1. Early symptoms can be asymptomatic, and most of them are diagnosed during surgery and pathological examination. 2. Abdominal distension, a mass in the abdomen or lower abdomen, or a rapid growth of the mass in the late stage often occur, and the course of disease is often short. 3. There may be symptoms of bladder or rectal compression. 4. It may be accompanied by cachexia such as pain, fever, anemia, weakness and emaciation. Such as tumor rupture or torsion can cause acute abdominal pain. 5. Some ovarian tumors can secrete estrogen or testosterone, which can cause endocrine symptoms such as abnormal vaginal bleeding, postmenopausal bleeding, precocious puberty in adolescent girls, secondary amenorrhea in women of childbearing age, masculinity and so on. 6. Signs: (1) General examination: Pay special attention to superficial lymph nodes, breast, abdomen (swelling, ascites, mass), liver, spleen and rectum. (2) Pelvic examination: Double river examination and triple diagnosis should be conducted to examine the uterus and its accessories, and pay attention to the position, lateral differentiation, size, shape, texture, mobility, surface condition, tenderness, and tubercle of the posterior fossa of the uterus. Special attention should be paid to the possible signs of malignant tumor, such as bilateral, solid or cystic solid, tumor surface nodules or irregular shapes, poor or inactive activity, retrofossa nodules, rapid tumor growth, ascites, advanced cachexia, hepatosplenomegaly, omental mass and intestinal obstruction.
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The etiology of ovarian cancer is not clear at present, and its incidence may be related to age, fertility, blood type, mental factors and environment. Ovarian cancer can occur at any age. The older you get, the more you will get sick. Generally more common in menopause and menopausal women. Different types of ovarian cancer have different age distributions. Most epithelial ovarian cancers have different age distributions. Epithelial ovarian cancer mostly occurs in 40 ~ 60 years old. Sex cord stromal tumor is similar to ovarian epithelial carcinoma and increases with age. Germ cell tumors are more common in young women before the age of 20. Single or childless women have a high incidence of ovarian cancer. According to statistics, the incidence of ovarian cancer in single people is 60% ~ 70% higher than that in married people. It has been found that people with type A blood have a high incidence of ovarian cancer. The incidence of type O blood is very low. Mental factors have certain influence on the occurrence and development of ovarian cancer. Impatient personality and long-term mental stimulation will damage the host immune monitoring system and promote tumor growth. Experiments show that ovaries are very sensitive to smog pollution in industrial cities, and polycyclic aromatic hydrocarbons such as benzopyrene can be transformed into more reactive forms by enzymes in ovarian cells after being brought to ovaries through blood flow. The main thing is to destroy oocytes. Ovaries are also sensitive to cigarettes. Women who smoke 20 cigarettes a day have early amenorrhea and a high incidence of ovarian cancer. People who are often exposed to talcum powder and asbestos are more likely to develop ovarian cancer.
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Although the etiology and pathogenesis of ovarian cancer are still unclear in western medicine, according to medical experts in China? Quot The description and theoretical analysis of traditional Chinese medicine show that exogenous pathogenic factors, internal injury diet and emotional depression are its pathogenic factors, and the imbalance of viscera, yin and yang, qi and blood and the damage of vital qi are its pathogenic basis. Often mutually causal, eventually leading to phlegm-dampness, stagnation of qi and blood in chong and ren, pulse condition, and finally leading to ovarian cancer. The pathological essence of this disease always belongs to the deficiency of the essence and excess of the essence.
