Adolescent and Pediatric Ovarian Tumors
Introduction
Introduction to adolescent and pediatric ovarian tumors Ovarian tumors in adolescents and children are rarer than in adults. The incidence of ovarian tumors under 20 years old is only 5% to 10%, but ovarian tumors are most common in genital tumors during this age. The most common ovarian tumors in adolescents and children are germ cell tumors, including teratomas, anaplastic tumors, endodermal sinus tumors, embryonal cancer, and primary choriocarcinoma, accounting for about 60%, and only 20% of adults. There are significant differences in ovarian tumors between young, adolescent and adult. 70% to 80% of adult ovarian tumors are epithelial tumors, while epithelial tumors account for only 17% of patients under 20 years of age. Borderline tumors are rare. Some scholars have reported The incidence of epithelial tumors was 0.5% for those aged <9 years, 16% for those aged 10 to 13 years, and 38% for those aged 14 to 17. , basic knowledge The proportion of diseases: the incidence of ovarian tumors under 20 years old is only 0.005% to 0.010% Susceptible people: women Mode of infection: non-infectious Complications: teratoma, choriocarcinoma, ovarian tumor, adolescent and pediatric ovarian tumor
Cause
Adolescent and pediatric ovarian tumors
(1) Causes of the disease
The cause of ovarian tumors in adolescents and children: the onset of disease within 1 year of age is related to the hormone in the mother's body; the premenstrual period before menarche is due to endocrine activity, and the teratoma originates from the developmental variation of the cells during the embryo, immature teratoma It is derived from primordial germ cells and consists of three germ layers: inner, middle and outer.
(two) pathogenesis
1. The cytogenetic study of teratoma found that most mature teratoma showed normal 46, XX karyotype. In rare cases, the karyotype of teratoma can be trisomy or triploid, mature teratoma. It consists of well-differentiated outer, middle, and endoderm-derived tissues (the most ectodermal components). Cell and molecular genetic studies have shown that although the teratoma tissue has a karyotype of 46, XX, its karyotype with the host is There are genetic differences, and nuclear heterogeneity studies of chromosome centromeres have found that female hosts are mostly heterozygous karyotypes, while teratoma tissues are mostly homozygous karyotypes, with authors on chromosome terminal isozyme sites. Studies have found that although the heterogeneity of the karyotype of the teratoma tissue is homozygous, and the chromosomal isozyme site of the teratoma is heterozygous as the host, it is considered that the benign teratoma originates from The second meiotic failure or the single germ cell in which the second polar body fuses with the egg cell, the so-called parthenogenesis process, and later the authors found that some mature teratomas have heterogeneous markers of chromosome centromere and host cells. Karyotype It is completely consistent, and the failure of the first meiosis is also one of the mechanisms of teratoma.
Some scholars have analyzed the karyotypes of 21 mature teratomas. 13 cases were homozygous centromere heterogeneity markers, 8 cases showed heterozygous markers, and the host karyotypes showed heterozygotes. At the same time, in 13 teratomas with chromosomal markers homozygous, all enzyme polymorphisms were also homozygous, suggesting another possible mechanism of teratoma, namely, self-replication of mature egg cells. In 1987, Ohama et al. performed chromosomal heterogeneity and HLA polymorphism on 128 ovarian teratomas, and further proposed the multi-original mechanism of teratoma formation.
To sum up, there are five possibilities for the mechanism of ovarian mature teratoma:
(1) The first meiotic failure of the egg cell or the fusion of the first polar body and the egg (type I), which is characterized by the heterozygosity of the tumor cell and the host cell chromosome centromere marker; The point of heterozygosity or homozygosity depends on whether the chromosomal centromere and the terminal marker are interchanged and exchanged at the time of meiosis, and if there is no interchange, the terminal marker is heterozygous. When one crossover occurs, 50% behave as heterozygosity, and if 2 interchanges occur, 75% behave as heterozygosity.
(2) The second meiotic failure or the fusion of the second polar body and the egg (type II): the teratoma chromosome centromere markers are homozygous, and the chromosome end markers are meiotic The change can be expressed as homozygosity or heterozygosity.
(3) Self-replication in the nucleus of mature egg cells (type III): This type of teratoma has homozygosity for both centromere markers and chromosome ends.
(4) The first and second meiosis of primordial germ cells failed (type IV): this type does not undergo meiosis, and the chromosomal centromere and terminal markers of the teratoma formed after mitosis are shared with the host. Consistent, showing heterozygosity.
(5) Two egg fusions (V type): This type of teratoma chromosome centromere and terminal markers can be either heterozygous or homozygous.
