contours are uneven (smooth), fuzzy (clear);

The structure is cystic, cystic-solid, solid;

Multiple septa of varying thickness with fragmentary thickenings;

Parietal growths;

The presence of fluid in the retrouterine space, early onset of ascites;

Rich vascularization of the solid component, septa and capsule.

From the above ultrasound signs it follows that ovarian cancer is an extremely polymorphic formation, which can have the appearance of a follicular cyst and a heterogeneous internal structure, including all kinds of components (Fig. 8, 9). However, the listed echographic symptoms correspond to late stages, when the prognosis for the patient’s life is unfavorable. Unfortunately, for the initial stages

There are no reliable echographic signs of the disease.

Considering the relevance of early diagnosis of ovarian cancer and the long-term absence of clinical signs, during ultrasound examination of the pelvic organs it is necessary to take into account minimal changes in the ovaries for subsequent in-depth examination in order to exclude malignant neoplasms.

Sonographic markers to suspect ovarian cancer:

Marked asymmetry in the size of the ovaries;

Partial disappearance of the contour of an enlarged ovary;

The presence of a formation characteristic of a follicle or retention cyst, of any size in postmenopausal women;

The appearance of pathological zones of hypervascularization in the ovary;

The presence of free fluid in the retrouterine space outside of ovulation or in postmenopausal women. If one of the listed signs is detected (Fig. 10), dynamic echographic observation is necessary for 1-2 months. If there are two or more signs, an urgent consultation with a gynecological oncologist is required. When diagnosing ovarian cancer or suspecting it, it is necessary to examine the mammary glands, abdominal organs, thyroid gland and, of course, lymph nodes. Sex cord stromal tumors are represented mainly by hormone-producing neoplasms. This group includes feminizing (granulosa cell, theca cell), masculinizing (androblastoma, etc.) tumors, as well as hormonally indifferent fibroma.

Tumors of the sex cord stroma of embryonic gonads

Granulosa cell tumor

Granulosa cell tumor (folliculoma) arises from granulosa cells of the follicle and from the remains of sex cord cells. It occurs in all age groups - from childhood to old age, but most often between the ages of 40 and 60 years. The average age for benign forms is 50 years, for malignant forms - 39 years. According to L.N. Vasilevskaya et al., malignant forms are observed in 4-25% of patients, according to Ya.V. Bokhman - 66%. The tumor is hormonally active and produces estrogens. In 50-85% of cases it is combined with hyperplastic processes of the endometrium (polyps, glandular-cystic and atypical hyperplasia) and in 25% - with endometrial cancer. There is also a frequent combination with uterine fibroids, internal endometriosis and serous cystadenomas. In the presence of a tumor in girls, premature puberty occurs; in young women, the development of a tumor is accompanied by temporary amenorrhea, which is replaced by acyclic bleeding and miscarriage. In postmenopause, uterine bleeding and psychophysiological “rejuvenation” occur. Malignant granulosa cell tumors are often bilateral, invade the capsule and are accompanied by a pronounced adhesive process. The tumor metastasizes to the greater omentum, uterus, fallopian tubes, bladder, and liver. If the tumor is malignant, the manifestations of hormonal activity decrease, which, according to Ya.V. Bokhman, is associated with a decrease in the differentiation of tumor cells during malignancy.

Sonographic signs of granulosa cell tumor nonspecific. The size of the formation is on average 10 cm. It has a lobulated solid structure with cystic inclusions of various sizes. There are also cystic variants that mimic serous cystadenomas. M.A. Chekalova et al. highlight the following echographic types:

1) cystic single-chamber with thin

and a thick capsule;

2) cystic-solid with large cavities;

3) solid-cystic with large and small cavities;

4) solid.

Doppler sonography reveals hypervascularization of the solid component, especially the central part, with a mosaic type of blood flow. RI is in the range of 0.36-0.59, which is on average 0.46.

The following help in making a diagnosis: combination with estrogen-dependent pathology of the endometrium and myometrium, absence of uterine involution in postmenopausal age, as well as clinical and anamnestic data.

Theca cell tumor

Theca cell tumor (thecoma) arises from the theca cells of the ovary, is an estrogen-producing tumor, accounts for 3.8% of all ovarian tumors, and mainly occurs in women over 50 years of age. The tumor is usually benign, malignancy is observed in 4-5% of cases. In any form, it can be accompanied by ascites, hydrothorax and anemia (Meigs triad), which disappear after tumor removal (Fig. 11). As a rule, the tumor is unilateral.

Sonographic signs are nonspecific, the structure is similar to a granulosa cell tumor, and there are also combinations with endometrial hyperplastic processes, uterine fibroids, and internal endometriosis. Dopplerography reveals multiple zones of vascularization in the central part of the tumor, a mosaic type of blood flow is noted, IR ranges from 0.39 to 0.52, with an average of 0.48.

Fibroma

Fibroma develops from the ovarian stroma, does not have hormonal activity, makes up about 7% of all ovarian tumors, and occurs mainly in postmenopause. As a rule, benign forms are found. Ascites and hydrothorax are often observed, which disappear after tumor removal. The tumor grows slowly and is often associated with uterine fibroids.

Sonographic signs are more specific for small tumor sizes. An ultrasound examination reveals a unilateral formation of a regular round-oval shape, with clear contours, a fairly homogeneous structure, high echogenicity, and can create an acoustic shadow (Fig. 12). With Doppler ultrasound, single vessels are detected no more often than in 14.3% of cases. As it grows, due to insufficient blood supply, dystrophic changes, hyalinosis, and necrosis occur in the fibroma, which leads to the formation of cystic cavities. Thus, the structure of the tumor becomes cystic-solid, and the acoustic shadow behind the fibroma disappears.

Fibromas are often part of tumors that have a complex histological structure: adenofibromas, cystadenofibromas, etc. In these cases, the neoplasm has a diverse structure, including both a cystic component and solid structures. As reported by V.N. Demidov and Yu.I. Lipatenkov, during Dopplerography of adenofibromas, blood flow is recorded in the solid component, and cystadenofibromas - in the septa in 42.9% of cases in the form of single color loci, and IR is in the range of 0.46-0.63 with an average value of 0.54.

Androblastoma.

Androblastoma (adenoblastoma, Sertoli and Leydig cell tumor, masculinoma) develops from elements of the male gonad, has androgenic activity, makes up 0.4-2.0% of ovarian tumors, is mainly observed at the age of 20-35 years, but also occurs in girls. More often the tumor is benign, but up to 30% of androblastomas in prepubertal age have a malignant course. The clinical course is characterized by the phenomena of defeminization and masculinization. Sonographic signs of androblastoma are nonspecific; ultrasound images are similar to estrogen-producing tumors. With Doppler ultrasound, these tumors are vascularized in 100% of cases, there are multiple color loci in the central part, IR 0.40-0.52, average IR value 0.45.

Germ cell tumors arise from elements of the undifferentiated gonad due to genetic disorders or developmental defects and are the most common (up to 73%) tumors in children and adolescents, 30% of them are malignant. Tumors of this group are often found in pregnant women. Among women of reproductive age, germ cell tumors are registered in 10-15% of all ovarian tumors. The group includes dysgerminoma and teratoma (mature and immature).

Dysgerminoma

Dysgerminoma is the most common malignant tumor among all malignant tumors of childhood and pregnancy. There are both tumors homogeneous in histological structure and tumors of mixed structure (with elements of other histological groups). Hormonal activity is not characteristic of dysgerminoma, however, if there is a mixed structure of the tumor (for example, in combination with chorocarcinoma), then an increase in human chorionic gonadotropin is observed. The tumor usually completely replaces the ovarian tissue, grows into the capsule and fuses with surrounding tissues and organs into a single conglomerate. Localization is often unilateral, but can also be bilateral. The tumor is usually fast-growing and reaches large sizes. The shape can be either oval or irregular. The contour of the formation is lumpy. Ultrasound examination reveals a solid formation, characterized by the presence of areas of high and medium echogenicity and high sound conductivity, which is comparable to liquid structures (Fig. 13). Literature data on the use of Doppler ultrasound are contradictory. According to some sources, only single color loci of venous blood flow are determined, according to others, in 100% of cases there is hypervascularization with a mosaic type of blood flow.