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There are many kinds of ovarian tumors, ranking first among all organs in the body. Common ovarian malignant tumors are introduced as follows. Serous cystadenocarcinoma is the most common ovarian malignant tumor. Two-thirds of them are bilateral, and their cancer cells are often characterized by cysts and nipples, but they still retain their original tissue morphology more or less. Some form a large number of regular vesicles, and sometimes the epithelium protrudes into the cavity to form epithelial clusters or nipples. Histological classification: highly differentiated (grade ⅰ), moderately differentiated (grade ⅱ) and poorly differentiated (grade ⅲ). 2. Mucinous cystadenocarcinoma is multilocular, but it is more benign in ovarian mucinous tumors, accounting for about 5% ~ 40%. The appearance is smooth, round or lobulated, and the section is cystic and multilocular, accompanied by solid areas. Nipples can be seen on the inner wall of capsule, but less than plasma cancer. The cystic cavity contains bloody colloidal mucus, and bleeding and necrosis are common in the solid area. Microscopically, it is characterized by: ① more than three layers of epithelial layer; ② Severe epithelial dysplasia with abnormal mucus secretion; ③ The glands are backward; ④ mitosis is active; ⑤ Interstitial infiltration. Histological classification: (1) Highly differentiated (Grade I): columnar epithelium with more than 3 layers of epithelial hyperplasia. The nipple branches are slender, irregular in shape and less interstitial. The cells on the nipple surface are depolarized, arranged in disorder, with unequal nuclear sizes and many mitotic stages. Sometimes too much mucus is secreted, which can't escape from the cell, making the cytoplasm boundary disappear. (2) Moderate differentiation (Grade II): columnar epithelium or low columnar epithelium, with * * * wall, a small amount of mucus in cells, a large number of cell nests infiltrating in stroma, and more mitotic stages. (3) Low differentiation (grade III): the gland structure is not obvious, epithelial cells grow in clusters or diffuse, the nuclear atypia is obvious, and there are many mitotic stages. There is little mucus in the cells. 3.55% ~ 60% of malignant endometrial carcinoma tumors are unilateral, cystic or mostly solid, cystic fluid is mostly bloody, sometimes accompanied by chocolate cyst. Smooth or nodular appearance, or surface nipple growth. Microscopically similar to endometrial carcinoma, squamous metaplasia is common. According to the morphological arrangement of glands and the degree of cell differentiation, tumors can be divided into three grades: (1) well-differentiated (grade I): well-differentiated, mainly with gland structure and a small number of mitotic stages. (2) Moderate differentiation (Grade II): the solid part accounts for 65,438+0/2, the gland shape is irregular, a large number of small glands are interconnected, and the mitotic stage is obvious. (3) Low differentiation (Grade III): gland structure is rare, tumor cells proliferate in large numbers, destroying gland cavities, forming diffuse areas and increasing mitotic phases. 4. Malignant clear cell tumors are mostly cystic and solid, not very hard, and vary in size, with unilateral tumors and bilateral tumors reaching 24%. The section is fish-like or light yellow. Often accompanied by bleeding and necrosis. Careful examination can often find endometriosis. Transparent cells, spinous cells and eosinophils can be seen under the microscope. The nucleus is heteromorphic and mitotic. 5. Immature teratoma tumors are mostly unilateral giant tumors with smooth capsule, but often adhere to surrounding tissues or tear easily during operation. Most sections are solid with cystic areas; Occasionally, cysts are the main body, and there are solid areas in the cyst wall. The solid area is soft and delicate, showing variegated and colored bleeding and necrosis, and sometimes bone, cartilage, hair or brain tissue can be seen; Cystic areas are usually filled with serous fluid, mucus or colloid. Microscopically, the tumor consists of mature and immature tissues from three germ layers. The ectoderm is mainly nerve tissue and skin, the mesoderm is mainly fibrous connective tissue, cartilage, bone, muscle and undifferentiated mesenchymal tissue, and the endoderm is mainly glandular tube-like structure, and sometimes bronchial or gastrointestinal epithelium can be seen. These tissues are at different stages of maturity and have no organ-like arrangement. Immature tissue mainly refers to neuroepithelial tissue, which can form chrysanthemum-shaped group or neural tube structure, or diffuse into pieces. Norris et al. (1976) put forward a