postmenopausal ovarian cancer
Introduction
Introduction to postmenopausal ovarian malignancies Ovarian tumors are common tumors of female genitalia. Ovarian cancer is one of the three major malignant tumors of female genital tract. Ovarian cancer is a tumor with a particularly high cause of death. The ovary is located in the deep part of the pelvic cavity. It is not easy to be found or found. The tissue is complicated, so it is difficult to find its tumor early. There is still no effective diagnosis method for ovarian malignant tumors. basic knowledge The proportion of illness: about 2% over 50 years old Susceptible population: menopausal women Mode of infection: non-infectious Complications: abdominal pain, nausea and vomiting, peritonitis, shock, acute abdomen
Cause
Causes of postmenopausal ovarian malignancies
(1) Causes of the disease
Postmenopausal women with ovarian function decline, low immune function plus genetic factors, viral infection, fertility factors, smoking, economic status, ethnicity, geographical environment and other factors have a certain relationship with tumor development.
(two) pathogenesis
1. Histological classification
The classification of ovarian tumors is currently generally based on the histological classification developed by the World Health Organization (WHO, 1972). The following types are common:
(1) epithelial ovarian tumors: ovarian epithelial tumors are tumors derived from body cavity epithelium, accounting for 50% to 70% of ovarian tumors. The malignant type is also called primary ovarian cancer, which is the most common type of malignant ovarian tumor. It accounts for 85% to 90%, mostly in women aged 40 to 60 years. This type of tumor is derived from the germinal epithelium on the surface of the ovary, while the germinal epithelium comes from the original body cavity epithelium and has the potential to differentiate into various mullerian epithelium. Epithelial differentiation, formation of serous tumors; differentiation into the cervical mucosa, the formation of mucinous tumors; differentiation into the endometrium, the formation of endometrioid tumors.
According to histological characteristics, ovarian epithelial tumors can be divided into benign, borderline and malignant. The histological morphology and biological behavior of borderline tumor are between benign and malignant, which is equivalent to low malignancy. Low potential and malignant, the prognosis is significantly better than malignant tumors.
(2) ovarian germ cell tumor: ovarian germ cell tumor is a group of tumors derived from primitive ovarian germ cells, accounting for 20% to 40% of ovarian tumors, germ cells have all the functions of tissues, undifferentiated are dysplasia Embryonic pluripotent is embryonal carcinoma; differentiates into embryonic structure into teratoma; differentiates into extraembryonic structure into endodermal sinus tumor, choriocarcinoma, germ cell tumor occurs in children and adolescents, prepubertal incidence accounts for 60%~ 90%, only 4% after menopause.
85% to 97% of ovarian germ cell tumors are teratomas, 95% of which are mature teratomas, which are benign tumors, but 2% to 4% of them will have malignant transformation, mostly in postmenopausal women.
(3) ovarian cord stromal tumor: ovarian cord stromal tumor is derived from the sexual gonad and interstitial tissue in the original gonad, accounting for 5% of the ovarian tumor, the sex cord interstitial is derived from the mesenchymal tissue of the body cavity, Differentiation into male and female, sexual cord epithelial differentiation to form granulosa cells or supporting cell tumors; differentiation into interstitial cells to form follicular cell tumor or stromal cell tumor, such tumors often have endocrine function, it is also called functional tumor.
Granulosa cell tumors account for about 80% of mesenchymal tumors. They are low-grade malignant tumors, which are divided into human and juvenile types. Most of the adult granulosa cell tumors occur in postmenopausal women.
(4) ovarian metastatic tumors: ovarian metastatic tumors account for 5% to 10% of ovarian tumors, and their primary sites are often the gastrointestinal tract, breast and reproductive organs.
2. Ovarian malignant tumor metastasis pathway
The metastasis route is mainly through direct spread and abdominal cavity implantation. The tumor cells can directly invade the capsule, involve adjacent organs, and are widely planted on the surface of the greater omentum. The tumor with limited appearance can also be found in the peritoneum, omentum, diaphragm, etc. Subclinical metastasis, ovarian malignant tumors generally have a 50% rate of transverse metastasis, and increase with the increase.
