Liquid solid formation. Cystic ovarian formation: causes of pathology, methods of treatment

The ovaries (female gonads) are paired organs located on both sides of the uterus. The most complete morphological classification of ovarian tumors (that is, reflecting their microscopic structure) was developed by experts from the World Health Organization. It includes benign, borderline (low grade) and malignant neoplasms. Benign tumors, unlike malignant ones, do not go beyond the ovaries, so surgical treatment in most cases ensures recovery.

In this article, we will focus only on benign tumors and tumor-like formations of the ovaries. According to the above classification, they include:

I. Epithelial tumors:

1) serous

2) mucinous

3) endometrioid

4) clear cell (mesonephroid)

5) benign Brenner tumor

6) mixed epithelial

II. Sex cord stromal tumors (thecoma, fibroma, androblastoma)

III. Germinogenic tumors (dermoid cysts, ovarian struma)

IV. Tumor-like processes

1) single follicular cyst and corpus luteum cyst

2) multiple follicular cysts (polycystic ovaries)

3) multiple luteinized follicular cysts and (or) corpus luteum (tecalutein cysts)

4) endometriosis

5) superficial epithelial inclusion cysts (germinal inclusion cysts)

6) simple cysts

7) inflammatory processes

8) paraovarian cysts

9) luteoma of pregnancy

10) ovarian stroma hyperplasia and hyperthecosis

11) massive ovarian edema

True tumors (groups I, II, III) are similar to tumor-like processes (group IV) only in appearance, but differ significantly in origin and structure (morphology). Unlike tumors of other organs, ovarian neoplasms are characterized by considerable diversity. Perhaps this is due to the complex process of embryonic (intrauterine) development of the ovaries: they are formed from the derivatives of all three germ layers, from which all organs and tissues of the human body are laid and formed. Epithelial tumors develop from the epithelial cells that cover the outside of the ovaries. Sex cord stromal tumors and germ cell tumors have a more complex origin from cells of other tissues, embryonic remnants in the female gonad; their development occurs against the background of a violation of hormone metabolism.

Tumors of the ovaries are common. In gynecological hospitals, up to 12% of all abdominal operations are accounted for by them and the complications associated with them. If we consider all neoplasms of the female genital organs, then ovarian tumors occupy about 10-12%, of which 75-80% are benign. Of the latter, the most common are serous and mucinous cystadenomas and dermoid cysts (see below).

Characteristics of some benign ovarian tumors

Serous cystadenoma (syn. cilioepithelial cystoma), single-chamber (consists of one cavity) or multi-chamber (it includes several cavities), looks like a cyst, more often than one ovary, up to 20 cm in diameter, with a smooth outer and inner surface, but can have growths like papillae. The epithelial cells that form this tumor produce a serous fluid, clear or yellowish, that fills its cavity (or cavities). Other serous benign tumors of the ovaries include papillary cystadenoma (characterized by papillary growths), superficial papilloma (warty growths are located on the surface of the ovaries), as well as adenofibroma and cystadenofibroma (thick-walled cyst or very dense tumor without a cavity, like a fibroma, sometimes produces female sex hormones estrogen leading to hyperestrogenism).

Mucinous cystadenoma (syn. pseudomucinous cystoma) is usually multi-chamber, unilateral (in 10% of cases bilateral), has a smooth capsule; can reach very large sizes, up to 30 kg or more; contents - mucous liquid of a dense consistence. Mucinous adeno- and cystadenofibroma, unlike the previous tumor, resemble fibroma - a dense knot, inside of which are small or large cysts; occasionally their growth is accompanied by hyperestrogenism. Serous and mucinous benign ovarian tumors develop between the ages of 20 and 60 years with a peak incidence at 45-60 years of age.

Mixed epithelial tumors consist of cavities of serous and mucinous type, therefore they are often called dimorphic.

Endometrioid adenoma and cystadenoma are often bilateral tumors up to 10-20 cm in size with tarry contents. Usually observed in women 30-50 years old.

Endometrioid adenofibroma and cystadenofibroma are rare, resembling a fibroma with small cysts in appearance.

In the early stages, all of these tumors usually proceed without any manifestations. With serous tumors, symptoms appear earlier than with mucinous ones. As the tumor grows, there are pains in the lower abdomen, an increase in its volume, urination and defecation disorders. The last two symptoms are observed with large tumors due to compression of neighboring organs - the bladder and rectum. Ascites (fluid accumulation in the abdominal cavity) is rare; this symptom is more characteristic of malignant tumors. In pre- and postmenopause, uterine bleeding may be the first symptom, especially in the presence of hyperestrogenism. Brenner's tumor is asymptomatic, occurs after 45 years, usually affects one ovary (usually the left), turning it into a dense knot with cysts of various diameters; There are bloody discharge from the genital tract. This tumor is indistinguishable from a fibroma in appearance, an accurate diagnosis is made only on the basis of a histological examination. With ovarian fibroma, Meigs' syndrome is often observed: ascites (see above) and hydrothorax (fluid accumulation in the pleural cavity), anemia. Thecoma is a unilateral tumor from microscopic size up to 20-30 cm in diameter, dense consistency, yellow in section. Nine out of 10 patients with thecoma are postmenopausal, one is under the age of 30 years. In half of the cases, thecomas produce excessive amounts of estrogen, which causes the development of concomitant endometrial cancer or uterine fibroids. Benign androblastomas are more often observed at the age of 20-30 years in the form of unilateral dense tumors, with a diameter of 1 to 15 cm. The name of the tumor (androblastoma) emphasizes its ability to synthesize male sex hormones. Indeed, masculinizing androblastoma causes defeminization (loss or weakening of female secondary sexual characteristics), and then a viril syndrome (the appearance in a woman's body of male, androgen-dependent signs, that is, dependent on male sex hormones). However, there is also a feminizing androblastoma that produces female sex hormones estrogens, which leads to hyperestrogenism, manifested by hyperplasia of the endometrial glands, uterine bleeding, menstrual irregularities, growth of uterine fibroids and other pathological conditions. Dermoid cyst (syn. Mature teratoma) - the most common of germ cell tumors - usually unilateral (only 10% of cases affect both ovaries). The value may be different, but usually does not exceed 15 cm; contains mature tissues that are not related to the genitals - bones, cartilage, skin, teeth, hair, fat. The high fat content provides this tumor with greater mobility and, as a result, a high risk of torsion of its legs (see below). Dermoid cyst is formed in the period of embryonic development; further growth occurs under the influence of age-related changes and other unknown factors.

