Obstetrics and Gynecology - A. M. Gromova 2000

Benign Tumors of the Female Reproductive Organs
Benign Ovarian Tumors
Epithelial Benign Ovarian Tumors

Serous Tumors

The group of epithelial ovarian neoplasms includes tumors composed of one or more types of surface epithelium and stroma in various combinations. However, the histogenesis of cilioepithelial formations remains not fully understood. There are three main hypotheses explaining THE ORIGIN OF these tumors:

1) The Theory of origin from the surface epithelium;

2) from rudiments surrounding the Ovary and located in the region of its hilum;

3) from displaced areas of tubal and uterine epithelium.

Cilioepithelial ovarian tumors are characterized by A wide variety of structures. The largest group of benign tumors is cystomas, which are divided into serous and mucinous.

Serous cystomas (cilioepithelial). Simple serous cystoma (secretory) is typically a unilocular formation with smooth walls. The content is a clear, pale straw-colored fluid. The inner surface of the capsule wall is lined with a single layer of cuboidal, sometimes ciliated, epithelium. In its Structure, the ciliated epithelium resembles the lining of the uterine mucosa and fallopian tubes. In these cystomas, epithelial secretion prevails over proliferation. Their frequency accounts for 11% of all ovarian tumors and 45% of cilioepithelial tumors. They are most commonly observed in women aged 30–50, usually unilateral, and rarely reach large sizes. These cystomas generally have a round or oval shape and a smooth, shiny surface. If an accompanying inflammatory process is present, the surface may appear dull and covered with numerous adhesions. In the majority of cases (72%), they are unilocular, less frequently bilocular (10%) and multilocular (18%). During a gynecological examination, the tumor is usually detected on one side. It typically presents with a small size, smooth surface, tense-elastic consistency, mobility, and is painless. Clinically, it rarely manifests itself, often discovered during routine check-ups or when patients seek medical attention due to cramping lower abdominal pain (on the right or left depending on the affected ovary) and in the lumbar region (due to Torsion of the cystoma pedicle, capsule rupture or Hemorrhage into it, or necrosis). These tumors possess no hormonal activity, and the Menstrual cycle remains undisturbed. Ultrasound and laparoscopy make the Diagnosis of this ovarian tumor straightforward.

Treatment is exclusively surgical, consisting of the removal of the tumor along with the ovary. In cases of bilateral ovarian involvement, both Ovaries are removed regardless of the patient's age.

Papillary cystomas (papillary cystadenoma) are tumors characterized by the presence of papillary outgrowths. They are more frequently encountered during reproductive age, less commonly during the Climacteric period, and are almost never observed before Puberty. Their frequency is 7% of the total number of tumors and 34% of epithelial tumors. They have a high propensity for malignant transformation (up to 70% of cases).

The Development of papillary cystomas is frequently characterized by bilateral ovarian involvement and intraligamentary tumor Location. Quite often, they are accompanied by ascites.

Depending on the localization of the papillae, the following forms are distinguished:

1) inverted form (papillae are located inside the cystoma);

2) everted form (papillae are located exclusively on the outer surface of the cystoma capsule);

3) mixed form (papillae are located both inside and on the outer surface of the cystoma).

The papillae are lined with tall or flat epithelium, and their stroma can be dense or loose. The outgrowths may fill the greater part of the cystoma and visually resemble a cauliflower. The epithelial lining is usually single-layered, although Cell nuclei are situated at different levels, creating the impression of stratification. Occasionally, psammoma bodies are found in papillary cystomas; they are characterized by a convoluted concentric and spherical shape. Previously, their presence was considered a sign of malignancy, although this assumption has not been confirmed in modern practice.

The proliferation of papillae on the outer surface of the cystoma is often accompanied by their spread over the Peritoneum, but this does not indicate a malignant nature, as the papillae may regress after the removal of the primary tumor. Most papillary cystomas do not exceed 10 cm in diameter. The content of these tumors is serous or serous-hemorrhagic, fluid, though it can be viscous, ropy, and often turbid due to dystrophy and breakdown processes of some papillae, as well as a higher content of mucinous mass.

Clinical symptoms in papillary cystomas appear earlier than in smooth-walled ones, which may be attributed to bilateral involvement and intraligamentary tumor location. The earliest symptom is lower abdominal pain, sometimes radiating to the lower back and lower extremities, often accompanied by dysuria. Patients may also note abdominal enlargement, defecation disorders, general weakness, fatigue, poor Sleep, and loss of appetite. Menstrual dysfunction and Infertility are also present.

During a gynecological examination, a tumor with an uneven, bumpy surface (due to multiple papillae) is detected, which is closely attached to the Uterus, has limited mobility or is fixed (due to intraligamentary placement), and is painless. Because of its intimate connection with the uterus, it is often mistaken for a subserous Uterine Fibroid nodule.

Papillary cystomas quite frequently (up to 40%) coexist with other tumor-like Diseases of the reproductive Organs, such as Ovarian Cysts, uterine myoma, internal uterine Endometriosis, and malignant uterine tumors.

Treatment is exclusively surgical. The Scope of surgical intervention is the same as in the case of a simple serous cystoma.

Proliferating Serous Tumors

According to the WHO Classification, these cystomas are categorized as borderline ovarian tumors, representing precancerous conditions. Macroscopically, proliferating serous ovarian tumors share the same features as non-proliferating ones; they are more frequently bilateral and accompanied by ascites.

The distinction from benign tumors lies in marked epithelial proliferation manifested by true stratification, The formation of epithelial papillae lacking stroma, the appearance of mitoses, and occasionally nuclear anomalies, although the cellular atypia and infiltrative growth observed in carcinomas and proliferating tumors are absent.

