Diagnosis and surgical treatment of ovarian tumors
Treatment of malignant ovarian tumors is always comprehensive in nature. The choice of specific tactics depends on the stage, morphology, and differentiation grade of the tumor, its sensitivity to chemotherapy and radiation therapy, as well as the patient's age, immune status, and comorbid conditions.
Additional methods are used to clarify the diagnosis:
- Chest X-ray fluoroscopy — to rule out metastasis.
- Chromocystoscopy — helps determine the stage of the process, which is especially relevant for large and fixed masses.
Surgical intervention is the leading stage of treatment.
- Standard scope: hysterectomy with adnexectomy and mandatory removal of the greater omentum (omentectomy) followed by morphological examination.
- Access: lower midline laparotomy. It allows the tumor to be extracted without damaging the capsule, perform a complete revision of the abdominal cavity, and carry out the required scope of intervention.
In debilitated and elderly patients, the scope can be reduced to supracervical amputation with subtotal resection of the omentum. In young women with malignant processes, removal of the affected adnexa, resection of the contralateral ovary, and subtotal resection of the omentum are permissible. Organ-sparing surgeries are possible only in stage I.
Accurate staging requires intraoperative revision: collection of peritoneal fluid, examination of para-aortic lymph nodes (with biopsy if enlarged). If radical surgery is not immediately possible, a two-stage approach is used: neoadjuvant chemotherapy first, followed by surgical intervention.
Ectopic pregnancy: etiology and risk factors
Normally, fertilization occurs in the ampullary region of the fallopian tube, after which the fertilized ovum is transported to the uterus due to muscular contractions and the beating of epithelial cilia. In ectopic pregnancy, this process is disrupted. Progressive and interrupted forms of the disease are distinguished.
The pathogenesis is based on two key mechanisms: delayed transport of the fertilized ovum and premature trophoblast activity.
Factors disrupting normal migration:
- Inflammatory and surgical: adhesive processes following adnexal inflammation or surgeries on the abdominal cavity and tubes.
- Hormonal and IVF: progesterone drugs slow down peristalsis, leading to early implantation.
- Peristalsis disorders: against the background of intrauterine contraceptive use, endometriosis, stress, endocrine pathologies, or prolonged lactation.
- Anatomical: genital infantilism (long tortuous tubes with weak contractility).
- Mechanical compression: by myoma nodes, cysts, or ovarian tumors.
Additionally, external ovum migration (when corpus luteum is found in the ovary on the side opposite to the tubal pregnancy) and the trophoblast factor (early production of proteolytic enzymes) are distinguished.
Pathogenesis of injuries and outcomes of tubal pregnancy
Chorionic villi (villi choriales) actively invade the fallopian tube wall, releasing enzymes. This leads to sequential melting, thinning, and destruction of the tube tissues, which is inevitably accompanied by vessel opening and bleeding.
Interruption of a progressive pregnancy usually occurs at 6–8 weeks of gestation. Possible outcomes:
- Tubal abortion (most common). The fertilized ovum detaches and is expelled into the abdominal cavity by antiperistaltic waves. Blood accumulates near the infundibulum, forming a peritubular hematoma. In a complete abortion, the expelled ovum dies, mummifies, and calcifies.
- Fallopian tube rupture.
- Early death and resorption of the embryo (rare). It leads to the accumulation of fluid (hydrosalpinx) or blood (hematosalpinx) in the tube lumen.
Other localizations are extremely rare: ovarian, cervical (primary or secondary), and abdominal pregnancy. Full-term extrapyramidal/ectopic pregnancy is a casuistry; the fetus is delivered via laparotomy, and the placenta in such cases is usually attached to the liver, omentum, or an accessory uterine horn.
Clinical presentation of pregnancy interruption
Both tubal abortion and tubal rupture manifest with symptoms of an "acute abdomen". The clinical picture of tubal abortion develops gradually and includes two groups of signs.
Signs of existing pregnancy:
- Doubtful: nausea, weakness, drowsiness, changes in taste and smell.
- Probable: delayed menstruation, breast tenderness.
Symptoms of interruption (at 2–3 weeks of delay):
- Pain syndrome: cramping lower abdominal pain periodically radiating to the rectum.
- Hemorrhagic syndrome: appearance of scanty dark spotting from the genital tract. They occur due to the rejection of the decidually transformed endometrium.
In an atypical course, menstrual delay may be absent: scanty bloody discharge and pain appear precisely on the days of expected menstruation, which complicates timely diagnosis.
Briefly: answers to topical questions
What clinical forms of ovarian apoplexy are distinguished depending on the predominant symptoms?
Depending on the clinical manifestations, painful and hemorrhagic forms of ovarian apoplexy (apoplexia ovarii) are distinguished.
- Painful form — accompanied by acute lower abdominal pain radiating to the rectum, lower back, and sacrum. In this form, hemodynamics are stable, and signs of intraabdominal hemorrhage and peritoneal irritation symptoms are absent.
- Hemorrhagic form — characterized by pronounced bleeding into the abdominal cavity, where the prognosis directly depends on the timeliness of diagnosis and treatment.
Which pathological changes and structures in the ovary are most often subject to rupture during apoplexy?
During ovarian apoplexy, rupture may involve the vessels of the follicle, follicular cyst, ovarian stroma, corpus luteum, or corpus luteum cyst. The rupture is preceded by the following pathological changes:
- Vascular disorders — under the influence of peak levels of gonadotropic hormones, particularly LH, ovarian vascular permeability increases and hyperemia occurs.
- Hematoma formation — a hematoma forms in the follicle or corpus luteum.
- Tissue rupture — intra-ovarian pressure rises rapidly, leading to a disruption of ovarian tissue integrity and bleeding.
During laparoscopy, a corpus luteum with a linear rupture or a rounded tissue defect with signs of bleeding may be visualized.
To memorize the causes of disturbed ovum migration, use the rule of "Five I's" (translated from Russian "Five V's"): Inflammation, Interventions (surgery/IVF), Intrauterine devices (contraceptives), Infantile/Congenital anomalies (infantilism), Intense compression (tumors).
Class and exam questions
What is the standard extent of surgery for ovarian cancer?
The standard surgical scope includes hysterectomy with adnexectomy and mandatory removal of the greater omentum to prevent the development of ascites.
What are the main mechanisms of ectopic pregnancy development?
Two main factors are the delayed movement of the fertilized ovum through the fallopian tube and the premature increase in the proteolytic activity of the trophoblast.
What occurs during a tubal abortion?
The fertilized ovum detaches from the tube wall and is expelled into the abdominal cavity due to antiperistalsis. This is often accompanied by the formation of a peritubular hematoma.
Why does spotting or bleeding occur during the termination of an ectopic pregnancy?
Scanty dark spotting from the genital tract is caused by the rejection of the decidually transformed mucous membrane of the uterus (endometrium).
What else to study on this topic
- Classification and management tactics for epithelial ovarian tumors
- Diagnosis of germ cell neoplasms and sex cord-stromal tumors
- Borderline ovarian tumors: classification features
- Etiology and pathogenesis of tumor-like ovarian lesions
- Diagnostic methods for patients with pelvic masses
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