Unlike functional cysts (see below), all of the above tumors never spontaneously regress (that is, they do not disappear without treatment) or while taking oral contraceptives. The main method of their treatment remains surgical. The volume of the operation depends on the age of the patient, her desire to preserve the reproductive function, the nature of the tumor. At a young age, with benign ovarian tumors, they try to perform an organ-preserving operation - removal of the tumor while maintaining healthy ovarian tissue. If this fails, an oophorectomy (removal of the entire ovary) is performed. It should be remembered that the removal of the ovary along with the cyst increases the risk of infertility. Before surgery, it is necessary to check the condition of the uterus (ultrasound, diagnostic curettage) in order to exclude its pathology. In pre- and postmenopause, extirpation of the uterus with appendages is preferable, especially in the presence of concomitant uterine fibroids.

Complications of true benign ovarian tumors:

1) Malignant degeneration of a tumor, or the occurrence of cancer in it, or malignancy. This process does not depend on the size of the tumor. It was noted above that surgical treatment guarantees recovery in benign ovarian tumors. However, in general, untimely surgery for benign ovarian tumors causes a malignant process in the ovaries in about 30-50% of patients. The frequency of malignancy varies with various benign ovarian tumors. For example, it is higher in serous tumors than in mucinous ones. Malignant neoplasms grow into neighboring organs, their cells are able to spread through the lymphatic and blood vessels, which ends with the formation of metastases in the lymph nodes and distant organs. Therefore, chemotherapy is added to the surgical treatment of malignant ovarian tumors, less often irradiation of the pelvis or abdominal cavity, hormone and immunotherapy. The process of degeneration of benign ovarian tumors into malignant ones often occurs asymptomatically or is accompanied by a slight deterioration in the general condition. And only the late stages of ovarian cancer are accompanied by a decrease in appetite, an increase in the volume of the abdomen, discomfort in the abdomen, flatulence, a feeling of rapid satiety after eating, dyspepsia, malaise, frequent urination, difficult defecation, weight gain or loss. Therefore, early diagnosis of benign ovarian tumors is extremely important!

2) Capsule rupture. Benign ovarian tumors (most commonly dermoid cysts, cystadenomas, and endometrioid tumors) can rupture or microperforate and cause acute pain, bleeding, shock, and aseptic peritonitis (i.e., inflammation of the peritoneum caused by exposure to germ-free tumor contents). In such cases, urgent surgery is indicated. Aseptic peritonitis, especially with endometrioid and dermoid cysts, is a common cause of adhesions that increase the risk of infertility. In addition, when cystadenomas with papillae rupture, implantation (engraftment) of tumor elements along the peritoneum and their further growth can occur.

3) Tumor pedicle torsion(cysts, cystomas). The pedicle of the tumor is formed by stretched (due to volume formation) ligaments of the ovary (infundibulopelvic and own), as well as its mesentery (a section of the posterior leaf of the broad ligament of the uterus to which it is attached). Vessels supplying the tumor and nerves pass through the pedicle of the tumor. Torsion of the tumor stem occurs suddenly or gradually, usually after a change in body position, physical activity, it can be complete and partial. As a result of torsion, especially complete torsion, the nutrition of the tumor is disturbed, which is manifested by the clinic of an acute abdomen. Severe pains appear, the muscles of the anterior abdominal wall are tense; there may be nausea and vomiting, stool and gas retention. Against the background of pale skin, the temperature rises, the pulse quickens, and blood pressure decreases. An urgent operation is required. The delay in the operation leads to necrosis (necrosis) of the neoplasm, the addition of a secondary infection (through the blood and lymphatic vessels), which causes suppuration of the tumor. Peritonitis develops, the tumor is soldered to neighboring organs.

Risk factors for benign ovarian tumors include: genetic predisposition, early or late onset of menarche (first menstruation), menstrual dysfunction, infertility, early (before 45 years) or late (after 50 years) menopause, uterine fibroids, endometriosis, inflammation of the uterine appendages. The risk of epithelial ovarian tumors increases with age. Women with mucinous tumors are more likely to have comorbidities such as obesity, diabetes, and thyroid dysfunction.