Teratomas

Teratomas are the most common of germ cell tumors. They are detected from a very young age and represent a group of tumors, very diverse in their constituent tissues, which originate from germ layers of varying degrees of differentiation. In cases where the tissues are highly differentiated, the neoplasms are called mature teratomas; in cases of low differentiation, they are called immature teratomas (teratoblastomas).

Mature teratomas(dermoid cyst, dermoid, mature cystic teratoma) make up 97% of all teratomas. The tumor is usually unilateral, mobile, slow-growing, single-chamber, its size ranges from 5 to 15 cm, but can reach 40 cm. There is a report of dynamic observation of a patient with a teratoma of one ovary, in whom after 7 months the size of the tumor doubled and a similar appearance appeared neoplasm in the other ovary. A mature teratoma is represented by a cystic formation with a fibrous capsule, with local thickening due to an intraluminal elevation called the dermoid (parenchymal or cephalic) tubercle, which is the source of growth of the internal contents of the tumor. The lumen of the neoplasm contains serous fluid, mucus, fat, hair, skin, teeth, bones, cartilage and nerve tissue. In rare cases, thyroid tissue (ovarian struma) and the rudiments of the intestinal tube are found. There are benign cystic teratomas, cystic teratomas with malignancy and solid teratomas. Pronounced morphological polymorphism, various combinations of liquid and solid components lead to different options for the echographic image of mature teratomas

There are three main types of ultrasonic structure.

1) Cystic form (actually dermoid cyst). Occurs in 47-60% of cases. The internal contents are an- and hypoechoic, which is characteristic of serous fluid or low-density fat. In the liquid contents there are point or linear hyperechoic inclusions, which can be hair or small lumps of fat. In some cases, a parietal intraluminal formation of low or high echogenicity is determined - a dermoid tubercle (Fig. 14).

2) Predominance of the dense component. Occurs in 20-43% of cases. In this case, the internal contents are represented by inclusions of various shapes and sizes, with clear or unclear contours, high echogenicity, up to the appearance of an acoustic shadow behind some fragments that are cartilage, bone tissue or teeth. The absorption effect of ultrasonic waves is not typical for hair, skin, adipose, nervous and thyroid tissue. Teratomas of this type of structure, as a rule, do not exceed 4 cm in diameter and are most often correctly diagnosed by ultrasound. This is partly facilitated by the preserved unchanged ovarian tissue, which is found along the periphery of the small tumor (Fig. 15).

3) Mixed structure. Occurs in 9-20% of cases. The tumor has a heterogeneous internal structure, which is characteristic of most ovarian tumors with the exception of serous ones (Fig. 16). It has been noted that this type of teratomas most often undergoes malignancy. Teratomas with a predominance of a dense component, as well as a mixed structure, in some cases are not visualized by ultrasound due to their acoustic identity with the surrounding tissues. This is also facilitated by their high mobility due to their long stalk. To identify such tumors, it is necessary to use both transvaginal (transrectal) and transabdominal types of scanning, the combined use of which can increase the diagnostic accuracy to 86.0-97.1%. Given the presence of a long stalk, teratomas are more likely than other neoplasms to undergo torsion. When using color Dopplerography, either complete avascularization of a mature teratoma or single color loci are noted, and with spectral Dopplerography, IR is determined within the range of 0.4-0.6.

Immature teratomas(teratoblastoma, embryonal teratoma, teratocarcinoma) make up 1.0-2.5% of all malignant ovarian tumors, occur in women 20-30 years old, are characterized by rapid growth and hematogenous metastasis, combined with ascites. Menstrual function is preserved in these tumors. Ultrasound examination reveals a formation of irregular shape, with an uneven and unclear contour, of a cystic-solid structure. When Dopplerography is performed, the tumor is hypervascularized mainly in the central parts, with a mosaic type of blood flow, IR below 0.4.

Metastatic (secondary) ovarian tumors range from 5 to 20% in relation to other malignant tumors; they arise as a result of metastasis of malignant neoplasms of various localizations by lymphogenous, hematogenous or implantation routes. Young women (under 40 years of age) are predominantly affected. Most often, metastasis to the ovaries occurs in breast cancer (about 50%), but it is also possible in tumors of the gastrointestinal tract, liver, gallbladder, thyroid gland, and internal genital organs. Metastatic tumors are accompanied by ascites in 70% of cases; they should be considered as stage IV cancer of spread. Metastatic neoplasms are characterized by bilateral damage to the ovaries.

Ultrasound examination in the early stages reveals an increase in size and a decrease in echogenicity of the ovaries, up to the absence of images of the follicular apparatus. As the tumor grows, which is morphologically identical to the tumor of the primary focus, the contours become lumpy, and the internal structure becomes heterogeneous, cystic-solid (Fig. 17).

M.A. Chekalova et al. identified some features of metastatic tumors with a primary focus in the mammary gland and gastrointestinal tract. Thus, according to the authors, breast cancer in 73% of cases affects both ovaries, breast cancer metastases are rarely large and are often detected in non-enlarged ovaries, while neoplasms from the gastrointestinal tract in 47% of cases have bilateral localization, and large metastases predominate (more than 10 cm in diameter). However, the authors note the limited value of echography in the diagnosis of metastatic tumors from the breast.

A solid ovarian mass is a benign or malignant tumor. To identify pathology, ultrasound of the pelvic organs and histological examination are performed.

Ultrasound image. Cystic-solid formation of the ovary. Click to enlarge

Features of formations in the pelvic area

Based on the ultrasound, it can be assumed that the patient has a solid ovarian tumor. Their features are listed below:

1. With incomplete torsion, the appendage itself appears as a solid neoplasm, which is caused by tissue edema.
2. Fibroma looks like a solid tumor that has reduced sound conductivity due to the volume of connective tissue.
3. Cystadenofibromas have a specific structure, which is due to the presence of areas with calcification in them.
4. Other foreign inclusions of the ovaries are metastases from oncological structures of the gastrointestinal tract, lymphomas.

Differential diagnosis of formations is carried out after micro- and macroscopic excision of the tumor. Based on their appearance, they are divided into mucinous and cystic. Dermoids stand apart.

Most often, a cystic-solid formation of the ovary is a Brenner tumor. Sometimes it has a heterogeneous structure. On a section, such a tumor is represented by numerous chambers, inside of which there is liquid or mucous exudate. The inner lining is smooth or strewn with papillary growths, loose.

Characteristics of neoplasms

Features of benign ovarian structures:

1. Cystadenomas are single-chamber formations with thin walls and a diameter of 5 to 20 cm. They contain yellowish exudate inside.
2. Cystic teratomas are up to 10 cm in size. They are filled with particles of body tissue.

Benign solid foreign inclusions of the ovaries are formed from connective tissue and are defined as dense, mobile, uneven formations. Occurs during menopause.

Features of malignant neoplasms:

1. Mucinous and serous cystadenocarcinoma. The tomogram reveals clear solid areas. This distinguishes such foreign inclusions from benign structures.
2. Papillary growths, areas of dead tissue are manifestations of the oncological process. If there are no obvious signs of cancer, then the diagnosis is confirmed/refuted based on histological examination of the material.

Differential diagnosis

Features of tumors:

1. When dense tumor-like inclusions are revealed during a gynecological examination, sometimes we are talking about undifferentiated adenocarcinomas.
2. Ovarian formations that produce female and male sex hormones (androblastoma), benign or low-grade malignant.

The following is taken into account:

1. Malignant solid inclusions are often metastatic adenocarcinomas.
2. If the patient has ascites, hydrothorax and benign fibroma, then this is called “Meigs Syndrome” (it is rare).

While maintaining the integrity of the ovary, formations do not manifest themselves until the abdomen enlarges due to ascites. Sometimes, against the background of changes in the size of the uterine appendages, cycle disruptions and sensations of pressure in the pelvic area occur, which is due to the involvement of the bladder and rectum in the pathological process.

True benign solid neoplasms of the ovaries (benign teratomas, etc.) do not resolve spontaneously. There is no clear answer as to whether they can precede oncology (scientists have not yet come to a general conclusion). Thus, the attending physician is required to pay close attention to tumors of the appendages.

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Tumors and tumor-like formations of the ovaries

Tumors and tumor-like formations of the ovaries are 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.

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.

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:
  • 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. Granulosastromal 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 is 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 is of greatest clinical importance 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) is 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 unilateral, 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 - potentially malignant serous tumor. 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 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 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.

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 one (the 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.

