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Background and precancerous conditions

Most malignant ovarian tumors develop against the background of previous benign tumors. Therefore, all true benign ovarian tumors should be considered as precancerous conditions.

Ovarian tumors more often develop in women with a certain premorbid background. Women with this background should be classified as a risk group for the development of ovarian tumors (background conditions).

Ovarian tumors differ from tumors of other organs by a wide variety of morphological and clinical currents. All of them can be malignant at different times and with different frequencies. Not always, even histologically, it is possible to determine the beginning of this process (malignancy). Therefore, it is considered justified to distinguish between malignant and benign ovarian tumors, highlighting borderline conditions. This is reflected in the International (WHO, 1997) classification.

International Classification of Ovarian Tumors

I. Epithelial tumors.

A. Serous tumors.

1. Benign:

a) cystadenoma and papillary cystadenoma;

b) superficial papilloma;

c) adenofibroma and cystadenofibroma.

2. Borderline (potentially low grade):

a) cystadenoma and papillary cystadenoma;

b) superficial papilloma;

c) adenofibroma and cystadenofibroma.

3. Malignant:

a) adenocarcinoma, papillary adenocarcinoma and papillary cystadenocarcinoma;

b) superficial papillary carcinoma;

c) malignant adenofibroma and cystadenofibroma.

B. Mycinous swollen.

1. Benign:

a) cystadenoma;

b) adenofibroma and cystadenofibroma.

2. Borderline (potentially low grade).

3. Malignant:

a) adenocarcinoma and cystadenocarcinoma;

b) malignant adenofibroma and cystadenofibroma.

B. Endometrioid tumors:

1. Benign:

a) adenoma and cystadenoma;

b) adenofibroma and cystadenofibroma.

2. Borderline (potentially low grade):

a) adenoma and cystadenoma;

b) adenofibroma and cystadenofibroma.

3. Malignant:

a) carcinoma:

- adenocarcinoma;

- adenoacanthoma;

- malignant adenofibroma and cystadenofibroma;

b) endometrioid stromal sarcoma;

c) mesodermal (Muller) mixed tumors, homologous and heterologous.

G. Clear cell (mesonephroid) tumors.

1. Benign: adenofibroma.

2. Borderline (potentially low grade).

3. Malignant: carcinoma and adenocarcinoma.

D. Tumors of Brenner.

1. Benign.

2. Borderline (borderline malignancy).

3. Malignant.

E. Mixed epithelial tumors.

1. Benign.

2. Borderline (borderline malignancy).

3. Malignant.

G. Undifferentiated carcinoma.

H. Unclassified epithelial tumors.

II. Tumors of the stroma of the genital cord.

A. Granulosa-stromal cell tumors.

1. Granulosa cell tumor (benign, malignant).

2. Tecom-fiber group:

a) tecom (benign, malignant);

b) fibroma;

c) unclassifiable.

3. Mixed.

B. Androblastomas, tumors from Sertoli and Leydig cells.

1. Highly differentiated:

a) tubular androblastoma; Sertoli tumor;

b) tubular androblastoma with the accumulation of lipids; Sertoli tumor with accumulation of lipids (Lesen lipid folliculoma);

c) a tumor from Sertoli and Leydig cells;

g) a tumor from Leydig cells; chylus cell tumor

2. Intermediate (transitional) differentiation.

3. Low-grade (sarcomatoid). 4. With heterologous elements.

B. Ginandroblastoma.

G. Unclassified tumors of stroma of the genital cord.

III. Lipid cell (lipoid cell) tumors.

IV. Germ cell tumors.

A. Dysgerminoma.

B. Tumor of the endodermal sinus.

B. Embryonic carcinoma.

G. Polyembryoma.

D. Chorionepithelioma.

E. Teratomas.

1. Immature.

2. Mature:

a) solid;

b) cystic:

- dermoid cyst;

- dermoid cyst with malignancy.

3. Mopodermalnye (highly specialized):

a) ovarian struma;

b) a carcinoid;

c) ovarian struma and carcinoid;

d) others.

V. Gonadoblastoma.

A. Pure (without admixture of other forms).

B. Sour cream (with dysgerminoma and other forms of germinogenic tumors).

VI. Tumors of soft tissues non-specific for the ovaries.

VII. Unclassified tumors.

Viii. Secondary (metastatic) tumors.