Lymphatic metastasis is also an important way, there are 3 ways:
(1) along the ovarian blood vessels, from the ovarian lymphatics up to the para-aortic lymph nodes.
(2) From the ovarian lymphatics to the iliac crest, the extra-orbital lymph nodes, and then through the iliac crest to the para-aortic lymph nodes.
(3) along the round ligament into the extra-orbital and inguinal lymph nodes.
Hematogenous metastasis is rare, and can be transferred to the liver and lungs in the late stage.
Prevention
Postmenopausal ovarian malignancy prevention
Strengthen the monitoring and screening of high-risk groups and improve the rate of early diagnosis.
Complication
Postmenopausal ovarian malignant tumor complications Complications abdominal pain nausea and vomiting peritonitis shock acute abdomen
Such as ovarian tumor rupture or pedicle torsion often cause severe abdominal pain, nausea, vomiting, sometimes lead to internal bleeding, peritonitis and shock, is a common gynecological acute abdomen, about 3% of ovarian tumors will rupture, abdominal blows, sexual intercourse, gynecology Examination, puncture, etc. can cause traumatic rupture; tumor overgrowth or invasive growth can cause spontaneous rupture through the wall of the capsule. About 10% of ovarian tumors can be reversed, and venous return is blocked, and the tumor is highly congested or The blood vessels are ruptured and the tumor is necrotic.
Symptom
Postmenopausal symptoms of ovarian malignant tumors Common symptoms Amenorrhea menopause, weight loss, abdominal pain, vaginal bleeding, abdominal distension, ascites, edema, androgen, excessive postmenopausal bleeding
Symptom
The early stage of ovarian malignant tumors is often asymptomatic. It is accidentally discovered by gynecological examination for other reasons. Once the symptoms often manifest as abdominal distension, abdominal cramps and masses, and ascites, the severity of the symptoms depends on the following points:
(1) The size, location, and degree of invasion of adjacent organs: tumors of serous or mucinous ovarian cancer may be larger; tumors of the original ovarian benign tumors rapidly increase and ascites occur; Infiltration or compression of the surrounding tissue can cause abdominal pain, low back pain or pain in the lower extremities; if the pelvic vein is pressed, lower extremity edema can occur; in the advanced stage, it shows signs of weight loss such as weight loss and severe anemia.
(2) The histological type of tumor: such as functional tumor can produce the corresponding symptoms of estrogen or androgen excess, peri-menopausal women can have more menstrual periods, prolonged period and other abnormal vaginal bleeding, a small number of patients will also appear Continuous amenorrhea or irregular bleeding; menopausal women have postmenopausal bleeding, breast swelling, breast enlargement and so on.
2. Signs
The triad examination can be performed in the posterior vagina and the pelvic cavity is scattered in the hard ganglia. The mass is mostly bilateral, solid, or semi-solid, the surface is uneven, fixed, often accompanied by ascites, sometimes in the groin, sputum The lower or the clavicle can touch the swollen lymph nodes. After the menopause, the vaginal foramen is shallow and flat. Generally, the double diagnosis is difficult to detect the tumor or the posterior fornix metastasis. Therefore, it is necessary to emphasize the triple diagnosis. In 1971, Barber first proposed After menopause, it touches ovarian syndrome (PMP0). The size of normal ovary before menopause is about (3.5×2.0×1.5) cm3, about 1-2 years after menopause is about (2.0×1.5×0.5) cm3, and about 2 years after menopause. For (1.5 × 0.75 × 0.5) cm3, if the ovarian enlargement after menopause is found, attention should be paid to further confirm the diagnosis.
Examine
Examination of postmenopausal ovarian malignancies
1. Tumor marker examination:
1).CA125 80% of patients with ovarian epithelial cancer have higher levels of CA125 than normal. Because other tumors and non-neoplastic diseases such as endometriosis are also positive, it is necessary to use other methods for differential diagnosis. Tracking monitoring is more meaningful, and more than 90% of CA125 levels are consistent with disease remission or deterioration, especially for serous adenocarcinoma.
2). AFP has specific value for immature teratoma, ovarian endodermal sinus tumor, mixed dysplasia.
3). HCG is specific for primary ovarian choriocarcinoma.