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).

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.

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Ultrasound diagnosis of ovarian tumors

Introduction

Currently, the most common method for diagnosing ovarian tumors is ultrasound.

In cases where a gynecological examination reveals one or another pathological formation in the pelvic cavity, the ultrasound doctor must resolve a number of issues: 1) visualize the palpable formation on echograms; 2) establish its nature (liquid or soft tissue); 3) accurately localize relative to the uterus, ovaries, and bladder; indicate the number and size of formations, as well as make an accurate description of the echographic characteristics of the object; 4) determine (or make an attempt to determine) the morphological nature of the pathological focus.

A number of physiological and pathological processes occurring in the ovaries are accompanied by an increase in their size: maturation of the follicle, the appearance of various cysts, the presence of endometriosis, inflammatory processes, benign and malignant tumors. In most cases, patients require surgical treatment. Clarification of the diagnosis before surgery is necessary to determine the scope of surgical intervention, the nature of preoperative preparation and the necessary qualifications of the surgeon.

Cysts represent the most common volumetric pathology of the ovaries and are retention formations that arise as a result of excessive accumulation of tissue fluid in the previous cavities. The development of cysts is observed mainly during reproductive age. In most cases, these are functional formations, the size of which does not exceed 4-5 cm. In the postmenopausal period, cysts occur in 15-17% of patients.

Tumors originating from the surface epithelium account for about 70% of all ovarian tumors. Among them, benign variants (serous and pseudomucinous) occur in 80% of patients. Benign ovarian tumors (excluding hormone-producing ones), regardless of their structure, have much in common in their clinical manifestations. The early stages of the disease are asymptomatic and even when the first symptoms appear, patients often do not consult a doctor, or the doctor does not recommend surgical treatment, preferring dynamic observation. Malignant ovarian tumors are detected in 20% of all neoplasms of the female reproductive system.

Early diagnosis of ovarian cancer is one of the main problems in gynecological oncology. Despite the variety of diagnostic methods used, about 80% of patients are admitted to specialized hospitals with advanced stages of the disease. This is determined by the peculiarities of the clinical course of ovarian cancer: the absence of symptoms of the disease in the early stages, late seeking medical help, as well as the lack of oncological alertness among general practitioners, therapists, and antenatal clinic doctors.

For several decades, ultrasound diagnostics has been successfully used to differentiate tumors of the uterus and appendages. A comparison of echography data and morphological studies indicates a high accuracy of identifying tumor-like formations of the ovaries and determining their internal structure. However, in a number of cases of benign neoplasms of the appendages, especially in pre- and postmenopausal patients, transvaginal echography does not allow differentiating the nature of tumor growth.

Ultrasound makes it possible to detect the presence and determine the structure of tumor-like formations of the ovaries in almost 100% of cases. However, the use of the gray scale as an independent method today is irrational, since it does not allow assessing the nature of tumor growth and identifying patients at risk.

Color Doppler mapping (abbreviated as CD) contributes to more accurate differentiation of malignant and benign ovarian tumors. The main achievement of CDK in the diagnosis of tumor processes is the visualization and assessment of the blood flow of newly formed tumor vessels, which have their own characteristic features. Color Doppler mapping allows preoperative, non-invasive assessment and differentiation of tumors by the degree of changes in their vascular wall, by location and number of vessels, being a unique measure for assessing the malignancy of ovarian tumors. The ability to differentiate benign and malignant ovarian formations using color Doppler mapping (CDC) is a promising direction in ultrasound diagnostics, and comparison of echography and Doppler ultrasound data leads to a real increase in the accuracy of diagnosing ovarian tumor formations.

Also in recent years, the diagnosis of ovarian tumors has become possible using magnetic resonance imaging (MRI) and computed tomography (CT) scanners.

This work examines in more detail the classifications and main characteristic ultrasound signs of ovarian tumors of various etiologies.

1. Ultrasound diagnosis of ovarian tumors

Ovarian neoplasms occupy second or third place in the structure of oncological

diseases of the female genital organs, but the mortality rate from them comes first and is about 49%.

Ovarian tumors occur in all age groups, from early childhood to senile, but generally the incidence begins to increase after 40 years.

Women at risk include:

with ovarian dysfunction;

with postmenopausal bleeding;

long-term follow-up for pathology of the uterus and its appendages;

who have undergone surgery on the internal genital organs with preservation or resection of one or both ovaries;

those operated on for cancer of the breast, gastrointestinal tract and thyroid gland;

with a burdened heredity.

According to the 1973 WHO histological classification, ovarian tumors are divided into the following main groups:

epithelial tumors;

tumors of the sex cord stroma of embryonic gonads;

tumors from germ cells;

metastatic tumors;

other (rare) tumors.

Benign forms (together with borderline ones) make up approximately 80%, malignant - 20%.

There are features of the distribution of different types of benign neoplasms in women of different age groups (Fig. 1). If among patients under 20 years of age the most common tumor is germ cell tumor (70%), then in patients over 70 years of age epithelial tumors occur in 85% of cases.

Epithelial tumors represent the largest group and account for about 70% of all ovarian tumors. They develop from the surface (coelomic) epithelium covering the ovary and the underlying stroma, especially in the so-called inclusion cysts that arise in places of mesothelium regeneration after ovulation due to invagination of the epithelium into the stroma. Epithelial tumors include serous, mucinous and other rare ones. Each of these neoplasms can be benign, borderline or malignant.

Serous (cilioepithelial) cystadenomas make up 40% of all benign ovarian tumors, being the most common neoplasms in women 30-50 years old. Tumors are so named because the epithelium lining the tumor capsule produces serous fluid. If the inner surface of the cystadenoma is smooth, the tumor is called smooth-walled cystadenoma; in cases where there is proliferation along the inner or outer surface - papillary cystadenoma. In 10-12% of cases, these tumors are bilateral, sometimes they can be located intraligamentally, which limits their mobility. The size of tumors can range from 5 to 30 cm, but usually do not exceed 15 cm.

Sonographic signs of serous (smooth-walled) cystadenoma:

A mobile formation located above the uterus;

regular round shape;

the outer contour is smooth and clear;

capsule thickness from 1 to 8 mm;

single-chamber formation (can be multi-chamber);

the inner surface is clear, smooth;

the contents are anechoic;

in the capsule, as well as in the septa, arterial blood flow is recorded with a resistance index (RI) >0.5.

An important feature of the ultrasound image of smooth-walled cystadenoma is its almost complete identity with the follicular ovarian cyst. However, unlike a follicular cyst, a smooth-walled cystadenoma can reach a larger size and does not disappear during dynamic observation for 2-3 months. As reported

V.N. Demidov et al., in a third of cases, the internal structure of smooth-walled cystadenomas contained a finely dispersed, shifting suspension. Color Doppler mapping in 80% of cases reveals vessels in the tumor capsule, the IR in which with pulsed wave Doppler is >0.5.

Papillary cystadenomas have intraluminal parietal single or multiple inclusions (papillary growths), which are also found on the outer surface. On echography, vegetations can vary in size: from 2 mm to almost completely occupying the tumor cavity (Fig. 2). The internal contents are anechoic, but in some cases, according to A.N. Strizhakova et al., an echogenic suspension is visualized, the presence of which the authors regarded as a manifestation of hemorrhage. According to the WHO classification, papillary cystadenomas are classified as borderline tumors, and their malignancy rate reaches 50%. With color-coded techniques, blood flow is determined primarily in papillary growths, as well as in the capsule of the formation, in 89.2-98.6% of cases (Fig. 3). In benign forms of tumors, IR is >0.4, but in borderline forms it can be 0.4.

During ultrasound examination, the internal contents have pronounced polymorphism, which is associated with a large number of septa of different thicknesses, parietal growths and a suspension of mucin, which does not precipitate during prolonged immobility of the patient. Mucin is visualized in the form of echogenic inclusions of point, linear or irregular shape. Chambers within the same tumor may have a suspension of different echogenicity (Fig. 4). With jerky movements of the sensor, it moves into the cavity of the neoplasm.

With color Doppler, vessels are detected in the capsule and septa with a fairly high frequency (Fig. 5), and with Doppler, IR >0.4. When the tumor capsule ruptures and the abdominal cavity is seeded, peritoneal myxoma occurs, which has echographic signs similar to the maternal tumor, and in most cases is accompanied by ascites. Sensitization of the patient to mucin plays an important role in the development of peritoneal myxoma. The risk of malignant transformation of mucinous cystadenoma is up to 17%.

