Teratomas: From Benign to Malignant
Mature teratoma (dermoid cyst) has a favorable prognosis. On laparoscopy, it appears as a dense mass with an irregular yellowish-whitish color. An important differential diagnostic sign is its localization in the anterior fornix, whereas other tumors are more frequently concealed in the rectouterine pouch. The cyst pedicle is usually long and thin, and small hemorrhages may be visualized on the capsule. On ultrasound with color Doppler mapping (CDM), blood flow inside the tumor itself is practically absent. Treatment is exclusively surgical: young patients undergo cystectomy with the mandatory use of an evacuation bag, while supraservical hysterectomy with adnexectomy is indicated in perimenopause.
Immature teratoma (teratoblastoma) is a highly malignant tumor with low cell differentiation. It grows rapidly and can reach giant sizes. On cross-section, the tissue is variegated (ranging from pale gray to dark brown) and contains elements of all three germ layers: bone, cartilage, hair, and fatty masses. On palpation, it is a nodular, fixed, and tender mass. Ultrasound reveals a chaotic cystic-solid structure with pronounced neovascularization, central arteriovenous shunts, and a decreased resistive index. The tumor metastasizes to the peritoneum, retroperitoneal lymph nodes, liver, lungs, and brain.
Ovarian Cancer: Pathogenesis and Epidemiology
Ovarian cancer ranks second in frequency in gynecological oncology, second only to cervical cancer. In recent years, the peak incidence has "grown younger," shifting from 60–70 to 50–60 years of age.
Reliable etiological factors have not been identified, but three key hypotheses of development are distinguished:
- Hypothalamic-pituitary system hyperactivity. Chronic hyperestrogenemia does not cause direct tumor transformation, but creates a favorable background for the development of cancer in estrogen-sensitive tissues.
- "Incessant ovulation." Early menarche, late menopause, a small number of pregnancies, and a short duration of lactation lead to regular trauma to the ovarian cortical epithelium. This increases the risk of aberrant DNA damage with inactivation of suppressor genes.
- Genetic predisposition. Patients with familial autosomal dominant breast and ovarian cancer syndrome belong to the high-risk group.
Classification and Clinical Presentation of Cancer
Three main morphological forms of ovarian cancer are distinguished:
- Primary (no more than 5%): forms from the surface epithelium, has a glandular or papillary structure. The tissue completely lacks a mixture of benign and malignant elements.
- Secondary (80–85%): cystadenocarcinoma developing on the background of preceding benign or borderline tumors (serous, mucinous, or endometrioid).
- Metastatic (Krukenberg tumor): seeding of atypical cells from the gastrointestinal tract, breast, thyroid gland, or uterus. It is characterized by rapid bilateral growth, a dense or doughy consistency, and frequent development of ascites (in 60–70% of cases).
Clinically, the process remains asymptomatic for a long time, and there are no pathognomonic signs. In young women, the disease manifests as an "acute abdomen" in 22% of cases due to pedicle torsion or capsule perforation. In widespread disease (stages III–IV extending beyond the pelvis with distant metastases), intoxication progresses. Nausea, appetite distortion, alternating constipation and diarrhea, dysuria, lower extremity edema, pleural effusion, and abdominal enlargement due to ascites appear.
To memorize the sources of secondary cancer, use the abbreviation "SME": Serous, Mucinous, and Endometrioid cystadenomas are the main precursors of the malignant process.
Class and exam questions
Why is ovarian cancer often detected only at late stages?
Due to the complete absence of pathognomonic symptoms. The tumor develops latently for a long time, and with rapid growth and breakdown, the clinical picture is masked as general somatic gastrointestinal diseases or trivial intoxication.
How to differentiate a mature teratoma from an immature one using ultrasound with Doppler?
In a benign mature teratoma, vascularization is absent. A malignant immature teratoma is characterized by pronounced neovascularization, mosaic turbulent blood flow, and a resistive index below 0.4.
What is a Krukenberg tumor?
This is a metastatic ovarian cancer whose primary site is most commonly located in the gastrointestinal tract. Microscopically, it is distinguished by the presence of specific round signet-ring cells filled with mucus.
What else to study on this topic
- Surgical tactics for mature teratomas depending on the patient's age
- Hypotheses of ovarian cancer pathogenesis: the role of hyperestrogenemia and incessant ovulation
- Features of metastasis in immature teratoma (teratoblastoma)
- Differential diagnosis of "acute abdomen" syndrome in adnexal tumors
- Unified international staging system for ovarian cancer
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