Tumor-like lesions of the ovaries

Follicular cysts, corpus luteum cysts and thecalutein cysts are called functional because these tumor-like formations appear against the background of normal functioning of the ovaries (more often in adolescence and childbearing age) and are usually asymptomatic, may be an accidental finding during a gynecological examination. Less often, they are manifested by a violation of the menstrual cycle or sudden pain due to torsion of the leg or rupture of the formation, as evidenced by the picture of an acute abdomen (see above). The most common are follicular cysts, their diameter is not more than 8 cm. Cysts of the corpus luteum are less common. This diagnosis is valid if the diameter of the corpus luteum exceeds 3 cm. At smaller sizes, the formation is considered a variant of the true (menstrual) corpus luteum. When a cyst of the corpus luteum ruptures - ovarian apoplexy - intra-abdominal bleeding occurs (most often cysts of the right ovary rupture, usually on the 20-26th day of the menstrual cycle). If conservative methods used to stop bleeding are ineffective, surgery may be required. Follicular cysts and cysts of the corpus luteum usually disappear without treatment or while taking oral contraceptives. The patient or the girl's parents are warned about the possibility of torsion of the cyst leg. If the diagnosis is not in doubt (a malignant process in the ovaries is excluded) and the cyst has not undergone regression (it has not disappeared on its own), it is percutaneously (under ultrasound control) or laparoscopically punctured. The recurrence rate after such treatment is 50%. Thecalutein cysts are the rarest among functional ovarian cysts. Occur in 25% of patients with hydatidiform mole, 10% of patients with choriocarcinoma, during pregnancy, especially multiple, with diabetes mellitus, maternal and fetal incompatibility for antigens of the Rh system, induction (stimulation) of ovulation with hormonal drugs (clomiphene, human chorionic gonadotropin), as well as in women receiving gonadoliberin analogues. Thecalyutein cysts are more often bilateral, multi-chamber, can reach large sizes; usually disappear on their own after the cause or disease that caused their formation is eliminated. Often the ovaries are affected by endometriosis with the formation of endometrioid cysts, which are called "chocolate" because they contain a brown liquid. These cysts are up to 10 cm in diameter. They differ in origin from endometrioid tumors (see above), although they are difficult to distinguish externally.

Endometriosis (see article on our website) in adolescents and young women is one of the main causes of chronic pain in the lower abdomen, which increases during menstruation. Endometrioid cysts never resolve on their own and are subject to surgical treatment followed by hormonal therapy to prevent recurrence. If a woman plans to have children, an ovarian resection is performed, and the remaining endometrioid tissue is subjected to laser exposure (vaporization) or electrocoagulation.

Stromal ovarian hyperplasia is a non-tumor proliferation of ovarian tissue due to the multiplication of cells located in the stroma. Stroma is the skeleton, or basis of an organ, consisting of connective tissue cells with vessels and fibrous structures located in it, providing its supporting value. There is stromal ovarian hyperplasia at the age of 60-80 years, characterized by an excessive level of male sex hormones (hyperandrogenism), may be accompanied by obesity, arterial hypertension, diabetes mellitus and cancer of the uterine body.

Hyperthecosis occurs as a result of the acquisition by stromal cells of signs characteristic of corpus luteum cells. Hyperthecosis is often observed in older women. In childbearing age, it is accompanied by virilization (due to increased synthesis of male sex hormones by the ovaries), obesity, arterial hypertension, and diabetes mellitus. Less commonly, hyperthecosis may be accompanied by feminization phenomena due to increased production of female sex hormones by the ovaries. Pregnancy luteoma - an increase in one or two ovaries up to 15 cm or more in the last 3 months. pregnancy. Inflammatory processes in the ovaries cause their increase and the formation of adhesions. The fallopian tubes are drawn into this process; in such cases, they speak of an inflammatory adnex tumor (an inflammatory tumor of the appendages). Antibacterial therapy promotes recovery. A paraovarian cyst arises from an ovarian epididymis located above the ovary itself. Therefore, this cyst is located between the ovary and the fallopian tube, usually on the one hand, reaches up to 20 cm in diameter. Surgical treatment.

Diagnosis of benign ovarian tumors

Despite the morphological diversity of benign ovarian tumors and tumor-like formations, in the clinical picture they are united by a characteristic feature - poor symptoms or its complete absence at the initial stages of development. At this time, a gynecological examination may be uninformative. Therefore, the main method for diagnosing ovarian masses is ultrasound of the pelvic organs. Thanks to this method, which has recently become mandatory when examining gynecological patients, it is possible to determine the size of the ovarian mass formation, its structure (single-chamber or multi-chamber, cystic-solid or solid, that is, dense, without a cavity). Vaginal ultrasound provides more accurate information than conventional pelvic ultrasound. A special scale has been developed for assessing the ultrasound picture, which can be used to distinguish between benign and malignant ovarian tumors. A mass lesion detected before menarche or in postmenopause often turns out to be a true tumor, which requires additional diagnostic interventions or surgery. Laparoscopy allows diagnosing an ovarian tumor, it can be removed during this operation, provided that it is benign. In the case of malignancy of the tumor, they proceed to the operation using the usual (open, or laparotomic) access, and after a thorough revision of the pelvic and abdominal organs, the operation is performed in accordance with the stage of the malignant process. Determine the nature of the tumor, benign or malignant, helps determine the concentration of tumor-associated antigen CA 125 and secretory protein HE4. However, these markers can be elevated in some benign processes.

Currently, there is no prevention of benign ovarian tumors. Therefore, only regular gynecological examinations in combination with ultrasound can timely detect volumetric formations in the ovaries. It is necessary to be attentive to your health and pay attention to changes in the menstrual cycle and the appearance of certain symptoms that were not there before.