classification method of immature teratoma according to the content of this neuroepithelium in tumor, which is of great significance for treatment and prognosis judgment. Level 0: All mature organizations. Grade I: A few immature tissues (mainly colloid and primitive mesenchymal) have mitosis. There are few neuroepithelium, and each slice is limited to 1 /40 times the field of view. Grade Ⅱ: There are many immature tissues, and each piece of neuroepithelium accounts for more than 4 times /40 times of the visual field, which is often fused with sarcomatoid stroma. Recently, Norris and others proposed to combine this classification into two categories: low malignancy and high malignancy, that is, grade I did not receive postoperative chemotherapy, and grade II and III received postoperative chemotherapy. These classification methods must be based on sufficient materials, and take one piece per centimeter according to the maximum diameter of tumors in different areas of the naked eye. Six, asexual cell tumors are mostly unilateral, medium size, round, lobulated, smooth envelope, gray section, necrosis and bleeding. Microscopically, there are large round or polygonal cell groups separated by connective tissue, surrounded by lymphocyte infiltration. This kind of tumor often appears various hypogonadism or hermaphroditism. Seven, ovarian endodermal sinus tumor (yolk sac tumor) is mostly unilateral, and both sides are mostly caused by metastasis. Tumors are usually large in size, with a diameter exceeding 10cm, round or oval in shape, smooth in surface, complete in capsule, grayish-white in section, fragile in tissue, with gelatinous mucus in stroma, accompanied by bleeding, necrosis and easy to rupture. Microscopically, the structure is complex, mainly loose reticular structure and endoderm sinus-like structure. Tumor cells are flat, cubic, columnar or polygonal. Eight, granular cell tumor is the most common ovarian cord stromal tumor. It is a low-grade malignant tumor. Most of them are unilateral, with different sizes, smooth or lobulated surface, solid section, yellowish color, some of them are cystic, and sometimes there is bleeding and necrosis. Histologically, granular cells are radially arranged around the capsule. Granular cell tumor has endocrine function, secretes estrogen, appears pseudoprecocious puberty before puberty, causes menstrual disorder during childbearing age, prolongs endometrial hyperplasia after menopause, and even adenocarcinoma.
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There are four common metastasis routes of ovarian cancer: direct diffusion, lymphatic metastasis, hematogenous metastasis and implantation metastasis. 1. The common way for ovarian cancer to spread directly is to spread directly to adjacent tissues and organs, or to the serosa or peritoneal wall of abdominal organs, such as fallopian tube, uterus, bladder, serosa surface of rectum, mesentery and abdominal envelope of other organs. 2. Lymph node metastasis is mainly abdominal lymph node metastasis, mainly paraaortic lymph node metastasis and pelvic lymph node metastasis, or other distant lymph node metastasis. 3. Patients with advanced hematogenous metastasis can spread to lung, liver, bone and brain. 4. Implantation metastasis tumor cells fall off from the surface of tumor tissue and are planted on the surface of the whole basin, abdominal organs or tissues, resulting in implantation metastasis, which is also a common metastasis method.
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Because the ovary is located deep in the pelvic cavity, the early tumor is small, and it is difficult to have symptoms without metastasis or complications. Pelvic masses are often found in gynecological examinations. When the mass is large, it can squeeze the surrounding organs to produce various symptoms, such as pressing the bladder, which can cause dysuria or obstruction; If the rectum is compressed, constipation or poor stool may occur; Once complicated with ascites or metastasis, gastrointestinal symptoms such as abdominal distension, indigestion, loss of appetite and belching appear. Will appear; Chest tightness, dyspnea, palpitation, etc. It may occur if the amount of ascites presses the diaphragm upward or is accompanied by pleural effusion. If granulosa cell tumor, ovarian endometrioid carcinoma or other malignant tumors seriously damage bilateral ovarian tissues, menstrual disorder may occur, and abdominal pain, low back pain and leg pain may occur due to the infiltration and oppression of adjacent organs by malignant tumors; In advanced patients, emaciation, anemia and cachexia are common, and supraclavicular, axillary and even inguinal lymph node metastasis and enlargement can also occur.
