Ultrasound and diagnostic imaging
Visualization plays a primary role in the initial detection of pathology. The baseline method is echography, which allows assessment of the shape, contours, and internal structure of the formation. For example, mucinous cystadenoma is visualized as a large, often multilocular round or ovoid formation with thick septa. A specific echographic sign is the presence of fine suspension within the chamber cavities, which remains non-displaceable upon percussion by the ultrasound transducer. At the same time, Brenner tumor, as well as mixed and undifferentiated variants, demonstrate a nonspecific pattern, defined as heterogeneous solid or cystic-solid structures.
To differentiate between benign and malignant processes, the application of color Doppler mapping (CDM) is critical. Blood flow velocity curves in the ovarian artery, pulsatility index, and resistive index (RI) are evaluated. Benign neoplasms are characterized by the absence of vascularization zones. Conversely, malignant tumors are distinguished by active vascularization in the capsule, septa, and echogenic inclusions, while the RI usually does not exceed 0.4. Additional information is provided by 3D ultrasound, which allows a detailed study of the vascular bed and the spatial relationship of structures. X-ray computed tomography (CT) and magnetic resonance imaging (MRI) are used for confirmatory diagnostics.
Laboratory diagnostics and tumor markers
Biochemical and immunological methods are aimed at identifying specific tumor-associated antigens. Markers CA-125, CA-19.9, and CA-72.4 have the greatest clinical significance.
The CA-125 antigen is a key indicator: its elevation is detected in 78–100% of patients with ovarian cancer, especially with the serous type. The normal serum concentration of CA-125 is up to 35 IU/mL. The method has high specificity—exceeding the norm is recorded in only 1% of healthy women and about 6% of patients with benign formations. The main purpose of determining CA-125 is the dynamic monitoring of the condition of patients with malignant tumors at the stages before, during, and after completion of therapy.
Special attention is required for bilateral gonadal involvement. In such cases, it is necessary to rule out the metastatic nature of the process, in particular Krukenberg tumor. To search for a possible primary focus, examination of the gastrointestinal tract using radiological methods as well as endoscopy (gastroscopy and colonoscopy) is mandatory.
Endoscopic methods and surgical treatment
Treatment of ovarian neoplasms is strictly surgical. The choice of access and extent of intervention depends on the patient's age, the size of the formation, its degree of malignancy, and the presence of comorbid pathology. A critically important condition is performing frozen section biopsy (urgent histological examination) directly during the surgery.
Laparoscopy is widely used due to the high accuracy of intraoperative diagnostics and the ability to detect small tumors that do not cause palpable transformation of the appendages. However, the method has strict limitations: it is not indicated for malignant processes. An attempt at laparoscopic removal of a malignant tumor is associated with the risk of capsule integrity violation, dissemination (peritoneal seeding), and technical difficulties in performing omentectomy (removal of the greater omentum). If malignancy is detected intraoperatively, immediate conversion—transition to laparotomy—is necessary.
The scope of surgery varies:
- Simple serous cystadenoma: in young women, enucleation with preservation of healthy tissue is possible; in older age, removal of the appendages is indicated.
- Papillary cystadenoma: requires a more radical approach due to proliferative activity. With growths on the capsule surface, supravaginal amputation or hysterectomy with adnexectomy and omentectomy is performed. In young patients with unilateral lesions without capsular invasion, laparoscopy is acceptable, but strictly using an evacuating specimen retrieval bag.
Morphological pattern of papillary formations
Macroscopically, papillary serous tumors are cystic formations on the inner surface of the capsule of which exophytic growths are visualized. These structures have a papillary, nodular, or tuberous appearance, outwardly resembling cauliflower. The tissue of the growths is usually pinkish-red and fleshy, indicating abundant vascularization.
