Treatment of ovarian tumors

Risk factors and physical examination

Special attention during history taking is paid to patients from high-risk groups. Women presenting with the following factors require careful monitoring:

• Impaired normal ovarian function and fertility issues.
• Prolonged follow-up due to tubo-ovarian inflammatory masses.
• Recurrent endometrial hyperplastic processes, especially in the postmenopausal period.
• History of surgical interventions for benign adnexal tumors.

During a bimanual gynecological examination, malignant neoplasms are most often bilateral. On palpation, they are defined as firm, nodular masses of oval or irregular shape, with sharply limited or completely absent mobility. A specific physical sign of malignancy is the so-called "spikes" — painless firm growths posterior to the uterus that project into the rectal lumen. As a rule, the tumor process is accompanied by significant fluid accumulation — ascites. A rectovaginal examination is mandatory to accurately assess tumor invasion into the parametrial and pararectal tissue.

Sonography and blood flow assessment

The gold standard for primary imaging is high-resolution transvaginal sonography (TVS) supplemented with color Doppler mapping (CDM).

Sonographic criteria of malignancy include:

• Significant dimensions of the space-occupying lesion (often bilateral).
• Irregular shape and thickened, uneven capsule.
• Presence of multiple papillary growths within the cyst and internal septa of varying thickness.
• Accumulation of free fluid (ascites) in the abdominal cavity and small pelvis.

The use of CDM and spectral Doppler sonography makes it possible to detect zones of neovascularization — numerous randomly distributed vessels both in the periphery and in the central structures of the tumor (in the septa and vegetations). A key hemodynamic marker of malignancy is low vascular resistance: the resistance index (RI) drops below 0.4 (calculated by measuring systolic and diastolic blood flow).

Three-dimensional sonography (3D US) provides the opportunity to study in detail the spatial relief of the inner capsule wall and accurately determine the volume of the mural solid component. Isolated 3D reconstruction of the vascular bed (three-dimensional angiography) clearly demonstrates a pathological tortuous network with numerous anastomoses, which reliably distinguishes cancer from a benign process.

Tomography, laparoscopy, and tumor markers

To clarify the diagnosis and assess the extent of the process, X-ray computed tomography (CT) and magnetic resonance imaging (MRI) are used. On tomograms, malignant tumors appear as space-occupying structures with nodular contours, inhomogeneous internal density (a combination of fluid and soft tissues), and a thickened capsule. A specific task of CT is the visualization of clear boundaries between the intestine, uterus, and urinary bladder to detect adhesions in the small pelvis.

Final morphological verification of the tumor histotype is achieved using laparoscopy. During the endoscopic intervention, the surgeon performs a targeted tissue biopsy and collects peritoneal fluid for cytological analysis.

Laboratory diagnostics rely on the study of serum tumor-associated antigens (CA-125, CA-19.9, CA-72.4). The level of CA-125 (normal up to 35 IU/mL) is elevated in 78–100% of patients with ovarian cancer. However, due to low specificity in early stages, this marker cannot be used as a screening test. Its main clinical value is monitoring the patient's condition and evaluating the effectiveness of ongoing treatment.

The complete examination algorithm necessarily includes ultrasound of the abdominal cavity, thyroid, and mammary glands, mammography, as well as endoscopic and radiological studies of the gastrointestinal tract (gastroscopy, colonoscopy, barium enema). This complex allows for an accurate diagnosis in 80–85% of cases. For the remaining patients, only diagnostic laparotomy provides a definitive answer.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Ultrasound machine settings for capturing low-velocity blood flow (WMF, PRF).
• Three-dimensional reconstruction of the vascular bed (3D angiography) and evaluation of neoangiogenesis.
• The role of computed tomography in detecting adhesions in the small pelvis.
• Complete examination algorithm: why mammography and GI endoscopy are needed in suspected ovarian cancer.

Other topics in the "Gynecology" section

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