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1. At present, B-ultrasound and color ultrasound are commonly used in ultrasonic examination. Ultrasound showed that ovarian malignant tumors were mostly mixed or solid. Because of the rapid growth of tumor, it is often accompanied by bleeding, necrosis and degeneration, which makes the internal interface of tumor complicated. Ultrasound showed tumor differentiation, chaotic echo and irregular boundary. If the mass is mixed, the capsule halo is fuzzy, the outline is unclear, and the interval is thick, generally more than 3cm. Nodular solid dark areas protrude into the septum and the capsule cavity on the capsule wall. Masses are often fixed or accompanied by ascites. According to literature reports, the coincidence rate of ultrasound in differentiating benign and malignant tumors can reach 52% ~ 80%. In recent years, scholars at home and abroad have reported that the diagnostic accuracy of benign and malignant tumors can be improved to over 90% by using color Doppler ultrasound. But ultrasound still has its limitations. The diagnosis of solid tumors and local malignant nodules with diameters less than 1 cm cannot be made. Moreover, there are many kinds of ovarian tumors, and it is impossible to clearly diagnose the pathological types by ultrasound examination. 2. Cytological examination showed that malignant tumor was highly invasive. Even if the tumor is confined to the ovary, tumor cells may have invaded the tumor capsule or grown to the surface of the capsule. Because of the low adhesion between tumor cells, tumor cells are easy to fall off. Therefore, if the fluid accumulated in uterus and rectal fossa is aspirated through the posterior fornix of vagina for cytological examination, the exfoliated tumor cells can often be found. If no liquid can be obtained by aspiration, 200ml of normal saline can be injected and then aspiration can be performed. The positive rate was higher after centrifugation. Clinically, this method is often used for early diagnosis of ovarian cancer, differential diagnosis of ascites and late follow-up of ovarian cancer. In recent years, for pelvic masses suspected of malignant tumors, slender needles are often used to puncture the masses directly through vagina or abdominal wall, and aspiration cytology is performed on the masses to help diagnosis. The diagnosis rate can reach more than 90%. As for whether fine needle puncture will lead to tumor metastasis through pinhole, it is generally considered that this possibility is very small. Some scholars observed ovarian cysts during operation and in vitro, and found that cystic fluid leaked through small holes, so fine needle aspiration was not suitable for active cystic masses. Some people think that surgery and/or chemotherapy within two weeks after fine needle puncture will not increase the risk of malignant tumor spread. 3. Computed tomography can determine the full range of lesions, which is helpful to determine the staging of ovarian cancer and find recurrence and metastasis. 4. Lymphography In recent years, lymphography has been used to help determine the lymph node involvement of ovarian cancer. According to foreign reports, 30% ~ 50% of ovarian cancer patients have metastasis of aorta and pelvic lymph nodes. Some scholars reported that 12% of patients with ovarian cancer were diagnosed as stage I ~ II by abdominal exploration, indicating that the aorta and pelvic lymph nodes were involved. 5. Immunological diagnosis ① Alpha-fetoprotein (AFP): Clinical research shows that the serum AFP value of patients with yolk sac tumor of ovary is continuously rising. Some scholars have proved that AFP exists in cytoplasmic granules and extracellular transparent body by comparing the immunohistochemical studies of tumors, and the latter may be the accumulation of AFP synthesized by cells. After surgical resection of the tumor, the serum AFP value decreased rapidly. When the tumor recurred, the AFP value increased > 20μ g/ml before obvious clinical lesions appeared. Therefore, AFP is an important index for the diagnosis, treatment and monitoring