Classification and histogenesis
Depending on the cellular composition, three main groups are distinguished:
- Ovarian type (most common). These include granulosa-stromal cell tumors: the granulosa cell tumor and the thecoma-fibroma group.
- Testicular type (rare). These are Sertoli-stromal cell neoplasms, a typical representative of which is arrhenoblastoma.
- Unclassified. The diagnosis is established when it is morphologically impossible to clearly differentiate between the female and male types of structure.
According to the nature of hormone secretion, tumors are divided into feminizing (produce estrogens; include thecoma and granulosa cell tumor) and masculinizing (produce androgens; e.g., arrhenoblastoma).
Characteristics of feminizing tumors
These neoplasms have different origins and macroscopic appearances:
- Granulosa cell tumor. Arises from tissue histologically resembling the granular epithelium of a maturing follicle. Accounts for up to 4% of all hormone-producing formations. Most commonly affects children and young women. Visually has a clear capsule, a yellowish color on cross-section, pronounced lobularity, as well as areas of necrosis and focal hemorrhages. Possesses a higher malignant potential.
- Thecoma. Develops from structures resembling the theca cells of atretic follicles. Occurs three times less frequently, predominantly in peri- and postmenopausal women. Macroscopically, it is a solid node of intense yellow color, 5–10 cm in diameter, usually without a capsule, cysts, or hemorrhages. Almost always unilateral and extremely rarely undergoes malignant transformation.
Clinical presentation of hyperestrogenism
The symptoms of feminizing tumors directly depend on the patient's age and the level of estrogens produced:
- In girls ("juvenile type"). False precocious puberty occurs. Acyclic bloody discharge appears, the uterus enlarges, vulvar cyanosis and vaginal rugosity are observed (positive "pupil" sign). At the same time, ovulation is absent, while bone age and general somatic development strictly correspond to calendar norms.
- In the reproductive period. Dysfunctional uterine bleeding becomes the main manifestation.
- In postmenopause. Metrorrhagia is the leading symptom. Due to estrogen excess, patients may look younger than their years (external "rejuvenation" effect). High hormonal levels provoke proliferative processes in the uterus: glandular-cystic hyperplasia (including with atypia), polyp growth, and significantly increase the risk of developing endometrial adenocarcinoma.
Diagnostics and surgical treatment
Bimanual examination palpates a dense or firm-elastic, painless, unilateral mass ranging from 4 to 20 cm in size.
Ultrasound imaging demonstrates a rounded echopositive mass with multiple echonegative inclusions. A crucial diagnostic clue is the correlation of the ovarian tumor with a thickened endometrium. Color Doppler mapping (CDM) reveals a "variegated mosaic" of vessels with a predominance of the venous bed. Spectral Doppler shows low systolic velocity and a resistance index of less than 0.4. The accuracy of such a diagnostic complex reaches 91.3%.
Treatment is exclusively surgical. The scope of intervention (from removing the adnexa on the affected side to hysterectomy with adnexectomy and total omentectomy) depends on the patient's age and the size of the node.
Mandatory intraoperative rules for any ovarian tumor:
- Cut and examine the internal structure of the extracted formation before completing the surgery.
- Perform a thorough revision of the abdominal cavity: examine the liver, stomach, intestines, and appendix.
- Palpate the omentum and para-aortic lymph nodes to rule out metastases (which most frequently affect the serous surfaces and parietal peritoneum).
Briefly: answers to topical questions
What clinical symptoms are caused by masculinizing ovarian tumors (e.g., arrhenoblastoma)?
Masculinizing ovarian tumors (arrhenoblastomas) cause symptoms of virilization that develop gradually and progress through stages from defeminization to masculinization. The main manifestations include:
- Defeminization — amenorrhea, infertility, reduction of the mammary glands.
- Masculinization — deepening of the voice, hirsutism, increased libido, reduction in subcutaneous adipose tissue thickness, clitoral hypertrophy, male facial features, and body contours.
To memorize the clinical presentation of feminizing tumors by age: JRP (Juvenile — Early maturation, Reproductive — Cycle disorders, Postmenopause — Pseudorejuvenation and Polyps).
Class and exam questions
Why is puberty in girls with a granulosa cell tumor called false?
Because the external signs of hyperestrogenism (enlargement of the uterus, bloody discharge) occur without true activation of the hypothalamic-pituitary system and without ovulation. Meanwhile, the child's bone age strictly corresponds to calendar norms.
What is the main ultrasound sign that helps suspect a feminizing tumor in postmenopause?
The key to the diagnosis is the combination of an ovarian mass with pronounced endometrial pathology (hyperplasia, polyps), which is completely atypical for the normal course of postmenopause.
How to macroscopically distinguish thecoma from a granulosa cell tumor?
Thecoma usually lacks a capsule, is solid on cross-section, without cysts or necrosis. A granulosa cell tumor, in contrast, has a clear capsule, a lobular structure, and often contains areas of hemorrhage.
What are the criteria for malignancy of these neoplasms?
About 80% of tumors are benign. Malignancy is confirmed by the presence of recurrences and metastases, which are most frequently localized on the parietal peritoneum, omentum, and the serous surface of abdominal organs.
What else to study on this topic
- Arrhenoblastomas: clinical presentation and diagnostics of masculinizing tumors
- Surgical tactics for mucinous cystadenomas and Brenner tumors
- Ultrasound differential diagnostics of cystic variants of feminizing tumors
- Pathogenesis of endometrial adenocarcinoma development against the background of thecoma
- Technique of laparoscopic evacuation of large ovarian cystomas
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