Solid ovarian mass with no blood flow. Cystic solid mass of the ovary. Treatment of an ovarian tumor

ESSAY

Ultrasound diagnosis of ovarian tumors

Introduction

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

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

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

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

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

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

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

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

Color Doppler imaging (abbreviated as CDM) contributes to a more accurate differentiation of malignant and benign ovarian tumors. The main achievement of color flow diagnostics in the diagnosis of tumor processes is the visualization and evaluation of the blood flow of newly formed tumor vessels, which have their own characteristic features. Color Doppler mapping allows preoperative, non-invasive assessment and differentiation of tumors according to the degree of changes in their vascular wall, localization and number of vessels, being a kind of measure for assessing the malignancy of ovarian neoplasms. The possibility of differentiating benign and malignant ovarian formations using color Doppler mapping (CDM) is a promising direction in ultrasound diagnostics, and the comparison of echography and Dopplerography data leads to a real increase in the accuracy of diagnosing tumor-like ovarian formations.

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

In this paper, the classifications and the main characteristic ultrasound signs of ovarian neoplasms of various etiologies are considered in more detail.

1. Ultrasound diagnosis of ovarian neoplasms

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

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

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

The risk group should include women:

with impaired ovarian function;

with postmenopausal bleeding;

long-term registered in the dispensary for the pathology of the uterus and its appendages;

who underwent operations on the internal genital organs with the preservation or resection of one or both ovaries;

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

with burdened heredity.

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

epithelial tumors;

tumors of the stroma of the sex cord of the embryonic gonads;

germ cell tumors;

metastatic tumors;

other (rare) tumors.

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

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

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

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

Sonographic signs of serous (smooth-walled) cystadenoma:

Mobile formation, located above the uterus;

correct rounded shape;

the outer contour is even, clear;

capsule thickness from 1 to 8 mm;

formation is single-chamber (may be multi-chamber);

the inner surface is clear, even;

anechoic content;

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

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

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

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

Mucinous cystadenoma

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

Sonographic signs of mucinous cystadenoma:

The shape is correct, round-oval;

outer contours are even or bumpy;

the formation is multi-chamber, with multiple partitions of various thicknesses;

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

a capsule of different thickness, in it (as well as in the partitions) blood flow with IR> 0.4 is recorded.

Ultrasound examination of the internal contents has a pronounced polymorphism, which is associated with a large number of partitions of different thicknesses, parietal growths and mucin suspension, which does not precipitate during a long immobile state of the patient. Mucin is visualized as echogenic inclusions of dotted, linear or irregular shape. Chambers within the same tumor may have a suspension of different echogenicity (Fig. 4). With jerky movements by the sensor, it moves into the cavity of the neoplasm.

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

endometrioid epithelial tumor

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

Uroepithelial tumor

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

Superficial papilloma

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

Mixed and unclassifiable epithelial tumorshave a non-specific echographic image in the form of formations with a heterogeneous solid or cystic-solid structure.

ovarian cancer

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

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

FIGO classification of ovarian cancer (excluding substages)): stage - the tumor is limited to the ovary (ovaries); stage - spread to nearby organs (uterus, fallopian tubes, etc.); stage - spread beyond the small pelvis and (or) metastases to the retroperitoneal lymph nodes; stage - distant metastases.

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

Sonographic signs of ovarian cancer:

Multi-chamber (single-chamber) education;

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

the structure is cystic, cystic-solid, solid;

multiple partitions of various thicknesses with fragmentary thickenings;

parietal growths;

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

rich vascularization of the solid component, septa and capsule.

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

There are no reliable echographic signs of the disease.

Given the relevance of early diagnosis of ovarian cancer and the long absence of clinical signs, ultrasound examination of the pelvic organs should take into account minimal changes in the ovaries for a subsequent in-depth examination in order to exclude a malignant neoplasm.

Sonographic markers to suspect ovarian cancer:

pronounced asymmetry in the size of the ovaries;

partial disappearance of the contour of the enlarged ovary;

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

the appearance of pathological zones of hypervascularization in the ovary;

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

Sex cord stromal tumors of embryonic gonads

Granulosa cell tumor

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

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

) cystic unicameral with a thin

and thick capsule;

) cystic-solid with large cavities;

) solid cystic with large and small cavities;

) are solid.

Dopplerography reveals hypervascularization of the solid component, especially the central part, with a mosaic type of blood flow. IR is in the range of 0.36-0.59, which averages 0.46.

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

Theca cell tumor

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

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

Fibroma

Fibroma develops from the stroma of the ovary, does not have hormonal activity, makes up about 7% of all ovarian tumors, occurs mainly in postmenopausal women. As a rule, there are benign forms. Ascites and hydrothorax are often observed, which disappear after removal of the tumor. The growth of the tumor is slow, there is a frequent combination with uterine myoma.

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

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

Androblastoma.

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

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

Dysgerminoma

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

Teratoma

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

Mature teratoma(dermoid cyst, dermoid, mature cystic teratoma) account for 97% of all teratomas. The tumor, as a rule, is unilateral, mobile, slow-growing, single-chamber, its dimensions range from 5 to 15 cm, but can reach 40 cm. neoplasm in the other ovary. Mature teratoma is represented by a cystic formation with a fibrous capsule, with local thickening due to an intraluminal elevation, called a dermoid (parenchymal or head) tubercle, which is the source of growth of the internal contents of the tumor. In the lumen of the neoplasm there are serous fluid, mucus, fat, hair, skin, teeth, bones, cartilage and nervous tissue. In rare cases, thyroid tissue (ovarian struma) and rudiments of the intestinal tube are found. There are benign cystic teratomas, cystic teratomas with malignancy and solid teratomas. Pronounced morphological polymorphism, various combinations of liquid and solid components lead to different types of echographic images of mature teratomas

There are three main types of ultrasonic structure.

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

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

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

Immature teratoma(teratoblastoma, embryonic teratoma, teratocarcinoma) account for 1.0-2.5% of all malignant ovarian tumors, occur in women 20-30 years old, are characterized by rapid growth and hematogenous metastasis, combined with ascites. Menstrual function in these tumors is preserved. Ultrasound examination determines the formation of an irregular shape, with an uneven and fuzzy contour, a cystic-solid structure. On Doppler sonography, the tumor is hypervascularized mainly in the central regions, with a mosaic type of blood flow, IR is below 0.4.

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

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

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

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

ovary cyst ultrasound

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

retention cysts;

inflammatory tubo-ovarian formations;

disturbed ectopic pregnancy;

The tactics of managing the patient depends on the identification of belonging to these groups.

Differential diagnostic echographic signs of tumor-like processes of the uterine appendages and ovarian tumors are presented in Table. one.