Endometrioid epithelial tumor

Endometrioid epithelial tumor arises from terminal cysts localized in the ovaries, or from endometrioid heterotopias, which are implants of endometrioid-like tissue, which, in turn, can lead to the formation of all tumors of the endometrioid group: adenoma, adenocarcinoma, malignant adenofibroma, stromal sarcoma and mesodermal mixed tumor . In most cases there is a malignant course. In approximately half of the cases, both ovaries are affected, in 25% there is a combination with endometrial cancer. Echographically, the tumor is represented by a cystic formation with papillary growths and a heterogeneous internal structure with the presence of zones of reduced and medium echogenicity due to hemorrhagic and (or) necrotic masses (Fig. 6).

Uroepithelial tumor

Uroepithelial tumor (Brenner tumor) is rare, the incidence is from 0.6 to 2.6%) among all ovarian neoplasms, occurs mainly in elderly women (average age 63 years), in most cases has a benign course, combined with hyperplasia and cancer endometrium. Brenner's tumor can be found as part of other epithelial neoplasms. Most often, one ovary is affected, the average size of the tumor is 5-10 cm. On echography, the shape is regular, round-oval, the contours are clear, uneven, the structure is solid or cystic-solid with inclusions of high echogenicity.

Superficial papilloma

Superficial papilloma is also a rare tumor and echographically represents an irregularly shaped formation with unclear contours, a heterogeneous structure due to alternating areas of high and low echogenicity, as well as cystic cavities with papillary growths (Fig. 7).

Mixed and unclassified epithelial tumors have a nonspecific echographic image in the form of formations with a heterogeneous solid or cystic-solid structure.

Ovarian cancer

Ovarian cancer in the vast majority of cases arises from preexisting benign or borderline epithelial tumors, and primary cancer accounts for 4-5%.

There are serous, papillary and mucinous cystadenocarcinoma, superficial papillary carcinoma, malignant cystadenofibroma and other morphological types. In Russia, ovarian cancer consistently ranks third after cancer of the body and cervix, while mortality from it ranks first and amounts to 49%, and the average five-year survival rate of patients does not exceed 20-28%. Ovarian cancer occurs in women of all age groups, but the peak incidence is observed between 60 and 70 years, and in Moscow - 50 and 60 years. In approximately 80% of cases, the diagnosis is made in stages I-III. Such late detection of cancer is associated with a long asymptomatic course and a lack of oncological alertness among doctors. A malignant tumor is characterized by rapid growth, early, extensive metastasis and invasion into neighboring organs.

FIGO classification of ovarian cancer (without substages): stage - tumor is limited to the ovary (ovaries); stage - spread to nearby organs (uterus, fallopian tubes, etc.); stage - spread beyond the pelvis and (or) metastases in the retroperitoneal lymph nodes; stage - distant metastases.

It should be noted that, starting from stage I, the tumor can grow into the capsule, which leads to the development of ascites. The aggressiveness of the course and, therefore, the prognosis of the disease is also influenced by the degree of differentiation of the tumor: Grade I - highly differentiated; Grade II - moderately differentiated and Grade III - poorly differentiated.

Sonographic signs of ovarian cancer:

Multi-chamber (single-chamber) formation;

contours are uneven (smooth), fuzzy (clear);

the structure is cystic, cystic-solid, solid;

multiple septa of varying thickness with fragmentary thickenings;

wall growths;

the presence of fluid in the retrouterine space, early onset of ascites;

rich vascularization of the solid component, septa and capsule.

From the above ultrasound signs it follows that ovarian cancer is an extremely polymorphic formation, which can have the appearance of a follicular cyst and a heterogeneous internal structure, including all kinds of components (Fig. 8, 9). However, the listed echographic symptoms correspond to late stages, when the prognosis for the patient’s life is unfavorable. Unfortunately, for the initial stages

There are no reliable echographic signs of the disease.

Considering the relevance of early diagnosis of ovarian cancer and the long-term absence of clinical signs, during ultrasound examination of the pelvic organs it is necessary to take into account minimal changes in the ovaries for subsequent in-depth examination in order to exclude malignant neoplasms.

Sonographic markers to suspect ovarian cancer:

pronounced asymmetry in the size of the ovaries;

partial disappearance of the contour of an enlarged ovary;

the presence of a formation characteristic of a follicle or retention cyst, of any size in postmenopausal women;

the appearance of pathological zones of hypervascularization in the ovary;

the presence of free fluid in the retrouterine space outside of ovulation or in postmenopausal women. If one of the listed signs is detected (Fig. 10), dynamic echographic observation is necessary for 1-2 months. If there are two or more signs, an urgent consultation with a gynecological oncologist is required. When diagnosing ovarian cancer or suspecting it, it is necessary to examine the mammary glands, abdominal organs, thyroid gland and, of course, lymph nodes. Sex cord stromal tumors are represented mainly by hormone-producing neoplasms. This group includes feminizing (granulosa cell, theca cell), masculinizing (androblastoma, etc.) tumors, as well as hormonally indifferent fibroma.

Tumors of the sex cord stroma of embryonic gonads

Granulosa cell tumor

Granulosa cell tumor (folliculoma) arises from granulosa cells of the follicle and from the remains of sex cord cells. It occurs in all age groups - from childhood to old age, but most often between the ages of 40 and 60 years. The average age for benign forms is 50 years, for malignant forms - 39 years. According to L.N. Vasilevskaya et al., malignant forms are observed in 4-25% of patients, according to Ya.V. Bokhman - 66%. The tumor is hormonally active and produces estrogens. In 50-85% of cases it is combined with hyperplastic processes of the endometrium (polyps, glandular-cystic and atypical hyperplasia) and in 25% - with endometrial cancer. There is also a frequent combination with uterine fibroids, internal endometriosis and serous cystadenomas. In the presence of a tumor in girls, premature puberty occurs; in young women, the development of a tumor is accompanied by temporary amenorrhea, which is replaced by acyclic bleeding and miscarriage. In postmenopause, uterine bleeding and psychophysiological “rejuvenation” occur. Malignant granulosa cell tumors are often bilateral, invade the capsule and are accompanied by a pronounced adhesive process. The tumor metastasizes to the greater omentum, uterus, fallopian tubes, bladder, and liver. If the tumor is malignant, the manifestations of hormonal activity decrease, which, according to Ya.V. Bokhman, is associated with a decrease in the differentiation of tumor cells during malignancy.

Sonographic signs of granulosa cell tumor are nonspecific. The size of the formation is on average 10 cm. It has a lobulated solid structure with cystic inclusions of various sizes. There are also cystic variants that mimic serous cystadenomas. M.A. Chekalova et al. The following echographic types are distinguished:

) cystic single-chamber with thin

and a thick capsule;

) cystic-solid with large cavities;

) solid-cystic with large and small cavities;

) solid.

Doppler sonography reveals hypervascularization of the solid component, especially the central part, with a mosaic type of blood flow. RI is in the range of 0.36-0.59, which is on average 0.46.

The following help in making a diagnosis: combination with estrogen-dependent pathology of the endometrium and myometrium, absence of uterine involution in postmenopausal age, as well as clinical and anamnestic data.

Theca cell tumor

Theca cell tumor (thecoma) arises from the theca cells of the ovary, is an estrogen-producing tumor, accounts for 3.8% of all ovarian tumors, and mainly occurs in women over 50 years of age. The tumor is usually benign, malignancy is observed in 4-5% of cases. In any form, it can be accompanied by ascites, hydrothorax and anemia (Meigs triad), which disappear after tumor removal (Fig. 11). As a rule, the tumor is unilateral.

Sonographic signs are nonspecific, the structure is similar to a granulosa cell tumor, and there are also combinations with endometrial hyperplastic processes, uterine fibroids, and internal endometriosis. Dopplerography reveals multiple zones of vascularization in the central part of the tumor, a mosaic type of blood flow is noted, IR ranges from 0.39 to 0.52, with an average of 0.48.

Fibroma develops from the ovarian stroma, does not have hormonal activity, makes up about 7% of all ovarian tumors, and occurs mainly in postmenopause. As a rule, benign forms are found. Ascites and hydrothorax are often observed, which disappear after tumor removal. The tumor grows slowly and is often associated with uterine fibroids.

