Ovarian masses are a common gynecological disease, which can occur at any age, but are most common between the ages of 20 and 50. In recent years, with the accelerated pace of life and increased work pressure, the incidence of ovarian masses is on the rise and is developing at a younger age. Because the ovaries are located deep in the pelvic cavity and lack of typical symptoms when the masses are small, early lesions are not easily detected and are mostly discovered by chance during gynecologic ultrasound examinations. Some patients only pay attention to the increase in size of the mass when it is accompanied by pressure symptoms such as lower abdominal cramping, frequent urination, constipation, or when a mass is palpated in the lower abdomen, or when complications arise. In order to give readers a better understanding of ovarian masses, we will now briefly introduce you to the knowledge of ovarian masses from the following aspects.
I. What is an ovarian mass
After all, what is an ovarian mass? Simply put, ovarian masses are swellings that grow inside or on the surface of the ovaries. According to the texture of the mass, it can be classified as cystic, cystic solid and solid. They can occur in one ovary or both. Ovarian masses do not refer exclusively to a particular disease, but rather encompass a group of diseases in which ovarian masses are the manifestation. They can be divided into two main categories based on their relationship to tumors, namely non-redundant (i.e., non-neoplastic lesions) and redundant (i.e., ovarian tumors).
Non-redundant ovarian cysts are benign, generally small in diameter, not exceeding 5 cm, and often disappear on their own without treatment. Non-redundant ovarian cysts can be divided into functional cysts, endometriotic cysts (i.e. chocolate cysts) and inflammatory ovarian cysts. Functional cysts are clearly associated with gynecologic endocrine function and can be subdivided into follicular cysts, luteal cysts, and follicular membrane flavin cysts. In contrast, superfluous ovarian masses, i.e., tumorigenic lesions, are not always malignant.
Superfluous ovarian masses, i.e. ovarian tumors, can be divided into four major categories according to their histological components: (1) ovarian epithelial tumors; (2) ovarian germ cell tumors; (3) ovarian interstitial tumors; and (4) ovarian metastatic tumors. They can also be divided into benign, junctional and malignant according to their benignity and malignancy. Benign ovarian tumors are generally curable by surgery and have a good prognosis. Junctional ovarian tumors, including junctional plasmacytoma and junctional mucinous cystadenoma, are low-grade malignant potential tumors with slow growth, low metastasis rate and late recurrence, and generally have a good prognosis. In contrast, malignant ovarian tumors mainly include: plasmacytic cystic adenocarcinoma, mucinous cystic adenocarcinoma, ovarian endometrioid carcinoma, clear cell carcinoma, undifferentiated carcinoma, immature teratoma, endodermal sinus tumor, granulosa cell tumor, etc. Malignant ovarian tumors generally have a poor prognosis.
Clinical manifestations of ovarian masses
The occurrence of ovarian masses is mostly silent. When the masses are small, they are asymptomatic and often found by chance during gynecological ultrasound examination. When the mass increases to a medium size, you often feel abdominal swelling, lumbosacral discomfort, or a mass can be found in the lower abdomen. If the mass increases and fills the pelvic and abdominal cavities, pressure symptoms such as frequent urination, constipation, palpitations, etc. may appear. At this time, the abdomen is often significantly enlarged and may be accompanied by mobile turbid sounds.
In addition to the above mentioned discomfort caused by the enlargement of the mass, some types of ovarian masses may also present with other symptoms. For example, functional ovarian cysts are associated with gynecologic endocrine factors and may cause symptoms such as irregular menstruation, menopause, and infertility; ovarian endometriosis cysts are often associated with dysmenorrhea, periodic lower abdominal pain, and painful intercourse, and some patients may also experience infertility and increased spontaneous abortion; ovarian inflammatory cysts are often associated with infertility and pelvic infection; and malignant ovarian tumors are often asymptomatic in early stages or may have Malignant ovarian tumors are often asymptomatic in early stage, or may have some non-specific symptoms, such as loss of appetite, indigestion, abdominal distension, nausea and other discomfort. These discomforts often do not attract patients’ attention, but when symptoms such as abdominal distension, abdominal mass, ascites, abdominal pain, abnormal vaginal bleeding, emaciation, anemia, cachexia, swollen inguinal or supraclavicular lymph nodes appear, the lesions are mostly in advanced stage.
This shows that unexplained discomfort and menstrual irregularities should be taken seriously and thoroughly examined. Married women and women who have a regular sex life should undergo a comprehensive gynecological examination every one to two years for early detection of ovarian masses and other gynecological diseases, even if there are no uncomfortable symptoms. For women who have not had sex, they are often too shy to see a gynecologist, and this is one of the reasons why young women’s conditions are delayed. For these people, the pelvic ultrasound examination in the routine medical checkup plays a crucial role.
