Solid cyst. Cystic solid brain tumor: causes, consequences, treatment

Many renal formations are not palpable during examination until the very late stage of disease development. As a rule, kidney cancer is a solid tumor of the kidney, which in half of cases of renal cell cancer is diagnosed completely accidentally during various studies regarding another disease. Today, the classic triad of symptoms (gross hematuria, flank pain and palpable abdominal mass) that accompany various types of malignant renal neoplasms is very rare. That is why it is very important to identify the disease in a timely manner. For this purpose, modern diagnostic techniques and equipment are used.

Clinical picture

We have figured out what a solid renal formation is - kidney cancer. Only a third of patients with this disease have the following symptoms, indicating the likelihood of a malignant kidney tumor:

• cachexia;
• high blood pressure;
• fever;
• weight loss;
• amyloidosis;
• neuromyopathy;
• anemia;
• increased ESR;
• disturbances in liver function;
• polycythemia;
• hypercalcemia.

It is worth knowing: some patients, in addition to the listed symptoms, may have signs of a metastatic process, namely a persistent cough and bone pain.

Diagnostics

Any kidney formations must be differentiated from other kidney diseases. That is why a whole range of procedures is carried out during the diagnostic process:

1. Physical examination is not very important in terms of diagnosis. However, if the following symptoms are detected during it, this is a reason for a more detailed examination of the patient:

• enlarged cervical lymph nodes;
• a tumor is palpable in the abdominal cavity;
• permanent varicocele;
• Bilateral swelling of the legs may indicate involvement of the venous system.

1. Laboratory diagnostic methods. The most commonly used parameters are serum creatinine, GFR, hemoglobin level, ESR, serum calcium concentration, alkaline phosphatase and LDH - lactodehydrogenase. The functions of both kidneys are assessed separately in the following cases:

• if the high level of creatinine in the blood suggests a decrease in the activity of the organ;
• if there is a risk of a significant decrease in kidney function during treatment;
• in patients with concomitant diseases that can provoke a decrease in renal function (pyelonephritis, diabetes, renovasculitis, urolithiasis, polycystic kidney disease).

1. Radiation diagnostics. Many renal formations are clearly visualized on CT or when performing ultrasound for another disease. In this case, according to visualization, renal neoplasms can be divided into cystic and solid.
2. Presence of contrast. The main distinguishing feature of all malignant solid formations is the presence of contrast enhancement. As a rule, ultrasound, magnetic resonance and computed tomography are used to diagnose and characterize various renal formations. Most of them can be accurately diagnosed using various imaging techniques. Ultrasound with contrast liquid can be indicative in particularly difficult cases, for example, with chronic renal failure with a contraindication to the use of other contrasts.
3. Imaging on CT and MRI used to clarify the nature of education. It is important to obtain images of the tumor before and after contrast injection. This will allow you to evaluate the contrast using the Hounsfield scale. Conclusive evidence of contrast enhancement is a change in tumor contrast by at least 20 units.

An abdominal CT scan can also diagnose renal cell carcinoma and provide the following additional information:

• about the functioning and structure of the contralateral organ;
• involvement of the venous system in the pathological process;
• the growth of a primary neoplasm extending beyond the boundaries of the organ;
• enlargement of regional lymph nodes;
• condition of the liver and adrenal glands.

To obtain information about the blood supply to the kidneys, CT angiography is performed using a contrast agent. If this information is not enough, you can resort to MRI and obtain the following information:

• determine contrast enhancement of renal tumors;
• examine the malignancy in detail;
• assess the degree of damage to the venous system.

Important: MRI is indicated for patients with an allergic reaction to intravenous contrast agents, as well as for pregnant women with preserved renal function.

Other studies

Renal cavography and arteriography are used only as additional diagnostic methods in patients with specific indications. In patients with symptoms of decreased organ functioning, the question of the need for isotope renography must be raised. They also undergo a complete assessment of kidney function. This will optimize treatment and preserve organ function.

Other non-standard research methods include PET - positron emission tomography. The true significance of this technique, used to diagnose RCC and monitor the progression of the disease, has not yet been fully established.

If metastases to other organs are suspected, a computed tomography scan of the chest is performed. This is the most accurate way to diagnose metastases in the lungs. If a computed tomography scan is not available for any reason, at least a chest x-ray should be performed.

Analysis algorithm

When identifying any renal tumors, it is important to adhere to the following analysis algorithm:

• It is important to find out whether this formation is cystic or not.
• If this is not a cystic neoplasm, it is necessary to clarify the presence of macroscopic fat inclusions. If they are present, this is more typical of angiopyolipoma.
• It is important to exclude renal cancer, which is masquerading as an infectious disease or heart attack.
• It is necessary to exclude metastatic lesions of the organ and lymphoma.

Classification

Another method for assessing solid renal formations is to determine their shape. All solid neoplasms are divided into:

• Bean-shaped - these formations practically do not deform the contour of the organ. They are usually localized in the renal parenchyma. Such tumors are poorly visualized and are usually completely invisible on CT without the use of contrast.
• Ball-shaped - found most often. Usually these are extensive tumors that significantly deform the contours of the organ. Typical representatives of this type include renal cell carcinoma and oncocytoma.

The most important indicator of the malignancy of a tumor is its size. But it is also important to take into account the histological assessment of the formation. Moreover, the risk of metastasis formation is directly related to the size of the tumor.

Important: if the size of the tumor is no more than 3 cm, then the risk of metastases is small.

By the way, most kidney tumors are no more than four centimeters in size. That is why many of them belong to the group of poorly differentiated renal cell carcinomas. These are painful malignant or benign kidney formations. Tumors measuring 10-20 mm, removed surgically, in most cases (56%) turn out to be benign, and only in 13% of cases when removing a tumor measuring 60-70 mm, their benign nature is confirmed.

Biopsy and histology

The main purpose of a biopsy is to determine the malignancy of the tumor, its type and differential grade. Percutaneous biopsy is indicated in the following cases:

• if there are large formations in the organ that are subject to nephrectomy;
• patients with metastases before systemic therapy.

Histological examination is carried out after a biopsy of the tumor tissue or after its surgical removal. In this case, three histological subtypes are distinguished:

• papillary occurs in 15% of cases;
• clear cell is diagnosed in almost 90% of cases;
• chromophobic is detected in 5% of patients.

All these histological types differ in molecular genetic changes and histological criteria. Worldwide, there has been an increase in the number of asymptomatic tumors that are accidentally diagnosed during research for another disease. Despite this, many patients with RCC have all the clinical symptoms, so timely diagnosis and treatment of these renal diseases will prolong and save the patient’s life.

Cystic-solid brain tumor is a mixed type. It consists of a single soft node of tumor cells surrounded by a capsule, inside which there are numerous smooth-walled cysts.

Causes of tumor appearance

The key reason for the development of cystic-solid tumors, as well as other brain tumors, is the effect on the human body of various carcinogenic factors, which include:

• ionizing radiation;
• excessive exposure to sunlight;
• industrial contact with carcinogens (asbestos, acrylonitrile, benzene, benzidine-based dyes, vinyl chloride, coal and petroleum tars, phenol-formaldehyde, etc.);
• oncogenic viruses (adenoviruses, herpes virus, retroviruses).

In some cases, neoplasms may have a hereditary etiology and develop as a consequence of genetic mutations.

Consequences of cystic-solid brain tumor

A direct consequence of the developed neoplasm is compression (squeezing) of surrounding tissues and cells, which, in turn, can lead to complete desensitization of the limbs, disruption of the gastrointestinal tract and urinary organs. Complications that develop after treatment (radiation and chemotherapy) can also be considered a consequence of the impact of the tumor.

Tumor treatment

Operable tumors are treated through surgery. This method is complicated by the fact that complete removal of the tumor is required to avoid possible relapses, so during the operation some healthy cells are also removed. In recent years, less invasive methods of performing such interventions using ultrasound and laser technology have been actively introduced into neurosurgical practice. Removal of a solid neoplasm is combined with aspiration of the contents of cysts, the walls of which may not require removal.

If the tumor is inoperable, then the following methods are used:

• symptomatic pharmacotherapy (its goal is to improve the general condition of the patient and neutralize the obvious symptoms of the disease);
• radiation therapy;
• chemotherapy.

Gynecology: textbook / B. I. Baisova et al.; edited by G. M. Savelyeva, V. G. Breusenko. - 4th ed., revised. and additional - 2011. - 432 p. : ill.

Chapter 16. OVARIAN DISEASES

Chapter 16. OVARIAN DISEASES

The most common diseases of the ovaries include tumor-like formations and tumors; purulent processes are less common (see the chapter “Inflammatory diseases of the female genital organs”).

Tumor-like formations are cysts, the liquid contents of which stretch the walls without proliferation of cellular elements. With true ovarian tumors, cell proliferation is observed.

16.1. Tumor-like formations of the uterine appendages

Tumor-like formations include ovarian retention cysts: follicular (73%), corpus luteum cysts (5%), thecalutein (2%), endometrioid (10%), paraovarian (10%).

Cysts are not capable of proliferation; they are formed as a result of retention of excess fluid in preformed cavities and cause significant enlargement of the ovary. They can form from a follicle, corpus luteum, paraovary (epioophoron), endometrioid heterotopias implanted on the surface of the ovary (see "Endometriosis").

Cysts are observed mainly during the reproductive period, but are possible at any age, even in newborns. The incidence of cysts in postmenopausal women is 15%.

The formation of ovarian cysts is promoted by dishormonal, inflammatory and other processes, leading to congestive hyperemia of the pelvic organs.

Follicular cysts arise due to the accumulation of fluid in the cystic-atretic follicle as a result of hormonal disorders.