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

ПризнакиРетенционная кистаВоспалительнще образование Тубоовариальное образованиеНарушенная внематочная беременность Истинная опухоль яичников Возраст больнойДо 40 летДо 40 летДо 40 летСтарше 40 летРазмер образованияДо 70 ммДо 70 ммДо 50 ммСвыше 50 ммКонтурЧеткий, ровныйНечеткий, неровныйНечеткий, неровныйЧеткий, ровныйТолщина стенки (капсулы)Тонкая (утолщенная)НеравномернаяНе определяетсяРазличнаяКоличество камерОднокамерноеМногокамерноеПсевдо-многокамерноеМногокамерноеЭхогенностьНизкаяСмешаннаяСмешаннаяСмешаннаяСтруктураОднороднаяНеоднороднаяНеоднороднаяНеоднороднаяСвободная Abdominal fluid

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

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

The cystic form of a mature teratoma is differentiated from a non-ovulated follicle, follicular and endometrioid cyst. The teratoma has a thicker capsule than the derivatives of the follicle, and the final diagnosis is made during dynamic observation. Doubling the contour of the wall of the endometrioid cyst, its heterogeneity, as well as non-displaced fine suspension can help in differentiation from mature teratoma. In addition, the suspension in the teratoma often looks like small strokes, which is not found in endometriomas.

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

Multilocular cystic tumors may mimic thecalutein cysts. The shape of the cystic cavities of the tumor is irregular, in contrast to the retention cysts. In addition, thecalutein cysts are always a two-way process. If there is ascites, then attention is paid to the absent or reduced mobility of the intestinal loops, characteristic of the tumor process, while in hyperstimulation syndrome, the intestinal loops move freely in the ascitic fluid. Information about taking drugs that stimulate folliculogenesis is of great importance. In the diagnosis, the exclusion of signs of trophoblastic disease helps, in doubtful cases, chorionic gonadotropin is determined.

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

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

When conducting an ultrasound examination, attention should be paid to causing pain from pressure on the anterior abdominal wall or when bringing the transvaginal probe to the object under study, as this helps to exclude the inflammatory genesis of the adnexal formation or a disturbed ectopic pregnancy. In addition, with an ovarian tumor, the clarity of the contour of the formation is often preserved, in contrast to inflammation of the appendages or hematoma that occurs as a result of a rupture of the tube or tubal miscarriage. Additional signs will be detected symptoms of endometritis or endometrial decidual reaction. A laboratory study of blood, a smear from the vagina and cervical canal, as well as the determination of chorionic gonadotropin are necessary. The absence of appropriate changes makes it possible to exclude the inflammatory process and disturbed tubal pregnancy.

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

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

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

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

Signs Benign tumor Malignant tumor Patient's age Up to 60 years Older than 60 years Localization Unilateral Often bilateral Tumor size Up to 15 cm Over 15 cm Contour Clear, even Indistinct, uneven Capsule thickness Up to 5 mm Over 5 mm Thickness of partitions

The severity of these signs largely depends on the size of the neoplasm and the duration of its existence, therefore, numerous works performed in our country and abroad are devoted to the use of Doppler ultrasound, which can be used to suggest a benign or malignant nature of ovarian tumors.

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

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

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

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

Summing up the data of domestic and foreign literature, when using Dopplerography, the following differential diagnostic signs can be distinguished (Table 3).

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

Signs Benign tumor Malignant tumor Vascular location Peripheral Central IR Above 0.4 Below 0.4 Mean MAC15 cm/s 30 cm/s Mean MBC 5 cm/s 10 cm/s Periphery to the center Dependence of Doppler parameters on the degree of tumor differentiation Independent Increase in MAC and MVS, decrease in IR from Grade I to Grade III Dependence of Doppler parameters on the age of the patient Independent Independent Dependence of Doppler parameters on the histological type of tumor Independent Independent

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

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

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

) MVS - in the venous locus with a maximum speed in the tumor.

Neglect of the above rules will easily lead to a diagnostic error.

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

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

Conclusion

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

List of sources

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

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

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

Bohman Ya.V. Guide to oncogynecology, St. Petersburg: Foliant, 2002. 542 p.

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

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

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

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

Demidov V.N., Gus A.I., Adamyan L.V. Adnexal cysts and benign

ovarian tumors: a practical guide. Issue II. M.: RAMN, 1999. 100 p.

Clinical guide to ultrasound diagnostics. T. 3 / Ed. Mitkova

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

ultrasound diagnostics in gynecology. Moscow: Vidar, 1997. 184 p.

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

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

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

Oncogynecology: A Guide for Physicians. / Ed. Gilyazutdinova Z.Sh.,

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

Serov V.N., Kudryavtseva L.I. Benign tumors and malignant

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

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

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

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An ovarian cyst is a fluid-filled sac that develops on the tissues of one or both ovaries.

All such formations are divided into functional and organic. The first are the result of a short-term malfunction of the organ, when the follicle does not break at the right time and does not release the egg. Cysts of this type either disappear on their own in a month, or are easily treated with hormonal drugs. Organic cysts are more difficult to treat and may require surgery. In addition, cystic tumors can be either benign (mucinous and serous cystadenomas, dermoid cyst, cystedenofibroma, and sclerosing stromal tumor) or malignant (serous and mucinous cystadenocarcinomas, Brenner's cystic tumor, endometrioid carcinoma, cystic metastasis, and immature theroma).

It is believed that ovarian cysts can be the result of:

• Early onset of menstruation;
• Hormonal disorders in the thyroid gland;
• Abortions and other methods of termination of pregnancy;
• Various diseases of the reproductive system;

Types of ovarian cysts in women

There are the main types of ovarian cystic formations:

Physiological cysts are the norm

• Follicle
• corpus luteum

Functional cysts

• Follicular cyst
• Cyst of the corpus luteum
• Thecalyutein cysts
• Complicated functional cysts: hemorrhagic cyst, rupture, torsion

Benign cystic tumors (cystomas)

• Dermoid cyst (mature teratoma)
• Serous cystadenoma
• Cystadenoma mucinous
• Cystedenofibroma
• Sclerosing stromal tumor

Malignant cystic tumors (cystomas)

• Serous cystadenocarcinoma
• Cystadenocarcinoma mucinous
• endometrioid cancer
• Brenner's cystic tumor
• Immature teratoma
• cystic metastasis

Other cysts

• Endometrioma (chocolate cyst)
• Polycystic ovaries (Stein-Leventhal syndrome)
• Postmenopausal cyst
• ovarian hyperstimulation syndrome

Normal anatomy and physiology of the ovaries in reproductive age

Before considering pathological changes, let us highlight the normal anatomy of the ovary. The ovary of a woman at birth contains over two million primary oocytes, about ten of which mature during each menstrual cycle. Despite the fact that about a dozen Graaffian follicles reach maturity, only one of them becomes dominant and reaches a size of 18–20 mm by the middle of the cycle, after which it ruptures, releasing the oocyte. The remaining follicles decrease in size and are replaced by fibrous tissue. After the release of the oocyte, the dominant follicle collapses, and in its inner lining, the growth of granulation tissue begins in combination with edema, as a result of which the corpus luteum of menstruation is formed. After 14 days, the corpus luteum undergoes degenerative changes, then a small scar remains in its place - the white body.