Ovarian tumors can occur in women at any age, more often in 40-50 years, and rarely in girls. Ovarian tumors are divided into 4 groups: epithelial, connective tissue, hormonally active and teratoma. In each of these groups, tumors are benign and malignant, but there is no clear boundary between them, since with a histologically benign structure of an ovarian tumor, the course of the disease can be malignant (rapid tumor, its implantation along the peritoneum, metastasis).

Of the benign tumors of the ovary, epithelial tumors are most often observed - serous and pseudomucinous cystomas. Cystomas with papillary growths on the surface are potentially malignant due to their frequent malignancy. The malignant form of epithelial tumors - develops mainly from pre-existing benign tumors. Connective tissue tumors: benign -, malignant -.

Hormonally active ovarian tumors are divided into two groups: 1) "feminizing" - granulosa cell (synonymous with follicle) and thecoma (synonymous with thecacellular tumor); 2) "masculine" - arrhenoblastomas. A special form of dyshormonal ovarian tumors is dysgerminoma, which occurs mainly in girls during puberty. Teratomas (see) and dermoids (see) are also observed in the ovary. A variety of teratoblastomas - (see), a characteristic feature of which is the appearance of chorionic gonadotropin in the urine.

Ovarian tumors can occur in women of any age, most often between 40 and 50 years old, but sometimes in girls. In terms of frequency, they rank second among tumors of the female genital organs. Benign forms prevail. Sources of origin of ovarian tumors are very diverse. MF Glazunov identifies three groups of them: 1) normal components of the ovary (basic and rudimentary); 2) embryonic remnants and dystopias; 3) postnatal growths, heterotopias, metaplasias and paraplasias of the epithelium. A feature of ovarian tumors is the blurring of the boundaries between benign and malignant forms and sometimes a purely malignant course of the disease with a relatively benign morphological structure of the tumor or with weak features of possible malignancy (polymorphism, atypia, mitosis) without visible infiltrative growth.

The largest group of ovarian tumors are tumors of epithelial origin. In accordance with the nature of the contents of the cystic cavities of these tumors, they are divided into serous and pseudomucinous, and according to the characteristics of the epithelium lining them, the name “cilioepithelial” is added to the first, and “glandular” to the second. Serous cilioepithelial tumors - cystomas (cystoma cilioepitheliale, blastoma cilioepitheliale, cystoma serosum simplex, dropsy of the ovary) - make up the bulk of benign ovarian tumors: they are truly benign tumors, have a round or ovoid shape, often single-chamber, one-sided. Tumors can reach gigantic sizes. The contents of the cavities are liquid, transparent, of various colors. When a significant value is reached as a result of intracavitary pressure, the epithelium lining them flattens and loses cilia, and in some places completely atrophies.

Proliferating cilioepithelial cystomas (papillary; synonym: papillary cystoadenoma, or cystoadenoma, papillary cyst, proliferating papillary cyst, endosalpingeoma, etc.) have papillary growths on the walls in the form of single or multiple outgrowths that gradually fill the tumor cavities. For the most part, these are bilateral multi-chamber formations, immobile due to adhesions with surrounding tissues, sometimes false, less often truly intraligamentous. The accompanying adhesive process is explained by the perifocal reaction and the previous inflammation of the appendages. Papillary growths can be located on the outer surface of the cyst and pass to the peritoneum. These tumors are potentially malignant due to their frequent overt malignancy. The age of patients - more often from 30 to 50 years; about 1/5 of the patients are under 30 years old. The peculiarity of the anamnesis is insufficient childbearing function.

Malignant cilioepithelial tumors are included in the group of ovarian cancers.

Pseudomucinous (glandular) cystomas are less common than cilioepithelial ones. As a rule, these are multi-chamber tumors (resembling a honeycomb on a cut), tuberous, occasionally single-chamber, round or ovoid, not quite regular in shape. Tumor chambers of various sizes, with more or less dense partitions. The contents of the cavities are mucus-like, thick, of various colors - pseudomucin (not deposited, in contrast to mucin, with acetic acid). The tumor capsule consists of dense connective tissue, but as the tumor grows, it can become thinner in places, which is accompanied by rupture of individual cavities. The contents are then poured into the abdominal cavity. Due to the severity of the tumor, its leg tends to stretch, and it is with these tumors that its torsion often occurs. Secerning pseudomucinous cystomas can reach gigantic sizes.

There is a type of secernating pseudomucinous ovarian cystoma called ovarian pseudomyxoma.

These are single-chamber formations with thin, easily torn walls. The thick contents of the cystoma, when ruptured, pour into the abdominal cavity and serve as a source of peritoneal pseudomyxoma. In this case, the abdominal cavity is gradually filled with jelly-like masses coming from the ovarian tumor and from the foci that have arisen in different parts of the peritoneum. The rupture of pseudomyxomas of the ovary occurs spontaneously as they reach a more or less significant size, or during a gynecological examination, or during an operation. With a benign histological structure, these tumors are clinically malignant, because they tend to progress and recur. Their morphological malignancy is also possible.

Proliferating pseudomucinous cystomas are characterized by pronounced proliferation of the epithelium with exophytic or submerged growth, i.e., with the formation of papillae or diverticulum-shaped depressions. Macroscopically, this is expressed by visible papillary growths or focal thickening of the wall. These tumors are also multi-chambered, but with a predominance of small chambers. Sometimes patients develop ascites. In some cases, malignancy of pseudomucinous cysts occurs. In different parts of the same tumor, there may be different morphological structures: from secernating to malignant.