Follicular cysts occur in women with endocrine metabolic disorders that contribute to the development of hyperestrogenism and chronic anovulation (single-phase menstrual cycle). They occur mainly during reproductive age, in rare cases they can occur in postmenopause, and even less often in fetuses and newborns. A sign of the transition of the physiological process of follicle maturation into a pathological follicular cyst is the diameter of a liquid formation of more than 30 mm. Fluid accumulates in the cyst cavity as a result of extravasation from blood vessels or due to its ongoing secretion by the granulosa epithelium.

Morphologically, a follicular cyst is a thin-walled liquid formation, the wall of which consists of several layers of follicular epithelium. Outside the follicular epithelium is fibrous connective tissue. As the cyst enlarges, the follicular epithelium undergoes dystrophic changes, becomes thinner, desquamates and undergoes atrophy. The wall of the cyst can consist only of connective tissue, lined from the inside with flat or cubic cells; in most cases, these cysts are unilocular. Several cysts can appear simultaneously in the ovary, which, gradually increasing in size, merge with each other, which creates the impression of a multi-chamber formation.

Macroscopically, follicular cysts are small (50-60 mm in diameter), smooth and thin-walled formations containing a transparent light yellow liquid.

Clinically, follicular cysts do not manifest themselves in most cases. In some cases, there is a delay in menstruation, and pain of varying intensity in the lower abdomen is possible. Usually pain appears during the formation of a cyst.

Complications include torsion of the cyst pedicle, rupture of the cyst wall, or hemorrhage into the formation cavity. Clinically, these complications are manifested by severe pain in the lower abdomen, accompanied by nausea and vomiting. Torsion of the pedicle of the cyst leads to an increase in formation as a result of impaired venous circulation, tissue edema and hemorrhage (see Chapter 17 "Acute abdomen" in gynecology).

During a gynecological examination, the follicular cyst is palpated on the side or in front of the uterus, elastic in consistency, often one-sided, round, with a smooth surface, 5-6 cm in diameter, mobile, slightly painful. Bilateral follicular cysts are often a consequence of ovarian hyperstimulation during infertility treatment.

The diagnosis of ovarian cyst is established on the basis of the clinical picture and dynamic ultrasound with colorectal dosage and laparoscopy.

Follicular cysts on echograms are single-chamber, round-shaped formations located mainly on the side or posterior of the uterus. The inner surface of the cyst is flat, smooth, its wall is thin (up to 2 mm), the contents are anechoic, with a high level of sound conductivity. Often, in patients of active reproductive age, a section of intact ovarian tissue is visualized on the side of the follicular cyst. Behind the formation there is always an acoustic amplification effect. The diameter of the cysts varies from 2.5 to 6 cm (Fig. 16.1).

Dynamic ultrasound allows one to differentiate a follicular cyst from a smooth-walled serous cystadenoma.

With CDK, single areas of blood flow are identified in a follicular cyst, located exclusively on the periphery of the formation, with low speed and average resistance (IR - 0.4 and higher).

For an uncomplicated cyst, observation of the patient for 6-8 weeks and anti-inflammatory or (if indicated) hormonal therapy are indicated.

Rice. 16.1. Follicular ovarian cyst. Ultrasound

piya. Follicular cysts undergo gradual regression and usually disappear within 1-2, less often - 3 menstrual cycles.

If conservative treatment is ineffective or a complication occurs, surgical treatment is indicated. For follicular cysts, the method of choice is laparoscopic access, in which, if the remaining ovarian tissue is not changed, the cyst is enucleated or a tumor-like formation is removed (Fig. 16.2).

After surgical treatment, therapy aimed at normalizing menstrual function, cyclic vitamin therapy (folic acid, ascorbic acid, vitamin E), nootropic drugs (piracetam) and contraceptives for 3 months are recommended. In the perimenopausal period, the uterine appendages on the side of the cyst are removed.

The prognosis is favorable.

Rice. 16.2. Follicular ovarian cyst. Laparoscopy

Corpus luteum cyst occurs due to the accumulation of fluid at the site of the burst follicle, sometimes it may contain blood. Such cysts occur only during a two-phase menstrual cycle. It is believed that these cysts are formed as a result of impaired lymph and blood circulation in the corpus luteum; They are found between the ages of 16 and 45.

Microscopically, luteal and thecal lutein cells are detected in the wall of the corpus luteum cyst.

Clinically, the cyst usually does not manifest itself in any way. The menstrual cycle is rarely disrupted. There are no specific clinical signs. In some cases, pain in the lower abdomen may be noted at the time the cyst appears.

The most common complication is hemorrhage into the cyst cavity, often in the stage of development of the corpus luteum. Bleeding can be intense and accompanied by the clinical picture of an “acute abdomen.”

In most cases, corpus luteum cysts undergo reverse development. The layer of luteal cells is gradually replaced by connective tissue, and the formation can turn into a cyst, the inner surface of which is devoid of epithelial lining.

The diagnosis of corpus luteum cyst is established on the basis of anamnestic data, the results of a clinical examination, ultrasound and colorectal dosage, and laparoscopy.

With a two-manual vaginal-abdominal examination, the corpus luteum cyst is located mainly on the side or posterior of the uterus. It is round in shape, mobile, with a smooth surface, elastic consistency, with a diameter of 3 to 8 cm, and can be sensitive to palpation.

The echographic picture of corpus luteum cysts is very diverse. The structure of the cyst can be completely homogeneous and anechoic or have a small or medium mesh structure, and these structures fill the entire cyst or a small part of it. In the cyst cavity, multiple irregularly shaped septa are detected, which are displaced during percussion by an ultrasonic formation sensor. In a number of observations, dense inclusions of increased echogenicity - blood clots - are visualized in the cyst cavity. Scanograms reveal inclusions located near the wall, up to 1 cm in diameter, of irregular shape; in isolated cases, a dense formation is suspended in the cyst cavity. Sometimes the entire cavity of the cyst is filled with echogenic contents (blood), as a result of which the echographic image resembles a tumor. Despite the significant differences in the internal structure of corpus luteum cysts, their sound conductivity is always high (Fig. 16.3).

CDC makes it possible to exclude points of vascularization in the internal structures of corpus luteum cysts and thus carry out a differential diagnosis with ovarian tumors.

In the corpus luteum cyst there is intense blood flow along the periphery (the so-called coronary) with low vascular resistance (IR)<0,4), что нередко напоминает злокачественную неоваскуляризацию (рис. 16.4).

To exclude errors, dynamic ultrasound with colorectal dosage is necessary in the 1st phase of the next menstrual cycle. With a corpus luteum cyst, observation is indicated for 1-3 menstrual cycles, since its reverse development is possible. Otherwise, surgical treatment is indicated -

Rice. 16.3. Corpus luteum cyst with hemorrhage into the cavity. Ultrasound

Rice. 16.4. Corpus luteum cyst. Ultrasound, power doppler

removal (enucleation) of a cyst within healthy ovarian tissue using laparoscopic access. Retention cysts are usually small, with a thin transparent wall through which homogeneous contents are visible. During laparoscopy, several small cysts may be visible. When illuminated from the side, retention formations acquire a uniform bluish tint.

The data from ultrasound with color doppler, CT, MRI for retention formations in describing their shape, size, structure and location are the same. When using contrast-enhanced techniques, retention formations do not accumulate contrast agent, and this is a differential diagnostic sign of a cyst, indicating a retention space-occupying formation.

The prognosis is favorable.

Paraovarian cysts located between the layers of the broad ligament of the uterus. They arise from the rudiments of the mesonephric duct, oophoron, and also from the coelomic epithelium. Paraovarian cysts make up from 8 to 16.4% of all ovarian formations. These cysts are diagnosed mainly between the ages of 20 and 40, but can occur in girls, as well as during puberty. In childhood and adolescence, paraovarian cysts sometimes have papillary growths on the inner surface. Cysts can be either small (5-6 cm) or gigantic, occupying the entire abdominal cavity.

Macroscopically, the paraovarian cyst has a round or oval shape, a tight-elastic consistency, with transparent liquid contents. The formation is usually single-chamber, located mainly on the side and above the uterus. The wall of the paraovarian cyst is thin (1-2 mm), transparent, with a vascular network consisting of vessels of the mesentery of the fallopian tube and the cyst wall. At the upper pole of the formation, as a rule, there is an elongated, deformed fallopian tube. The ovary is located at the posteroinferior pole of the cyst, sometimes along its lower surface. The contents of the cyst are mostly homogeneous - transparent watery liquid. The wall consists of connective tissue and muscle bundles; the inside of the cyst is lined with cylindrical ciliated, cuboidal and flat single-row or multi-row epithelium.

A small paraovarian cyst initially does not have a “pedicle”, but as it grows, one of the leaves of the broad ligament of the uterus protrudes and a cyst pedicle is formed. Such a “leg” may include the fallopian tube, and sometimes the ovarian ligament.

Clinically, paraovarian cysts often do not manifest themselves in any way. As the cyst grows, patients complain of pain in the lower abdomen and an enlarged abdomen. Rarely, menstrual irregularities and infertility occur.

A complication of a paraovarian cyst may be torsion of its “leg” with the development of clinical symptoms of an “acute abdomen”.

Verification of a paraovarian cyst presents significant difficulties. A two-manual gynecological examination on the side and above the uterus reveals a formation with a diameter of 5 to 15 cm, elastic consistency, limited mobility, painless, with a smooth, even surface.

The main and practically the only ultrasonic a sign of paraovarian cysts is the visualization of a separately located ovary (Fig. 16.5). The paraovarian cyst is round or oval, the wall is thin (about 1 mm). Education is always single-chamber. The contents of the cysts are mostly homogeneous and anechoic; in some cases, a fine suspension can be detected.

In isolated observations, parietal growths are visualized on the inner surface of the cyst wall. In CDK, paraovarian cysts are avascular.

Since paraovarian cysts are observed in young patients, surgical laparoscopy is preferable to prevent adhesions. For an uncomplicated cyst, the operation is reduced to its enucleation

Rice. 16.5. Paraovarian cyst. Ultrasound

with dissection of the broad ligament of the uterus (preferably from the front). In this case, the ovary and fallopian tube are preserved. The fallopian tube contracts and restores its previous shape. No relapses are noted. The prognosis is favorable.

