Oothecomas occupy one of leading places among all the neoformations occurring in women. Except for mammary tumors the ovarian newgrowths among all the oncological diseases of woman genital sphere are second only to endometrial and endocervical carcinomas on frequency. About 80% of ovarian tumors are of nonmalignant nature and occur mainly in women aged 20-45 years old (Paltsev M.A., Anichkov N.M., 2001), 90% of all the neoformations make epithelial neoplasms, the serosal ones among them are registered in 70% of the cases (Petrovic O. et al., 1992). In this group 60% are referred to benign tumors (adenocystoma), 15% - to marginal, 25% - to malignant ones. Serosal tumors, which are referred to the newgrowths from the superficial (coelomic) epithelium, afflict women of all ages, but more often - those aged from 41 to 50 years old (Kolosov A.E., 1996).
Clinically similar tumors manifest themselves when achieving certain sizes, most often - 5-10 cm in diameter, and by associated with them complications. We submit our own sectional and surgery observations of large-sized ovarian adenocystomas. In the first case the prior disease - is an ovarian adenocystoma with extremely rare daughter cyst unconnected with the mother one anatomically in another cavity of the body, which was not diagnosed pro vita through twenty years long. The second observation appeared a finding of the operating table. The third one - is an intravital diagnostication of a large-sized oothecoma represented in the form of various tumor growths combination in the juvenile age and a successful operative therapy.
The patient R., 75 years old, had been suffering from various forms of "tumor growth" (abdominal cavity organs, lungs) for the last 20 years. At the autopsy investigation there was a cyst up to 150 mm in diameter, 3000 ml volume, with fancifully crooked bulges located between the intestinal loops, found in the abdominal cavity. In other localizations - in the region of spleen, sigma and appendix - there were independent, anatomically unconnected with each other cysts, each one - up to 100-200 ml volume. Round these formations there was a frank adhesive process registered with the deformation of the close round organs (liver, bile cyst, spleen, gaster). There was no gastrointestinal tract obstruction through. There was sclerosis, hyalinosis and petrification of the thickened up to 10-15 mm large-sized cyst with a keen bulge of the navel ring forwards in the umbilical region.
In the right pleural cavity there was a cyst of 140 mm in diameter with a keen edging of the right lung to the back bone, its compression into a slab to 10 mm thick and mediastinal displacement to the left. Its content represented an odorless opacity grayish fluid. Shtiftic, neutral, cubical and mucus secerning cells were detected there cytologically and pathohistologically. Hialinized connective-tissue papillae emerged in the cyst lumen. The wall itself - is dense, fibroid, with petrification regions. All the cysts represented ovarian adenocystomas with connective-tissue papillae and the epithelium without malignant change phenomena.
The patient G., 72 years old, had been suffering from polycystic ovary for the last 25 years. When, 18 years ago, the greatest one from the cysts had achieved the size of a chicken egg, he was offered an operative therapy, which she refused from.
She was operated on incarcerated umbilical hernia. At the abdominal incision a giant round shape Rockitansky´s tumor with dimensions of 190x230x250 mm, weighing 7000 g, was found. The intestinal loops were pushed off to the lateral channels of the abdominal cavity. The cyst wall is thick, fibroid, with large regions of hyalinosis and petrification. Branching and plain, low connective-tissue papillae covered with epithelial cubical, nonsecreting cells typical of ovarian adenocystomas were seen on its internal surface.
In the ectatic umbilical ring and hernial sac a fatty tissue at various stages of necrosis and infiltrative hemorrhage into it was found. There were no clinical data concerning the like formations, though of smaller volume, in other localizations.
The patient K., 23 years old, applied to the gynecological hospital with the complaints for volumetric gain of the stomach, pains irradiating to the small of the back in its lower departments for three weeks, infertility.
A faintly mobile formation with clearly-defined boundaries, soft, elastic, coming up to the navel, was determined at palpation. The stomach was increased up to 18-19 weeks of pregnancy. At the ultrasound investigation of the right ovary a large-sized (d = 170 mm) fluid formation coming from the ovary from the small pelvis to the navel was detected.
The right ovary was resected and the operational material was investigated pathohistologically using standard methods.