Graafian follicles: small cystic formations found in the structure of the ovary are normal in all women of reproductive age (in the premenopausal period). The size of the follicles varies depending on the day of the menstrual cycle: the largest (dominant) usually does not exceed 20 mm in diameter by the time of ovulation (14th day from the onset of menstruation), the rest do not exceed 10 mm.

Ultrasound of the ovary is normal. Sonograms show the ovaries containing several anechoic simple cysts (Graaffian follicles). Follicles should not be confused with pathological cysts.

What do ovaries look like on an MRI? On T2-weighted MRI, Graafian follicles appear as hyperintense (i.e. bright in signal) cysts with thin walls surrounded by a less intense ovarian stroma.

Normally, in some women (depending on the phase of the menstrual cycle), the ovaries can intensively accumulate a radiopharmaceutical (RP) during PET. To distinguish these changes from the tumor process in the ovaries, it is important to correlate them with the patient's anamnestic data, as well as with the phase of the menstrual cycle (the ovaries intensively accumulate the radiopharmaceutical in its middle). Based on this, it is better for women before menopause to prescribe PET in the first week of the cycle. After menopause, the ovaries practically do not capture radiopharmaceuticals, and any increase in its accumulation is suspicious of a tumor process.

Ovarian PET-CT: increased accumulation of a radiopharmaceutical (RP) in the ovaries of a woman in the premenstrual period (normal variant).

Ovaries after menopause

The entry into the postmenopausal period is the absence of menstruation for one year or more. In Western countries, the average age of menopause is 51–53 years. In postmenopause, the ovaries gradually decrease in size, Graaf's follicles stop forming in them; however, follicular cysts may persist for several years after menopause.

On a T2-weighted MRI (left), a postmenopausal woman's ovaries appear as dark "clumps" near the proximal end of the teres ligament. On the right of the tomogram, a hypointense left ovary, devoid of follicles, is also visualized. Although slightly larger than expected, the ovary looks completely normal overall. And, only if it is possible to detect an increase in the size of the ovaries compared to the primary study, the differential diagnostic series should first of all include a benign neoplasm, for example, fibroma or fibrothecoma.

Functional ovarian cysts

Much more common are benign functional ovarian cysts, which are Graafian follicles or corpus luteum, which have reached a significant size, but otherwise remain benign. In the early postmenopausal period (1–5 years after the last menstrual period), ovulatory cycles may occur, and ovarian cysts may also be found. And even in late menopause (more than five years after the end of the menstrual period), when ovulation no longer occurs, small simple cysts can be found in 20% of women.

What is a functional ovarian cyst? If ovulation has not occurred and the wall of the follicle has not torn, it does not undergo reverse development and turns into a follicular cyst. Another variant of a functional cyst is an increase in the corpus luteum with the formation of a corpus luteum cyst. Both formations are benign and do not require drastic measures. An expert second opinion helps to distinguish them from malignant variants.

Follicular cysts

In some cases, ovulation does not occur and the dominant Graafian follicle does not regrow. When it reaches a size of more than 3 cm, it is called a follicular cyst. These cysts are usually 3–8 cm in size, but can be much larger. On ultrasound, follicular cysts appear as simple, unilocular, anechoic cystic masses with a thin and even wall. In this case, neither lymph nodes accumulating contrast, nor any soft tissue component of the cyst, nor septa that increase with contrast, nor fluid in the abdominal cavity (with the exception of a small physiological amount) should be detected. In follow-up studies, follicular cysts may resolve spontaneously.

Cyst of the corpus luteum

The corpus luteum can become obliterated and filled with fluid, including blood, resulting in the formation of a corpus luteum cyst.

Ultrasound: corpus luteum cyst. Small complex ovarian cysts are visible with blood flow in the wall, which is detected by Doppler sonography. A typical circular blood flow in the Doppler study was called the "ring of fire". Note the good permeability of the cyst to ultrasound and the absence of internal blood flow, which is consistent with changes characteristic of a partially involuted corpus luteum cyst.

It should be noted that women taking hormonal oral contraceptives that suppress ovulation usually do not form a corpus luteum. Conversely, the use of ovulation-inducing drugs increases the chance of developing corpus luteum cysts.

Pelvic ultrasound: corpus luteum cyst. On the left side of the sonogram, there are changes (“ring of fire”) typical of a corpus luteum cyst. On the right in the photo of the ovarian preparation, a hemorrhagic cyst with collapsed walls is clearly visible.

Corpus luteum cyst on MRI. Axial T2-weighted tomography shows an involuted corpus luteum cyst (arrow), which is a normal finding. The right ovary is not changed.

Hemorrhagic ovarian cysts

A complex hemorrhagic ovarian cyst is formed when bleeding from a Graafian follicle or follicular cyst. On ultrasound, hemorrhagic cysts look like single-chamber thin-walled cystic structures with fibrin strands or hypoechoic inclusions, with good ultrasound permeability. On MRI, hemorrhagic cysts are characterized by a high signal intensity on T1 FS scans, while on T2 WI they give a hypointense signal. With Doppler sonography, there is no internal blood flow, the component that accumulates contrast is not detected inside the cyst on CT or MRI. The wall of the hemorrhagic cyst has a variable thickness, often with the presence of vessels located circularly. Although hemorrhagic cysts usually present with acute pain symptoms, they may be an incidental finding in an asymptomatic patient.


On sonograms, a hemorrhagic cyst with a blood clot simulating a neoplasm is determined. However, Doppler sonography did not reveal any internal blood flow in the cyst, and its permeability to ultrasound was not reduced.

MR picture of a hemorrhagic ovarian cyst: in the T1 WI mode without fat suppression, a complex cyst is detected, characterized by a hyperintense signal, which can be caused by both the fatty component and the blood. On T1 WI with fat suppression, the signal remains hyperintense to confirm the presence of blood. After the introduction of contrast based on gadolinium preparations, no contrast enhancement is observed, which allows us to confirm the hemorrhagic nature of the ovarian cyst. In addition, it is necessary to include endometrioma in the differential diagnostic series.