Crayfish. For the unification and possible comparison of various observations on ovarian cancer, the Cancer Committee of the International Federation of Gynecologists and Obstetricians proposed to use the following classification according to the stages of the disease, determined by clinical examination and trial laparotomy data.

Stage I. The tumor is limited to the ovaries. Stage Ia. The tumor is limited to one ovary. Stage I6. The tumor is limited to both ovaries. Stage II. The tumor affects one or both ovaries with spread to the pelvic area. Stage IIa. Primary and secondary lesions are surgically removed. Stage II6. Primary and/or secondary lesions are not surgically removed. Stage III. The tumor affects one or both ovaries, there are widespread metastases, but partial removal is possible. Stage IIIa. The presence of abdominal spread and (or) metastases. Stage IIIb. Distant metastases outside the abdominal cavity (outside the peritoneum). Stage IV A tumor that affects one or both ovaries is completely inoperable. Stage IVa. Cases in which the operation is performed. Stage IV6. Doubtful cases that are probably ovarian carcinoma. Note: The presence of ascites does not affect staging.

In accordance with the instructions of the Ministry of Health of the USSR, the following classification of ovarian cancer is used. I stage. Tumor within one ovary without metastases. II stage. The tumor has spread beyond the ovary, affecting the second ovary, uterus, one or both tubes. III stage. The tumor has spread to the parietal pelvic peritoneum. Metastases to regional lymph nodes, omentum. IV stage. An ovarian tumor invades neighboring organs: the bladder, rectum, intestinal loops with dissemination along the pelvic peritoneum or with metastases to distant lymph nodes and internal organs. Ascites.

It is also customary to divide ovarian cancer into primary, arising in them in the absence of preexisting benign tumors, secondary, developing on preexisting benign tumors, and metastatic.

Primary ovarian cancer is especially malignant, because even with a small tumor size it can give extensive dissemination. Usually these are bilateral, less often unilateral formations, dense or uneven in consistency, with a bumpy, less often smooth surface. The microscopic structure of these tumors is solid or glandular-solid. Secondary cancer occurs mainly on the basis of papillary cilioepithelial, rarely pseudomucinous cysts and macroscopically, in the absence of dissemination, is similar to the picture of proliferating cysts. In the same tumor, cancer of the papillary and glandular structure can be found in different areas during histological examination.

Metastatic ovarian cancer occurs by lymphogenous, hematogenous, or implantation pathways. The most common primary localization of cancer in this case is the gastrointestinal tract, especially the stomach, mammary gland, body of the uterus. However, any tumor of any organ (including hypernephroma) can metastasize in the ovary and even in its pre-existing cyst (MF Glazunov). The morphological structure of metastatic ovarian tumors usually corresponds to that of the primary tumor. A special form of metastatic ovarian tumors are Krukenberg tumors. Being metastases of cancer of the stomach or intestines, these tumors are characterized by ring-shaped cells filled with mucus, with a nucleus pushed to the periphery, scattered separately or in groups in a loose-fibered, edematous stroma.

Metastatic ovarian tumors are more common in young women, prone to rapid growth, often bilateral. Quite often they are found already at their considerable sizes though can sometimes come to light only at microscopic examination. The shape of the tumors is oval, round, kidney-shaped or irregular (with infiltrative growth). The consistency is different and is associated with the histological structure. Krukenberg tumors usually have an elastic consistency due to edema of the stroma. In most cases of metastatic ovarian tumors, they are accompanied by ascites.

Connective tissue tumors of the ovary can be benign (fibromas) or malignant (sarcomas). Ovarian fibroma is a dense, unilateral, usually mobile formation with diffuse or nodular growth. Ovarian fibroma is sometimes accompanied by ascites (without pleurisy). Among all ovarian tumors, fibroma is from 1.7 to 7.5% [E. N. Petrova and V. S. Frinovsky, G. Barzilay].

Many tumors were previously classified as ovarian sarcomas, which over the following years were identified as special groups of hormonally active tumors (tecomas, dysgerminomas, granulosa cell tumors, arrhenoblastomas, etc.) and ovarian sarcomas are rare in modern statistics. Ovarian sarcomas currently include only hormonally “silent” tumors that have a sarcomatous structure, but whose morphology cannot be used to judge their histogenesis. Ovarian sarcomas are characterized by rapid growth, soft texture, a tendency to decay and hemorrhage, with a smooth or bumpy surface, usually unilateral. Like ovarian cancer, they can occur as a result of metastasis (lymphosarcomas, melanosarcomas). Brenner's tumor occupies a special place among other ovarian tumors. It consists of connective tissue components (such as fibroma) and epithelial (in the form of strands, islets of cells with a light, well-defined cytoplasm, sometimes with the formation of cysts). This tumor is usually not included in the category of hormonally active, although it is often accompanied by hyperestrogenization or masculinization phenomena. Brenner's tumor is similar in shape, size, and consistency to a fibroma. It is usually benign, but malignant forms also occur. The tumor is rare, and an accurate diagnosis is usually made only after histological examination.