The macroscopic investigation testified: the oothecoma is d=160 mm; the wall is fibroid, rather hard, its internal and external surfaces are even, smooth, glossy, well vasculated; the vessels are large, tree-like branching. The cystic content is grayish, transparent, fluid, 3000 ml volume. In one cystic segment there was a cavity of 40 mm in diameter with brown content of fluid consistency, with chondral, osseous and hairy inclusions in the wall, and also a fragment of osseous tissue seemingly resembling a tongue bone. In another segment of the cyst there was a yellow body cyst (d=10mm) immured into the fibroid wall. In the third segment, on its internal surface, there was a papillary excrescence in the form of a thin 10 mm long villus (d=1mm), grayish, with a clean surface located.
The microscopic investigation testified: the ovary capsule is desmogenous, fibroid. In separate departments it is more rich in fibrous structures, in others - vice versa - in cellular fibrocyte- and fibroblast-, tissular lymphocyte- and histiocyte-type elements, with commonly defined, but faintly manifested phenomena of their atypism. In some visual fields on the fibroid capsule there were lipocytes with the coarsened stroma and extensive network of blood channels.
The ovary tissue is rather compact and vasculated, with a greater number of maturating follicles and starting forming white bodies. Fine serosal and mucic cysts inlayed with one-row cubical and pavement epithelium were noticed. In the cytoplasm of the last cellular formations fine vacuoles, mainly in their apical departments, were seen. Blood vessels are thin-walled, filled with blood unevenly. The overgrown yellow body vaguely divided from the cortical layer of the organ consisted of loosely disposed polygonal cells with foamed and honeycombed cytoplasm rich in glycolipoproteids. The cores - are large, roundish, rich in chromatin. The central region of the yellow body - is ectatic and filled with bloody masses with haemolysis occurrences and without it.
On the internal surface of the serous retention cyst fibroid capsule there was a middlenoded fibromatous formation up to 20 mm in diameter - a dense, hard fibroma rich in fiber structures, with dystrophic changes up to sclerosis and hyalinosis, with a decreased content of cellular elements and vessels. The atypism of the above listed cellular-fiber structures was manifested insignificantly.
In the other segments of the cyst wall there were elements of secerning cilioepithelial cyst (adenocystoma) represented by a papillary excrescence with a soft, faintly fibrous stroma. On its basic membrane there was a one-row cubical epithelium with small apically disposed vacuoles filled with serous fluid. In separate regions the epithelial coating had a two-row structure; the papillary stroma contained a rather developed blood supply. The perivascular fiber structures - are expanded, with ajar venules and arterioles.
In separate high-power fields there were small, so-called "chocolate cysts" of incomplete genesis - organizing and being organized hemorrhages into the serous daughter cyst, and also structural elements of dermo-affinity: osteoid, chondroid tissues and skin derivatives´ anlages - hair follicles.
Thus, the time protracted ovarian cystadenomas can reach more than considerable sizes and become very rare findings of operating and sectional tables. The epithelial cells of even encapsulated forms of these space-occupying lesions are able to penetrate with the thoracic cavity by hematogenous and lymphogenous ways, implant there and develop to the sizes analogous to the mother formation. The only analogous to the mentioned one case is described by one of us earlier (Razin P.S., Razin A.P., 2000). In the comprehensible literature about the possibility of serous oothecomas spread there were single mentions in the context: "Non-encapsulated variants of serous tumors are able to spread through the peritoneum" (Paltsev M.A., Anichkov N.M., 2001). Clinically, such multilocular ovarian cystadenomas without malignant change occurrence are able to simulate a large variety of diseases, the inclusive of cancerous ones.
The last of the observations represented by us differs by the combination of a large-sized serous cyst and with the regions of adenocystoma and teratoma - a dermoid tumor including various kinds of tissues (osteoid, chondroid and skin derivatives), being a congenital abnormality. The neoformation is defined by us as a mixed ovarian benign neoplasm, one component of which is represented by a cyst with neoplasm growth from the germinal epithelium (a cystadenoma), another one - by a benign neoplasm of the connective tissue (a fibroma), a third one is of herminogenous genesis (a teratoma in the form of a dermoid cyst containing three tissue types). Taking into account the patient´s syndactylia, which is a congenital malformation as well, there are good reasons to speak about the syndrome of multiple defects, which includes the congenital abnormality of ovaries and bony frame.
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The work is submitted to the Scientific International Conference "Scientific Research of Higher School on Priority Orientations of Science and Technology", May, 6-16, 2008, Savona - Hamburg, came to the editorial office on 12.02.2008.