Sonographic signs are more specific for small tumor sizes. An ultrasound examination reveals a unilateral formation of a regular round-oval shape, with clear contours, a fairly homogeneous structure, high echogenicity, and can create an acoustic shadow (Fig. 12). With Doppler ultrasound, single vessels are detected no more often than in 14.3% of cases. As it grows, due to insufficient blood supply, dystrophic changes, hyalinosis, and necrosis occur in the fibroma, which leads to the formation of cystic cavities. Thus, the structure of the tumor becomes cystic-solid, and the acoustic shadow behind the fibroma disappears.

Fibromas are often part of tumors that have a complex histological structure: adenofibromas, cystadenofibromas, etc. In these cases, the neoplasm has a diverse structure, including both a cystic component and solid structures. As reported by V.N. Demidov and Yu.I. Lipatenkov, during Dopplerography of adenofibromas, blood flow is recorded in the solid component, and cystadenofibromas - in the septa in 42.9% of cases in the form of single color loci, and IR is in the range of 0.46-0.63 with an average value of 0.54.

Androblastoma.

Androblastoma (adenoblastoma, Sertoli and Leydig cell tumor, masculinoma) develops from elements of the male gonad, has androgenic activity, makes up 0.4-2.0% of ovarian tumors, is mainly observed at the age of 20-35 years, but also occurs in girls. More often the tumor is benign, but up to 30% of androblastomas in prepubertal age have a malignant course. The clinical course is characterized by the phenomena of defeminization and masculinization. Sonographic signs of androblastoma are nonspecific; ultrasound images are similar to estrogen-producing tumors. With Doppler ultrasound, these tumors are vascularized in 100% of cases, there are multiple color loci in the central part, IR 0.40-0.52, average IR value 0.45.

Germ cell tumors arise from elements of the undifferentiated gonad due to genetic disorders or developmental defects and are the most common (up to 73%) tumors in children and adolescents, 30% of them are malignant. Tumors of this group are often found in pregnant women. Among women of reproductive age, germ cell tumors are registered in 10-15% of all ovarian tumors. The group includes dysgerminoma and teratoma (mature and immature).

Dysgerminoma

Dysgerminoma is the most common malignant tumor among all malignant tumors of childhood and pregnancy. There are both tumors homogeneous in histological structure and tumors of mixed structure (with elements of other histological groups). Hormonal activity is not characteristic of dysgerminoma, however, if there is a mixed structure of the tumor (for example, in combination with chorocarcinoma), then an increase in human chorionic gonadotropin is observed. The tumor usually completely replaces the ovarian tissue, grows into the capsule and fuses with surrounding tissues and organs into a single conglomerate. Localization is often unilateral, but can also be bilateral. The tumor is usually fast-growing and reaches large sizes. The shape can be either oval or irregular. The contour of the formation is lumpy. Ultrasound examination reveals a solid formation, characterized by the presence of areas of high and medium echogenicity and high sound conductivity, which is comparable to liquid structures (Fig. 13). Literature data on the use of Doppler ultrasound are contradictory. According to some sources, only single color loci of venous blood flow are determined, according to others, in 100% of cases there is hypervascularization with a mosaic type of blood flow.

Teratomas

Teratomas are the most common of germ cell tumors. They are detected from a very young age and represent a group of tumors, very diverse in their constituent tissues, which originate from germ layers of varying degrees of differentiation. In cases where the tissues are highly differentiated, the neoplasms are called mature teratomas; in cases of low differentiation, they are called immature teratomas (teratoblastomas).

Mature teratomas (dermoid cyst, dermoid, mature cystic teratoma) make up 97% of all teratomas. The tumor is usually unilateral, mobile, slow-growing, single-chamber, its size ranges from 5 to 15 cm, but can reach 40 cm. There is a report of dynamic observation of a patient with a teratoma of one ovary, in whom after 7 months the size of the tumor doubled and a similar appearance appeared neoplasm in the other ovary. A mature teratoma is represented by a cystic formation with a fibrous capsule, with local thickening due to an intraluminal elevation called the dermoid (parenchymal or cephalic) tubercle, which is the source of growth of the internal contents of the tumor. The lumen of the neoplasm contains serous fluid, mucus, fat, hair, skin, teeth, bones, cartilage and nerve tissue. In rare cases, thyroid tissue (ovarian struma) and the rudiments of the intestinal tube are found. There are benign cystic teratomas, cystic teratomas with malignancy and solid teratomas. Pronounced morphological polymorphism, various combinations of liquid and solid components lead to different options for the echographic image of mature teratomas

There are three main types of ultrasonic structure.

1) Cystic form (actually dermoid cyst). Occurs in 47-60% of cases. The internal contents are an- and hypoechoic, which is characteristic of serous fluid or low-density fat. In the liquid contents there are point or linear hyperechoic inclusions, which can be hair or small lumps of fat. In some cases, a parietal intraluminal formation of low or high echogenicity is determined - a dermoid tubercle (Fig. 14).

) Predominance of the dense component. Occurs in 20-43% of cases. In this case, the internal contents are represented by inclusions of various shapes and sizes, with clear or unclear contours, high echogenicity, up to the appearance of an acoustic shadow behind some fragments that are cartilage, bone tissue or teeth. The absorption effect of ultrasonic waves is not typical for hair, skin, adipose, nervous and thyroid tissue. Teratomas of this type of structure, as a rule, do not exceed 4 cm in diameter and are most often correctly diagnosed by ultrasound. This is partly facilitated by the preserved unchanged ovarian tissue, which is found along the periphery of the small tumor (Fig. 15).

) Mixed structure. Occurs in 9-20% of cases. The tumor has a heterogeneous internal structure, which is characteristic of most ovarian tumors with the exception of serous ones (Fig. 16). It has been noted that this type of teratomas most often undergoes malignancy. Teratomas with a predominance of a dense component, as well as a mixed structure, in some cases are not visualized by ultrasound due to their acoustic identity with the surrounding tissues. This is also facilitated by their high mobility due to their long stalk. To identify such tumors, it is necessary to use both transvaginal (transrectal) and transabdominal types of scanning, the combined use of which can increase the diagnostic accuracy to 86.0-97.1%. Given the presence of a long stalk, teratomas are more likely than other neoplasms to undergo torsion. When using color Dopplerography, either complete avascularization of a mature teratoma or single color loci are noted, and with spectral Dopplerography, IR is determined within the range of 0.4-0.6.

Immature teratomas (teratoblastoma, embryonal teratoma, teratocarcinoma) make up 1.0-2.5% of all malignant ovarian tumors, occur in women 20-30 years old, are characterized by rapid growth and hematogenous metastasis, and are combined with ascites. Menstrual function is preserved in these tumors. Ultrasound examination reveals a formation of irregular shape, with an uneven and unclear contour, of a cystic-solid structure. When Dopplerography is performed, the tumor is hypervascularized mainly in the central parts, with a mosaic type of blood flow, IR below 0.4.

Metastatic (secondary) ovarian tumors account for 5 to 20% in relation to other malignant tumors; they arise as a result of metastasis of malignant neoplasms of various localizations by lymphogenous, hematogenous or implantation routes. Young women (under 40 years of age) are predominantly affected. Most often, metastasis to the ovaries occurs in breast cancer (about 50%), but it is also possible in tumors of the gastrointestinal tract, liver, gallbladder, thyroid gland, and internal genital organs. Metastatic tumors are accompanied by ascites in 70% of cases; they should be considered as stage IV cancer of spread. Metastatic neoplasms are characterized by bilateral damage to the ovaries.

Ultrasound examination in the early stages reveals an increase in size and a decrease in echogenicity of the ovaries, up to the absence of images of the follicular apparatus. As the tumor grows, which is morphologically identical to the tumor of the primary focus, the contours become lumpy, and the internal structure becomes heterogeneous, cystic-solid (Fig. 17).

M.A. Chekalova et al. identified some features of metastatic tumors with a primary focus in the mammary gland and gastrointestinal tract. Thus, according to the authors, breast cancer in 73% of cases affects both ovaries, breast cancer metastases are rarely large and are often detected in non-enlarged ovaries, while neoplasms from the gastrointestinal tract in 47% of cases have bilateral localization, and large metastases predominate (more than 10 cm in diameter). However, the authors note the limited value of echography in the diagnosis of metastatic tumors from the breast.