4). Sex hormone granulosa cell tumor, follicular cell tumor produces a higher level of estrogen, serous, mucinous tumor can sometimes secrete a certain amount of estrogen.
2.B type ultrasound examination
Can detect the location, size, shape and nature of the mass, to understand whether the mass is from the ovary, suggesting that the mass is cystic or solid, benign or malignant, and can identify ovarian tumors, ascites and tuberculous effusions, B-mode ultrasound The clinical diagnosis coincidence rate is >90%, but the solid tumor with diameter <1cm is not easy to measure. The color Doppler ultrasound scan can measure the blood flow changes of the ovary and its new tissue, which is helpful for diagnosis.
3. Radiological examination
In the ovarian teratoma, the abdomen plain film can be seen in the teeth and bone. The wall of the capsule is a calcified layer with increased density. The cystic cavity is transparent and transparent. The venous pyelography can understand the pelvic cavity, kidney, ureter obstruction or displacement, swallowing examination, Oral enema air contrast angiography or breast soft tissue radiography to understand the presence of tumors in the gastrointestinal tract or breast, lymphography can determine the presence or absence of lymph node metastasis, improve the accuracy of staging, CT, MRI can more clearly show liver, lung nodules and retroperitoneal Lymph node metastasis.
4. Laparoscopy
The general condition of the mass can be directly seen, and the entire pelvic and abdominal cavity and the transverse iliac crest are observed. Multi-point biopsy is performed on the suspicious site, and the peritoneal fluid is taken for cytological examination, but the retroperitoneal lymph node cannot be observed by laparoscopy, and a huge mass or Laparoscopy is contraindicated in adhesive masses.
Diagnosis
Diagnosis and diagnosis of postmenopausal ovarian malignant tumors
Diagnosis can be based on symptoms, signs and laboratory tests.
The staging of ovarian malignancies is now using the phased method revised by FIGO (1986).
Differential diagnosis
1. Identification of ovarian malignant tumors and benign tumors.
2. Differential diagnosis of ovarian malignant tumors
(1) Endometriosis: Adhesive mass formed by ectopic disease and rectal uterus concave uterus and ovarian malignant tumor are difficult to distinguish, the former often have progressive dysmenorrhea, menorrhagia, irregular bleeding before menstruation, etc. Postmenopausal ectopic endometrial tissue can be gradually atrophied and absorbed. Progesterone therapy can be used for identification. B-mode ultrasound and laparoscopy can help identify, and sometimes laparotomy is needed to confirm the diagnosis.
(2) pelvic connective tissue inflammation: a history of abortion or puerperal infection, manifested as fever, lower abdominal pain, gynecological examination of the attachment area tissue thickening, tenderness, flaky blocks up to the pelvic wall, treatment with antibiotics to relieve symptoms, mass reduction If the symptoms after treatment, the signs are not improved, but the block is increased, should be considered as ovarian malignant tumors, B-mode ultrasound to help identify.
(3) tuberculous peritonitis: often with ascites, pelvic and abdominal cavity adhesion block formation, more history of tuberculosis, systemic symptoms are weight loss, fatigue, low fever, night sweats, loss of appetite, menstrual scarcity or amenorrhea, gynecological examination of the mass position The shape is irregular, the boundary is unclear, and it is fixed. The drum sound and voiced sound are unclear at the time of percussion. B-mode ultrasound examination, X-ray gastrointestinal examination can assist diagnosis, and if necessary, laparotomy.
(4) Tumors other than the genital tract: it needs to be differentiated from retroperitoneal tumor, rectal cancer, sigmoid colon cancer, and the retroperitoneal tumor is fixed. The lower position makes the uterus or rectum shift. The intestinal cancer has typical gastrointestinal symptoms. B Ultrasound examination, barium enema, intravenous pyelography, etc. can help identify.
(5) metastatic ovarian tumors: difficult to identify with primary ovarian tumors, if in the attachment area and bilateral, moderately large, kidney-shaped, active solid mass, should be suspected of metastatic ovarian tumor, if the patient has Gastrointestinal symptoms, digestive tract cancer, breast cancer history, diagnosis can basically be established, but most cases have no history of primary tumor.