Hormonally active tumors of the ovary (dyshormonal) are usually classified into two groups of tumors: 1) granulosa cell and thecomas (“feminizing”); 2) arrhenoblastomas, luteomas and tumors from chyle cells ("masculine"). Granulosa cell tumor (synonym: folliculoma, granulose epithelioma, follicular adenoma, Kalden's tumor, cylindroma, endothelioma, pflugeroma, basal cancer, folliculoid cancer) originates from the cells of the granulosa membrane of the ovarian follicles. Tumors are almost always unilateral, ovoid in shape, smooth or bumpy, yellowish in color, often uneven in texture (soft, dense, elastic), due to the presence of cystic cavities. A typical structure for a granulosa cell tumor should be considered as complexes of granulosa cells, clearly separated from the stroma. The cells are small, with a dark nucleus and a narrow rim of the cytoplasm. There are cysts ("follicles") lined with layers of granulosa cells. The cells of the inner layer of such cysts are light, vacuolated. Numerous structural variants of granulosa cell tumors are possible. They occur at any age of women, starting from early childhood, more often in 40-50 years. The malignant nature of granulosa cell tumors of the ovary is observed in almost 40% of cases (ID Nechaeva). According to the definition of M. F. Glazunov, structurally and functionally malignant forms may not differ from benign ones. Malignant forms give extensive metastasis, sometimes after a more or less prolonged remission.

Thecoma (synonym: thecacellular tumor, fibroma thecacellulare xantomatodes) originates from the spindle-shaped cells of the cortical layer of the ovary, is less common and occurs mainly in older women. These are unilateral, round or ovoid tumors, with a smooth surface, dense or densely elastic consistency. Unlike fibromas, it is diffuse yellow or mottled yellow on section. Usually mobile if there are no adhesions. Symptoms of hyperestrogenization in thecomas are more pronounced, and coexistence with cancer of the uterine body is more often observed. In the structure of the thecoma (see), inactive areas are found, similar to fibroma, formed by strands of spindle-shaped cells located in different directions, and functioning areas. In the latter, there are many capillaries, cellular elements form clearly defined groups of cells with soft foamy cytoplasm and light nuclei. These cells contain lipids and secrete a proteinaceous fluid, due to which cavities containing this fluid are found in thecomas. A malignant course with tecomas is less common; malignant thecomas are sometimes erroneously described as sarcomas.

Masculine tumors of the ovary are rare, mainly arrhenoblastoma. Usually unilateral tumor, but describe the simultaneous or sequential occurrence of arrhenoblastomas in both ovaries. The shape of the tumors is round or oval, with a smooth or bumpy surface, gray, yellow or mixed color, sometimes with foci of hemorrhage and with cavities containing a serous-looking liquid. Various variants of the structure of arrhenoblastomas are possible (see).

A special form of dyshormonal ovarian tumors is dysgerminoma, which is sometimes referred to as a group of teratoid tumors. It occurs more often in girls during puberty and in young women (see Dysgerminoma).

Teratomas (mature teratoma), or germ cell tumors, can be benign - dermoid cyst (dermoid), struma, and malignant - teratoblastoma (immature embryonic teratoma). Mature teratoma (see) is a single-chamber (rarely multi-chamber) formation, with a smooth, thin wall, which contains mature differentiated tissues, most often hair, fat, teeth, cartilage, sometimes thyroid tissue. These tumors occur at any age of a woman, but more often from 20 to 40 years. Tumors in the vast majority of cases are unilateral and tend to be located in front of the uterus, mobile, soft consistency. Plain x-ray of the pelvis reveals bony elements of the cyst content.

Teratoblastoma consists of a variety of cells, which can basically be classified as epithelial or mesenchymal-like (MF Glazunov). Tumors of a solid or cystic-solid structure, ovoid or round shape, whitish hue, heterogeneous consistency, with a bumpy or smooth surface. Their feature (as in dysgerminomas) is rapid growth, early metastasis and predominant occurrence in the early period of a woman's life (the first three decades). Often they are bilateral, purely malignant. A frequent companion is ascites.

A variety of teratoblastomas - chorionepithelioma (see) is distinguished by the presence of gonadotropins in the urine.

Symptoms and course. In the initial period, when an ovarian tumor occurs, as a rule, there are no symptoms of the disease. Sometimes there is pain in the lower abdomen.

As the tumor (usually malignant) grows, an effusion appears in the abdominal cavity, the abdomen enlarges, bowel function and urination are disturbed. Patients complain of bloating, deterioration of health, weakness. With hormonally active tumors, signs appear according to the nature of the tumor: with “feminizing” tumors, it is early in girls, and in women in the period of resumption of the menstrual cycle or its semblance, etc .; with “masculine” - facial hair growth, etc. The examination reveals an increase in one or both ovaries, their compaction or uneven consistency, sometimes metastases of the tumor in the small pelvis or already beyond it.

Treatment benign ovarian tumors are always surgical, malignant - combined (surgical, chemotherapy and radiation therapy). With tumors that are already inoperable and with contraindications to surgery, only chemotherapy is used or it is combined with radiation therapy. Patients with suspected ovarian tumor should be urgently referred to a doctor.

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

Solid foreign inclusions of the ovaries are less common than fibroids of the genital organ. Often they are thecomas and fibromas of the appendages. According to the results of ultrasound, rapidly growing epithelial tumors (cystadenofibroma) have similarities with solid formations. When a fibroma appears, or the volume of fluid in the peritoneal region increases, i.e., benign ascites occurs.

An ultrasound picture. Cystic-solid formation of the ovary. Click to enlarge

Features of formations in the pelvic region

Ultrasonography suggests that the patient has a solid ovarian mass. Their features are listed below:

  1. With incomplete torsion, the appendage itself appears as a solid neoplasm, which is provoked by tissue edema.
  2. looks like a solid tumor with 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 phenomena 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. In appearance, they are divided into mucinous and cystic. Dermoids stand apart.