The karyotype analysis of mature teratoma is more than 90%, 46, XX, a small number may have a number or structural abnormalities, of which trisomy is more common, the incidence of chromosomal abnormalities in mature teratoma is about 7%; In immature teratomas, the incidence of chromosomal abnormalities is as high as 60% or more, the most common of which is trisomy. Chromosomal structural abnormalities are often encountered, and chromosomes with abnormal structural abnormalities are 3, 5, 7, and 8. And chromosome 9, studies have shown that immature teratoma has the biological characteristics of transformation to mature teratoma, but when the immature teratoma is reversed to mature teratoma, whether its abnormal karyotype also changes simultaneously Is the normal diploid karyotype? Studies have shown that after the immature teratoma is induced to become mature by chemotherapy, its abnormal karyotype does not reverse.
Gross: Most tumors are unilateral, with similar incidence on the left and right sides, and 8% to 15% on both sides. The size varies greatly, ranging from very small (0.5cm) to huge (40cm), but most of them are 5 ~15cm, the tumor is round, oval or lobulated, the surface is smooth, the capsule is intact, the cut surface is mostly a large sac, and it can also have multiple rooms; containing hair and sebum-like substances, the inner wall of the capsule is often visible or Multiple, solid or cystic protrusions of varying sizes, called head nodules, with hair and teeth on the surface of the head nodules, bone, cartilage and adipose tissue on the cut surface.
Microscopically: the outer wall of the capsule is interstitial to the ovary, the inner wall is lined with skin, hair and skin attachments. The multiple tissues of the three germ layers are often seen at the head nodules, often accompanied by foreign body giant cell reactions.
2. Immature teratoma
Mostly unilateral, round or oval, lobulated or nodular, due to the tendency of tumor tissue to break through the envelope, the capsule is often incomplete, the surface is rough, and adheres to the surrounding tissue, generally 10 ~ diameter 30cm, brown or blue-gray, the cut surface has different color and quality due to different tissues. The tumor is relatively solid, and there are some cystic areas. The capsule contains viscous liquid, but there are few hair, fat or bone. In the softer, poorly differentiated areas, necrosis and hemorrhage may occur. The microscope is mostly embryonic tissue and immature three kinds of germ layer tissues, among which immature nerve tissues are more common, and peritoneal plants are common. Histological grades are generally lower than primary tumors.
Prevention
Adolescent and pediatric ovarian cancer prevention
Regular census: Ovarian tumors are often found in time. Once the diagnosis is clear, surgery should be performed early.
Daily self-examination: Wake up in the morning, when the urine has not been relieved, the legs are flexed, the abdominal wall is loosened, and then the lower abdomen is carefully touched by hand, and a lump may be found. The abdomen of the adolescents is thinner and the abdominal muscles are not well developed. As long as there is a lump, it is easy to touch through the abdominal wall. Smaller children can be examined by the mother. When adolescents have abdominal symptoms, such as abdominal pain, bloating, especially when abdomen lumps are found, in addition to the common reasons, it is also necessary to consider the possibility of ovarian tumors.
Complication
Adolescent and pediatric ovarian tumor complications Complications Teratoma choriocarcinoma ovarian tumor adolescents and pediatric ovarian tumors
Immature teratoma often combines with other germ cell tumor components, such as endodermal sinus tumors, dysgerminoma, and choriocarcinoma.
Symptom
Symptoms of adolescents and children with ovarian tumors Common symptoms Peritoneal irritation under abdominal masses Peripheral hemorrhage Persistent pain Ascites abdominal pain Bloating Acute abdominal pain precocious
1. The incidence of ovarian tumors in children is low, but the tumor grows fast after the occurrence, the degree of malignancy is higher than that of adults, the initial symptoms are not obvious, and it is difficult to diagnose early. If the treatment is not timely or incomplete, the prognosis is poor.
2. During the embryonic period, the ovary is located in the abdominal cavity, and it is reduced to the pelvic cavity until puberty. The pelvis of the child is small and cannot accommodate large tumors. Therefore, the young girl suffers from ovarian tumors, often with abdominal mass as the main symptom.
3. Abdominal pain is a common symptom, mostly persistent pain in the umbilical or lower abdomen. It is caused by tumor stimulation of the peritoneum, intra-abdominal hemorrhage, compression of surrounding tissues or adhesions. Sometimes malignant tumors can cause abdominal pain by themselves.