On ultrasound, a soft tissue (solid) component is determined in both ovaries. However, ultrasound permeability on both sides is intact, suggesting the presence of hemorrhagic cysts. Dopplerography (not shown) shows no blood flow in the formations.

How to distinguish a hemorrhagic cyst on an MRI? In T1 mode, a component with high signal characteristics (fat, blood or protein-rich liquid) is determined in both formations. With fat suppression, the signal intensity does not decrease, which generally makes it possible to exclude teratoma containing adipose tissue and confirm the presence of hemorrhagic fluid.

Endometrioid ovarian cyst (endometrioma)

Cystic endometriosis (endometrioma) is a type of cyst formed by endometrial tissue growing into the ovary. Endometriomas are found in women of reproductive age and can cause long-term bothersome pelvic pain associated with menstruation. Approximately 75% of patients with endometriosis have ovarian involvement. On ultrasound, the signs of endometrioma may vary, but in most cases (95%) endometrioma looks like a "classic" homogeneous, hypoechoic cystic formation with diffuse low-level echogenic areas. Rarely, an endometrioma is anechoic, resembling a functional ovarian cyst. In addition, endometriomas can be multi-chambered, and septa of varying thickness can be found in them. Approximately one third of patients, upon careful examination, show small echogenic lesions adjacent to the wall, which may be due to the presence of cholesterol accumulations, but may also represent blood clots or debris. It is important to distinguish these lesions from true wall nodules; if present, the diagnosis of endometrioma becomes extremely likely.

A transvaginal sonogram shows a typical endometrioma with hyperechoic lesions in the wall. Dopplerography (not shown) failed to detect blood vessels in these lesions.

Endometrioid ovarian cyst: MRI (right) and CT (left). Computed tomography is used primarily to confirm the cystic nature of the formation. MRI can usually be used to better visualize cysts that are poorly differentiated on ultrasound.

On MRI, hemorrhagic contents inside the endometrioma leads to an increase in signal intensity on T1 WI. On T1 WI with fat suppression, the endometrioma remains hyperintense, in contrast to teratomas, which are also hyperintense on T1 WI but hypointense on T1 FS. This sequence (T1 FS) should always complement the MR study, as it allows you to detect small lesions that are hyperintense on T1.

polycystic ovary syndrome

Radiological imaging techniques either suggest polycystic ovary syndrome (PCOS), also called Stein-Leventhal syndrome, or are used to confirm the diagnosis.

Radiation criteria for PCOS:

• Presence of 10 (or more) simple peripheral cysts
• The characteristic appearance of the "string of pearls"
• Enlargement of the ovaries (at the same time, in 30% of patients, they are not changed in size)

Clinical features of polycystic ovary syndrome:

• Hirsutism (excessive hair growth)
• Obesity
• Fertility disorder
• Hair growth (baldness) by male pattern
• Or increased androgen levels

What does polystosis of the ovaries look like? On the left on the MRI tomogram, a typical picture in the form of a “string of pearls” is determined. On the right, in a patient with an increased content of androgens in the blood, an enlarged ovary is visualized, as well as multiple small simple cysts located on the periphery. Obvious is associated obesity. In this patient, MRI can confirm the diagnosis of PCOS.

Ovarian hyperstimulation syndrome: theca-luteal cysts

Ovarian hyperstimulation syndrome is a relatively rare condition caused by excessive hormonal stimulation of hCG (human chorionic gonadotropin) and usually manifesting bilateral ovarian disease. Excessive hormonal stimulation can occur with gestational trophoblastic disease, PCOS, as well as during hormone treatment or during pregnancy (rarely with a normal pregnancy with a single fetus) with self-resolution after the birth of a child (according to studies). Excessive hormonal stimulation often occurs with gestational trophoblastic disease, fetal erythroblastosis, or multiple pregnancies. Radiological methods of research usually reveal a bilateral enlargement of the ovaries with the presence of multiple cysts that can completely replace the ovary. The main differential criterion for ovarian hyperstimulation syndrome is characteristic clinical and anamnestic data.

A sonogram performed on a young pregnant woman shows multiple cysts in both ovaries. On the right, an invasive mass in the uterus is determined, comparable to gestational trophoblastic disease. The conclusion about this disease was made on the basis of characteristic clinical and anamnestic data (the fact of pregnancy in a young woman) and a sonogram, which revealed signs of an invasive form of gestational trophoblastic disease.

Inflammation of the appendages (salpingoophoritis) and tubo-ovarian abscess

A tubo-ovarian abscess usually occurs as a complication of an ascending (from the vagina to the cervix and fallopian tubes) chlamydial or gonorrheal infection. At the same time, complex cystic formation of the ovary with a thick wall and the absence of vascularization is detected on CT and MRI. Thickening of the endometrium or hydrosalpinx makes the diagnosis of a tubo-ovarian abscess more likely.

Axial contrast-enhanced CT shows a complex cystic mass on the left, resembling an abscess, with a thick wall that accumulates contrast and gas inclusions inside.

On CT in the sagittal plane (left), one can see that the ovarian vein approaches the mass, confirming its nature (arrow). On the coronal tomogram (right), it is possible to assess the anatomical relationship between the formation and the uterus. A gas bubble is visualized in the uterine cavity, which suggests an infectious onset right here, with the subsequent spread of infection through the fallopian tube to the ovary.

Mature teratoma (dermoid cyst) of the ovary

A mature cystic teratoma, also called a dermoid cyst, is an extremely common ovarian mass that may be cystic in nature. "Mature" in this context means a benign lesion as opposed to an "immature", malignant teratoma. Benign cystic teratomas usually occur in young women of childbearing age. On CT, MRI, and ultrasound, they appear unilocular in (up to) 90% of cases, but may be multilocular or bilateral in about 15% of cases. Up to 60% of teratomas may contain calcium inclusions in their structure. The cystic component is represented by a fatty fluid produced by the sebaceous glands located in the tissue lining the cyst. The presence of fat is diagnostic of teratoma. On ultrasound, it has a characteristic cystic appearance with a hyperechoic solid nodule in the wall called a Rokitansky node or dermoid plug.

Ultrasound visualizes Rokitansky's node or dermoid plug (arrow).

Liquid-fat levels may also be detected due to density differences (fat, as a lighter and less dense substance, floats on the surface of the water). It is also possible to visualize thin echogenic lines ("streaks"), the presence of which is due to the "hair" in the cyst cavity. Mature cystic teratomas, even of a benign nature, are most often removed surgically, since they cause an increased risk of ovarian torsion.

Complications of a dermoid ovarian cyst:

• Torsion of the ovary
• infection
• Rupture (spontaneous or as a result of trauma)
• Hemolytic anemia (a rare complication that resolves after resection)
• Malignant transformation (rare)

What does a dermoid ovarian cyst look like on an MRI? A cystic lesion with hyperintense signal is seen, within which there are septa (found in approximately 10% of such cysts). In the fat suppression mode, the suppression of the signal intensity is determined, which allows you to confirm the presence of a fatty component and make a conclusion about a teratoma.