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

Characteristics of neoplasms

Features of benign ovarian structures:

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

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

Features of malignant neoplasms:

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

Differential Diagnosis

Features of tumors:

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

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, the formations do not manifest themselves until the abdomen is enlarged due to ascites. Sometimes, against the background of a change in the size of the uterine appendages, cycle failures and sensations of pressure in the pelvic region 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 unequivocal decision whether they can precede oncology (scientists have not yet come to a general conclusion). Thus, close attention to adnexal tumors is required from the attending physician.

Most often, pathology is diagnosed in young women of reproductive age.

What is an ovarian cyst

Each month, a small capsule called a follicle forms in the ovaries. This is a normal process that provides the natural environment for the maturation of the ovary. In the middle of the cycle, the capsule bursts and the egg gets a free path to the fallopian tube for fertilization. In place of the ruptured follicle, a corpus luteum is formed, which is necessary for the proper functioning of hormones and gestation.

If for some reason the follicle does not burst and fluid accumulates, then this is already a pathology - a follicular cyst. Such a cyst forms on one of the ovaries and can reach more than five centimeters in diameter. It is important to note that such a neoplasm has the ability to resolve itself after a few months.

Cysts can develop in conjunction with such pathological conditions:

  • dull pain in the lower abdomen;
  • the formation of cartilage, hair, or bone accumulations in one of the ovaries. This phenomenon most often requires prompt resolution;
  • in the case of the presence of endometriotic cysts, it is possible for blood to enter the ovary with progressive endometriosis. Such a pathology prevents conception and provokes the appearance of a strong pain syndrome in the lower abdomen during menstruation;
  • the formation of cystadenomas up to 30 centimeters in size, which do not show any symptoms;
  • The most common pathology is polycystic ovary syndrome, which is manifested by the growth of a large number of cysts of different sizes. This condition is characterized by an irregular menstrual cycle, the development of infertility, an increase in the production of male sex hormones;
  • cancer development. Accompanied by the slow formation of cysts.

It is worth noting that, despite the good quality of cysts, in rare cases they tend to degenerate into malignant ones. It is important to regularly undergo preventive examinations and monitor your own health.

Formation of the left ovary: causes

It is impossible to accurately establish the causes that provoke the formation of cysts. However, medical practice shows that there are several factors that prevent the release of fluid from the ovaries. Among them:

  • early first menstruation (up to 11 years);
  • abortions;
  • thyroid pathology;
  • violations in the menstrual cycle;
  • left-sided adnexitis;
  • inflammatory processes in the genitals;
  • surgical interventions in the pelvic area;
  • hormonal imbalance;
  • previously diagnosed cystic masses.

Basically, polycystic ovaries are classified as diseases of the hormonal type.

Symptoms of mass formation of the left ovary

Most often, the presence of cysts does not cause any symptoms. You can see them only on an ultrasound examination. However, 10% of patients with PCOS experience the following symptoms:

  • nausea;
  • bleeding from the vagina between cycles;
  • pain in the lower abdomen on the left side;
  • soreness during sex and after physical exertion;
  • attacks of sudden acute pain in the lower abdomen;
  • irregular menstruation;
  • false urge to urinate or defecate;
  • palpation of the cyst during palpation, an increase in the abdomen;
  • infertility;
  • obesity;
  • fever;
  • constipation;
  • tachycardia.

The symptoms of a cyst of the left ovary are very similar to the manifestations of disorders in the gastrointestinal tract, heart or pancreas. It is very important to undergo a complete medical examination if any signs of malaise appear. Even in the absence of symptoms, in order to prevent women need to visit a gynecologist every six months.

Cystic formation of the left ovary: consequences

The most common complications of a cyst of the left ovary: cyst rupture, torsion of the cyst stem, degeneration into a malignant tumor, displacement of neighboring organs due to pressure exerted on them by the cyst. The last complication is fraught with the development of infertility, painful syndrome and disturbances in the functioning of internal organs.

Rupture of the ovary is also very dangerous and can lead to severe blood loss, the development of peritonitis, and the death of the patient.

Causes of cyst rupture:

  • Active movements during intercourse.
  • Physical exhaustion.
  • Impaired blood clotting.
  • Hormonal imbalance.
  • Thin walls of the follicle due to any inflammatory process.

Sharp pains in the lower abdomen, fainting, fever, vaginal discharge, pallor of the skin and general weakness should alert. If you find one or more of these signs, you should immediately consult a doctor.

Treatment of cystic formation of the left ovary

Some types of cysts are able to resolve on their own. When making a diagnosis, it is necessary to conduct all the necessary examinations to accurately determine the type of cyst. Very often it is possible to achieve a positive effect from the use of conservative treatment. Electrophoresis, ultraphonophoresis, magnetotherapy, mud therapy, irrigation, baths, hormone treatment have proven themselves well.

Therapy is selected based on the individual characteristics of the patient's body, age and course of the disease. Surgical resolution is necessary for the rapid growth of cysts, the serious condition of the patient, certain types of cysts, and to exclude the malignancy of the process.

There are cases when surgery can result in such complications: the inability to have children, the formation of adhesions in the fallopian tubes.

If prompt resolution is required, it is important to choose the most gentle method possible. One of these is laparoscopy, which allows you to perform an operation using an endoscope through special small punctures. The procedure involves quick rehabilitation and a minimum of complications.