2. Principles of differential diagnosis of tumors and tumor-like processes of the ovaries

ovary cyst ultrasound

The lack of oncological alertness of ultrasound diagnostic doctors, the polymorphism of the echographic image of tumors and tumor-like processes of the ovaries and the lack of reliable signs of malignancy of tumors in the early stages make it extremely difficult to differentiate the benign and malignant course of the disease. Considering the absence of specific echo-graphic signs of most ovarian tumors, the ultrasound diagnostician should first of all set himself the task of identifying not the morphological affiliation of the ovarian mass, but the group of diseases to which this mass may belong:

retention cysts;

inflammatory tubo-ovarian formations;

disrupted ectopic pregnancy;

The tactics of patient management depend on identifying membership in these groups.

Differential diagnostic echo-graphic signs of tumor-like processes of the uterine appendages and ovarian tumors are presented in Table. 1.

Table 1. Differential diagnostic echographic signs of tumor-like processes of the uterine appendages and ovarian tumors - true ovarian tumors

Signs Retention cyst Inflammatory formation Tubo-ovarian formation Disturbed ectopic pregnancy True ovarian tumor Patient age Up to 40 years Up to 40 years Up to 40 years Over 40 years Size of formation Up to 70 mm Up to 70 mm Up to 50 mm Over 50 mm Contour Clear, smooth Fuzzy, uneven Fuzzy, uneven Clear, smooth Wall thickness ( capsules) Thin (thickened) Uneven Not determined Various Number of chambers Single-chamber Multi-chamber Pseudo-multi-chamber Multi-chamber Echogenicity Low Mixed Mixed Structure Homogeneous Heterogeneous Heterogeneous Heterogeneous Free fluid in the abdominal cavity Absent Available Available Available Type of vascularization on Doppler ultrasound Only Peripheral Mixed Mixed Mixed Pain during examination Absent Available Available Available Absent

None of the listed signs should be taken as absolute, since in each of the positions there are exceptions characteristic of both the specific morphological structure of the disease, the course of the pathological process, and the individual characteristics of the patient.

Unilocular serous cystadenoma (especially small ones) should be differentiated from a follicular cyst. In serous cystadenoma, the capsule is thicker than the wall of a follicular cyst, and during dynamic observation after 1-2 months, tumor regression is not observed. The absence of menstrual irregularities can also help in diagnosis.

The cystic form of mature teratoma is differentiated from a non-ovulated follicle, follicular and endometrioid cyst. Teratoma has a thicker capsule than follicle derivatives, and the final diagnosis is made during follow-up. Doubling the contour of the wall of an endometrioid cyst, its heterogeneity, as well as a non-displaceable fine suspension can help in differentiation from a mature teratoma. In addition, the suspension in a teratoma often has the appearance of small streaks, which is not found in endometriomas.

The cystic form of mature teratoma differs from hydrosalpinx primarily in its shape and location. The tumor is characterized by a regular, round shape and high mobility. The tumor is often found at or even above the fundus of the uterus. The fallopian tube has an irregular, tube-like shape and is located along the posterolateral surface of the uterus, descending into the retrouterine space.

Multilocular cystic tumors can mimic thecallutein cysts. The shape of cystic tumor cavities is irregular, unlike retention cysts. In addition, theca lutein cysts are always a two-way process. If there is ascites, then pay attention to the absent or reduced mobility of intestinal loops, characteristic of a tumor process, while with hyperstimulation syndrome, intestinal loops move freely in ascitic fluid. Information about taking medications that stimulate folliculogenesis is of great importance. The diagnosis helps by excluding signs of trophoblastic disease; in doubtful cases, human chorionic gonadotropin is determined.

A mature teratoma with a predominance of a dense component giving an acoustic shadow is differentiated from a foreign body in the pelvis, as well as from fecal stones. The absence of a history of surgical interventions on the abdominal and pelvic organs makes it possible to diagnose a tumor. In cases where a fecal stone is suspected, it is advisable to re-examine after bowel movement and taking drugs that reduce flatulence (Espumizan, activated carbon).

All tumors of a cystic-solid structure must be differentiated from a corpus luteum cyst, a tubo-ovarian formation of inflammatory origin, and a disturbed ectopic pregnancy. Color Dopplerography of the internal contents, which are vascularized in a tumor, while in a corpus luteum cyst it is always avascular, helps to distinguish a tumor from a corpus luteum cyst.

When conducting an ultrasound examination, you should pay attention to the pain caused by pressing on the anterior abdominal wall or when bringing the transvaginal sensor to the object being examined, as this helps to exclude the inflammatory genesis of the adnexal formation or a disturbed ectopic pregnancy. In addition, with an ovarian tumor, a clear contour of the formation is often preserved, in contrast to inflammation of the appendages or hematoma that occurs as a result of a ruptured tube or tubal miscarriage. Additional signs will be detected symptoms of endometritis or decidual reaction of the endometrium. A laboratory test of blood, a smear from the vagina and cervical canal, as well as a determination of human chorionic gonadotropin are required. The absence of appropriate changes allows us to exclude the inflammatory process and impaired tubal pregnancy.

Differential diagnosis of fibroids is carried out with subserous uterine fibroids, in which an intact ovary is determined, which can be difficult to detect in postmenopausal women. In these cases, it is possible to apply the technique of simulating a two-handed examination, when it is possible to retract the tumor to a distance sufficient to adequately assess the external contour of the uterus and exclude the presence of a node emanating from the myometrium.

Tumors of a cystic-solid structure have to be differentiated from uterine fibroids, which have malnutrition and, as a consequence, degenerative changes (cystic cavities) in the node, which is helped by visualization of both ovaries.

The second stage of the work of an ultrasound physician in the differential diagnosis of ovarian tumors is not an assessment of the morphological affiliation of the formation, but an attempt to distinguish between benign and malignant processes, the main echographic criteria of which are presented in Table. 2.

Table 2. Differential diagnostic echographic signs of benign and malignant ovarian tumors

Signs Benign tumor Malignant tumor Age of the patient Up to 60 years Over 60 years Localization Unilateral Often bilateral Tumor size Up to 15 cm Over 15 cm Contour Clear, even Fuzzy, uneven Capsule thickness Up to 5 mm Over 5 mm Thickness of septa Uniform Uneven Papillary growths Rarely Often Movable MobilityImmobileFree fluid in the abdominal cavityNoYesYes

The degree of severity of the listed signs largely depends on the size of the tumor and how long it has existed, therefore, numerous works carried out in our country and abroad are devoted to the use of Doppler ultrasound, with the help of which it is possible to assume the benign or malignant nature of ovarian tumors.

A feature of malignant growth is the phenomenon of neovascularization, in which

the tumor, under the influence of angiogenic factors, induces the growth of its capillaries, and the latter contribute to its growth. An essential characteristic of newly formed malignant tumor vessels is the lack of smooth muscle cells, which leads to low resistance to blood flow. Another feature of the structure of the vascular system of malignant neoplasms is multiple shunts, which contribute to the appearance of high rates of intratumoral blood flow. At the same time, benign tumors, the vessels of which have a smooth muscle component, are characterized by higher resistance of the vascular bed and lower blood flow rates. Thanks to this difference in the structure of intratumoral vessels, differential diagnosis of benign and malignant ovarian formations with Doppler sonography becomes possible. Visualization of vessels using color Doppler mapping is possible in 23-47% of cases with benign tumors and 95-98% of cases with malignant tumors. Arterial blood flow was recorded in 69% of cases with benign and 100% of cases with malignant tumors, and venous blood flow in 54 and 73% of cases, respectively. The use of power Doppler mapping increases the frequency of visualization of vessels mainly at the expense of venous ones. Currently, there is no encouraging data on the use of three-dimensional reconstruction techniques, including the vascular tree of the tumor, to clarify the nature of the tumor process. But if this technique is used with simultaneous intravenous administration of an ultrasound contrast agent, the results of differentiating benign and malignant processes are improved.

The tumor vascularization system is represented by many small, very thin vessels, abnormal in shape and location, randomly scattered within the tumor tissue. The blood flow in these vessels is characterized by extremely low vascular resistance, high speed and varied direction. The peculiarities of blood flow are due to the transformation of blood vessels into wide capillaries or sinusoids, devoid of smooth muscle, the presence of precapillary drainages and multiple arteriovenous anastomoses with very low vascular resistance, which provide high kinetic energy of blood flow and wide variability in its direction. As a result of numerous studies, it was revealed that the described type of blood circulation is a feature of primary malignant tumors of the uterus and ovaries, which confirms the hypothesis that all fast-growing malignant neoplasms produce their own vessels to ensure further growth.