Cystadenoma and cystadenofibroma of the ovary

These formations are also common cystic tumors of the ovaries (cystomas), which can be either serous or mucinous (mucous). On ultrasound, mucinous cystadenoma is more often an anechoic unilocular mass that may resemble a simple cyst. Mucinous cystadenomas often consist of several chambers, which may contain a complex fluid with inclusions of protein debris or blood. "Papillary" protrusions on the walls suggest a possible malignancy (cystadenocarcinoma).

Ovarian cyst on ultrasound. On transvaginal examination (upper left), a 5.1 x 5.2 cm cyst of the left ovary is detected (anechoic and without septa). However, a nodule is found on the posterior wall of the cyst with no evidence of internal blood flow on Doppler examination (upper right); in this case, the differential diagnostic series includes a follicular cyst, an accumulation of debris, and a cystic neoplasm. MRI (below) shows thin septa in the lesion that accumulate contrast. Tumor nodes, lymphadenopathy, metastases to the peritoneum were not detected. The minimum amount of ascitic fluid is determined. The formation was verified as a cystadenoma by biopsy.

Ovarian cystoma: MRI. On MRI scans performed on the same patient five years later, the mass grew. On T2 WI, a complex cyst is visualized in the left ovary with a solid nodule from the posterior wall. After the introduction of contrast on T1 FS, a slight increase in signal intensity from thin partitions and a node in the wall is determined. MRI data did not allow differentiation between benign (eg, cystadenoma) and malignant neoplasm of the ovary. Histological examination of the resectate confirmed cystadenofibroma.

Malignant cystic tumors of the ovaries

Radiation diagnostic methods, such as ultrasound or MRI, are not intended to determine the histological type of the tumor. However, with their help, it is possible to differentiate benign and malignant neoplasms with varying degrees of certainty and determine the further tactics of patient management. The detection of radiation signs of malignant tumor growth should aim the attending physician (gynecologist, oncologist) for further active elucidation of the nature of the cyst (surgical intervention with biopsy, laparoscopy). In unclear and controversial cases, re-interpretation MRI of the pelvis is useful, as a result of which you can get a second independent opinion of an experienced radiation diagnostician.

Serous cystadenocarcinoma

Ultrasound shows a complex cystic-solid mass in the left ovary, and another large complex mass containing both a solid and a cystic component in the right half of the pelvis

CT scan of the same patient revealed a complex cystic-solid mass with thickened septa that accumulated contrast in the right ovary, highly suspicious of a malignant tumor. There is also bilateral pelvic lymphadenopathy (arrows). Histopathological examination confirmed serous cystadenocarcinoma of the ovary (the most common variant)

CT and photograph of a gross specimen of serous ovarian cystadenocarcinoma.

Ultrasound (left) shows a large multi-chamber cystic mass in the right parametrium; some of the chambers are anechoic, in others uniform low-level echogenic inclusions are visualized due to protein content (in this case, mucin, but hemorrhages can look similar). Partitions in the formation are mostly thin. There was no blood flow in the septa, no solid component, no signs of ascites. Despite the absence of Doppler blood flow and a solid component, the size and multi-chamber structure of this mass suggest a cystic tumor and recommend other, more accurate diagnostic methods. Contrast-enhanced CT (right) shows similar changes. The formation chambers have different densities corresponding to different protein content. Histopathological examination confirmed mucinous cystadenocarcinoma with low malignant potential.

Endometrioid ovarian cancer

Bilateral cystic-solid ovarian masses are suspicious for tumor and require further evaluation. The value of radiation research methods is to confirm the fact of the presence of education; however, it cannot be concluded that it is absolutely certain to be benign or malignant. In patients who are found to have epithelial tumors (a much more common group of ovarian neoplasms), even after surgical treatment, determining the exact histological variant of the tumor does not affect the prognosis as much as FIGO (international federation of obstetricians and gynecologists) stage, degree of differentiation, and completeness resection of the tumor.

The sonogram (left) shows an enlargement of both ovaries, inside which there is both a cystic and a soft tissue (solid) component. CT scan of the same patient shows a large cystic-solid mass extending from the pelvis to the abdomen. The role of CT in this case is to stage the formation, however, based on CT (MRI), it is impossible to determine the histological structure of the tumor.

Cystic metastases to the ovaries

Most often, metastases to the ovaries, for example, Krukenberg metastases - screenings of cancer of the stomach or large intestine, are soft tissue formations, but often they can also be cystic in nature.

CT shows cystic masses in both ovaries. You can also see the narrowing of the lumen of the rectum, caused by a cancerous tumor (blue arrow). Clearly visible cystic metastases of rectal cancer in the deepening of the peritoneum (red arrow), in general, are not a typical finding.

Treatment of ovarian cancer

Treatment of patients with ovarian cancer traditionally involves initial staging followed by aggressive cytoreductive intervention in combination with intraperitoneal cisplatin. In the early stages (1 and 2), total hysterectomy and bilateral salpingo-oophorectomy (or unilateral if a woman of childbearing age wishes to preserve her fertility, although this approach is controversial) are used.

For patients with advanced tumors (stages 3 and 4), cytoreductive intervention is recommended, which involves partial removal of the volume of tumor foci; this operation aims not only to improve the quality of life of patients, but also to reduce the likelihood of intestinal obstruction and eliminate the metabolic effects of the tumor. Optimal cytoreductive intervention involves the removal of all tumor implants larger than 2 cm; with suboptimal, the transverse size of the remaining tumor nodes exceeds 2 cm. Successful cytoreductive surgery increases the effectiveness of chemotherapy and leads to an increase in survival.

Patients with stage 1a or 1b ovarian tumors may require only selective surgery without subsequent chemotherapy, while those with more advanced stages require postoperative chemotherapy with cisplatin (the most effective drug for ovarian cancer). Despite the fact that a positive response to therapy with platinum drugs reaches 60-80%, about 80-90% of women with the third stage of the disease and about 97% with the fourth stage die within 5 years.

In patients treated for ovarian cancer, the most effective control method is to measure the serum level of CA-125 and physical examination. Repeat laparotomy remains the most accurate method for assessing the effectiveness of chemotherapy, however, it gives a lot of false negative results and does not lead to an increase in survival. CT is used to find a macroscopic lesion and avoids a second biopsy. If, using diagnostic methods, residual tumor tissue is detected, the patient may be prescribed additional treatment; however, radiological methods show a large number of false negative results.

