Surgical tactics in granulosa cell tumors
The choice of surgical intervention volume is always individualized. It is based on the characteristics of the neoplasm itself, a visual assessment of the contralateral (second) ovary, and the presence of concomitant gynecological or extragenital diseases.
A mandatory step in any surgery is urgent histological examination of the tissues. Intraoperative revision includes a thorough examination of the abdominal cavity, palpation of para-aortic lymph nodes, and assessment of the second ovary (if enlarged, biopsy is indicated).
If histology confirms a benign nature, the scope of surgery depends on the patient's age:
- In girls, the most conservative, ovary-sparing approach is used — only the affected organ is removed.
- In women of reproductive age, the standard is the removal of the uterine adnexa exclusively on the affected side.
- In the peri- and postmenopausal period, subtotal hysterectomy or total hysterectomy with adnexa is indicated (the decision depends on the condition of the endometrium).
Small benign nodes are successfully removed via a laparoscopic approach. However, if urgent histology reveals a malignant process, the surgical tactics change radically: the patient is indicated for total hysterectomy with bilateral salpingo-oophorectomy, supplemented by omentectomy.
Ovarian fibroma: etiology and pathomorphology
Fibroma is a relatively rare benign tumor, accounting for 2.5 to 4% of all ovarian neoplasms. By origin, it develops from connective tissue and is essentially a hormonally inactive thecoma. At the microscopic level, its structure is formed by interlacing bundles of spindle-shaped cells actively producing collagen.
Most commonly, the pathology is diagnosed in women aged 40–60 years. A crucial clinical fact: fibromas do not occur before the onset of puberty. The size of the node can vary from 3 to 15 centimeters.
Many patients have a burdened premorbid background, including chronic menstrual and reproductive dysfunctions. Fibroma is frequently combined with uterine fibroids (leiomyomas) or cystic changes in the same ovary. The neoplasm grows slowly, and a sharp increase in its size usually indicates the development of dystrophic processes. With increased mitotic activity, the tumor is classified as borderline with low malignant potential.
Clinical presentation and Meigs' syndrome
The tumor is localized strictly in one ovary, appears as a well-defined node, and does not secrete steroid hormones. On cross-section, the tissue looks dense, white, and fibrous. Sometimes areas of edema, cystic degeneration, or zones of diffuse calcification are found within it.
In approximately 10% of cases, the course of the disease is complicated by the development of Meigs' syndrome. This is a classical clinical triad including:
- Ascites (accumulation of fluid in the abdominal cavity).
- Hydrothorax (fluid in the pleural cavity).
- Anemia.
The pathogenesis of the syndrome is related to the fact that edematous fluid transudes from the tumor tissue into the abdominal cavity, from where it moves through anatomical diaphragmatic defects into the pleural cavities. Due to pronounced ascites, fibroma is often mistakenly suspected to be a malignant process.
Diagnostic criteria for fibroma
On bimanual vaginorectal/vagino-abdominal examination, a rounded or ovoid mass is palpated laterally or posteriorly to the uterus. It has a smooth surface, is mobile, and is completely painless. The consistency of the node is extremely dense, almost stony. The pathology must be differentiated from a subserous pedunculated myoma node.
Instrumental diagnostics relies on the following methods:
- Ultrasound: a rounded mass with clear contours is visualized. The internal structure is echopositive (medium or reduced echogenicity). A specific echographic marker is marked sound attenuation directly posterior to the tumor.
- Color Doppler ultrasound (CDU): confirms the avascularity of the node (no blood vessels are detected inside).
- Laparoscopy: reveals a dense tumor with a whitish capsule, a smoothed relief, and scarce vascularization (vessels are noticeable only in the fallopian tube zone).
Treatment of fibroma is exclusively surgical, and the prognosis is favorable.
Stromal-cell tumors (Androblastoma)
Androblastoma (Sertoli-Leydig cell tumor) belongs to the group of hormonally active masculinizing neoplasms. This is a rare pathology, accounting for about 1.5–2% of all ovarian tumors. Its histogenesis is associated with Sertoli-Leydig cells (hilar and stromal elements), which begin to overproduce male sex hormones.
Briefly: answers to topical questions
What specific clinical symptoms of masculinization (virilization) are observed in patients with androblastoma?
Patients with androblastoma exhibit late signs of masculinization that develop after defeminization:
- deepening of the voice;
- hirsutism — male-pattern hair growth;
- increased libido;
- decrease in the thickness of subcutaneous adipose tissue;
- clitoromegaly;
- masculine facial features and body contours.
Which primary malignant extragenital tumors most frequently metastasize to the ovaries (Kruckenberg tumor)?
Malignant tumors of the gastrointestinal tract, stomach, breast, and thyroid gland metastasize to the ovaries as Kruckenberg tumors. Colorectal cancer is also among the frequent primary sites of secondary ovarian involvement.
What is the specific histological picture of a metastatic Kruckenberg tumor?
Microscopic examination of a metastatic Kruckenberg tumor reveals signet-ring round cells filled with mucus.
Through which pathways does gastrointestinal cancer metastasize to the ovaries?
Malignant tumors of the gastrointestinal tract metastasize to the ovaries via three main pathways. These routes of spread include:
- Hematogenous pathway — transport of tumor cells via the bloodstream;
- Lymphogenous pathway — retrograde lymphatic spread of the tumor against the natural flow of lymph;
- Implantation pathway — peritoneal dissemination, in which cells spread along the peritoneum.
Class and exam questions
At what age does ovarian fibroma most commonly occur?
The peak incidence occurs at the age of 40–60 years. It is important to note that this tumor does not occur before puberty.
What scope of surgery is indicated if malignancy of the tumor is confirmed?
In malignant cases, total hysterectomy with bilateral salpingo-oophorectomy is indicated, along with mandatory omentectomy.
How does an ovarian fibroma appear on ultrasound?
On ultrasound, this is a rounded or oval mass with clear contours, echopositive. A specific sign is marked sound attenuation directly posterior to the tumor.
Why is a fibroma sometimes mistaken for a malignant neoplasm?
Due to the frequent concurrent development of ascites (accumulation of fluid in the abdominal cavity), which clinically mimics the picture of a malignant process.
What else to study on this topic
- Pathogenesis and stages of development of dystrophic changes in ovarian fibroma.
- Differential diagnosis between fibroma and a subserous pedunculated myoma node.
- Hormonal profile and clinical manifestations of masculinization in androblastoma.
- Borderline ovarian tumors with low malignant potential: criteria for mitotic activity.
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