For information about endometrioid cysts, see Chapter 13, “Endometriosis.”

16.2. Ovarian tumors

Morphology Ovarian tumors are very diverse. This is primarily due to the fact that the ovaries (unlike other organs) do not consist of two components - parenchyma and stroma, but of many elements of different histogenesis. There are many tissue variants that provide the main functions of this organ: maturation of germ cells and the production of sex hormones (integumentary epithelium, egg and its embryonic and mature derivatives, granulosa cells, theca tissue, hilus cells, connective tissue, blood vessels, nerves, etc.) . In the origin of ovarian tumors, an important role is played by rudiments preserved from the period of embryogenesis. Many tumors develop from postnatal areas of epithelium, growths susceptible to metaplasia and paraplasia, in particular from the epithelium of the fallopian tubes and uterus, which can implant on the surface of the ovary.

Some ovarian tumors develop from the epithelium, which is capable of submersible growth, from which sex cord tumors are formed: granulosa cell tumors, thecomas, and androgen-producing tumors (androblastomas) from the remains of the male part of the gonad.

Risk factors With regard to the occurrence of ovarian tumors, ways to prevent this disease are determined. These include: early or late menarche, late (after 50 years) onset of menopause, menstrual irregularities. With a risk of ovarian tumors

associated with decreased reproductive function of women, infertility, and non-pregnancy. Chronic inflammatory diseases of the uterine appendages can form the premorbid background of the tumor process.

Great value in etiology and pathogenesis Ovarian tumors are attributed to genetic factors, neurohumoral and endocrine disorders.

Due to the diversity of cellular elements of ovarian tumors, there are many classifications, of which the most acceptable are those based on microscopy of ovarian formation. In modern gynecology, the histological classification of ovarian tumors is used (WHO, 1973). In clinical practice, you can use a simplified diagram of the most common variants of ovarian formations. The scheme is based on the microscopic characteristics of tumors taking into account the clinical course of the disease. Depending on the cellular composition, ovarian formations are divided into:

Epithelial tumors;

Sex cord stromal tumors;

Germ cell tumors;

Rare tumors;

Tumor-like processes.

All types of tumors are divided into benign, borderline (low-grade ovarian tumors) and malignant. The classification takes into account one of the most important features of ovarian tumors - often cancer develops against the background of previous benign ovarian tumors.

Variants of the most common ovarian tumors

I. Tumors of the surface epithelium and stroma of the ovaries (cystadenomas).

Serous tumors:

Simple serous cystadenoma;

Papillary (rough-papillary) serous cystadenoma;

Papillary cystadenoma.

Mucinous tumors:

Pseudomucinous cystadenoma.

Endometrioid tumors (see Chapter 13 "Endometriosis").

Brenner tumors.

Ovarian cancer.

II. Tumors of the sex cord and ovarian stroma.

Granulosastromal cell tumors:

Granulosa cell tumor;

Tecoma;

Fibroma.

Androblastomas.

III. Germ cell tumors.

Dysgerminoma.

Teratomas:

Mature;

Immature.

Epithelial ovarian tumors

The largest group of benign epithelial ovarian tumors are cystadenomas (formerly known as cystomas). Depending on the structure of the epithelial lining and internal contents, cystadenomas are divided into serous And mucinous.

Serous tumors account for 70% of all epithelial ovarian neoplasms. They are divided into simple serous (smooth-walled) and papillary (papillary).

Simple serous cystadenoma (smooth-walled cilioepithelial cystadenoma, serous cyst; rice. 16.6) - 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 epithelium is determined, reminiscent of that in the fallopian tube and capable of becoming indifferent, flattened-cubic in formations stretched by the contents. The epithelium in some areas may lose cilia, and in some places even be absent; sometimes it 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

Rice. 16.6. Smooth-walled (simple serous) cystadenoma of the ovary. Hematoxylin and eosin staining, χ 400. Photo by O.V. Zairatiantsa

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. Simple serous cystadenoma rarely develops into cancer.

Papillary (rough papillary) serous cystadenoma - a morphological type of benign serous cystadenomas, observed less frequently than smooth-walled serous cystadenomas. Accounts for 7-8% of all ovarian tumors and 35% of all cystadenomas. The tumor has the appearance of a single or multi-chamber cystic neoplasm, on the inner surface of which 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 (psammoma bodies - Fig. 16.7).

Rice. 16.7. Papillary serous cystadenoma. Hematoxylin and eosin staining, χ 120. Photo by O.V. Zairatiantsa

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

A significant difference between papillary serous cystadenoma and rough-papillary cystadenoma is the ability of the integumentary epithelium to rapidly proliferate, creating more or less mature structures. Papillary growths of a soft consistency often merge with each other and are 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-like appearance, raising suspicion of malignant growth.

Papillary cystadenomas can spread over a long distance, disseminate throughout the peritoneum, and lead to ascites.

The tumor is limitedly mobile, with a short stalk, often bilateral, sometimes located intraligamentally. The occurrence of ascites is associated with the growth of papillae along the surface of the tumor, along the peritoneum and a violation of the resorptive ability of the peritoneum of the uterine-rectal space. Everting papillary cystadenomas are much more often bilateral; in this case, 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.

Borderline papillary cystadenoma (low grade) 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.

The most serious complication of papillary cystadenoma is its malignancy - transition to cancer.

Mucinous cystadenoma (pseudomucinous cystadenoma) ranks second in frequency (after cilioepithelial tumors) and is a benign neoplasm of the ovary (formerly called pseudomucinous tumor)

The tumor is detected in all periods of life, more often in the postmenopausal period. It 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 filled with mucous content, which is mucin containing glycoproteins and heteroglycans. True mucinous cystadenomas do not have papillary structures. The size of mucinous cystadenoma is usually significant; there are also gigantic 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 may even be visible due to significant stretching. The contents of the chambers are mucous or jelly-like, yellowish, less often brown, hemorrhagic.

The epithelium lining borderline cystadenomas is characterized by polymorphism and hyperchromatosis, as well as increased mitotic activity of the nuclei (Fig. 16.8). Borderline mucinous cystadenoma differs from mucinous carcinoma in the absence of invasion of the tumor epithelium.

Rare epithelial ovarian formations include pseudomyxoma of the ovary and peritoneum, and Brenner's tumor.

Pseudomyxoma of the ovary and peritoneum - a type of mucinous tumor arising from mucinous cystadenomas, cystadenocarcinomas, as well as from diverticula of the appendix. The development of pseudomyxoma is associated with rupture of the wall of a mucinous ovarian tumor or with 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, we can talk about a malignant or benign variant of pseudomyxomas, since they do not infiltrate or grow into the tissue.

Mucin spreads in the abdominal cavity between the intestinal loops. During microscopic examination, individual epithelial cells are difficult to find. Pseudomyxoma often leads to depletion of the body and death.

Surgical treatment involves removing the mucin, but the process often recurs and the mucin accumulates again.

Rice. 16.8. Mucinous cystadenoma of the ovary. Hematoxylin and eosin staining, χ 120. Photo by O.V. Zairatiantsa

Brenner tumor (fibroepithelioma, mucoid fibroepithelioma) - fi-

broepithelial tumor, including ovarian stromal cells.

Recently, the origin of the tumor from the integumentary coelomic epithelium of the ovary and from the chyle has been increasingly substantiated. The incidence of benign Brenner tumor is approximately 2% of all ovarian tumors. It occurs both in early childhood and in women over 50 years of age. The tumor has a solid structure in the form of a dense node, the cut surface is grayish-white, with small cysts.

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.

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. The possibility of developing proliferative forms of Brenner tumor and malignancy cannot be excluded.

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. In appearance and consistency, the tumor often resembles ovarian fibroma.

Mixed epithelial tumors characterized by a combination of serous and mucinous epithelial structures.

Macroscopically, 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.

Clinical symptoms epithelial ovarian tumors. Benign ovarian tumors, regardless of their structure and clinical manifestations, have many similar features. Ovarian tumors often occur asymptomatically in women over 40-45 years of age. There are no specifically reliable clinical symptoms of any tumor. However, with directed questioning of the patient, it is possible to identify complaints of dull, aching pain of varying severity in the lower abdomen, in the 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. As a rule, pain is not associated with the menstrual cycle. Paroxysmal or acute pain is caused by torsion of the tumor stalk (partial or complete) or perforation of the tumor capsule (see "Acute abdomen" in gynecology).

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

With papillary cystadenomas, often bilateral, ascites is possible. The most serious complication of papillary cystadenoma remains malignancy.

With large tumors (usually mucinous), there is a feeling of heaviness in the lower abdomen, the abdomen itself becomes enlarged, and the function of neighboring organs is disrupted (constipation and dysuria appear). Reproductive function is impaired in every 5th examined woman (primary or secondary infertility).

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

Diagnostics epithelial ovarian tumors. Despite technological progress, diagnostic thinking based on vaginal and rectoabdominal examination has not lost its importance. With a two-handed 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 surface of the tumor. A tumor that has reached a certain size is palpated (when the volume of the ovary increases due to the tumor). 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 previous abdominal operations. 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 recto-vaginal examination helps to exclude malignancy, during which one can determine the absence of “spikes” in the posterior fornix, overhang of the fornix with ascites, and invasion of the rectal mucosa.

During a two-manual vaginal-abdominal examination in patients with simple serous cystadenoma in the area of ​​the uterine appendages, a volumetric formation is determined posterior or to the side of the uterus, round, often ovoid in shape, tight-elastic consistency, with a smooth surface, with a diameter of 5 to 10 cm, painless, mobile on palpation.

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

During a two-manual gynecological examination mucinous cystadenoma is determined posterior to the uterus. A formation with a lumpy surface, uneven, often of tight-elastic consistency, round in shape, limited mobility, diameter from 9 to 20 cm or more, the tumor is sensitive to palpation.