Third, complications of ovarian masses
Because ovarian masses lack typical symptoms in the early stages, they sometimes have their first manifestation as complications, so it is important to understand their common complications. There are four types of common complications as follows.
1. Torticollis: It is a common gynecologic emergency abdominal condition, which occurs in masses with a long, moderately large, mobile tumor tip and a weight on one side (e.g., teratoma). It often occurs when the patient suddenly changes position, or when the size and position of the uterus changes during pregnancy and puerperium. Typical symptoms are sudden onset of severe pain on one side of the lower abdomen, often accompanied by nausea, vomiting and even shock.
2.Rupture: It is divided into spontaneous rupture and traumatic rupture. In the case of rupture of a small mass, only mild abdominal pain may be felt or the ovary may be found to be restricted in movement. The latter is mainly due to the inflammatory reaction of the ruptured cystic contents stimulating the local peritoneum and ovaries, resulting in adhesions between the ruptured ovary and the surrounding tissues, causing the ovary to be fixed in the pelvis and resulting in limited ovarian activity. After the rupture of a large mass, a large amount of cystic contents can flow into the pelvic and abdominal cavity, which can cause peritoneal irritation and acute abdominal symptoms, manifesting as severe abdominal pain often accompanied by nausea and vomiting, and in severe cases can lead to intra-abdominal hemorrhage, peritonitis and shock. It is worth noting that the above symptoms should be distinguished from ectopic pregnancy when they occur in women of childbearing age.
3. Infection: It is relatively rare, mostly caused by the twisting or rupture of the mass, and can also come from the spread of infection foci in neighboring organs, such as appendiceal abscess. Clinical manifestations include fever, abdominal pain, lump and abdominal pressure, rebound pain, abdominal muscle tension and elevated white blood cells.
Malignancy: benign ovarian tumors may become malignant, but early malignancy is asymptomatic and not easily detected. If the tumor grows rapidly and the abdominal circumference increases rapidly within a short period of time, malignancy should be suspected.
Common examination methods of ovarian masses
1.Imaging examination
Ultrasound examination has become an important examination method in gynecological screening because of its easy operation, low price and repeatable operation, and it is also the most common and ideal examination method for ovarian masses. It can not only accurately detect the location, size and shape of the mass, but also identify whether it is cystic or solid. In addition, it can also make a preliminary judgment on the benign and malignant nature of the tumor, with an accuracy rate of 65.6% for the qualitative diagnosis of malignant ovarian masses. Color Doppler ultrasound scanning on the basis of ultrasound examination can determine the changes of blood flow in the ovary and the mass, which can help to diagnose ovarian masses and differentiate their benign and malignant nature. Generally, ovarian malignant tumors are richer in blood flow.
The qualitative diagnostic accuracy of CT and MRI examinations for ovarian malignant masses is 80-95% and 90%, respectively. CT is the most commonly used test to evaluate the infiltration, metastasis and staging of ovarian malignant tumors, and it has a certain reference value in determining the size, nature, infiltration of the organs around the ovary, the presence of liver, spleen and lymphatic metastasis and determining the surgical procedure. Although CT and MRI are more accurate than B ultrasound, there is still a possibility of missing the diagnosis for tumors <1 cm in diameter.
Chest and abdominal radiographs have diagnostic significance in determining the presence of pleural effusion, pulmonary metastasis and intestinal obstruction. The abdominal X-ray can also show the structure of ovarian teratoma such as teeth, bone and cystic wall calcification.
2.Tumor marker examination
Tumor markers are protein antigens or bioactive substances produced by abnormal expression of tumor cells, which can be detected in tissues, blood, body fluids and excreta of tumor patients, and help in tumor diagnosis, differential diagnosis and monitoring. The ideal tumor marker should be abnormal when a tumor occurs, and normal when no tumor occurs. However, there is no ideal tumor marker yet. At present, the tumor marker test is only of reference value, so do not be overly nervous when some tumor markers are abnormal.