Prevention of cysts of the left ovary

To protect yourself from the development of cysts and other gynecological diseases, you need to follow a low-calorie vitamin diet, exercise, reduce exposure to sun and hot baths, and regularly visit a gynecologist.

A special place in the prevention of cysts is given to oral combined contraceptives.

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The frequency of ovarian tumors is up to 19-25% of all tumors of the genital organs. Establishing the diagnosis of a true tumor in the area of ​​the appendages is an indication for an urgent examination and referral to a hospital for surgical treatment. The most common ovarian cysts are follicular and corpus luteum cysts, most of which are retention formations.

Follicular cyst- a single-chamber liquid formation that has developed as a result of anovulation of the dominant follicle.

Cyst of the corpus luteum- accumulation of serous fluid in the cavity of the ovulated follicle.

Diagnosis of ovarian cysts is based on a bimanual examination, ultrasound followed by Doppler examination of blood flow in the wall and the tumor-like formation itself, computed and magnetic resonance imaging, and therapeutic and diagnostic laparoscopy. In addition, it is possible to determine the oncomarkers CA-125, CA19-9 in blood serum.

For differential diagnosis of liquid formations of the ovaries, ultrasound is important. Follicular ovarian cysts on the periphery always have ovarian tissue. The diameter of the cysts varies from 25 to 100 mm. Follicular cysts are usually solitary formations with a thin capsule and homogeneous anechoic content. There is always an acoustic signal amplification effect behind the cyst. They are often combined with signs of endometrial hyperplasia.

Usually, follicular cysts disappear spontaneously within 2-3 menstrual cycles, therefore, if they are detected during ultrasound, dynamic monitoring with mandatory cyst echobiometry is necessary. This tactic is dictated by the need to prevent ovarian torsion.

The corpus luteum cyst regresses by the beginning of the next menstrual cycle. On the echogram, the cysts of the corpus luteum are located on the side, above or behind the uterus. The sizes of cysts range from 30 to 65 mm in diameter. There are four variants of the internal structure of the corpus luteum cyst:

  1. homogeneous anechoic formation;
  2. homogeneous anechoic formation with multiple or single complete or incomplete irregularly shaped septa;
  3. homogeneous anechoic formation with parietal moderate density smooth or mesh structures with a diameter of 10-15 mm;
  4. formation, in the structure of which a zone of fine and medium mesh structure of medium echogenicity is determined, located parietal (blood clots).

Endometrioid cysts on echograms are determined by formations of a round or moderately oval shape, 8-12 mm in diameter, with a smooth inner surface. Echographic distinguishing features of endometrioid cysts are a high level of echo conductivity, unevenly thickened walls of the cystic formation (from 2 to 6 mm) with a hypoechoic internal structure containing many point components - a fine suspension. The size of the endometrioid cyst increases by 5-15 mm after menstruation. This suspension does not move during percussion of the formation and when the patient's body is moved. Endometrioid cysts give the effect of a double contour and a distal enhancement, that is, an enhancement of the far contour.

The pathognomonic features of dermoid cysts are the heterogeneity of their structure and the absence of dynamics in the ultrasound image of the cyst. In the cavity of the cyst, structures characteristic of fatty accumulations, hair (transverse striation) and bone tissue elements (dense component) are often visualized. A typical echographic sign of dermoid cysts is the presence of an eccentrically located hyperechoic formation of a rounded shape in the cyst cavity. V. N. Demidov identified seven types of teratomas:

  • I - a completely anechoic formation with high sound conductivity and the presence on the inner surface of the tumor of a small formation of high echogenicity, round or oval in shape, which is a dermoid tubercle.
  • II - anechoic formation, in the internal structure of which multiple small hyperechoic dashed inclusions are determined.
  • III - a tumor with a dense internal structure, hyperechoic homogeneous contents, with an average or slightly reduced sound conductivity.
  • IV - the formation of a cystic-solid structure with the presence of a dense component of high echogenicity, round or oval in shape with clear contours, occupying from Uz to % of the tumor volume.
  • V - the formation of a completely solid structure, consisting of two components - hyperechoic and dense, giving an acoustic shadow.
  • VI - a tumor with a complex structure (a combination of cystic, dense and hyperechoic solid, giving an acoustic shadow, components).
  • VII - tumors with a pronounced polymorphism of the internal structure: liquid formations containing septa of various thicknesses, dense inclusions of a spongy structure, fine and medium-dispersed hypoechoic suspension.

Dermoid and large endometrioid formations of the ovaries are subject to surgical treatment.

Therapeutic tactics for corpus luteum cysts and small (up to 5 cm) follicular cysts is expectant, since most of these formations undergo regression within several menstrual cycles on their own or against the background of hormonal treatment. Lesions larger than 5 cm in diameter tend to become tolerant to hormonal treatment due to destructive changes in their internal lining resulting from high pressure in the cyst.

If the liquid formation remains unchanged or increases in size against the background of hormonal treatment, then surgery is indicated - laparoscopic cystectomy or resection of the ovary within healthy tissues.

In the postoperative period, all women are shown the use of combined oral contraceptives for 6-9 months. Of the physiotherapeutic methods of treatment, ultrasound, mud, ozocerite, sulfide waters are used. Zinc electrophoresis, SMT with fluctuating or galvanic current is less effective. It is desirable to conduct 3 courses of electrophoresis and 2 courses of exposure to other factors.

Ed. V. Radzinsky

"Benign tumors and tumor-like formations of the ovaries" and other articles from the section