During two-manual vaginal-abdominal examination in patients with a verified diagnosis Brenner tumors on the side and posterior to the uterus, a volumetric formation of ovoid or (more often) round shape, dense consistency, with a smooth surface, 5-7 cm in diameter, is determined

visible, painless. Brenner's tumor often resembles subserous uterine fibroids.

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

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

(Fig. 16.9).

have papillary growths unevenly located on the inner surface of the capsule in the form of parietal structures of various sizes and increased echogenicity. Multiple very small papillae give the wall a rough or spongy appearance. Sometimes lime is deposited in the papillae; on scanograms it has increased echogenicity. 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) two-chamber. They are located lateral or posterior to the uterus, sometimes thin linear septa are visualized (Fig. 16.10).

Mucinous cystadenoma has multiple septa 0.2-0.3 cm thick, often in certain areas of cystic cavities. Suspension is visualized only in relatively large formations. Mucinous cystadenoma is often large, with a diameter of >20 cm, (sometimes up to 50 cm), almost always multilocular, located mainly on the side and behind the uterus,

Rice. 16.9. Simple serous cystadenoma of the ovary.

Ultrasound

Fig.16.10.Papillaryse-

pink cystadenoma of the ovary. Ultrasound

round or ovoid in shape. A finely dispersed suspension of medium or high echogenicity, which is not displaced by percussion with an ultrasonic sensor, is visualized in the cavity. The contents of some chambers may be homogeneous (Fig. 16.11).

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

CDC helps more accurately differentiate benign and malignant ovarian tumors. Based on the blood flow velocity curves in the ovarian artery, the pulsation index and IR, malignancy of tumors can be suspected, especially in the early stages, since active vascularization is inherent in malignant tumors, and the absence of vascularization zones is more typical for benign neoplasms. With CDK good

Rice. 16.11. Mucinous cystadenoma of the ovary. Ultrasound, energy doppler

high-quality epithelial ovarian tumors are characterized by moderate vascularization in the capsule, septa and echogenic inclusions. IR does not exceed 0.4.

The use of ultrasound scanners that provide three-dimensional reconstruction (3D) of the acoustic picture makes it possible to visualize in more detail the vascular bed of the ovarian formation, assess the depth and spatial relationship of normal and pathological structures.

To diagnose ovarian tumors, CT and MRI are used.

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” (Fig. 16.12).

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 malignant ovarian tumors, which determines the need to exclude malignancy before surgery. If malignant growth is detected during laparoscopy, it is advisable to proceed to laparotomy (conversion), since during laparoscopic removal of a cystadenoma with malignant degeneration, the integrity of the tumor capsule and contamination of the peritoneum may be disrupted, and difficulties may arise when removing the omentum (omentectomy).

In the diagnosis of ovarian tumors, a large place is given to the determination of specific biological substances 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).

Rice. 16.12. Simple serous cystadenoma. Laparoscopy

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 ovarian cancer patients, 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 treatment and after its completion).

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

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

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

The extent of surgical treatment helps determine an urgent histological examination. At simple serous cystadenoma at a young age, it is permissible to remove the tumor, leaving healthy ovarian tissue. In older women, the uterine appendages are removed on the affected side. At simple serous cystadenoma of borderline type (low grade) in women of reproductive age, the tumor on the affected side is removed 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, it 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, removal of the appendages on the affected side and a biopsy of the other ovary are acceptable (Fig. 16.13). 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 are performed at any age.

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

At borderline papillary cystadenoma unilateral localization in young patients interested in preserving reproductive function, removal of the uterine appendages on the affected side, resection of the other ovary and omentectomy are acceptable (Fig. 16.14).

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

Rice. 16.13. Papillary serous cystadenoma of the ovary. Papillary growths on the inner surface of the capsule

Rice. 16.14. Borderline ovarian tumor (serous borderline cystadenopapilloma). Hematoxylin and eosin staining, χ 200. Photo by O.V. Zairatiantsa

Treatmentmucinous cystadenoma surgical: removal of the appendages of the affected ovary in patients of reproductive age. In the pre- and post-menopausal periods, 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 remove the contents with an electric suction through a small hole.

Regardless of the morphological identity of the tumor, before the end of the operation it should be cut and the internal surface of the tumor should be examined.

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 for surgical treatment of cystadenomas is favorable.

TreatmentBrenner tumors operational. In young patients, removal of the uterine appendages on 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.

Tumors of the sex cord of the ovary and stroma (hormonally active)

Sex cord stromal tumors include granulosastromal cell tumors (granulosa cell tumor and thecom fibroma group) (Fig. 16.15) and androblastomas, tumors that arise from granulosa cells, theca cells, Sertoli cells, Leydig cells, and ovarian stromal fibroblasts. Hormone-dependent tumors are divided into feminizing (granulosa cell and thecoma) and masculinizing (androblastoma).

Most neoplasms contain ovarian-type cells (granulosastromal cell tumors). A smaller part is represented by derivatives of testicular type cells (Sertoli - stromal cell tumors). If it is impossible to differentiate between female and male types of tumors, the term “unclassified tumors of the sex cord and ovarian stroma” can be used.

Tumors of the sex cord stroma account for about 8% of all ovarian tumors.

Feminizing tumors occur at any age: granulosa cell - more often in children and young adults, thecoma - in pre- and postmenopause and extremely rarely in children.

Granulosa cell tumor makes up from 1 to 4% of hormone-producing ovarian tumors, develops from granulosa tissue, similar in structure to the granular epithelium of the maturing follicle; more common in adolescence and reproductive periods. Tecoma consists of cells similar to theca cells of atretic follicles and is usually observed during peri- and menopause. Granulosa cell tumors account for 1-2% of all ovarian neoplasms. Thecomas are 3 times less common.

Rice. 16.15. Granulosa cell tumor of the ovaries. Hematoxylin and eosin staining, × 200. Photo by O.V. Zairatiantsa

Clinical manifestations associated with the hormonal activity of feminizing tumors. Granulosa cell tumor of the “juvenile type” causes premature puberty, which is more correctly considered false due to the lack of ovulation. Girls develop irregular bleeding from the genital tract with little development of secondary sexual characteristics; features of estrogenic influence are determined - the “pupil” symptom, cyanotic vulva, vaginal folding, enlargement of the uterine body. Somatic development is not accelerated. Bone age corresponds to calendar age. During reproductive age, dysfunctional uterine bleeding is possible.

Feminizing tumors in old age usually manifest as metrorrhagia, which is a particularly significant symptom of the tumor. In the postmenopausal period, the level of estrogen hormones is increased with “rejuvenation” of the patient. Proliferative processes can be detected in the endometrium: glandular cystic hyperplasia, often with atypia of varying degrees, endometrial polyps, and the possible development of endometrial adenocarcinoma.

Diagnosis established on the basis of the expressed clinical picture, data from a general examination and gynecological examination, functional diagnostic tests, hormone levels, ultrasound with colorectal dosage, laparoscopy.

Feminizing ovarian tumors with two-handed vaginal-abdominal study are defined as unilateral formations with a diameter of 4 to 20 cm (average 10-12 cm), dense or tight-elastic

skoy consistency (depending on the proportion of fibrous or thecamatous stroma), mobile, smooth-walled, painless.

Granulosa cell tumor It has a clear capsule, on the section - pronounced lobulation and yellow color, focal hemorrhages and areas of necrosis. U tecoms the capsule is usually absent: the section shows a solid structure, tissue with a yellowish tint up to an intense yellow color. Foci of hemorrhage and cysts are not typical. In most cases, thecomas are unilateral and rarely become malignant. The diameter ranges from 5 to 10 cm.

On echograms, feminizing tumors are visualized as a unilateral, rounded formation with a predominantly echo-positive internal structure and echo-negative inclusions, often multiple. The diameter of the tumor is 10-12 cm.

The tumor may have cystic variants; in such cases it resembles ovarian cystadenoma. The sound conductivity of tumors is normal. Comparison of anamnestic data, echographic picture with visualized pathology of the endometrium (especially in postmenopausal age) helps to establish the correct diagnosis.

With CDK, multiple zones of vascularization are visualized both in the tumor itself and along its periphery. The internal structures of the formation have the appearance of a motley mosaic with a predominance of venous blood flow. In the spectral Doppler mode, blood flow in ovarian tumors has a low systolic velocity and low resistance (IR).<0,4). Точность диагностики при УЗИ с ЦДК составляет 91,3% (рис. 16.16, 16.17)

Feminizing tumors can be benign (80%) or malignant. Malignancy is determined by metastases and relapses. Metastases occur predominantly in the serous covering of the abdominal organs, on the parietal peritoneum and in the omentum. Granulosa cell tumor is most often malignant, and very rarely - thecoma.

Treatment for feminizing tumors, surgery is the only option. The volume and access (laparotomy-laparoscopy) depend on the patient’s age, size

Rice. 16.16. Thecoma of the ovary. Ultrasound, CDC

Rice. 16.17. Granulosa cell tumor. Ultrasound,

CDC

formation, condition of the other ovary and concomitant genital and extragenital pathology.

During the operation, an urgent histological examination, revision of the abdominal cavity, and a thorough examination of the collateral ovary are performed. If it increases, a biopsy is indicated; they try to determine the condition of the para-aortic lymph nodes.

In girls with a benign granulosa cell tumor, only the affected ovary is removed; in patients of the reproductive period, removal of the uterine appendages on the affected side is indicated. In peri- and postmenopausal age, supravaginal amputation of the uterus with appendages or extirpation of the uterus with appendages is performed (depending on changes in the endometrium). Small tumors can be removed by surgical laparoscopy.

In case of a malignant tumor (according to the results of an urgent histological report), extirpation of the uterus with appendages on both sides and removal of the omentum are indicated.