Methods for diagnosing the disease

To date, ovarian cysts are fairly well diagnosed using a range of tools:

• An examination by a gynecologist, during which the patient's complaints are clarified, and it is also determined whether the appendages are enlarged and whether there are painful sensations in the lower abdomen.
• Pregnancy test. It is necessary not only to exclude an ectopic pregnancy, but also to determine the possibility of a computed tomography.
• Ultrasound examination, which allows you to quickly and with high accuracy determine the presence of a cyst and control the dynamics of its development.
• laparoscopic examination. Its advantage lies in the fact that it gives absolutely accurate results and, if necessary, an accurate and minimally invasive surgical intervention can be performed during the procedure.
• Computed and magnetic resonance imaging.

CT scan for ovarian cyst

CT and MRI are fairly accurate methods to determine the presence of a cyst, to suggest whether it is benign or malignant, to clarify its size and exact location, etc. In addition, in the case of a malignant cyst, diagnostics using contrast makes it possible to establish whether the tumor has metastasized to other organs and accurately determine their location.

CT is performed using X-rays, which makes it possible to obtain sections of the organ in increments of approximately 2 mm. The sections collected and processed by the computer are assembled into an accurate three-dimensional image. The procedure is absolutely painless, does not require complex preparation (all you need to do is to follow a certain diet a couple of days before the procedure and, in case of constipation, take a laxative) and lasts no more than 20 minutes.

Considering that the cut step is 2 mm, CT can detect formations from 2 mm in cross section and more. These are rather small cysts and tumors that are at an early stage of development. Such accuracy of CT diagnostics allows you to start timely treatment and avoid more serious consequences.

Contraindications of the method are pregnancy (due to irradiation of the body with X-rays) and allergic reactions to a contrast agent (in the case of CT with contrast). Such allergic reactions are not very common.

Second opinion is very easy

A feature of almost any modern diagnostic method, be it ultrasound, MRI or CT, is the possibility of obtaining an erroneous result for objective or subjective reasons. Objective reasons include errors and shortcomings of diagnostic equipment, while subjective reasons include medical errors. The latter can be caused by both a lack of experience of the doctor and banal fatigue. The risk of getting false positive or false negative results can cause a lot of trouble and even lead to the fact that the disease goes into a more severe stage.

A very good way to reduce the risk of misdiagnosis is to get a second opinion. There is nothing wrong with this, it is not distrust of the attending physician, it is just getting an alternative look at the results of tomography.

Today it is very easy to get a second opinion. To do this, you just need to upload the CT results to the National Teleradiological Network (NTRS) system, and in no more than a day you will receive the opinion of the best specialists from the country's leading institutions. No matter where you are, you can get the best advice possible in the country wherever you have internet access.

Vasily Vishnyakov, radiologist

Ovarian cysts are diagnosed in both young girls and middle-aged women, sometimes the pathology occurs even in newborn girls. With menopause, cystic formations are observed in about 10 women out of 100. A benign formation usually affects only one ovary on the right or left side, rarely the pathology is bilateral. This common gynecological disease does not pose a threat to life, but it is important for every woman to know what ovarian cysts are.

A cyst is a pathological neoplasm that looks like a rounded seal. Cysts are classified as benign tumors that form against the background of hormonal failure in the female body. The histological structure of the neoplasm can be completely different, depending on the nature of the origin. In the cavity of the cyst there is a different content, it can be: liquid, mucous or jelly-like. Inside there may be exudate of blood plasma, blood and purulent cells.

Only one tumor may be formed, but cases of multiple formations are not uncommon. When several cysts accumulate on the ovaries at once, this condition is called polycystic or cystoma. Depending on the intensity of the development of pathology, neoplasms can reach very large dimensions. Cystic formation very rarely transforms into a cancerous tumor, but if not properly treated, it can seriously affect the health and reproductive system of a woman.

Reasons for the formation of pathology

Hormonal disorders are the main reason for the development of the disease. Low immunity can aggravate the pathology, since a weakened body is unable to resist infections.

Main reasons:

• puberty;
• pregnancy, childbirth, abortion;
• menopause;
• obesity;

• chronic diseases of the reproductive system;
• inflammatory and infectious processes;
• pathology of the endocrine system;
• hormone replacement therapy;
• non-compliance with sexual hygiene.

Features of the pathology

The ovaries are paired sex glands, small in size and located on both sides of the uterus. The main function of these organs is the production of the main female hormones (progesterone and estrogen) and the production of eggs. It depends on the work of the ovaries whether a woman can have children. Therefore, any pathology of these organs seriously affects the reproductive system.

The cyst can be unilateral and bilateral, in the first case one ovary is affected, in the second two at once. Cystic formations of the right ovary in terms of symptoms are practically no different from the anomaly of the left ovary.

This pathology in 90% of cases does not manifest itself for a long time. A doctor can detect a neoplasm during a preventive examination and ultrasound.

The main symptoms of pathology:

• soreness in the lower abdomen;
• pain on the right or left side of the abdomen near the ovaries;
• sharp fluctuations in weight;
• problems with conception;
• discomfort during intercourse;
• increase in vaginal discharge;
• bleeding between periods;
• frequent urination;
• difficult defecation;
• bloating and the appearance of a rounded tummy;
• intermenstrual vaginal bleeding;
• failure of the menstrual cycle.

Usually, ovarian cysts do not cause much discomfort to a woman, but this pathology can be accompanied by severe complications (torsion of the leg, rupture, suppuration of the cyst) that are life-threatening for a woman. In this case, an emergency operation is performed and the cystic neoplasm is removed. Therefore, it is important to undergo a full diagnosis in a timely manner and begin the necessary treatment.

Diagnosis and constant monitoring of the development of the disease is carried out using ultrasound. Treatment can be both surgical and medical, depending on the clinical picture of the disease.

Types of cysts

The most dangerous and intractable pathology is considered to be a solid cystic formation, such a tumor has a hard shell, clear boundaries. Inside the neoplasm contains the tissue component of the organ. A solid cystic tumor cannot resolve on its own and does not change its size. Such a formation over time, as a rule, degenerates into a malignant tumor. Therefore, it is important to visit a gynecologist at least once a year, this will help to identify and cure the disease in a timely manner. According to the generally accepted classification, the following types are distinguished:

• Follicular cyst- the most common neoplasm. The cause of the occurrence is not occurring ovulation during the menstrual cycle. Most often, such a cyst occurs in adolescent girls at the stage of puberty. A functional cyst often resolves on its own within two to three monthly cycles.
• Paraovarian cyst- formed from the epididymis of the ovary. This cystic tumor is capable of reaching the largest size among other types. Symptoms of the pathology are mild and the tumor may not appear for a long time. Due to the large size, there is pressure on the nearest organs. For this reason, frequent urination and pain during urination may occur.

