Ovaries are important reproductive organs of women and the source of female life. They are a pair of ovoid, pea-sized tissues located on either side of the uterus. They are quiet organs, and most of the time we do not feel their presence. But most of the time, the ovaries silently store and nurture the seeds of life – the eggs – and secrete the important endocrine hormones that maintain female sexuality. Perhaps because of the complexity and mystery of life’s construction, the ovaries exhibit a higher risk of disease than other organs. More than 30 diseases can occur in the small ovary, more than in most organs, and the vast majority of them are neoplastic. What is even more frightening is that ovarian malignancies always occur silently, and by the time they are detected most have progressed to an advanced stage, losing the opportunity for complete surgical removal. Such a mysterious and important organ needs more understanding and attention from us. The first step in understanding ovarian tumors is to start with her types.
Ovarian tumors are usually divided into four major categories according to their pathological characteristics.
1. epithelial tumors, which have the highest proportion and include common plasmacytoma, mucinous tumors, endometrioid tumors, etc.
2. germ cell tumors, which have a high proportion, including common teratomas, etc.
3. sex cord-mesenchymal tumors.
4. special kinds of tumors including mesenchymal tumors, metastatic tumors, etc.
Ovarian tumors can also be simply divided into benign, malignant and junctional categories.
Benign tumors are mostly asymptomatic and found by chance during physical examination, usually with long course and slow growth, often in one ovary, mostly cystic, with smooth surface, showing liquid dark area with clear border and normal tumor index CA125 on ultrasound. In contrast, malignant tumors have a short course, mostly bilateral, with solid or cystic irregular enlargement, abdominal distension, abdominal masses, ascites, and dark areas with disorganized light clusters with unclear boundaries and elevated CA125 on ultrasound. In addition, there are also junctional tumors, which are characterized by potential malignant tendency, with various aspects of performance between benign and malignant tumors.
In the following, we introduce several most common ovarian tumors and corresponding countermeasures according to the age of tumor predilection.
The most common hazards in children and adolescents – germ cell tumors that do not affect fertility.
1. Teratoma: Also known as dermatomal cyst, it is the most common type of germ cell tumor. More than 95% of them are benign mature teratomas and very few are malignant immature teratomas. It produces hair, teeth and some oil in the ovaries. It is best to remove them early because they do not disappear on their own and may grow and cause ovarian torsion. The average age of immature teratoma at the time of diagnosis is 11-14 years old, half of them occur before menstruation, and they commonly have abdominal lumps and abdominal pain, which may expand if the tumor breaks down, and the prognosis is poor.
2.Asexual cell tumor: Also known as germ cell carcinoma, it is the most common moderately malignant germ cell tumor in children and adolescents. It is commonly seen as an enlarged abdominal mass with a relatively rapid course of disease. It can also be a mixed type of asexual cell tumor, i.e. containing other germ cell tumor components, such as gonadoblastoma, immature teratoma, endodermal sinus tumor, mature teratoma, and choriocarcinoma.
3. Endodermal sinus tumor: Extremely malignant, also once called yolk sac tumor, which contains many small sacs resembling yolk sac vacuoles. The tumor tissue spreads rapidly through the lymphatic tract and abdominal tissues, and the course of the disease is short. It is more often associated with abdominal pain and is mostly stage III at the time of diagnosis, with an average age of 18-19 years at diagnosis, and is characterized, among other things, by an increase in serum AFP.
The treatment of benign germ cell tumors is mainly surgical. Since most of the patients are young girls or young women, ovarian tumor debulking or adnexal resection on the affected side is usually performed in order to preserve the reproductive function. Of course after surgery, ovarian function may be affected to some extent. For women who have completed childbirth, they can directly remove the whole uterus and both adnexa. Treatment of malignant germ cell tumors is usually surgery + chemotherapy. Again, in order to preserve fertility, surgery is usually performed to remove only the affected adnexa, followed by 3-6 courses of chemotherapy. After chemotherapy, pregnancy and childbirth are still possible.
Common ovarian tumors in women of childbearing age – physiological and benign are the main ones.
1. Functional cysts: These are the most common ovarian cysts in women of childbearing age. In women with ovulatory cycles, follicular cysts or corpus luteum cysts are formed when an abnormal amount of follicular fluid collects within the follicle or corpus luteum. These functional cysts can sometimes be large, but usually disappear on their own within three months, with or without medication. They are usually seen in the mid to late menstrual period, after follicular development or ovulation. Therefore, when cystic structures of the ovaries are found on physical examination, they can be reviewed on the 5th day of menstruation to identify them, and most of the functional cysts will disappear.
2. Plasmacytic cystadenoma and mucinous cystadenoma: after three months of observation, the cysts that still exist may belong to epithelial ovarian tumors rather than functional cysts. This is because plasma cells and mucus cells with secretory function are encapsulated in the ovary after ovulation and continuously secrete fluid to form cysts. These cysts do not go away and require open surgery to remove them. Depending on the patient’s age, either ovarian cyst debridement or resection of the affected adnexa can be chosen.
3. Chocolate cysts: that is, endometrioid tumors of the ovary. It refers to endometriosis growing in the ovary, forming a large amount of sticky coffee-colored chocolate-like liquid in the ovary. Because the tumor grows larger over time, it gradually erodes normal tissue, causing irreversible damage to ovarian tissue. Persistent chocolate cysts can also interfere with ovulation and seriously affect fertility. After assessment of its severity, it usually requires open surgery.
It is important to note that unless the cyst is a functional cyst that resolves on its own, there is no way to rule out malignancy until the ovarian tumor does exist and is surgically removed and pathologically diagnosed. Considering the adverse consequences of ovarian malignancy, and considering the advances in minimally invasive laparoscopic techniques, we currently believe that surgical exploration is indicated and necessary for any solidly present ovarian tumor.