Ovarian fibroma occupies a special place among fibroids and develops from connective tissue. Essentially it is a hormonally inactive thecoma. The structure of the tumor is represented by intertwined bundles of spindle-shaped cells that produce collagen.

Ovarian fibroma is a relatively rare benign tumor. Fibromas make up from 2.5 to 4% of all tumors, occur at any age (more often at 40-60 years), tumor sizes range from 3 to 15 cm. Ovarian fibroma does not occur before puberty. Patients have an unfavorable premorbid background with frequent disturbances of menstrual and generative functions. Perhaps these disorders are caused by the same etiological factor that caused the tumor.

Ovarian fibroids are often combined with uterine fibroids. Both fibroma and cyst in the same ovary cannot be excluded. When combined with other diseases, the clinical picture is determined by the totality of their symptoms.

Ovarian fibroids are often discovered accidentally during surgery. The growth of fibroma is slow, but with dystrophic changes the tumor can quickly increase in size.

The tumor does not secrete steroid hormones, but in 10% of cases it may be accompanied by Meigs syndrome (ascites in combination with hydrothorax and anemia). The development of these processes is associated with the release of edematous fluid from the tumor tissue and its entry from the abdominal cavity into the pleural cavities through the hatches of the diaphragm. On section, fibroid tissue is usually dense, white, fibrous, sometimes with areas of edema and cystic degeneration; calcification is possible, sometimes diffuse. The tumor is localized in one ovary in the form of a clearly defined node.

With an increase in mitotic activity, the tumor is classified as borderline with low malignant potential.

Ovarian fibroma is diagnosed based on the clinical course of the disease and data from a two-manual vaginal-abdominal examination. The tumor must be differentiated from a pedunculated subserous myomatous node, as well as from tumors of other structures. A gynecological examination reveals a volumetric formation with a diameter of 5-15 cm, round or ovoid, dense, almost rocky consistency, with a smooth surface, mobile, painless, on the side or behind the uterus. Ovarian fibroma is often accompanied by ascites, so it is sometimes mistaken for a malignant neoplasm.

Diagnostics is helped by ultrasound with color circulation. Echograms show a round or oval formation with clear, even contours. The internal structure is predominantly homogeneous, echo-positive, with average or reduced echogenicity. Sometimes echo-negative inclusions are detected, indicating degenerative changes. Directly behind the tumor, pronounced sound absorption is determined. With CDK, the vessels in fibromas are not visualized, the tumor is avascular. The sensitivity and specificity of MRI and CT in the diagnosis of ovarian fibroma are equivalent to those of ultrasound.

At laparoscopy, ovarian fibroma is round or ovoid, with a smoothed surface relief and poor vascularization. The capsule is usually whitish, vessels are identified only in the area of ​​the fallopian tube. A whitish-pink tint of the color of the capsule is also possible. The consistency of the tumor is dense.

Treatment of fibroma is surgical. The scope and access of surgical intervention depend on the size of the tumor, the age of the patient and concomitant gynecological and extragenital diseases. As a rule, the uterine appendages are removed on the affected side in the absence of indications for hysterectomy in patients of reproductive age. For small tumors, laparoscopic access is used.

The prognosis is favorable.

Stromal cell tumors (androblastoma, Sertoli tumor). An-

droblastoma is a hormonally active masculinizing tumor and accounts for about 1.5-2% of all ovarian tumors. This is a masculinizing hormone-producing tumor containing Sertoli-Leydig cells (hilus and stromal). Formed in excess an-

Drogens inhibit the function of the pituitary gland, and the production of estrogen in the body decreases. The tumor is predominantly benign. Androblastoma occurs in patients under 20 years of age and in girls; in these cases, isosexual precocious puberty is often noted. The diameter of the formation is from 5 to 20 cm. The capsule is often clearly defined, the structure is often lobular, on the section the tumor is solid, yellowish, orange or orange-gray in color. The surviving other ovary is always atrophic and fibrous, as in postmenopausal women.

The main clinical manifestation of the tumor is virilization. Against the background of general health, amenorrhea occurs, infertility is noted, the mammary glands decrease (defeminization), later signs of masculinization appear - the voice becomes rougher, male-type hair develops (hirsutism), libido increases, the thickness of subcutaneous fatty tissue decreases, hypertrophy of the clitoris occurs, body contours and faces acquire masculine features. Symptoms of the disease usually develop gradually.

Clinical manifestations mainly depend on age. During the reproductive period, the patient consults a doctor, usually about amenorrhea and infertility. During menopause and postmenopause, in most cases, clinical signs are considered age-related phenomena and only with the development of masculinization do patients consult a doctor. The tumor develops slowly, so earlier visits to the doctor are usually associated with pain in the lower abdomen (with complications).

The diagnosis is established on the basis of the clinical picture and data from a two-manual vaginal-abdominal examination, as well as ultrasound with colorectal dosage.

During a gynecological examination, the tumor is determined on the side of the uterus, it is unilateral, mobile, painless, with a diameter of 5 to 20 cm, oval in shape, dense consistency, with a smooth surface. Ultrasound distinguishes solid, cystic and cystic-solid types. The echographic picture shows a heterogeneous internal structure with multiple hyperechoic areas and hypoechoic inclusions.

Doppler ultrasound has no definite value in determining the morphological structure of the tumor, but sometimes helps to detect the tumor.

Treatment For virilizing ovarian tumors, surgery is performed using both laparotomic and laparoscopic approaches. The volume and access during surgical treatment depend on the age of the patient, the size and nature of the space-occupying formation. For androblastoma in girls and patients of reproductive age, it is enough to remove the uterine appendages on the affected side. In postmenopausal patients, supravaginal amputation of the uterus and appendages is performed. After removal of the tumor, the woman’s body functions are restored in the same sequence in which the symptoms of the disease developed. A woman’s appearance changes very quickly, menstrual and reproductive functions are restored, but deepening of the voice, clitoral hypertrophy and hirsutism can remain for life. If a malignant tumor is suspected, panhysterectomy and removal of the omentum are indicated.

The prognosis for a benign tumor is favorable.

Germ cell tumors

Germ cell neoplasms arise from the primary germ cells of the embryonic gonads and their derivatives, from the three germ layers - ectoderm, mesoderm and endoderm.

Dysgerminoma (ovarian seminoma) - a malignant tumor of the ovary, has a strong resemblance to the corresponding testicular tumor. Dysgerminomas account for about 1-2% of ovarian tumors and about 3% of all malignant tumors. They are most often detected between the ages of 10 and 30 years (in approximately 5% of cases under 10 years of age and very rarely after 50 years of age).

Dysgerminoma is the most common malignant tumor in pregnancy. Consists of cells morphologically similar to primordial follicles. Dysgerminomas are believed to originate from primary germ cells. Normally, at the time of birth, all germ cells are part of the primordial follicles; germ cells that do not form follicles die. If this does not happen, then the germ cells acquire the ability to proliferate uncontrollably and give rise to a tumor. Dysgerminoma occurs in adolescents and young women with general and genital infantilism with late menarche. Abnormalities of the external genitalia are often observed. The tumor is usually unilateral.

A typical dysgerminoma is a solid tumor of a round or ovoid shape with a smooth whitish fibrous capsule. The tumor can reach significant sizes, completely replacing ovarian tissue; dysgerminoma with small nodes has a different consistency.

On the section, the tumor tissue is yellowish, pale brown with a pink tint. Large tumors are usually mottled due to hemorrhages and foci of necrosis of varying duration.

Clinical manifestations do not have specific signs. Hormonal activity is not typical for dysgerminoma.

The patients' complaints are nonspecific, sometimes there is a dull nagging pain in the lower abdomen, general malaise, dysuria, weakness, drowsiness, fatigue, and the menstrual cycle is often disrupted: prolonged amenorrhea can be replaced by uterine bleeding. Dysgerminoma is prone to rapid growth, metastatic spread and invasion into neighboring organs. Metastasis usually occurs lymphogenously with damage to the lymph nodes of the common iliac artery, the distal abdominal aorta and supraclavicular lymph nodes. Hematogenous metastases occur in the terminal stage of the disease, most often in the liver, lungs, and bones. Manifestations of dysgerminoma metastases are similar to the picture of the primary tumor.

Diagnosis established on the basis of the clinical course of the disease, data from a two-manual gynecological examination, ultrasound with colorectal dosage and morphological examination of the removed macroscopic specimen. During a gynecological examination, the tumor is usually located behind the uterus, often one-sided, round, with unclear contours, dense, tuberous.

flock, with a diameter of 5 to 15 cm (usually reaching large sizes), in the initial stage mobile, painless.

Ultrasound with color circulation is of great help. On echograms, the tumor has an echo-positive, medium echogenicity, often lobular structure. Inside the neoplasm there are often areas of degenerative changes, the contours are uneven, and the shape is irregular.

Doppler examination reveals multiple areas of vascularization both in the periphery and in the central structures of the tumor: with low IR (<0,4).

Treatment For dysgerminomas, only surgery followed by radiation therapy. It is advisable to use laparotomy access. With a unilateral tumor without signs of spread beyond the affected ovary in young women planning to have children in the future, we can limit ourselves to removing the uterine appendages on the affected side. In perimenopausal patients, extirpation of the uterus and appendages is performed, and the omentum is removed. During surgery, the integrity of the capsule should not be violated, as this significantly worsens the prognosis.

If the tumor spreads beyond the ovary, a more radical operation is indicated - removal of the uterus with appendages and omentum, followed by radiotherapy. Enlarged lymph nodes are subject to removal, and their area is subject to radiotherapy. Both the primary tumor and metastatic nodes respond well to radiotherapy. Pure forms of dysgerminomas are highly sensitive to radiation therapy, which determines the relatively favorable prognosis of the disease.

With proper treatment, complete recovery is possible. Currently, the 5-year survival rate of patients with unilateral encapsulated dysgerminoma without metastases reaches 90%. In terms of prognosis, metastases and germination beyond the ovary, large size and bilateral localization of dysgerminoma are unfavorable.