• Cyst (luteal) of the corpus luteum- is formed in the ovary in place of the non-regressed corpus luteum. This type of tumor resolves on its own after two to three menstrual cycles. Medical surgery is necessary only if bleeding occurs.
• Dermoid cyst- a benign volumetric formation, inside the cavity there are sebaceous glands and hair follicles. The neoplasm slowly increases in size over several years. If this cyst is found, surgery is required.
• Endometrial cyst- occurs against the background of endometriosis (proliferation of endometrial cells). Symptoms of pathology may not appear for quite a long time. The formation is formed from tissues similar to the endometrium, which lines the uterus from the inside. If the contents of the cyst enter the abdominal cavity, adhesions form.

If several cystic seals form on the ovaries at once, then this pathology is called polycystic ovaries. Specific signs of pathology are increased body hair growth, an increase in insulin in the blood, a sharp increase in weight, and the appearance of acne. The disease requires competent complex treatment aimed at eliminating not only neoplasms, but also concomitant symptoms.

Diagnosis and treatment

Cystic ovarian formations can be diagnosed with a standard gynecological examination. The doctor will be able to determine the size and location of the tumor by palpation. If the cyst is poorly palpable, then an ultrasound examination is performed.

Treatment for ovarian cysts will depend on the history and clinical presentation of the disease. It is taken into account that this neoplasm can spontaneously resolve within a few months. If the tumor increases significantly and intensively, then the woman may experience ovarian dysfunction. In case of a pronounced threat to the health and life of the patient, surgical intervention is applied.

In the presence of a small functional cyst, the doctor prescribes treatment with hormonal drugs. Usually therapy lasts no more than two months. Progress or deterioration of the condition is diagnosed by ultrasound.

With the ineffectiveness of drug therapy, a woman is recommended to remove cystic formations. Most often, laparoscopy of the ovary is performed, this is the least traumatic operation, after which there are no ugly scars. In severe cases, when doctors fear for the patient's life, an oophorectomy is performed - the removal of cystic formations along with the ovary. This method is used only in extreme cases.

After timely and high-quality treatment of ovarian cysts, the probability of conception in the future is very high. Modern medicine successfully treats various types of cystic formations with minimal consequences for a woman's health, while maintaining her reproductive functions.

Despite the fact that until an accurate diagnosis every ovarian neoplasm should be considered as potentially malignant, among all tumors of this localization, only 20% are malignant. History and physical examination data rarely distinguish between benign and malignant tumors.

In most cases, the diagnosis is established after macro- and microscopic examination. remote neoplasm. Ovarian tissue comes from several sources: coelomic epithelium, germ cells, and mesenchyme. Based on their appearance, ovarian tumors are divided into solid and cystic.

The most common benign cystic tumors- serous and mucinous cystadenomas, as well as cystic teratomas (dermoid cysts). Benign cystadenomas are ovoid single-chamber thin-walled formations with a diameter of 5-20 cm, filled with yellowish liquid or viscous contents. The size of benign cystic teratomas is usually no more than 10 cm, after an incision, adipose tissue, teeth or hair are found inside.

To malignant cystic tumors include serous and mucinous cystadenocarcinoma. On the tomogram, they are distinguished from benign tumors only by the presence of clear solid areas. External and internal papillary growths and areas of necrosis are signs of malignancy. In the absence of obvious tumor implants within the abdominal cavity, an accurate diagnosis helps to establish a histological examination of the surgical material.

source benign solid tumors of the ovaries(fibromas, thecomas or Brenner tumors), as a rule, connective tissue serves. Their size can be different - from small nodules on the surface of the ovary to large formations weighing several kilograms. On physical examination, they are defined as firm, slightly uneven, and mobile masses. These tumors often occur in postmenopausal women.

Meigs syndrome- the combination of benign ovarian fibroma with ascites and hydrothorax is rare.

Malignant solid tumors of the ovaries most often represented by primary and metastatic adenocarcinomas. Dense tumor-like formations detected during gynecological examination often turn out to be undifferentiated adenocarcinomas. The prognosis for life is poor. It must be remembered that inflammatory infiltrates (in chronic inflammatory diseases of the pelvic organs) can be very dense. Some solid ovarian tumors that secrete estrogens and androgens (androblastoma, gynandroblastoma, and hylus cell tumor) are benign or low grade.

With absence gap or torsion, most ovarian tumors are asymptomatic. Extensive dissemination (OC) in the peritoneum often does not manifest itself in any way until the enlargement of the abdomen due to ascites. On the other hand, any enlargement of the uterine appendages can cause menstrual irregularities and a feeling of pressure in the pelvis due to the deformity of the bladder and rectum.

True benign ovarian tumors, for example, serous and mucinous cystadenomas and benign cystic teratomas do not resolve spontaneously. The question of whether benign tumors can be precursors of malignant ones remains unanswered. Data were obtained on the occurrence of intraepithelial neoplasia in benign serous cystadenomas.

In addition, some authors have described transitional changes in normal epithelium to intraepithelial neoplasia at the initial stage. stages of invasive ovarian cancer (OC), and then to invasive cancer. It follows that if invasive cancer arises from benign epithelial adenomas, then surgical removal of these formations should lead to a decrease in the incidence of OC. However, according to the last 20 years, this has not happened.

endometriosis- a disease in which glands and stromal elements inherent in normal endometrium are found outside their normal localization. The most common sites of endometriosis foci are the ovaries, supporting the uterine ligaments, the peritoneum of the recto-uterine cavity, and the bladder.

The disease occurs mainly in nulliparous women Caucasian race at the age of 35-45 years. When the ovary is damaged, a cyst is formed, filled with a dark, "chocolate" liquid, the diameter of which rarely exceeds 12 cm; often it cannot be distinguished from a tumor. Endometriosis is characterized by nodular compaction of the sacro-uterine ligaments and other structures of the retrouterine space.

Pelvic pain is the most common symptom. Physical activity and sexual intercourse usually increase discomfort, but there is no correlation between the prevalence of endometriosis and clinical symptoms. In some cases, small lesions on the peritoneum cause pain that causes disability.

Inna Bereznikova

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- These are volumetric formations that are formed from the tissue of the ovary. Such diseases of the uterus are common, they are malignant and benign.

It should be noted that, depending on the cause, gradually benign tumors can develop into malignant ones and lead to an unfavorable prognosis. Ovarian tumors can appear in women of any age, accounting for 8% of gynecological diseases.

The risk group for the development of malignant pathologies includes patients who have not given birth, have bad habits, consume a lot of animal fats, or have a hereditary predisposition.