Mucinous Tumors

Pseudomucinous cystoma (mucinous cystadenoma) is the simplest form of mucinous cystomas. They are encountered more frequently than Other forms of mucinous cystomas, accounting for about 82%. They are predominantly unilateral, with bilateral ovarian involvement observed in 10% of cases. These tumors reach large sizes, ranging from 10 to 30 cm in diameter, and occasionally up to 50 cm. Their shape is round or oval. In most cases, cystomas are multilocular. The size of the chambers varies; sometimes the tumor consists of one large formation and small daughter cysts. The chamber content—pseudomucin—is a thick, gelatinous fluid of various colors (yellowish, brown, pale or dark green, dark red). The difference between pseudomucin and mucin is that upon the action of acetic acid, mucin precipitates, whereas pseudomucin remains unchanged. The wall of mucinous cystomas and septa is yellow and dense, and the inner surface of the chambers is smooth.

The epithelium lining the cystoma wall is single-layered, tall columnar, with a basally positioned Nucleus, bearing resemblance to the epithelium of the cervical canal. It possesses The ability to produce mucus, which contains Glycoproteins and heteroglycans. Alongside the tall columnar epithelium, a cuboidal and, in some cases, ciliated epithelium is occasionally found.

Among simple mucinous cystomas, smooth-walled and "glandular" cystomas are distinguished. The latter are characterized by the presence of crypt-like invaginations and gland-like structures. In the epithelium of some cystomas, argentaffin Cells can be detected, and even more rarely, Paneth cells.

Pseudopapillary mucinous cystomas are macroscopically almost indistinguishable from simple mucinous cystomas. Histologically, As a result of numerous crypt-like invaginations located consecutively, the impression of papillae formation is created, giving the tumor a pseudopapillary structure. Clinically, they are most frequently unilateral and multilocular.

True papillary pseudomucinous cystomas are bilateral in the majority of cases. Papillary growths, sometimes resembling cauliflower, are identified on the inner surface of the chambers. The papillae feature a Connective Tissue core with a single-layered epithelial lining. Cell height and shape may vary; alongside tall columnar epithelium, cuboidal and goblet cells are observed. Mitoses are rare, and some cells lose their ability to produce mucus.

Pseudomucinous cystomas develop asymptomatically until the tumor reaches a considerable size. Occasionally, patients notice abdominal enlargement and can palpate the tumor themselves. When the size is sufficiently large, signs of compression of adjacent organs (Urinary Bladder, rectum, Lumbosacral plexus, lymphatic and venous vessels) appear. The tumor is characterized by an uneven surface (partially soft, partially firm in consistency), and adhesion formation is possible.

Treatment is always surgical, involving the removal of the tumor along with the ovary.

Proliferating mucinous cystomas

Proliferating mucinous cystomas are regarded as a precancerous condition. The tumor is multilocular; its outer surface is smooth, while the inner surface bears papillary proliferations. The clinical course of the disease differs little from that of conventional pseudomucinous cystomas. Histologically, the characteristic feature is intensive epithelial proliferation, expressed in the loss of specific differentiation and cell Functions in certain areas, and the appearance of Stratified Epithelium (no more than 2–3 layers). Unlike malignant mucinous tumors, cellular atypia, numerous mitoses, and infiltrative growth are absent. For a correct diagnosis, additional tissue samples from the tumor must be examined. When proliferating tumors are present, the prognosis is favorable for most patients; therefore, in young women with unilateral involvement, treatment is limited to unilateral salpingo-oophorectomy.

Ovarian pseudomyxoma is a very rare tumor that, according to some authors, is a variant of pseudomucinous cystoma. As a result of mucin saturation, the cystoma walls may undergo necrosis and rupture, spilling the cyst contents into the Abdominal cavity. The fluid is not absorbed by the peritoneum but becomes encapsulated, leaving the entire peritoneal cavity covered with gelatinous masses that sustain a chronic inflammatory state accompanied by pain. Capsule rupture presents with acute abdomen symptoms. Treatment includes radical surgery involving the removal of all internal reproductive organs, resection of the greater omentum, clearance of the gelatinous mass from the abdominal cavity, followed by Chemotherapy or radiotherapy.

Brenner tumors are fibroepithelial tumors composed of ovarian stroma and nests of polyhedral or large transitional-type epithelial cells. Synonyms include mucinous fibroepithelioma, mucoid fibroepithelioma, and colloidal adenofibroma. Brenner tumors are quite rare, with an incidence of 0.4–1%, primarily occurring in patients over 50 years of age. Histologically, they consist of connective tissue (fibroma-like) and epithelial components (in the form of epithelial islets and cords, occasionally forming cysts). The tumor size ranges from a few millimeters to the size of an adult human HEAD, averaging 6–7 cm in diameter. The tumor is typically unilateral, with left-sided localization being more frequent. Its shape is round or oval, the outer surface is smooth, and a capsule is generally absent. In appearance, density, and fibrous structure On the surface, it resembles a fibroma. Its color is whitish-gray, sometimes with a yellowish tint. Small cavities and, more rarely, large cysts may be observed within the tumor tissue, with the cavity contents being predominantly mucous. Brenner tumors are generally benign; malignant transformation occurs very rarely.

In recent years, great attention has been paid to the hormonal activity of certain Brenner tumors, which is associated with the presence of a thecal reaction and stromal luteinized cells in the stroma. In 50% of patients with a Brenner tumor, manifestations of estrogen activity were detected in the form of endometrial hyperplasia accompanied by anovulatory bleeding and postmenopausal bleeding. Some tumors present with masculinization, which was explained by their ability to synthesize testosterone from progesterone in the presence of human chorionic gonadotropin. Treatment is surgical, involving the removal of the tumor along with the affected ovary.