4. Pediatric pelvis is small, the tumor rises rapidly to the abdominal cavity, the tumor pedicle is elongated after the ovarian tumor rises, and the child is moving, the cystic mass is more likely to be reversed, causing acute abdominal pain, tumor enlargement, tenderness, and peritoneal irritation. The incidence of pedicle torsion in children with ovarian tumors is significantly higher than that in adults.
5. Ovarian tumors with endocrine function, such as granulosa cell tumor, ovarian stromal tumor, ring tubular stromal tumor, primary choriocarcinoma, etc., can cause homosexual precocity symptoms.
Most of the adolescents and children with immature teratoma begin to enlarge the abdomen with blunt abdominal pain. As the tumor grows rapidly, the corresponding compression symptoms appear. Because of the uneven soft and hard tissue of the teratoma, the tumor is heavier and the ligament is pulled. Long, more susceptible to pedicle torsion, immature teratoma can be infiltrated into the surrounding, disseminated, early metastasis to the para-aortic lymph nodes, late disseminated through the bloodstream, 20% to 30% of patients with laparotomy when the capsule has been Perforation and/or peritoneal implantation, sometimes with bloody ascites.
Examine
Examination of ovarian tumors in adolescents and children
1. Alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG) are sensitive and reliable tumor markers, and should be routinely measured in adolescents and children with ovarian tumors.
(1) Determination of blood AFP: AFP is produced by the yolk sac of the embryo, and a small amount of AFP can be synthesized in the endoderm tissue. Therefore, the AFP level of endodermal sinus tumor, embryonic carcinoma and immature teratoma can be increased.
(2) Blood and urine HCG measurement: Blood and urine HCG were elevated in patients with ovarian primary choriocarcinoma.
(3) Blood CA125, CA199, CEA and other ovarian malignant tumor markers can be found, and related tumors can be found.
2. CT, MRI and other imaging examinations are helpful for diagnosis.
3. Patients with abdominal flat-skin-like cysts can be seen with a contour of the lumps, which can have calcifications and teeth.
4. Ultrasound examination indicates the nature of the abdominal mass, the extent of the mass and its relationship to the surrounding organs.
5. Fine needle aspiration cytology cytological examination of fine needle aspiration and liquid absorption, early detection of ovarian malignant tumor, the diagnostic accuracy rate is as high as 85% to 90%, but the cystic fluid overflows when the cystic mass is puncture, which can lead to intraperitoneal Adhesion, which brings difficulties to future operations; at the same time, there is a risk of cyst rupture and cancer cell spread after puncture. In addition, the young girl's intra-abdominal mass often forces the organ to be displaced, the abdominal cavity pressure is large, and the puncture is easy. Accidental injury to the organ must be especially careful.
6. Laparoscopy can identify abdominal and pelvic masses with different properties. Ovarian tumors need to be differentiated from Wilms tumors, giant spleen, mesenteric cysts, extremely inflated bladder and neonatal vaginal hydrops. Laparoscopy has an early stage in patients with ovarian malignant tumors. Diagnosis, re-stage, judge prognosis and guide treatment.
Diagnosis
Diagnosis and diagnosis of ovarian tumors in adolescents and children
diagnosis
1. Detailed medical history
For those with main symptoms such as abdominal pain, mass, abdominal distension, and abdominal enlargement, the medical history should be inquired in detail. In addition, should children be advised whether they have used estrogen drugs or not, and whether the mother has taken a large amount of estrogen during the fetal period. Endocrine tumors are important.
2. Gynecological examination
The genitals of adolescents and children are not yet mature. Especially the genitalia of children are located in the deep pelvic cavity. It is difficult to perform gynecological examination. Abdominal and anal examinations are generally performed. The younger the age, the larger the scope of examination for the anus examination. It is best to use the little finger to reach the rectum. If the condition is needed, the vaginal examination should still be performed. The double-diagnosis or anal examination can touch the size and shape of the ovary. If there is an ovarian tumor, the uterus will be affected when the mass is pushed.
3. Adolescents and children with immature teratoma due to large tumor volume, the morphological structure of a certain area can not reflect the overall appearance of the tumor, so it is necessary to conduct biopsy in multiple places. The diagnostic criteria are based on histological examination for the presence of immature tissue. .
Differential diagnosis
Diagnostics must be taken from the histological identification to help guide treatment and prognosis.
It should be differentiated from tumors with endocrine function. If it is a non-tumor endocrine sign, the endocrine symptoms will resolve spontaneously after stopping the drug; if it is caused by a tumor, the symptoms will gradually disappear after the tumor is removed.
Mature teratoma was identified with immature teratoma (Table 2).