Ovarian tumor, located in the pelvis

According to the symptoms of ovarian tumors (uterine appendages) can have the following stages of development:

1. first stage. Only the ovary is affected;
2. second stage. The disease spreads to other organs and structures of the small pelvis (zone of the uterus and fallopian tubes);
3. third stage. Metastases (tumor cells) are detected in the lymph nodes and inside the peritoneum;
4. fourth stage. Distant metastases (clusters of tumor cells) in other organs and joints are detected.

Symptoms and causes

The main symptoms of tumor neoplasms with lesions of the ovaries in the uterus include:

• bleeding from the organs of the uterus that occurs outside of menstruation;
• irregular menstrual cycle;
• discomfort and pain during intercourse;
• an increase in the size of the abdomen;
• infertility;
• frequent urination or the urge to have a bowel movement;
• with metastasis, bone pain, cough, jaundice, pathological fractures, neurological disorders may appear;
• non-specific symptoms (high ESR, anemia, weight loss, loss of appetite, fatigue and weakness).

Teratoma is characterized by rare pain, often similar to premenstrual symptoms. Therefore, for the timely treatment of pathologies, one should be attentive to any of their manifestations.

For the development of a tumor process on the ovaries, there are the following reasons:

1. earlier or later onset of the menstrual cycle;
2. late or early menopause;
3. bad habits;
4. hormonal imbalance.

Forms of manifestations

Neoplasms of the ovaries in the uterus are of the following types:

• benign ovarian tumors. They grow slowly, without affecting the lymph nodes and without forming metastases (without spreading to other organs);
• malignant. The tumors grow rapidly in size, they grow into the surrounding organs and tissues, spreading through the lymph or bloodstream to other organs, affecting the lymph nodes;
• metastatic. Tumors appear during metastasis (spread of cells) of a neoplasm that is located in another organ;
• hormone-producing (responsible for the production of sex hormones of the uterus).

According to the type and structure of the tissue for the formation of an ovarian tumor, the following types of disease are distinguished:

1. epithelial neoplasms: serous tumor (composed of secretion), mucinous tumor (unilateral, multi-chambered mass with mucus, which can be large in size), dark cell tumors, Gremor tumors (these are unilateral solid benign tumors of the ovary that produce estrogen), endometrial neoplasms (similar to endometrium and containing estrogen receptors);
2. stromal tumors: androblastoma (produces androgens), granulosa cell neoplasms (produce estrogens), thecoma (one-sided formation that appears with postmenopause);
3. germinogenic formations: (or dermoid cyst containing the rudiments of nails, hair, teeth, etc.), dysgerminoma.

Stromal tumors are rare, mostly found in women aged 50 years with uterine pathologies. Symptoms of the disease include bleeding, menstrual irregularities, abdominal pain, and increased hair growth. Benign stromal neoplasms include fibroma and tecoma. Granulosa cell tumor of the ovary consists of malignant Sertoli-Leiding cells.

Compared to stromal neoplasms, which can become malignant at an early stage of development, germ cell tumors are classified as benign. Now there are several types: teratoma, dysgerminoma, neoplasm of the endodermal sinus,. Symptoms of the formations include frequent urination, bleeding disorders, abdominal pain and flatulence.

Teratoma differs immature, mature, solid and cystic. Teratoma of the uterine appendages is often unilateral, so a tumor of the left or right ovary is isolated. But compared to the right-sided, it is less common due to less functional activity.

Epithelial tumors are benign, epithelial nature are diagnosed mainly without metastases that do not threaten the woman's life. These include Brenner's tumor, serous cystadenoma, and mucinous cystadenoma. To malignant epithelial formations include carcinoma. Diagnosis allows you to determine 3 degrees of the tumor, the increase of which indicates an unfavorable prognosis.

Mucinous tumors are less common than serous tumors. According to observations, these are mainly borderline and benign species. They have cysts with cavities, the sizes of which differ, lined with a cylindrical epithelium without cilia.

There are also borderline ovarian tumors that form in the epithelium. They have a low malignant potential and do not grow into the connective tissues of the organ. Compared to malignant neoplasms, borderline tumors grow slowly and are less dangerous.

Diagnostics

Diagnosis of tumors of the uterine appendages is based on the following activities:

Additionally, diagnosis may include a biopsy, Doppler sonography, barium enema, and other procedures. Diagnosis of teratoma and other tumors is made on the basis of primary symptoms and is refined using histological tests.

Women at risk for the appearance of ovarian pathologies should be examined at least once a year by specialists.

Treatment of tumors on the ovaries

Treatment for ovarian cancer depends on several factors:

• menopausal status;
• age;
• the size of the neoplasm. If the parameters of the tumor exceed 5 cm for more than 2 months, then its removal is required;
• ultrasonic indicators;
• tumor marker levels.

An ovarian tumor is treated with several types of operations:

• extirpation of the uterus and appendages, removal of the greater omentum (with a malignant process);
• removal of a tumor (including teratoma) with an ovary.

Also, the treatment of neoplasms can be carried out with the help of radiation therapy (directed radiation), chemotherapy (damage to tumor cells with drugs) and hormones. Hormonal treatment is carried out with the susceptibility of the pathology to hormones.

A popular operation is laparoscopy - treatment and removal of pathologies through a small incision using a surgical probe. Such treatment minimizes the complications associated with traditional access. The method is based on the use of a laser and the evaporation of the contents of the tumor, while maintaining the woman's ability to conceive. The procedure can be performed to diagnose if ovarian pathology is suspected.

Consequences and possible complications

A dangerous pathology is the torsion of the pedicle of an ovarian tumor associated with a violation of the blood supply to the organ. This leads to acute malnutrition of neoplasms in the uterine appendages with the rapid development of morphological changes.

Allocate gradual or acute, partial or complete torsion of the pedicle of the ovarian tumor. In this case, venous stasis occurs with an increase in the size of the tumor, the risk of hemorrhages in the abdominal cavity. Treatment of pathology is based on the operation - adnexectomy.

Also, untimely detection or treatment of benign neoplasms can lead to the appearance of malignant tumors, chronic abdominal pain, infertility and menstrual irregularities.

Improper treatment of tumors can lead to an increase in their size, worsening of the pathology, the appearance of metastases or death.

Possible consequences and complications during radiation therapy and chemotherapy include poor health, hair loss, vomiting, nausea, etc.

To prevent the appearance of an ovarian tumor, you need to follow preventive measures:

1. observe a healthy lifestyle (add physical activity, exclude canned, salty, smoked and fatty foods);
2. give up smoking and alcohol;
3. use oral contraceptives;
4. carry out timely diagnosis and treatment of hormonal dysfunction (analysis of the thyroid gland, ovaries, adrenal glands and glucose levels);
5. periodic examination by a gynecologist;
6. pregnancy planning to avoid miscarriage.

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