Teratomas. Mature teratoma refers to germ cell tumors. Depending on tissue differentiation, teratomas are divided into mature (dermoid cyst) and immature (teratoblastoma).

Mature teratomas are divided into solid (without cysts) and cystic (dermoid cyst). There are also monodermal teratomas - struma ovary and carcinoid ovary; their structure is identical to normal thyroid tissue and intestinal carcinoids.

Mature cystic teratoma is one of the most common tumors in childhood and adolescence; can occur even in newborns, which indirectly indicates its teratogenic origin. Mature teratoma occurs in reproductive age, in the postmenopausal period (as an accidental finding). It consists of well-differentiated derivatives of all three germ layers with a predominance of ectodermal elements (hence the term “dermoid cyst”). The tumor is a single-chamber cyst (a multi-chamber structure is rarely observed), is always benign and only rarely shows signs of malignancy. The structure of dermoid cysts includes the so-called dermoid tubercle, in which mature tissues and rudimentary organs are identified.

The capsule of a dermoid cyst is dense, fibrous, of varying thickness, the surface is smooth and shiny. A teratoma on a section resembles a bag containing a thick mass consisting of fat and hair, in the form of balls or strands of various lengths; well-formed teeth are often found. The inner surface of the wall is lined with columnar or cubic epithelium. Microscopic examination reveals tissues of ectodermal origin - skin, elements of neural tissue - glia, neurocytes, ganglia. Mesodermal derivatives are represented by bone, cartilage, smooth muscle, fibrous and adipose tissue. Endoderm derivatives are less common and usually include bronchial and gastrointestinal epithelium, thyroid and salivary gland tissue. The object of particularly careful histological examination should be the dermoid tubercle in order to exclude malignancy.

Symptoms Dermoid cysts differ little from those of benign ovarian tumors. A dermoid cyst does not have hormonal activity and rarely causes complaints. The general condition of the woman, as a rule, does not suffer. Pain syndrome is observed in a small number of observations. Sometimes dysuric phenomena appear, a feeling of heaviness in the lower abdomen. In some cases, the pedicle of the dermoid cyst becomes torsed, causing symptoms of an “acute abdomen” that require emergency surgical intervention.

A dermoid cyst is often combined with other tumors and tumor-like formations of the ovaries. It is extremely rare for a mature teratoma to develop a malignant process, mainly squamous cell carcinoma.

Diagnosis established on the basis of the clinical course of the disease, two-manual gynecological examination, the use of ultrasound with colorectal dosage, laparoscopy.

During gynecological examination, the tumor is located mainly anterior to the uterus; it is round in shape, with a smooth surface, has a long stem, is mobile, painless, and has a dense consistency. The diameter of a mature teratoma is from 5 to 15 cm.

A dermoid cyst involving bone tissue is the only tumor that can be identified on a plain X-ray of the abdominal cavity. Echography helps to clarify the diagnosis of mature teratomas (pronounced acoustic polymorphism).

Mature teratomas have a hypoechoic structure with a solitary echogenic inclusion, with clear contours. Directly behind the echogenic inclusion there is an acoustic shadow. Mature teratomas may have an atypical internal structure. Multiple small hyperechoic inclusions are visualized inside the tumor. In some cases, a weak enhancement effect is visualized behind the small-streak inclusions - a “comet tail”. Possibly a cystic-solid structure with a dense component with high echogenicity, round or oval shape, with smooth contours. Polymorphism of the internal structure of the tumor often creates difficulties in the interpretation of echographic pictures (Fig. 16.18).

Rice. 16.18. Mature teratoma. Ultrasound

With CDK, vascularization is almost always absent in mature teratomas; blood flow can be visualized in the ovarian tissue adjacent to the tumor; IR is within 0.4.

As an additional method in the diagnosis of mature teratomas after the use of ultrasound, it is possible to use CT.

During laparoscopy, the dermoid cyst is of an uneven yellowish-whitish color; upon palpation with a manipulator, the consistency is dense. The location of the cyst in the anterior fornix, in contrast to tumors of other types, usually located in the utero-rectal space, has a certain differential diagnostic significance. The stalk of a dermoid cyst is usually long and thin, and there may be small hemorrhages on the capsule.

Treatment mature teratomas surgical. The scope and access of surgical intervention depend on the size of the space-occupying lesion, the age of the patient and concomitant genital pathology. In young women and girls, partial resection of the ovary within healthy tissue (cystectomy) should be limited, if possible. It is preferable to use a laparoscopic approach using an evacuation bag. In perimenopausal patients, supravaginal amputation of the uterus with appendages on both sides is indicated. It is permissible to remove the uterine appendages from the affected side if the uterus is not changed.

The prognosis is favorable.

Teratoblastoma (immature teratoma) refers to malignant neoplasms of the ovary. The tumor is extremely immature and has low differentiation. Immature teratoma is much less common than mature teratoma. The tumor tends to grow rapidly and can reach significant sizes. Microscopic examination reveals a combination of derivatives of all 3 germ layers. The cut surface is usually variegated, from pale gray to dark brown. Upon examination, bones, cartilage, hair are determined; the tumor contains fatty masses.

The tumor is usually located on the side of the uterus. It is one-sided, irregular in shape, unevenly soft, in places dense in consistency - depending on the predominant type of tissue and necrotic changes, large in size, with a bumpy surface, inactive, sensitive to palpation. When the capsule grows, it is implanted into the peritoneum and metastasizes to the retroperitoneal lymph nodes, lungs, liver, and brain. Metastases of immature teratoma, like the main tumor, usually consist of various tissue elements with the most immature structures.

Patients complain of pain in the lower abdomen, general weakness, lethargy, increased fatigue, and decreased ability to work. Menstrual function is often not impaired. A blood test reveals changes characteristic of malignant tumors. With rapid growth, the clinical picture due to intoxication, decay and metastasis of the tumor is similar to that of general somatic diseases. This often leads to inadequate treatment. By the time of recognition, the tumor is already advanced.

The use of echography with color dispersion helps to clarify the diagnosis. Sonographic images reflect a mixed, cystic-solid structure of an immature teratoma with uneven, unclear contours. Like all malignant tumors, immature teratoma has a chaotic internal structure with pronounced neovascularization. With CDK, a pronounced mosaic pattern with turbulent blood flow and predominantly centrally located arteriovenous shunts is visualized. The peripheral resistance index is reduced (IR<0,4).

Treatment surgical. Supravaginal amputation of the uterus with appendages and removal of the omentum are acceptable. Immature teratomas are insensitive to radiation therapy, but can sometimes respond to combination chemotherapy. The prognosis is unfavorable.

16.3. Ovarian cancer

Early diagnosis and treatment of ovarian cancer remains one of the most difficult problems in oncology. Over the last 10 years, both in Russia and throughout the world, there has been a clear trend towards an increase in the incidence of ovarian cancer. It consistently ranks 2nd in the structure of gynecological tumors (after cervical cancer), and remains in 1st place in terms of mortality.

Currently, the etiological factors of malignant ovarian tumors have not been reliably determined. There are three main hypotheses. According to the first, ovarian tumors arise in conditions of hyperactivity of the hypothalamic-pituitary system, resulting in chronic hyperestrogenism. Estrogens do not directly lead to tumor transformation of cells, but create conditions under which the likelihood of cancer in estrogen-sensitive tissues increases. Another hypothesis is based on the concept of “continuous ovulation” (early menarche, late menopause, few pregnancies, shortened lactation). Constant ovulation leads to damage

destruction of the epithelium of the ovarian cortex, which, in turn, increases the likelihood of aberrant DNA damage with simultaneous inactivation of tumor suppressing genes. According to the third, genetic hypothesis, high-risk individuals include members of families with autosomal dominant breast and ovarian cancer.

According to world literature, hereditary forms of ovarian cancer are found in only 5-10% of patients. Advances in genetic engineering have made it possible to identify a number of oncogenes, the expression of which is associated with familial forms of ovarian cancer.

There is a relationship between the frequency of tumors of various morphological types and the age of patients. The peak incidence of ovarian cancer occurs between 60 and 70 years of age, but recently it has been recorded 10 years earlier.

Ovarian cancer can be primary, secondary and metastatic.

The specific incidence of primary cancer is no more than 5%. In primary cancer, the tumor is formed from the covering epithelium of the ovary, therefore, there is no mixture of benign and malignant elements. Primary cancer are called malignant tumors that primarily affect the ovary. According to histological structure, primary ovarian cancer is a malignant epithelial tumor of glandular or papillary structure (Fig. 16.19).

Secondary ovarian cancer(cystadenocarcinoma) is the most common and accounts for 80-85% of all forms of ovarian cancer; develops against the background

Rice. 16.19. Serous papillary ovarian cancer (serous cystadenocarcinoma). Hematoxylin and eosin staining, × 200. Photo by O.V. Zairatiantsa

benign or borderline tumors. Most often, secondary ovarian cancer occurs in serous papillary, less often in mucinous cystadenomas. Secondary lesions of the ovaries also include endometrioid cystadenocarcinoma.

Metastatic ovarian cancer(Krukenberg tumor) is a metastasis from the primary focus, which is most often located in the gastrointestinal tract, stomach, mammary gland, thyroid gland, and uterus. Metastases from malignant tumors of the gastrointestinal tract spread by hematogenous, retrograde lymphogenous and implantation routes. Metastases are usually bilateral. Ascites occurs in 60-70% of cases. The tumor grows very quickly. Macroscopically, the metastatic tumor is whitish, lumpy, and often fibrous on section. It may have a dense or doughy consistency, which depends on the ratio of the stroma and parenchyma of the tumor, as well as on secondary changes in the form of edema or necrosis. Microscopically, in metastatic cancer, ring-shaped round cells filled with mucus are determined.

Currently, a Unified International Classification has been adopted, which reflects both the stage of the process and the histological type of tumor.