The first killer of postmenopausal women – ovarian malignancy
Ovarian malignancy (ovarian cancer) occupies the 3rd place in the incidence of cancer of the female reproductive system, after cervical cancer and uterine body cancer. However, in recent years, due to the prevention and treatment of cervical cancer and uterine corpus cancer, the mortality rate of these two tumors has decreased greatly. Ovarian cancer, on the other hand, is still difficult to be detected in time due to its hidden location and inconspicuous early symptoms. Currently, ovarian cancer is the highest cause of death among cancers of the female reproductive system, and is the number one killer of the reproductive system of postmenopausal women.
Among ovarian malignant tumors, epithelial carcinoma is the most common, regardless of domestic or foreign data. Common ovarian malignancies include plasmacytoma, mucinous cystic adenocarcinoma, malignant endometrioid carcinoma, malignant clear cell carcinoma, immature teratoma asexual cell tumor, ovarian endodermal sinus tumor (yolk sac tumor), and granulosa cell tumor. Early-stage ovarian cancer may be asymptomatic and is mostly diagnosed during surgery and case examination. Late stage often has abdominal distension, lower abdominal mass or mass grows rapidly, and often has a short course of disease. There may be bladder or rectal compression symptoms. It may be accompanied by pain, fever, anemia, weakness and wasting and other cachectic manifestations. If the tumor ruptures or twists, it may cause acute abdominal pain. Some ovarian tumors can secrete estrogen or testosterone, which can lead to abnormal vaginal bleeding, postmenopausal bleeding, secondary amenorrhea in women of reproductive age, masculinization and other endocrine symptoms.
Surgery is the most important treatment for ovarian tumors.
Except for a small number of young patients in early stages, adnexal resection on the affected side to preserve fertility can be done if certain conditions are met. Most ovarian cancer surgeries require removal of the whole uterus, bilateral adnexa, followed by pelvic lymph node dissection and lesion removal. Most of them require 8-12 courses of adjuvant chemotherapy after surgery. This is followed by regular lifelong follow-up. Once the tumor progresses to advanced stage, surgery does not completely remove the lesion and the 5-year survival rate is still only 1/3.
Common ovarian tumor related questions
1. How to detect ovarian tumor early: As mentioned before, ovarian tumor is difficult to be detected early through symptoms, so regular medical checkups are especially important. It is recommended that women who are in a position to do so, especially middle-aged and older women, should have a gynecological ultrasound examination once a year. Once a mass in the ovarian region is found, relevant tumor indicators should be checked immediately. If the tumor indicators are normal, the examination can be repeated on the 5th day of menstruation, and if the mass persists, it should be removed by elective surgery. If the ovarian cancer indicators are abnormal, the malignancy of the tumor is highly suspected and surgery should be performed as soon as possible. In addition, if you feel bloated, feel a lump in your abdomen, or even have poor appetite, you should consider doing gynecological examination to exclude ovarian tumor.
2.How to read the tumor index report: the most commonly used ovarian cancer-related antigen, CA125, exists in epithelial ovarian cancer tissues and patient’s serum, and is an important indicator to assist in the diagnosis of malignant plasma ovarian cancer, as well as an indicator to observe the efficacy of ovarian cancer after surgery and chemotherapy, which can be continuously and dynamically observed. 95% of healthy adult women have CA125 levels ≤ 35 U/ml. if the patient’s serum CA125 level is twice the baseline level, vigilance should be raised. However, clinically common endometriosis, pelvic inflammatory disease, pancreatitis, hepatitis, cirrhosis, and even mild elevations of CA125 during early pregnancy are also seen. It is generally believed that CA125 greater than 200 U/ml is very inclined to consider malignancy. Therefore, there is no need to worry excessively when mildly elevated CA125 is found during physical examination.
In addition, many hospitals are also introducing another new tumor marker test, human epithelial protein 4 (HE4), which is also helpful for early diagnosis, differential diagnosis, treatment monitoring and prognosis assessment of ovarian cancer. Under normal physiological conditions, HE4 is expressed at very low levels in humans, but is highly expressed in both ovarian cancer tissues and patient serum. HE4 levels are age-dependent, with its levels increasing with age. HE4 is expressed at high levels in ovarian cancer cases, and more than 80% of those with significantly elevated levels have ovarian cancer. Specialists can also use HE4 in combination with CA125 to calculate a more accurate risk index for ovarian cancer malignancy. Of course, in most cases, the tumor index is only mildly elevated and the risk of malignancy is still very small.
3.What kind of people are prone to ovarian cancer: The cause of ovarian cancer is still unclear, and its development may be related to age, fertility, blood type, mental factors and environment. The incidence of ovarian cancer is high in celibate or infertile women. According to some statistics, the incidence of ovarian cancer in celibates is 60%-70% higher than that in married women. Mental factors have a certain influence on the development of ovarian cancer. Impatient personality and long-term mental stimulation can lead to damage of host immune surveillance system, which has a facilitating effect on tumor growth. Some tests have shown that ovaries are quite sensitive to smog pollution from industrial cities, which contains polycyclic aromatic hydrocarbon compounds capable of destroying oocytes. Ovaries are also sensitive to cigarettes, and women who smoke 20 cigarettes a day have early amenorrhea and a high incidence of ovarian cancer. Therefore, as with other tumors, healthy lifestyle habits and a good state of mind are important factors in the prevention and treatment of tumors. Because of the close relationship between ovaries and female reproductive endocrine, it is also very important for women to maintain a good endocrine environment for ovarian health.