13

Female Genital Tract

Thecomatosis

Thecomatosis is a pure stromal hyperplasia causing moderate enlargement of the ovary, which undergoes nodular changes. Histologically, the cortex is hyperplastic and shows intracellular fat deposits. Stromal hyperplasia occurs only in menopause.

Fig. 13.98 Endometriosis with bleeding: hypoechoic mass, hematomas (H) due to bleeding in foci of endometriosis. UT = uterus.

Inflammatory Adnexal Mass

13

Ovaries

Fig. 13.101 Adnexitis: nonhomogeneous hypoechoic fallopian tube (T), nonhomogeneous hyperechoic ovary (OV), surrounded by a fluid collection (E).

ponents, may show central anechoic necrosis, and tend to invade neighboring structures, producing ill-defined margins. It is common for ovarian carcinoma to coexist with uterine or tubal cancers. Primary malignant tumors of the ovary are indistinguishable from metastases arising from other primary malignancies.

Endometrioid adenocarcinomas are more heavily permeated by cysts and papillomas. They account for approximately 5% of ovarian tumors (Fig.13.105).

Ovarian cancers secreting hormones can cause hyperplasia of the endometrium (Fig.13.106, Fig.13.107).

Peritoneal carcinomatosis. Serous or mucinous carcinomas usually become disseminated throughout the abdominal cavity while the primary tumor itself is still relatively small. The peritoneum in these cases is studded with small tumor nodules and shows irregular hyperechoic thickening. Metastases are seeded

Fig. 13.102 Ovarian carcinoma: nonhomogeneous hypoechoic/hyperechoic mass (cursors) in the lower abdomen.

Fig. 13.103 Ovarian carcinoma, transvaginal ultrasonography; same patient as in Fig. 13.101.

Fig. 13.104 Ovarian carcinoma: hypoechoic tumor (cursors) combined with metastasis and intensive hypoechoic peritoneal carcinomatosis (PC).

13

Female Genital Tract

T and FIGO Categories for Ovarian Cancer (after WHO 201312)

T categories for fallopian tube cancer

Tx

Tis

T1

T1a

T1b

T1c

T2

T2a

T2b

T2c

T3

T3a

T3b

Fig. 13.105 Endometrioid ovarian carcinoma (TU), complex hyperechoic/cystic mass. UT = uterus; BL = bladder.

Fig. 13.108 Peritoneal carcinomatosis (cursors) in a nonovarian carcinoma of the ovary; 59-year-old woman: peritoneal carcinomatosis without a detectable ovarian carcinoma.

Fig. 13.106 Cystadenocarcinoma: hyperechoic polypoid masses (TU) of the cystic epithelium; C = cyst.

Fig. 13.109 Malignant ascites caused by a peritoneal carcinomatosis; nonhomogeneous fluid suspension with deposits of echogenic spots.

Fig. 13.107 Endometrial hyperplasia (transvaginal scan) in ovarian carcinoma: uterus with endometrial hyperplasia (16.3 mm).

early to the greater omentum (Fig.13.108). A large, flat, confluent, hypoechoic tumor may be formed ( 8.3a,d, 8.6f, Fig. 8.34). Hypoechoic masses also form on the diaphragm and along the umbilical vein. With the associated obstruction of lymphatic drainage, the serous fluid produced by the tumor cells usually leads to a copious ascites that is often bloodtinged on percutaneous aspiration (Fig.13.109). Cytological analysis of the ascites has a diagnostic accuracy of 80%.

Metastasis. Lymph node metastases (paraaortic, inguinal, lesser pelvis) are of minor importance. Ovarian carcinoma spreads hematogenously to the pleura, lung, and liver and less commonly to the brain and bone.

Differential diagnosis. Differentiation from intestinal carcinoma can be difficult. Bowel cancers are frequently associated with hepatic and lymph node metastases, but they rarely show omental involvement or peritoneal carcinomatosis with ascites.

In differentiating ovarian cancer from uterine myomas, a short, firm pedicle not attached to the cornual region suggests a subserous myoma, whereas a soft, mobile pedicle connected to the cornual region suggests an ovarian tumor (Fig.13.110, Fig.13.111). The full differential diagnosis is listed in Table 13.3.

Table 13.3 Differential diagnosis of ovarian masses

●Gallbladder hydrops

●Splenic tumor

●Pelvic kidney, renal tumor, hydronephrosis

●Pancreatic cysts

●Mesenteric cysts

●Bowel tumors, diverticulosis

●Tuberculous conglomerate masses

●Nodal packages in the mesentery

●Distended bladder

●Uterine myomas

●Tumors of the pelvic connective tissue (lipoma, sarcoma, endothelioma, retroperitoneal liposarcoma, retroperitoneal pseudomyxoma, osteoma, enchondroma)

●Tumors of the bony pelvis (may invade the connective tissue)

The sonographic criteria for carcinoma are as follows:

●Larger than 5 cm

●Nonhomogeneous, cystic-solid

●Ill-defined margins

●Lobulated or nodulated

●Echogenic

Borderline Criteria

Borderline tumors are tumors that have a low malignant potential:2

●Epithelial tumors

●Confined to the organ

●No stromal invasion

●Amenable to curative surgery

●Five-year survival rate 80–90%, even with peritoneal seeding

●Occurrence in premenopausal women: two-thirds of malignant tumors in women under age 40 are borderline tumors, as opposed to only 10% in women over age 40.