IX. Tumor-like processes.

A. Luteoma of pregnancy.

B. Hyperplasia of ovarian stroma and hypertosis.

B. Massive ovarian edema.

G. Single follicular cyst and corpus luteum cyst.

D. Multiple follicular cysts (polycystic ovaries).

E. Multiple luteinized follicular cysts and / or corpus luteum cysts.

J. Endometriosis.

3. Superficial epithelial inclusion cysts (germinal inclusion cysts).

I. Simple cysts.

K. Inflammatory processes.

L. Paraovarial cysts.

Tumors of group I, developing from epithelial tissue, are the most numerous. Half of them are malignant, while others are highly likely to malign.

Often there are tumors of the ovaries of group II, developing from the stroma of the genital cord. Up to 30% of them also have a malignant course, and the rest often give late (after 5-30 years) relapses.

Lipid cell tumors (group III) are extremely rare and there are almost no malignant tumors.

Of the germinogenic tumors (group IV), a benign course is observed only with mature teratomas (dermoid cysts) and highly differentiated tumors such as ovarian struma. All other tumors of this group have a malignant course.

Tumors of groups V — VII are extremely rare.

Tumors of any localization in the body can cause metastatic ovarian tumors (group VIII), which are often bilateral and clinically proceed as primary, taking into account the symptoms of primary localization.

Of the tumor-like processes (IX group), the majority are retention formations (folliculin, luteal, teca-luteal, etc.). They arise due to the accumulation of liquid contents and stretching of the capsule of the follicle, corpus luteum, etc. A characteristic feature of retention formations is the absence of proliferating cellular elements, which is inherent in true tumors. Therefore, theoretically malignancy of retention formations should not be. However, the difficulties of differential diagnosis led to the same tactics of treatment of retention formations as true ovarian tumors.

Retention formations are usually the result of hormonal disorders caused by endogenous and exogenous (iatrogenic) factors.

The clinical picture of background and precancerous ovarian diseases, on the one hand, is characterized by a variety of symptoms, often specific for each type of tumor, and on the other, their scarcity. The latter circumstance is one of the important reasons that ovarian cancer in women all over the world is often diagnosed already in advanced (III – IV) stages. It is noted that this occurs in 70-80% of cases.

The background conditions for the development of ovarian tumors are those premorbid processes that occur in women belonging to risk groups of this pathology, with the corresponding clinical picture characteristic of them.

All ovarian tumors have a single symptomatology in the event of complications such as complete or partial torsion of the legs, capsule rupture, degeneration with tumor decay.

With a complete twist of the legs of the tumor (over 180 °), its blood supply and nutrition are sharply disrupted, gradually leading to necrosis.
This is manifested by the clinical picture of “acute abdomen”: sharp pains, symptoms of peritoneal irritation (peritoneal symptoms), nausea, vomiting, fever, increased heart rate. Subsequently, a clinic of peritonitis with all common and local manifestations is observed. With a partial torsion of the legs of the ovarian tumor, the noted symptoms develop more slowly and at first are less pronounced

A pain symptom and an increase in the abdomen are characteristic of all ovarian tumors, but they are often not pronounced and are not noticed by patients.

With ovarian fibroma, the only benign tumor, in addition to tecoma, symptoms similar to malignant tumors are noted: ascites, hydrothorax and anemia (Meigs triad). Ovarian tecoma can also be accompanied by ascites in both malignant and benign course.

Masculinizing tumors are more common in adolescence and young, as well as in postmenopausal ages and will be characterized by the phenomena of defemination and then virilization. In puberty, premature sexual development of a heterosexual type is noted

Granulosa cell (feminizing) tumors are manifested by symptoms of hyperestrogenia: in girls there is premature puberty of the isosexual type, in women of childbearing age - irregularities in the menstrual cycle, in women of the postmenopausal period - uterine bleeding.

With dysgerminomas, menstrual dysfunction is also observed.

Most ovarian tumors proceed with scant symptoms, even with the onset of malignancy processes. And therefore, even ovarian cancer is often diagnosed with the development of ascites, a specific symptom for this pathology.

Diagnosis of ovarian tumors is based on anamnesis data (especially burdened by tumor diseases, including a genealogical history in relatives), clinical picture, examination, and auxiliary research methods.

Currently, it is customary to distinguish early (preclinical) and clinical diagnosis of ovarian tumors. The effectiveness of the latter is well illustrated by the data provided by Ya.V. Bohman (1989): when patients were treated up to 1 month after the onset of their first symptoms, advanced stages (III – IV) of the disease were detected in 74.7%, up to 3 months in 85.8% and up to 6 months in 90 3% of patients. Therefore, it should be remembered that, in addition to the clinical, there is a preclinical period during which a tumor (malignant) process develops. That is why preventive examinations and auxiliary research methods are considered the most important in the early diagnosis of ovarian tumors.