The stage of the tumor process is determined based on clinical examination data and during surgery.

Classification of ovarian cancer

Stage I - the tumor is limited to one ovary.

Stage II - the tumor affects one or both ovaries and spreads to the pelvis.

Stage III - spread to one or both ovaries with peritoneal metastases beyond the pelvis and (or) metastases to the retroperitoneal lymph nodes.

Stage IV - spread to one or both ovaries with distant metastases.

Clinical picture. The diversity of morphological forms is one of the reasons for the heterogeneity of the clinical course of ovarian cancer. There are no pathognomonic signs. Localized forms of ovarian cancer, as a rule, remain asymptomatic; in young patients, pain sometimes occurs up to a pronounced “acute abdomen” (22%) due to the possibility of torsion of the leg or perforation of the tumor capsule. In other patients, symptoms appear due to the prevalence of the tumor process: intoxication, weight loss, general weakness, malaise, increased fatigue, decreased and perverted appetite, increased temperature, dysfunction of the gastrointestinal tract (nausea, vomiting, feeling of fullness in the epigastric region, heaviness lower abdomen, constipation alternating with diarrhea, dysuric phenomena). The abdomen becomes enlarged due to ascites. There may be effusion in one or both pleural cavities. Signs of cardiovascular and respiratory failure and swelling in the lower extremities appear.

Diagnostics diagnosis of a malignant tumor can be difficult due to the lack of pathognomonic symptoms in the early stages of the disease. Malignant neoplasms do not have obvious clinical signs,

distinguishing them from benign tumors. In this regard, patients at high risk for developing ovarian tumors require special attention. These are women with impaired ovarian function, long-term observation for tubo-ovarian inflammatory formations, recurrent hyperplastic processes of the endometrium in postmenopause, previously operated on for benign ovarian tumors, patients with impaired fertility function.

A bimanual gynecological examination often reveals bilateral tumors of oval or irregular shape, with a lumpy surface, dense consistency, of varying sizes, limited mobility and (or) immobility. Behind the uterus, dense, painless formations protruding into the rectum - “spikes” - are palpated.

In ovarian cancer, ascites is usually pronounced. Rectovaginal examination is necessary to determine the invasion of the cancer process into the pararectal and pararectal tissue.

Modern diagnosis of malignant ovarian tumors includes transvaginal echography using acoustic emitters with high resolution and color flow, which allows visualization of the blood flow of the organ. Measuring blood flow in systole and diastole makes it possible to judge the resistance of blood flow by calculating indicators of peripheral vascular resistance.

Echographically, a large volume formation is revealed, often bilateral, irregular in shape, with a thick, uneven capsule, with multiple papillary growths and septa (Fig. 16.20, 16.21). The septums, as a rule, are of unequal size; free fluid (ascites) is detected in the pelvis and abdominal cavity.

At color dopplerography in malignant ovarian tumors, many vessels (zones of neovascularization) are identified both along the periphery and in the central structures of the tumor on the septa and in papillary growths with low blood flow resistance (IR)<0,4) (рис. 16.22,

16.23).

Rice. 16.20. Ovarian cancer.

Ultrasound

Rice. 16.21. Ovarian cancer. Growths along the inner wall. 3D reconstruction

Rice. 16.22. Ovarian cancer. Ultrasound, CDC

Rice. 16.23. Ovarian cancer. Three-dimensional reconstruction of a newly formed vascular bed

CT and MRI.On computed tomograms, malignant neoplasms are visualized as volumetric formations, with uneven, bumpy contours, a heterogeneous internal structure (areas of fluid and soft tissue density), a thickened capsule with internal partitions of unequal thickness. CT allows you to determine clear boundaries between the uterus, bladder and intestines and thereby identify the adhesive process in the pelvis.

Laparoscopy makes it possible to perform a biopsy with a morphological study of the histiotype of the material and a cytological study of the peritoneal fluid.

The content of tumor-associated antigens in the blood serum of patients correlates with the course of the disease. The most important markers are CA-125, CA-19.9, CA-72.4. CA-125, which are found in 78-100% of ovarian cancer patients. The CA-125 level is above normal (35 IU/ml). In the initial forms of the tumor process, the specificity of CA-125 is low, so the tumor marker cannot be used as a screening test. CA-125 is of great value as a control of the effectiveness of treatment of common forms of the disease and during subsequent monitoring. In 80-85% of patients, the diagnosis can be established using the listed methods, although in some cases the final diagnosis is possible during laparotomy (Fig. 16.24).

Algorithm for examining patients with suspected ovarian cancer:

1) two-manual vaginal and rectovaginal examination;

2) Ultrasound of the pelvic organs with color circulation;

3) Ultrasound of the ovarian mass in 3D mode;

4) Ultrasound of the abdominal cavity, thyroid gland, breast;

5) RCT;

6) MRI;

7) mammography;

8) fluoroscopy, gastroscopy, irrigoscopy, colonoscopy;

Rice. 16.24. Ovarian cancer. Macropreparation

9) X-ray of the chest organs;

10) chromocystoscopy.

It is advisable to perform a chest X-ray to exclude metastases.

In addition to the listed methods, the stage of the malignant process can be clarified by chromocystoscopy (especially for large, immobile ovarian tumors). Patients with a diagnosed or suspected ovarian tumor (regardless of stage) must undergo surgery.

Treatment. When choosing treatment tactics for patients with ovarian cancer, one should take into account the stage of the process, the morphological structure of the tumor, the degree of differentiation, the potential sensitivity of a given tumor histiotype to chemotherapy and radiation treatment, aggravating factors, the patient’s age, immune status, chronic diseases as a contraindication to a particular treatment method .

Treatment for ovarian cancer is always complex. The leading, although not independent, method remains surgical: extirpation of the uterus and appendages and extirpation of the diseased omentum. For transection, a lower median laparotomy is used. This ensures removal of the tumor into the wound without breaking its capsule, creates conditions for a thorough inspection of the abdominal organs, and makes it possible, if necessary, to perform the operation in full.

In some patients (weak, elderly, with severe extragenital pathology), we can limit ourselves to supravaginal amputation of the uterus with appendages and subtotal resection of the greater omentum. The greater omentum must be removed and subjected to morphological examination. Removal of the omentum prevents the subsequent development of ascites (Fig. 16.25).

In young patients with malignant neoplasms, removal of the uterine appendages on the affected side, resection of the other ovary and subtotal resection of the greater omentum are acceptable. Similar

Rice. 16.25. Ovarian cancer. Metastasis to the omentum

Operations can only be performed on patients with stage I malignant transformation of the ovary. In stage II ovarian cancer, a radical operation is performed, which involves extirpation of the uterus with appendages and resection of the omentum.

The exact stage of the disease can only be determined with a thorough examination of the abdominal cavity. Be sure to examine the peritoneal fluid and inspect the para-aortic lymph nodes. Enlarged lymph nodes are punctured or biopsied for cytomorphological examination. If there is doubt about the patient's operability, it is advisable to perform surgical intervention at the 2nd stage, after chemotherapy, which increases the radicality of subsequent surgical treatment.

Control questions

1. Give the classification of ovarian tumors.

2. Epithelial tumors of the ovaries. What are their diagnosis and management tactics?

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Liver masses are being diagnosed more and more often, which is also explained by the spread of modern imaging techniques such as CT.

In most cases, liver tumors are not cancerous and sometimes do not even require treatment. However, formations found in the liver should not be taken lightly.

In US clinics, such diseases are dealt with by special multidisciplinary teams of doctors, including radiologists, hepatologists (liver disease specialists), oncologists and surgeons.

Benign formations in the liver are usually divided into solid and cystic.

Solid formations in the liver

1. Liver hemangioma.

Hemangiomas are the most common benign liver tumors. They are more common in women and may depend on hormonal levels. Symptoms of a hemangioma may include pain (usually for tumors larger than 6 cm) due to pressure on adjacent structures. Bleeding is rare. Diagnosis is carried out using CT or MRI. For asymptomatic hemangioma, regardless of size, American doctors usually do not recommend any intervention. For symptomatic tumors - surgical resection (removal).

2. Focal nodular hyperplasia (FNH).

Focal nodular (nodular) hyperplasia is the second most common benign tumor in the liver. It usually causes no symptoms, does not develop into cancer, and is not associated with a risk of rupture. Symptomatic FNH is usually large in size and causes compression of adjacent structures. Laboratory parameters are often normal, and the formation is confirmed radiologically. Sometimes a biopsy is recommended. Surgical removal is indicated only when the formation bothers the patient or the diagnosis is in question.

3. Liver adenoma.

Liver adenomas are quite rare, and there is a very strong association with the use of oral contraceptives. Large adenomas can cause pain, discomfort and a feeling of heaviness. Other symptoms include nausea, vomiting, and fever. Large tumors may cause bleeding (40%) and become malignant in approximately 10% of cases. MRI is used for diagnosis, sometimes a biopsy is required.

If the tumor was caused by taking oral contraceptives, then treatment consists of discontinuing COCs followed by monitoring. American doctors recommend removing all adenomas where malignancy (malignant degeneration) cannot be ruled out.

4. Focal fatty changes.

Focal fatty changes (FFC) occur more often in patients who have a history of diabetes, obesity, hepatitis C, or severe malnutrition. FFC can be asymptomatic, that is, it does not bother the patient in any way. These formations are diagnosed using MRI, and sometimes a biopsy is prescribed. Specific treatment is usually not required.

5. Nodular regenerative hyperplasia.

Nodular regenerative hyperplasia of the liver is very close to focal nodular hyperplasia. May cause symptoms associated with compression of adjacent structures. Occurs in autoimmune diseases such as rheumatoid arthritis. In some cases, it can develop into hepatocellular carcinoma (cancer).

Cystic formations in the liver

American experts recommend dividing cystic masses in the liver into two broad categories: infectious and non-infectious.