●Broad septa

●Bilateral

●Papillary deposits

●Free fluid

●On palpation: fixed, matted, firm (Table 13.4)

13

Female Genital Tract

Fig. 13.110 Tumor in the lower abdomen (abdominal pain): nonhomogeneous cystic mass with suspicion for ovarian tumor.

f Fig. 13.111 Peritoneal duplication; surgical specimen.

Table 13.4 TNM and FIGO classifications for ovarian cancer11

Primary tumor (T)

13

Ovaries

13

Female Genital Tract

13

Ovaries

13

Female Genital Tract

Clinical Aspects, Diagnosis, and Treatment of Ovarian Tumors

Symptoms

●There are no early symptoms.

●Ovarian tumors cause few if any complaints and have ample room to expand from the lesser to the greater pelvis. Often they are detected only after the abdominal girth increases. Many of these tumors are detected incidentally.

●Uterine bleeding (7%) occurs when there is a coexisting uterine tumor or when the ovarian cancer has penetrated the vaginal wall.

●Estrogen production and its associated symptoms occur in 18% of all ovarian tumors and 25% of ovarian carcinomas.

●In 70% of cases, metastases are already present at operation.

Typical complications

●Torsion of a pedunculated uterine tumor (10–20%) may be caused by an external force acting on the tumor (sudden deceleration), especially if the mass contains fluid. A gradual occlusion of the blood supply causes a gradual increase in complaints, while sudden occlusion produces a shocklike condition with peritonitis. Torsion can lead to necrosis.

●Infections occur in 2% of ovarian tumors, usually owing to the migration of infectious microorganisms from the bowel. They can lead to suppuration (pyogenic organisms) and putrefaction (putrefactive bacteria). The results are high intermittent fever and life-threatening peritonitis.

●Incarceration occurs if the tumor cannot move upward out of the lesser pelvis.

●Rupture occurs in 3% of all ovarian cysts, usually spontaneously and often as a result of torsion. Life-threatening internal bleeding can develop. The draining cystic fluid and spillage of cells lead to chronic ascites.

●Complaints relating to the complications are low back pain, a bloated feeling, difficulties in passing urine and stool, varices, and leg edema.

Diagnosis

Gynecological examination and ultrasonography by an experienced examiner using modern equipment should ensure that no malignant tumors are discovered incidentally at operation.

Tumor locations:

●Large ovarian tumors can exert traction on the uterus, causing it to assume a transverse position in the lesser pelvis.

●Small ovarian tumors are located in the lesser pelvis adjacent to the uterus, which they may displace.

●Dermoid cysts are often located anterior to the uterus.

●Tumors of the pelvic connective tissue are difficult to define.

Rule:

●The attachment of a tumor is located opposite the site of greatest mobility. Testing this mobility sign will usually help in distinguishing between an abdominal tumor and a tumor of genital origin.

Suspicious signs during palpation:

●Palpable nodule on the uterine attachment of the sacrouterine ligaments, in the cul-de-sac, or on the epiploic appendages of the rectum.

●Ovaries palpable after menopause.

Imaging and invasive studies

The patient may be examined by ultrasound, laparoscopy, CT (in exceptional cases; see below), or laparotomy with extirpation and histological evaluation.

Ultrasound with a well-distended bladder:

●Criteria for malignancy: solid, irregular, mixed solid/cystic elements, ascites.

●Criteria for benignancy: smooth, unilocular or multilocular cysts.

Cysts should not be aspirated:

●Danger of rupture and possible cell spillage.

●Needle aspiration cannot exclude intracystic carcinoma.

●Cyst aspiration is never curative.

Aspiration of ascites:

● The ascites in early ovarian carcinoma is free of tumor cells.

Laparoscopy:

●Laparoscopy is unsafe owing to the risk of cell spillage and uncertain because a wedge excision may be nondiagnostic. Because every ovarian tumor ultimately should be removed, laparoscopy merely wastes time.

CT:

●Whenever possible, CT should be performed only after menopause because of radiation exposure to the ovaries.

Treatment

●Wait for menstruation to occur before performing surgery, as functional cysts will regress spontaneously.

●With malignant ovarian tumors, both ovaries and fallopian tubes should almost always be removed along with the uterus and greater omentum because of the likelihood of metastases.

●A cure is possible if the largest tumor remnant left behind is no larger than 1–2 cm.

●Ovarian tumors are responsive to chemotherapy. If tumors recur, they do so quickly after the therapy is discontinued.

●Even during pregnancy, every true ovarian tumor should be surgically removed because of the risk of torsion, rupture, and suppuration in the puerperium (10%).

Prognosis

The prognosis depends critically on the timing of the first operation and the corresponding tumor stage, the histological type (serous tumors have a poorer prognosis than mucinous or endometrioid lesions), the degree of tumor differentiation (grading), the postoperative residual tumor mass, the age and the overall health of the patient.

The 5-year survival rates (after surgery and chemotherapy) are as follows:

Today, 70% of ovarian carcinomas are diagnosed in stage III or IV; the 5-year survival rate is 30%.

13

Ovaries

13

Female Genital Tract