The cytological method (punctate from the abdominal cavity through the posterior arch, from tumors, smears from the incisions of the tumor) allows the diagnosis of malignancy in 70–95% of cases.

Using X-ray methods, it is possible to detect ovarian tumors (pneumogynecoraphia) and the presence of metastases or primary sources for metastatic cancer (fluoroscopy and radiography of the gastrointestinal tract, lungs, etc.). Computed tomography is used for the differential diagnosis of benign and malignant ovarian tumors. The nuclear magnetic resonance method is even more accurate in this regard.

Ultrasound has found the widest application for the diagnosis of ovarian tumors and has significantly limited radiological and invasive methods. Ultrasound is often used in screening for early detection of ovarian tumors in women at risk.

Laparoscopy and diagnostic laparotomy are more complex, but the most informative methods prescribed at the 2nd stage of the examination.

Benign ovarian tumors are treated surgically. An exception may be tumor-like (retention) formations, in which, given the hormonal genesis of their development, hormone therapy can be used first. This is permissible with a thorough examination, confirming their retention nature, and the exclusion of other tumor and precancerous diseases of the genitals. This risky decision can only be made in relation to young women. In such cases, hormone therapy is carried out, similar to that of glandular cystic endometrial hyperplasia in women of childbearing age. In such cases, to assess the effectiveness of the treatment, control examinations in dynamics are shown (ultrasound, colposcopy, cytology, hysteroscopy). Fundamentally, due to the difficulties of differential diagnosis, surgical intervention is performed for both tumor-like diseases of the ovaries and true tumors.

The incision of the abdominal wall during surgery should be longitudinal for subsequent follow-up examination of the abdominal organs (omentum, stomach, liver, subphrenic region, intestines) and kidneys. During the operation, additional studies are carried out to diagnose a possible malignancy of the tumor (urgent cytological examination of smears from the tumor incision). With benign ovarian tumors in young women, you can limit yourself to resection within the healthy tissue with a thorough examination of the second ovary and histological examination of the removed drug. It is not advisable to do this with ovarian tumors of groups I, II, IV and V, in which a malignant course or a high risk of the tumor becoming cancer, as well as frequent relapses, are often noted.

In borderline tumors, the choice of treatment tactics is based on individual characteristics. More often it is the same as with malignant neoplasms: extirpation or amputation of the uterus with appendages and removal of the omentum, regardless of the results of visual examination, since in the absence of foci of macroscopic lesions, microcenters of malignant growth can occur. Subsequently, such patients undergo radiation therapy and chemotherapy according to indications.

Thus, during surgical interventions for benign tumors, the following rules should be observed:

• in childhood and puberty, it is necessary to strive to maintain unchanged ovarian tissue in both unilateral and bilateral tumors;

• at the reproductive age, the principles of organ-preserving or gentle treatment should also be observed (leaving the second ovary, uterus unchanged);

• in the postmenopausal period, radical surgery is indicated - removal of the uterus with appendages;

• in the premenopausal period (46–49 years), the question of treatment tactics is decided individually, depending on the type of tumor, the possibility of its potential malignancy. In case of preservation of the second ovary, it is advisable to resect it for pathological examination.

The pretumor states of the fallopian tubes are the least studied. The frequency of cancer of the fallopian tubes in relation to all malignant tumors of the genitals is 0.2-1.0%.

Evidence that chronic inflammatory processes often precede or combine with cancer of the tubes indicates that this pathology can be considered a pre-tumor state, although A.I. Serebrov denied the connection of malignant neoplasms with inflammatory processes.

The genesis of tube tumors due to hormonal disorders is not excluded.

Most often, from the precancerous conditions of the tubes, polyposis of the mucous membrane and lymphangioma are found, less often - myoma, lipoma, teratoma.

Clinically, tube tumors can be manifested by pain, serous or serous-bloody discharge, an increase in appendages. The diagnosis is made on the basis of anamnestic and clinical data, as well as special research methods (ultrasound, cytology, laparoscopy and diagnostic laparotomy).

Treatment with the correct diagnosis is surgical.

In order to prevent tube cancer, it is recommended to remove them during various operations related to genital pathology.
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