Microscopic examination reveals a complex histological architectonics with multiple branching of papillae in a tree-like manner. Each such papilla rests on a prominent fibrovascular (connective tissue) core containing blood vessels. The surface of the papillae is covered by proliferating epithelium forming gland-like and crypt-like structures. For definitive differential diagnosis between benign cystadenoma, borderline tumor, and cystadenocarcinoma, the pathomorphologist evaluates the degree of cellular atypia, mitotic activity, and the presence of epithelial invasion into the underlying stroma.
Briefly: answers to topical questions
Which tumor markers are specific for germ cell ovarian tumors?
Specific markers for germ cell ovarian tumors are three main serum markers.
- hCG (human chorionic gonadotropin), including the free beta-subunit — characteristic of choriocarcinoma, and also elevated in embryonal carcinoma and polyembryoma.
- AFP (alpha-fetoprotein) is produced by the yolk sac tumor and is also elevated in embryonal carcinoma, polyembryoma, and immature teratomas (in about 1/3 of cases).
- LDH (lactate dehydrogenase) is a specific marker for pure dysgerminoma, elevated in nearly 100% of cases.
A combined elevation of AFP and β-hCG is characteristic of embryonal carcinoma and polyembryoma.
Which histological types are classified as germ cell tumors of the ovary?
Germ cell tumors of the ovary include:
- Dysgerminoma
- Mature benign teratoma
- Immature teratoma
- Yolk sac tumor
- Embryonal carcinoma
- Choriocarcinoma
- Mixed germ cell tumor / mixed malignant germ cell tumor
The most frequent type among germ cell tumors is teratoma.
What are the components of a mature cystic teratoma (dermoid cyst)?
A mature cystic teratoma (dermoid cyst) contains derivatives of 2 or 3 germ layers.
- Capsule — dense, fibrous, with a smooth and shiny surface.
- Contents — a thick mass: sebum, hair in the form of tangles/strands; well-formed teeth are frequently present.
- Inner lining — columnar or cuboidal epithelium.
- Ectodermal derivatives — skin, neural tissue elements: glia, neurocytes, ganglia.
- Mesodermal derivatives — bone, cartilage, smooth muscle, fibrous, and adipose tissue.
- Endodermal derivatives are less common: bronchial and gastrointestinal epithelium, thyroid and salivary gland tissue.
Which ovarian germ cell tumor has the highest radiosensitivity?
Sources indicate a high sensitivity to radiotherapy for pure forms of dysgerminoma. They respond well to radiation therapy for both the primary tumor and metastases. With proper treatment, complete recovery is possible; the 5-year survival rate for a unilateral encapsulated tumor without metastases reaches 90%.
To remember the indications for emergency conversion (transition from laparoscopy to laparotomy), use the "RDT" rule: risk of Capsule rupture, threat of peritoneal Dissemination, technical difficulties of omentectomy.
Class and exam questions
How to distinguish a malignant tumor from a benign one on ultrasound?
The key criterion is vascularization, assessed by color Doppler mapping. Malignant tumors are typically characterized by active blood flow with a resistance index below 0.4, whereas benign areas usually lack vascularization.
Why check the gastrointestinal tract in bilateral ovarian lesions?
Bilateral localization may indicate a metastatic nature of the neoplasm (Krukenberg tumor). To rule out a primary gastrointestinal source, gastroscopy, colonoscopy, and X-ray examination are prescribed.
In which cases is laparoscopic tumor removal acceptable?
Laparoscopy is used for benign formations (e.g., in young patients with unilateral papillary cystadenoma without capsule invasion) with mandatory use of an extraction bag. If malignant growth is detected, an immediate conversion to laparotomy is indicated.
What else to study on this topic
- Histological classification of epithelial ovarian neoplasms.
- Technique of omentectomy in borderline and malignant processes.
- Differential diagnosis of Brenner tumor and undifferentiated formations.
- Management features of perimenopausal patients with cystic changes.
- Three-dimensional echography (3D ultrasound) in assessing the spatial relationship of pathological structures.
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