The commonly used tumor markers for ovarian malignancy are CA125, CA19-9, carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP) and human testicular secretory protein 4 (HE4). Among them, CAl25 is the most widely used marker for ovarian epithelial tumors, which can be used as an aid in the diagnosis, treatment and follow-up monitoring of ovarian cancer. CA125 is also elevated to varying degrees in some non-malignant diseases, such as ovarian endometriosis cysts, pelvic tuberculosis and other benign lesions, but rarely exceeds 200 U/ml. CA19-9 and carcinoembryonic antigen (CEA) can be elevated in some ovarian tumor patients, but their positive expression rate is not as high as that of CA125. AFP is a common marker in patients with endometriosis. HE4 is another highly recognized tumor marker for epithelial ovarian cancer after CA125. Therefore, HE4 combined with CA125 has shown superior clinical value in the early diagnosis of epithelial ovarian cancer and the differential diagnosis of benign and malignant tumors.
3.Laparoscopic exploratory surgery
Laparoscopic exploration is not only an effective examination tool but also a treatment modality for ovarian masses. For patients with pelvic masses suspected of ovarian malignancy and for patients with non-malignant tumors with indications for surgery, laparoscopic exploration can be performed to clarify the diagnosis. The roles of laparoscopy include ①, to clarify the diagnosis; ②, to obtain biopsies for histological diagnosis; ③, to observe the condition of peritoneum, diaphragm and organ surfaces; ④, to remove the mass or perform ovarian cancer staging surgery; ⑤, to judge the efficacy after surgery and chemotherapy.
4.Cytological diagnosis and histopathological diagnosis
Cytological examination such as aspiration from the posterior vaginal fornix can sometimes find cancer cells, but the positive rate is very low and has little value for diagnosis. If the ascites is obvious, it can be directly punctured from the abdomen, and finding cancer cells in the ascites or abdominal washings is of guiding significance to determine the clinical stage and choose the treatment method for early patients. Although the positive rate of finding cancer cells by puncturing ascites is high, the puncture may also cause infection, penetration of the tumor capsule wall causing spillage of fluid inside the capsule, or even complications such as skin and implantation at the puncture site, which should be carefully considered before puncture.
Histopathological examination is performed by taking out small pieces of tissue from the lesioned area of the patient’s body (depending on the situation, such methods as forceps, excision or puncture aspiration can be used) or surgically removing the specimen to make pathological sections to observe the morphological and structural changes of cells and tissues to determine the nature of the lesion and make a pathological diagnosis. In the case of ovarian cysts, specimens are mostly obtained at the same time of open surgery or laparoscopic surgery. Histopathological examination can be the most reliable basis for diagnosis.
V. How to initially determine the benignity and malignancy of ovarian masses
With the increasing incidence of ovarian masses in recent years, more and more women are troubled by ovarian masses and worry all day long whether the “ovarian mass” they are suffering from is the “ovarian cancer” everyone is talking about and whether it will threaten their lives. What are the risks? The benignity or malignancy of ovarian masses is not only a problem for patients, but also an issue of great concern for doctors. This is because it is the key to guiding treatment. For malignant ovarian tumors, there are few methods for early diagnosis and lack of effective treatment for advanced cases, and their mortality rate is the highest among gynecological malignancies. Thus, it is crucial to determine the benignity and malignancy of ovarian masses at an early stage. In addition to the above-mentioned auxiliary examinations that can help determine their benignity and malignancy, they can also be judged simply from the following aspects.
1. Medical history: Patients with benign ovarian masses have a long course of disease, the masses grow slowly, often not more than 5 cm in size, and most have no uncomfortable symptoms; whereas those with malignant tumors have a shorter course of disease, the masses grow rapidly, often larger in size, often greater than 5 cm in diameter, and sometimes accompanied by febrile symptoms.
2.General condition: Patients with benign tumors are mostly women of childbearing age, with good general condition and no conscious discomfort; while for patients with malignant disease, there may be no discomfort in the early stage, but with the rapid growth of the tumor and aggravation of the disease, cachexia such as rapid weight loss, poor mental condition and anemia may occur in a short period of time.
3.Signs: benign ones are often unilateral, cystic, movable, with smooth surface and intact envelope, often without abdominal fluid; while malignant ones are mostly bilateral, poorly movable, often adherent to surrounding tissues, may have partly solid components, with unsmooth and nodular surface, often with abdominal fluid, mostly bloody, in which cancer cells can be detected.
In summary, ovarian masses with the following characteristics should be alerted to the possibility of malignancy: ①, solid; ②, bilateral; ③, irregular tumor with nodules on the surface; ④, adhesions and fixation; ⑤, rapid growth of the mass; ⑥, nodules in the utero-rectal fossa; ⑦, ascites, especially bloody ascites; ⑧, malignant mass; ⑨, large omental mass, hepatosplenomegaly and gastrointestinal obstruction manifestations. Most of these malignant manifestations can only be detected during gynecological examination, which shows that regular gynecological examination is an indispensable guarantee for women’s health.
