Obstetrics and Gynecology - A.M. Gromova 2000

Malignant neoplasms of the female reproductive organs
Ovarian cancer

In terms of detection frequency among all FEMALE Reproductive System neoplasms, ovarian tumors rank second, while malignant forms account for 15-25% of these cases.

Malignant tumors can develop either secondary to benign ovarian neoplasms or arise as primary malignancies. Epithelial tumors undergo malignant transformation most frequently, followed much less commonly by fibromas, endometrioid neoplasms, and Brenner tumors. Dermoid cysts carry the lowest probability of malignancy.

Primary malignant ovarian tumors include Choriocarcinoma, immature teratoma, dysgerminoma, Gonadoblastoma, and undifferentiated carcinoma.

Clinical manifestations of the condition depend primarily on the extent of tumor dissemination and its specific biological properties. Sometimes the transition of a benign neoplasm into a malignant one occurs imperceptibly for the patient, which is why nearly 80% of women are diagnosed with malignant ovarian tumors only at stages III-IV.

Clinical staging Classification of malignant ovarian tumors

Stage I - tumor is limited to the Ovary;

Stage Ia - tumor is limited to one ovary, no ascites (i - capsule intact; ii - capsule ruptured);

Stage Ib - tumor is limited to both Ovaries, no ascites (i - capsule intact; ii - capsule ruptured);

Stage Ic - tumor involves one or both ovaries with the presence of ascites containing tumor Cells in the fluid (i - capsule intact; ii - capsule ruptured);

Stage II - tumor involves one or both ovaries with pelvic extension;

Stage IIa - extension and/or metastasis to the Uterus, fallopian tubes, or the other ovary;

Stage IIb - extension to other pelvic Tissues;

Stage III - tumor involves one or both ovaries with confirmed peritoneal metastasis outside the pelvis and/or regional Lymph node metastasis;

Stage IV - tumor of one or both ovaries with distant metastasis.

Determining the histological type of the tumor allows for the assessment of its degree of differentiation. The presence or absence of ascites does not allow for an evaluation of the extent of primary tumor dissemination.

TNM classification of malignant ovarian tumors (1985)

T - primary tumor extent;

T₁ - tumor limited to one ovary, which remains mobile;

T₂ - tumor involves both ovaries, which remain mobile;

T₃ - tumor extends to the uterus and tubes;

T₄ - tumor extends to other tissues;

N - regional Lymph Nodes;

N₀ - para-aortic lymph nodes not enlarged;

N₁ - enlarged para-aortic lymph nodes;

N(-) - no histological evidence of metastasis;

N(+) - histologically diagnosed metastases;

M - distant metastases;

M₀ - no evidence of distant metastases;

M₁ - presence of implantational or other metastases;

M₁a - metastases confined to the lesser pelvis;

M₁b - metastases located within the Abdominal cavity;

M₁с - metastases located outside the abdominal cavity, including retroperitoneal ones (excluding para-aortic);

G₁ - low-grade malignant tumor;

G₂ - definite malignant tumor.

Malignant transformation of an ovarian tumor is characterized by a combination of preclinical manifestations typical of benign tumors, progressive general fatigue, pronounced weight loss, decreased appetite, persistent menstrual irregularities, constant pain, and abdominal enlargement. Reliable clinical signs of tumor malignancy include ascites and hydrothorax. Bimanual examination reveals dense, heterogeneous masses in the uterine adnexa regions.

The detection during ultrasound of tumor capsule invasion and intra-abdominal metastases confirms the malignant Nature of the neoplasm. The Diagnosis is supported by cytological findings from punctates or lavages obtained via puncture of the abdominal cavity through the posterior vaginal fornix, the pleural cavity, or enlarged lymph nodes.

Cytological examination is performed both for diagnostic purposes and to monitor the effectiveness of Chemotherapy and detect disease relapses. Comprehensive cytological analysis using luminescent, phase-contrast, and supravital Cell/15.html">Microscopy is also informative. X-ray examinations allow for the diagnosis of distant Metastases in the chest and intestines, as well as the detection of Gastric Cancer (malignant ovarian tumors can be metastatic in origin due to primary gastric involvement—Krukenberg tumor). Pneumopelviography, phlebography, cavography, and lymphography are performed according to indications.

For Differential diagnosis and staging of the pathology, laparoscopy, cystoscopy, and rectosromanoscopy are utilized.

For intraoperative diagnosis of malignant ovarian neoplasms, radionuclide diagnostic Methods are employed using ¹⁹⁸Au (lymphography to assess lymph node status and detect Liver metastases) and tracer doses of ³²P, the accumulation of which in malignant tumors helps determine the character of tumor growth.

The Treatment of patients with malignant ovarian tumors involves surgery, a combination of chemotherapy and hormonotherapy, and Radiation therapy.

Macromorphological signs of ovarian tumor malignancy detected during surgery include peritoneal dissemination, the presence of ascites, and omental infiltration. In such cases, regardless of the patient's age, supracervical amputation or Hysterectomy with adnexectomy and omentectomy is performed. When adjacent Organs are involved, the extent of surgery and the feasibility of resecting these organs are determined on an individual basis. If radical surgery is unfeasible, debulking of the tumor within accessible limits, omentectomy, and partial removal of metastases are carried out.

Chemotherapy can be administered both preoperatively to optimize surgical conditions and postoperatively to eradicate small tumor foci and disseminates, stabilize the disease process, and prevent recurrences. Methotrexate, fluorouracil, cisplatin, and cyclophosphamide are used for chemotherapy. Currently, polychemotherapy is predominantly utilized: cyclophosphamide combined with fluorouracil; cisplatin; or methotrexate and fluorouracil. Malignant mucinous and serous tumors are the most sensitive to chemotherapy. A significantly lower therapeutic effect is observed in metastatic ovarian tumors, granulosa cell tumors, and androblastomas.

With the Introduction of antineoplastic chemical agents into practice, radiation therapy for Ovarian cancer has become significantly less common. Immature teratoma and dysgerminoma are the most radiosensitive. Serous and mucinous tumors exhibit the highest resistance. Granulosa cell tumors and thecomas occupy an intermediate position in terms of radiosensitivity.

Hormone therapy is also utilized in the comprehensive treatment of ovarian cancer, specifically androgenic preparations (testosterone propionate 50–100 mg of a 5% solution daily for 1.5–2 months, followed by methyltestosterone at 30 mg). The cumulative course dose of androgens is 4–6 g. Hormonotherapy provides only a temporary effect; while improving the General condition of patients, it sometimes contributes to a reduction in tumor size.

The prognosis for malignant ovarian tumors depends on both the stage of the process and the histological Structure OF THE tumor, the patient's age, and the treatment administered.

Malignant ovarian tumors predominantly recur within 1.5 years following initial treatment. Recurrences with metastases of solid and papillary tumors occur more frequently than others.

For stage I, the 5-year survival rate is 60–80%, for stage II—40–60%, for stage III—15–25%, and for stage IV—10%.