Non-infectious cystic formations in the liver:

1. Common bile duct cyst.

A common bile duct cyst is a kind of expansion of the bile duct of the liver. May be congenital or develop during life. In the latter case, it is detected mainly by chance. If a common bile duct cyst causes symptoms, these may include pain, nausea, vomiting, fever, and jaundice. Rarely, liver inflammation and cirrhosis may occur as a result of chronic obstruction of the bile ducts.

In a very rare hereditary disease, Caroli syndrome, pouch-like dilatation of the ducts can also be observed. Diagnosis requires imaging and a biopsy of the bile duct to rule out cancer. Treatment is surgical.

2. Simple liver cyst.

A simple liver cyst is a hollow formation, mostly single, filled with fluid. A simple cyst may be present from birth and remain undiagnosed until the age of 30-40. Sometimes a cyst causes symptoms: pain, discomfort, a feeling of fullness. Diagnosed radiologically. Symptomatic cysts can be treated by marsupialization (cutting and emptying the cyst contents), sometimes requiring partial liver resection.

3. Polycystic liver disease (PCLD).

Polycystic liver disease is an inherited disease that can be associated with cystic formations in the kidneys. Most patients have no symptoms and laboratory tests are normal. Liver cysts are numerous and tend to grow slowly. The symptoms are similar to a simple liver cyst. Ultrasound and CT scanning reliably identify these formations.

In the United States, genetic tests have long been developed that detect PCLD and help in genetic counseling for couples. Treatment for polycystic liver disease is the same as for simple cysts. If necessary, patients are put on a waiting list for a liver or kidney transplant if these organs are too damaged.

Infectious cystic formations in the liver:

1. Liver abscess.

Liver abscess is of bacterial origin. There are many situations in which a bacterial infection can enter the liver and cause an abscess. Pathological processes inside the bile ducts, which are accompanied by their obstruction, are responsible for most cases of the formation of abscesses in the liver.

Other possible causes: abdominal infections, liver injury, certain types of liver cancer therapy (TACE, RFA). In addition, infections from distant sites (dental infections or endocarditis) can travel to the liver and cause an abscess. According to American doctors, in 55% of cases the exact cause of the abscess cannot be determined. Symptoms of a liver abscess include fever, chills, nausea, vomiting, abdominal pain, and loss of appetite. A serious complication is rupture of the abscess. Treatment: antibiotic therapy, surgery.

Amoebic abscesses are common in people with weak immune systems, malnutrition, or cancer. Before the formation of a liver abscess, intestinal symptoms are observed in less than 1/3 of patients. Symptoms of an abscess include fever, severe pain, and mild jaundice (8%). 95% test for antibodies is positive. When making a diagnosis, CT or ultrasound is used. Treatment: infection control, sometimes aspiration of the abscess, surgical treatment.

With an hydatid cyst of the liver, the patient may experience pain and a feeling of heaviness. Pain is usually noted when the cyst becomes infected or ruptures. Some patients experience an acute allergic reaction when they rupture.

Hydatid cysts are diagnosed radiologically. In the United States, blood tests for antibodies are widely used to confirm invasion. Treatment includes chemotherapy (mebendazole and albendazole) and surgery (drainage or radical excision).

Konstantin Mokanov

A cyst is considered a benign tumor in the form of a sac that contains fluid. The size of this formation can vary from several mm to 15 cm. It can also have different localization, both inside and outside the organ. The tumor affects the ovary, kidneys, liver, urethra, pancreas, thyroid and mammary glands, and can be detected on the tailbone and some other organs.

A woman most often has no signs of a cyst. This pathology manifests itself clinically only with a significant increase in the cyst and compression of nearby organs.

A cystic formation can be diagnosed in a woman of any age. Often it disappears spontaneously and then appears again. You can read about why cysts form in.

In women, cysts come in several varieties. The reasons for the occurrence of one or another cystic formation are different. There are several general factors that contribute to their occurrence.

Among the reasons for the formation of cysts are:

• Disturbed menstrual cycle. A woman may complain of a prolonged absence of menstruation or, conversely, of a longer duration. Any irregularities in menstruation are caused by hormonal imbalance, which can lead to the formation of a cystic cavity.
• Changed hormonal levels. This can provoke the appearance of a cyst and also negatively affect the process of its treatment.
• Surgical interventions. Any surgical procedure can provoke the formation of cysts in the future. Women who have undergone a caesarean section, abortion or any other surgical intervention are at risk.
• Frequent stress. In people whose lives are full of experiences, metabolic processes are often disrupted, and pathology of the endocrine glands also occurs. These changes can provoke the formation of cystic neoplasms.
• Long-term use of hormones. These medications must be taken under the strict supervision of a physician. The drug should also be replaced in a timely manner, which will prevent the development of adverse consequences in the future.
• Infectious processes in the body. Absolutely any infection can provoke the formation of a cyst, so you should promptly treat all emerging diseases. Cysts in the ovary also form with frequent changes of sexual partners.

To make a correct diagnosis and subsequent effective treatment, you need to understand in detail the type of tumor, as well as the features of its treatment.

There are many types of cystic formations. Cysts are most often classified depending on the cause of their appearance and the nature of their contents.

There are cysts:

1. . This cyst can be luteal (the functioning of the corpus luteum is disrupted) and follicular (the cause of which is an unruptured graafian vesicle). In menopausal women, this pathology cannot be diagnosed.
2. Endometriotic in nature. This cyst appears as a result of excessive proliferation of endometrioid cells. The size of the formation can be huge, reaching 20 cm. Women complain of constant pain and disrupted menstrual cycle. Often it ruptures, which forces the woman to urgently go to the hospital.
3. . Usually this is a congenital formation containing bones, hair, and cartilage. Its formation occurs in embryogenesis. Characteristically, there are no obvious symptoms. This type of cyst requires prompt removal.
4. Formation. This formation is also called a serous cyst; it is multi-chambered and highly prone to spontaneous rupture.

Serous cysts

This group of cysts is characterized by formation inside the ovary (papillary tumor) or directly on the fallopian tube (paraturbar tumor).

Paraturbar tumors are diagnosed quite often. Their size is usually no more than 2 cm, they are filled with serous fluid and may contain several chambers. A distinctive feature of these cystic formations is their inability to transform into an oncological process.

Papillary cysts are located near the uterus. They are single-chamber, filled with transparent contents. During the growth process, they can cause discomfort in a woman. These formations will be deleted without fail.

Fibrous tumors

Another type of cyst is fibrous. It is represented by dense connective tissue and is much more difficult to treat than other cystic formations. In case of hormonal imbalances, there is a high probability of rapid tumor growth. This type of cyst includes dermoid, cystic adenoma, as well as pseudomucinous cyst, which can transform into a cancerous tumor.

Often fibrous tumors are diagnosed on the chest. In the first stages, the tumor does not manifest itself in any way, but subsequently the woman may complain of discomfort in the mammary gland. The pain is characterized by a cyclical nature, in which it intensifies before and after menstruation.

Among the reasons for the formation of fibrous growths is an increase in the mammary duct as a result of secretion accumulated in it, followed by the formation of a capsule. The size of the cyst ranges from a few mm to 5 cm.

Atypical formations

This formation is similar to a fibrous cyst. Its difference is the proliferation of cells inside the atypical formation.

The development of an inflammatory process in the cyst cavity is possible. As a result, the woman’s temperature rises, breast tenderness occurs, and regional lymph nodes become enlarged.

Cyst symptoms in a woman

The symptoms of cystic formations of various types have a certain similarity. All of them do not manifest themselves in any way at the initial stages, and only after a significant increase in their size do certain symptoms appear, which include:

• Lack of pregnancy for a long time;
• Disturbed menstrual cycle. This is explained by the intensive production of hormones by cysts;
• Pain during sexual intercourse;
• A large cystic formation can be palpated through the anterior abdominal wall;
• Complaints of lower back pain radiating to the leg;
• Disturbed urination process, characterized by pain and frequent urge. Often such manifestations are caused by the presence of a paraurethral cyst.

Depending on the location of the cyst, the formation can be palpated if it is actively growing.

Dangers and Consequences

If the pathology is not treated in a timely manner, the following dangerous consequences may occur:

• Torsion of the cyst stalk. At the same time, the woman feels pain in the lower abdomen, which requires immediate hospitalization.
• Apoplexy cyst. More often, this condition accompanies tumors of the corpus luteum and is characterized by the formation of hemorrhage. This situation also requires emergency assistance.
• Adhesive process. In addition to severe pain in the lower abdomen, infertility is diagnosed. Such complications occur more often with endometrioid cysts.
• Malignancy of the process. The provoking factors in this case are hormonal disorders, improper treatment, and poor environmental conditions.
• Development of infertility. This terrible complication can be diagnosed even after removal of the cystic formation.

The question often arises whether tumor formation is dangerous during pregnancy. The cyst must be identified and removed during pregnancy planning. If the diagnosis is made while the baby is expecting, the doctor gives his recommendations on treatment or removal of the tumor in each specific case. Hormonal changes that occur during pregnancy can provoke a sharp growth of the cyst and a high probability of its rupture.

Regular visits to the doctor will help avoid complications.

Treatment of cysts in women

Therapeutic tactics when a cystic formation is detected is determined by the location, size, and nature of the cyst.

You should definitely contact a qualified specialist to select the optimal treatment method, since in each situation the treatment is individual.

If the size of the cyst does not exceed 5 cm, they try to treat it with medication. In this case, you should be regularly observed by a specialist and undergo the necessary examinations to monitor the therapy process. In addition to the main treatment, physiotherapy is usually prescribed. The most commonly used are balneotherapy, electrophoresis and some other methods.

If conservative methods are ineffective, laparoscopic removal of the cyst is performed. This method allows the patient to recover in a short time after surgery. Often there is a need to remove part of the organ along with the tumor.

If you contact a medical facility in a timely manner and follow all medical recommendations, treatment of the cyst will be successful and result in a complete recovery.