Treatment of ovarian masses
The danger of ovarian masses to the body and their treatment depends on their nature. According to data, 95% of ovarian masses <5cm in diameter are non-tumorigenic. Generally speaking, for ovarian masses <5cm in diameter with basically normal tumor markers, they can be followed up closely, i.e. once every 2-3 months, to observe changes in size and tumor marker values of the masses. Such masses are usually physiological cysts, which do not require treatment and can disappear on their own during the follow-up period. Those with a diameter of >5 cm have indications for surgical investigation regardless of whether they are tumorigenic or not.
For ovarian masses >5 cm in diameter and those that persist or increase in size during follow-up, they should be considered as non-physiological masses, including non-redundant ovarian lesions (e.g. ovarian chocolate cysts) and ovarian tumors. They usually do not disappear on their own, which is what distinguishes them from physiological ovarian cysts. Most of these masses require surgical treatment and are now mostly treated by laparoscopic exploration or open surgery. Depending on the nature of the non-physiologic ovarian mass, the extent of surgical treatment varies in terms of resection. At the same time of surgical treatment, intraoperative specimens can be subjected to histopathological examination to further confirm the diagnosis, and clinical staging of the malignancy can also be performed intraoperatively to guide the postoperative adjuvant treatment plan.
1. Treatment of ovarian endometriosis cysts
For patients with ovarian endometriosis cysts, mild, asymptomatic patients (cyst diameter <3cm) can be treated with expectant therapy and regular follow up. For those with significant clinical symptoms and unwilling to undergo surgery, pharmacological treatment such as oral contraceptives or pseudo-menopause therapy (temporary menopause artificially created by suppressing pituitary function with oral gestodene or GnRH-A injections) can be used. However, those with large cysts and an urgent need for fertility, or those whose symptoms are not relieved by medication, whose local lesions are aggravated, or whose malignancy is suspected should undergo surgery. Surgery can be divided into conservative surgery, semi-radical surgery and radical surgery. In young patients, conservative surgery with cyst removal is usually used; in near-menopausal patients, radical surgery with total hysterectomy and double adnexa can be used. For non-radical surgery, postoperative medication is mostly required for adjuvant treatment. Currently, laparoscopic surgery + medication is considered the gold standard for the treatment of endometriosis.
2. Treatment of benign tumors
In patients with benign ovarian tumors, the scope of surgery should be decided according to their age, fertility requirements and the condition of the contralateral ovary. In young patients with unilateral benign tumors, debulking of the affected ovarian mass or oophorectomy should be performed, preserving the normal ovarian tissue on the affected side and the contralateral normal ovary as much as possible. For bilateral ovarian tumors, ovarian mass debulking should be performed to preserve normal ovarian tissues to improve the patient’s postoperative quality of life. For perimenopausal and postmenopausal women, adnexal resection on the affected side or hysterectomy and bilateral adnexal resection may be performed.
3.Treatment of junctional tumor
For patients with fertility needs, if the function of the opposite ovary is normal, ovariectomy is feasible; for other patients without fertility requirements, staged surgery including total hysterectomy and bilateral adnexal resection is generally recommended.
4.Treatment of malignant tumor
The treatment principle of malignant tumor is mainly surgery, supplemented by chemotherapy and radiotherapy according to the condition. The scope of surgery for malignant tumor is decided on the basis of total hysterectomy and double adnexal resection and according to the pathological type of tumor and the spread of lesions. Of course, for young and early stage patients, surgery to preserve the fertility function is also feasible. Adjuvant treatment after ovarian cancer is mainly chemotherapy, because ovarian epithelial cancer is more sensitive to chemotherapy, even if there is extensive metastasis, it can achieve certain efficacy. Radiotherapy has limited value in the treatment of ovarian epithelial cancer, but can be used for local treatment of metastatic foci in supraclavicular and inguinal lymph nodes and some limited foci in the immediate pelvic wall.
5.Other
Laparoscopic exploration or open exploratory surgery should be performed promptly for ovarian masses of unknown nature, especially if malignant changes are not excluded. Surgery should also be performed promptly in case of complications such as torsion or rupture of ovarian masses. If the ovarian mass is infected, anti-infective treatment should be given first and then surgical investigation should be performed if necessary.
There is no better method for the prevention of ovarian masses. It is recommended to keep a happy mood, pay attention to nutrition, strengthen resistance and, more importantly, to have regular gynecological examinations to detect microscopic lesions in time and to follow up on small swellings that have already appeared. Finally, I hope this article helps you to understand ovarian masses.