Blood flow in benign tumors has a different character. The vessels involved in the vascularization of benign formations of the uterus and ovaries are a direct continuation of the terminal branches of the uterine and ovarian arteries. Doppler characteristics of blood flow in these vessels are the constant presence of a low diastolic component, low velocity and high values ​​of the resistance index. According to most authors, peripheral, with single vessels, tumor vascularization should be associated with benignity, and the presence of multiple vessels in the central part, on the septa and in papillary growths is a sign of malignancy.

Summarizing the data from domestic and foreign literature, when using Doppler ultrasound, the following differential diagnostic signs can be identified (Table 3).

Table 3. Differential diagnostic Doppler signs of benign and malignant ovarian tumors

Signs Benign tumor Malignant tumor Location of vessels Peripheral Central IR Above 0.4 Below 0.4 Average MAC value 15 cm/s 30 cm/s Average MAC value 5 cm/s 10 cm/s Variability of Doppler indices Values ​​are monotonic Significant variability Dependence of Doppler indices on tumor size Does not depend With tumor growth, MAC and MAC increase , IR decreases IR dependence on localization Does not depend Reduction on periphery to the center Dependence of Doppler indices on the degree of tumor differentiation Doesn't depend Increase in MAC and MBC, decrease in IR from Grade I to Grade III Dependence of Doppler indices on the patient's age Doesn't depend Not dependent Dependence of Doppler indices on the histological type of tumor Doesn't depend Not depends

For the most effective use of Doppler ultrasound for the purpose of differential diagnosis of benign and malignant ovarian tumors M.N. Bulanov offers a multilocus analysis of intratumoral blood flow with the identification of different types of color loci:

) MAC should only be assessed at the arterial locus with the highest rate in the tumor;

) IR - in the arterial locus with the minimum index value in the tumor;

) MBC - in the venous locus with maximum speed in the tumor.

Neglecting the above rules will easily lead to a diagnostic error.

For the differential diagnosis of benign and malignant ovarian tumors, the threshold values ​​should be considered: for MAC -19.0 cm/s; for MVS -5.0 cm/s; for IR - 0.44 (Fig. 18). With a relatively low diagnostic accuracy of the threshold values ​​of individual Doppler indicators for true ovarian tumors.

Thus, the main achievement of CDK in the diagnosis of tumor processes is the visualization and assessment of the blood flow of newly formed tumor vessels, which have their own characteristic features. The tumor vascularization system is represented by many small, very thin vessels, abnormal in shape and location, randomly scattered within the tumor tissue. The blood flow in these vessels is characterized by extremely low vascular resistance, high speed and varied direction. The peculiarities of blood flow are due to the transformation of blood vessels into wide capillaries or sinusoids, devoid of smooth muscle, the presence of precapillary drainages and multiple arteriovenous anastomoses with very low vascular resistance, which provide high kinetic energy of blood flow and wide variability in its direction.

Conclusion

In recognizing tumors, pelvic ultrasound is of particular importance, because The clinical picture of many diseases is identical, and the findings of a gynecological examination are nonspecific. In these conditions, it is ultrasound that is the basis of the diagnostic process, the results of which determine the fate of the patient. It should be taken into account that this area of ​​ultrasound diagnostics presents significant difficulties in terms of differentiation, when during one study the doctor must exclude the presence of normal variants, inflammatory changes, uterine tumors and, most importantly, carry out a differential diagnosis between different types of ovarian cysts and tumors. This places a huge responsibility on the specialist and dictates the expediency of identifying some general provisions, the understanding of which largely ensures the success of the diagnostic process.

List of sources

1. Adamyan L.V., Kulakov V.P., Murvatov K.D., Makarenko V.N. Spiral

computed tomography in gynecology. M.: Antidor, 2001. 288 p.

Atlas of Ultrasound in Obstetrics and Gynecology / Peter M. Dubile, Carol B. Benson; under general ed. V.E. Gazhonova. - M.: MEDpress-infor, 2011. 328 p.

Bokhman Y.V. Guide to gynecological oncology, St. Petersburg: Foliant, 2002. 542 p.

Bulanov M.N. Ultrasound diagnostics in gynecological practice. CD. M.,

Vishnevskaya E.E. Handbook of gynecological oncology. Minsk: Belarus, 1994. 432 p.

Gynecology from ten teachers / Ed. Camp della S, Monga E. / Trans. from English under

ed. Kulakova V.I.M.: MIA, 2003. 309 p.

Demidov V.N., Gus A.I., Adamyan L.V. Cysts of the uterine appendages and benign

Ovarian tumors: A practical guide. Issue II. M.: RAMS, 1999. 100 p.

Clinical guidelines for ultrasound diagnostics. T. 3 / Ed. Mitkova

V.V., Medvedeva M.V.M.: Vidar, 1997. 320 p.

Ultrasound diagnostics in gynecology. M.: Vidar, 1997. 184 p.

Medvedev M.V., Zykin B.P., Khokholin V.L., Struchkova N.Yu. Differential. Ultrasound diagnostics in gynecology. M: Vidar, 1997. 645 p.

Novikova E.G., Chissov V.I., Chulkova O.V. and others. Organ-preserving treatment in

oncogynecology. M.: Vidar, 2000. 112 p.

Oncogynecology: A guide for doctors. / Ed. Gilyazutdinova Z.Sh.,

Mikhailova M.K.M.: MEDpress-inform, 2002. 383 p.

Serov V.N., Kudryavtseva L.I. Benign tumors and tumor-like

ovarian formation. M.: Triada-X, 2001. 152 p.

Strizhakov A.N., Davydov A.I. Clinical transvaginal echography. M., 1994.

Khachkuruzov S.G. Ultrasound in gynecology. Symptoms, diagnostic difficulties and errors. Guide for doctors. ELBI-SPb. 2000. 661 p.

Today, the thyroid gland ranks second in frequency of diseases after diabetes. Moreover, there is an increase in its pathologies. This is especially felt in large industrial centers, where, as a rule, there is iodine deficiency, poor ecology, etc.

Nodulation in women occurs 4-8 times more often, this is due to frequent hormonal changes. But older patients over 55 years of age are most susceptible to nodule formation.

The most common reasons are:

• iodine deficiency, selenium deficiency; bad ecology; working with radiation sources to which the thyroid gland is highly responsive;
• eating disorders;
• stress;
• pathologies of the gland itself in the form of inflammation, injuries, tumors;
• chronic infections;
• hereditary predisposition;
• hypothermia and overheating;
• excessive insolation;
• radiation therapy to the head;
• psychostress;
• work in paint and varnish production;
• with solvents, heavy metals, etc.

Formation of nodes and cysts

For certain pathological reasons, some thyroid cells begin to produce increased amounts of colloid. Colloid is a viscous liquid that fills the follicles of the gland and contains the prototype of its hormones - the protein thyroglobulin.

At the same time, the follicle begins to stretch and grow, this part of the gland begins to grow, but the gland itself does not change. A node is just such an uneven increase in a certain area of ​​the gland; these are round formations that are formed from the tissues of the gland itself.

If the outflow of colloid into the blood is disrupted, it accumulates in the follicle and a cavity with liquid contents is formed - a cyst. Cystic formation often occurs with microhemorrhages, dystrophy and hyperplasia of the gland. Both the node and the cyst have a dense shell - a capsule.

Types of knot formations

All neoplasms of the thyroid gland are divided according to their course into benign and malignant; by quantity into single (solitary) and multiple. Solitary nodes are more dangerous than multiple small ones, as with diffuse goiter.

According to the activity of hormones: toxic and calm non-toxic. The appearance of nodes increases with age. Benign nodes account for 95% of cases. This suggests that when nodes are discovered in you, you do not need to immediately prepare for death. Based on the structure of nodules, they are divided into cystic (liquid), solid and mixed:

• if the cystic component occupies ≤10%, it is a solid node;
• if from 11 to 50% - mostly solid;
• predominantly cystic – the cystic component occupies from 51 to 90%;
• with purely cystic – cysticity more than 90%, truly cystic nodes are rare; they are always benign.

The larger the cyst, the softer it is. This is an anechoic formation. Solid and predominantly solid are more common.

Cystic-solid formation of the thyroid gland

This is an encapsulated cavity, and it is filled with cells of the gland itself; there is no liquid medium in it. In 90% of cases, such formation is also benign. But if the case is neglected and no treatment was carried out, such a formation often becomes dangerous in the prognosis.

In this case, the tumor does not degenerate into a malignant one. These 10% are diagnosed with malignancy from the very beginning. The structure of the solid-cystic node is represented by zones of anechoicity, with areas of degeneration or hemorrhage.

Cysts can be localized in different lobes, the isthmus, or on both sides. Bilateral involvement is rare. The right-sided cyst is large, occurs more often and is more complex in morphology.

A cyst of the left lobe is less common, it is smaller and simpler in structure. Isthmus cysts are particularly dangerous because they are more prone to malignancy than others. It gives compartment syndrome earlier than others.

According to the content, a colloid cyst occurs more often than others; follicular; cystadenoma and cancer.

• Colloid cyst of the thyroid gland is a consequence of non-toxic nodular goiter. With uniform growth of nodes, a diffuse goiter occurs. Colloid cysts require only observation without treatment.
• Follicular cyst or follicular adenoma - there are no cavities with colloid here. The structure is dense, with a capsule.
• Solid node - consists entirely of epithelial tissue. A mixed solid-cystic formation does not resolve or shrink. Often filled with blood. It is these tumors that are more likely than others to transform into cancer. Right-sided cysts are characterized by bulging eyes and pronounced irritability. Early stages have no symptoms.
• Cystadenoma - due to circulatory disorders, existing nodes are transformed into a cyst. Because of this, the tissue of the node becomes necrotic. This is where a cavity appears. This transformation is observed in 35% of cases. In this case, there is a decrease in function and hypothyroidism develops.

• Cystic ones are the safest and easiest to treat. They can not only grow, but also shrink and disappear. But doctors still refer the patient for TAB to determine safety.
• Solid ones are dangerous when neglected; they are almost always malignant. Their shell is hard, they do not change their shape and size, and do not disappear. They have tissue fragments inside and no liquid component. They can reach tens of cm in size.
• Cystic-solid formation (thyroid nodule + cyst) of the thyroid gland - it can appear at any age; contains both tissue and fluid.
• Solid - does not mean size, but content; the stress is on the first syllable.

Pathogenesis of the cyst

It occurs in 3 stages: first, the outflow of fluid is disrupted; colloid accumulation occurs; the walls of the follicle stretch and the cyst grows.

Cysts themselves do not disrupt the functioning of the gland; it is disrupted due to other diseases.

Symptoms of the development of thyroid nodules

At the initial stages of their existence, nodules and cysts in the thyroid gland do not manifest themselves in any way. Their surface is smooth, they are elastic and roll under your fingers. Adjacent tissues do not change.

The patient begins to visit doctors when the size of the node increases to 3 cm, and the opportunity for conservative therapy is already missed.

Subsequently, compartment syndrome begins to manifest itself. This includes: difficulty breathing, local pain, dysphagia, lump and sore throat, muffled voice.

When the process is malignant, lymph nodes grow. With a toxic node with hyperfunction, the symptoms are: emotional instability, exophthalmos, tachycardia, intolerance to heat, agitation, insomnia.

Symptoms of a cystic-solid node

Having difficulty swallowing; shortness of breath when walking; hoarseness of voice; pain is not necessary. The occurrence of such nodes in both lobes is equally likely; they are usually small in size - up to 1 cm. But, although rarely, large volumes can occur.

Complications of cysts and nodes

Cysts can become inflamed and fester. Then all the characteristic signs of inflammation and intoxication appear with fever, pain, lymphadenitis, pus, etc. Malignancy is another, but the most terrible complication.

Diagnostic measures

The following diagnostic methods are required:

1. Ultrasound of the thyroid gland is the main method for diagnosing thyroid diseases. The existing lesion, its size and structure are identified.
2. FNA helps determine the benignity and malignancy of neoplasms. The biopsy material is sent for histology. It has been noted that after a puncture and aspiration of the contents from the cyst, in half of the cases its walls collapse and stop accumulating fluid. With very small formations, performing FNA is difficult, so there are also additional research methods.
3. Blood test for hormones - T3, T4 and TSH.

Scintigraphy is a scan of the thyroid gland, which is carried out using radioactive isotopes of technetium and iodine. The method determines the level of hormone production in the node and healthy tissue. According to the scintigraphy method, all nodes are divided into 3 groups according to the ability to accumulate isotopes. The fact is that the accumulation of isotopes can be observed in the tissues of the node (TU) and neighboring healthy tissue (HT):

1. Warm node – TU=ZT. The node is functioning.
2. Hot node - TU is larger than ZT - the node operates autonomously.
3. Cold node – TU is distributed only in healthy tissue. The node does not react to isotopes. One in 10 nodes is always cancer. Computed tomography – clarification of the size of the node and its malignancy.

Additional diagnostic methods:

1. Laryngoscopy – the larynx and vocal cords are assessed.
2. Bronchoscopy or fluoroscopy - examines the trachea.
3. Pneumography – determines the presence of nodule sprouting in the lung tissue. For the same purpose, angiography and fluoroscopy of the esophagus are performed.

Principles of treatment

If thyroid nodules and cysts are less than 10 mm in diameter, only monitoring is required. If the nodes and cysts are small and there are no disturbances in general health, the doctor will prescribe symptomatic remedies. TSH is monitored monthly, ultrasound is performed quarterly, and after a month of taking medications, the level of antibodies to the thyroid gland is determined.

If the size of the cyst is more than 10 cm, it is punctured; in case of benign nature of the formation, its inflammation and relapse, a repeated puncture is performed, fluid is suctioned and sclerosant (96-degree alcohol) is administered.

If a thyroid cyst suppurates, treatment will be antibacterial. If the tumor grows with compression syndrome or malignancy, surgical removal is indicated. This is also indicated when, after emptying, the cyst quickly gains fluid again (less than a week).

Surgery is also necessary when there is calcification of a node or cyst. In these cases, calcium salts contribute to the death of thyrocytes and their degeneration.

Another indication for surgery is that complications may occur after sclerosis of the cyst; the volume of formation is large and creates a cosmetic defect.

During surgery, the affected lobe of the thyroid gland is removed (hemistrumectomy), while the functionality of the gland is preserved.

If the entire gland is affected, subtotal removal is performed. Most of the gland is lost and the patient must receive hormone replacement therapy for life.

In addition, taking calcium supplements becomes mandatory because the parathyroid glands are removed during surgery.

During the operation, the removed tissue is examined for histology. In case of cancer, the operation becomes radical, i.e. All regional lymph nodes with fatty tissue are also removed - total strumectomy.

For cystic-solid formations, treatment is more complicated, because puncture can remove the liquid part of the cyst, but its tissue content remains and causes relapses. Therefore, if the node is more than 10 mm, the lesion is completely removed.

Prognosis and prevention

With a benign cyst, absolute recovery is possible, even with relapses. With a moderately malignant process without metastases, 7-8 out of 10 people are cured.

When a malignant tumor grows into neighboring tissues and metastases, the prognosis is unfavorable.

To prevent the appearance of nodes, the diet should be balanced, with sufficient amounts of vitamins and minerals.

If we are talking about iodine deficiency, its daily intake into the body should contain the norm. In addition, you should avoid walking in the sun with your neck exposed; physiotherapy for the neck area; irradiation.

Congenital anomalies, of course, will not disappear from this, but the risk of growths in a healthy person will be significantly lower.

Cystic-solid nodule is also mostly successfully treated. The type of treatment is determined by the size of the node. Nodules up to 1 cm are treated with tablets. For larger changes, puncture and subsequent resection of the node are performed.

Cystic-solid nodes can increase in number after 2-3 years. Or they may appear where they were not there before. Such cases require a special approach and solution.

If the formation is benign, restoring the function of the node becomes an important task. If the function is normal, only observation is carried out. In other cases, L-thyroxine is prescribed. Without restoring the functioning of the thyroid gland, the nodes may reappear. After all, nodes are essentially a compensatory reaction - an adaptive restructuring of gland tissue in response to hormone deficiency.