of yolk sac tumor. ② Chorionic gonadotropin: Determination of HCG-? Subunit is helpful to diagnose ovarian choriocarcinoma and germ cell tumor containing choriocarcinoma, and can accurately reflect the number of cancer cells, so it can also be used as an index to observe the effect of anticancer treatment. ③ Tumor-associated antigen (TAA): It is reported abroad that tumor-associated antigen exists in human ovarian cancer, which is a surface membrane protein existing in tumor cell membrane, especially in liquid-borne and mucinous cystadenocarcinoma, while benign ovarian tumors are negative in normal ovarian tissues. In recent years, serum CA 125 (monoclonal antibody against epithelial ovarian cancer) and CA 19-9 (monoclonal antibody against colon and rectal cancer) have been used to monitor patients with ovarian cancer. Serum CA 125 in 7 1% patients with ovarian cancer is higher than 100U/ml (normally lower than 35U/ml), while serum CA 19-9 in 30% patients is higher than 100U/ml (normally lower than 37U/ml) Therefore, it is considered that the monoclonal antibody is helpful for the diagnosis and follow-up of ovarian cancer patients. 6. Laparoscopy can visualize pelvic organs through abdominal cavity and determine the location and nature of lesions. Therefore, ovarian cancers such as pelvic endometriosis, pedicled hysteromyoma and tuberculous peritonitis can be distinguished. Ascites can also be aspirated for cytological examination. If there is no ascites, normal saline can be perfused through laparoscopy, and then ascites lavage fluid can be taken for cytological examination. Laparoscopic biopsy can also be performed on pelvic and abdominal masses or peritoneal implant nodules to obtain reliable histological basis, but ovarian cystic tumors are not suitable for biopsy to avoid leakage of cystic fluid into abdominal cavity. By directly observing diaphragm, liver, omentum and body surface, the spread of ovarian cancer can be evaluated. Diagnosis and differential diagnosis. Diagnosis (1) Clinical diagnosis 1. Irregular masses beside uterus, mostly bilateral. 2. Most tumors are solid, with nodular surface and unclear boundary, and are fixed with surrounding tissues or organs. 3. The tumor grows rapidly in a short time, with ascites and cachexia, or metastasis. 4. Ultrasound or CT examination suggests ovarian malignant tumor. Laboratory tests showed that tumor markers were positive. (2) Pathological diagnosis Through pathological diagnosis, the nature of the tumor can be clarified, so as to estimate the prognosis and make a treatment plan. (3) Clinical staging 1985, the International Society of Gynecology and Obstetrics (FIGO) revised the staging of ovarian tumors 1974. The new staging method is as follows: Stage I: The lesion is confined to the ovary. 1a: The lesion is confined to one ovary, with intact capsule, no tumor on the surface and no ascites. Ⅰ b: The lesion is confined to bilateral ovaries, with intact capsule, no tumor on the surface and no abdomen. ⅰC:ⅰC stage: ⅰa or ⅰb lesions have penetrated the ovarian surface; Or capsule rupture; Or malignant cells are found in ascites or peritoneal lavage fluid. Stage Ⅱ: The lesion involved one or both ovaries with pelvic metastasis. Ⅱ a: The lesion spread or transferred to uterus or fallopian tube. Ⅱ b: The lesion spread to other pelvic tissues. ⅱC:ⅱC stage: ⅱa or ⅱb lesions, the tumor has penetrated the ovarian surface; Or capsule rupture, or malignant cells were found in ascites or peritoneal lavage fluid. Stage ⅲ: The lesion involves one or both ovaries, accompanied by extrapelvic implantation or retroperitoneal lymph node or inguinal lymph node metastasis, and the superficial liver metastasis belongs to stage ⅲ. Ⅲ A: Lesions are generally confined to pelvic cavity, with negative lymph nodes, but peritoneum is implanted under microscope. Ⅲ b: The diameter of peritoneal implant tumor is less than 2 cm, and the lymph nodes are negative. Ⅲ C: Abdominal peritoneal implant tumor > 2 cm, or with retroperitoneal or inguinal lymph node metastasis. Stage Ⅳ: Malignant cells should be found when there is distant metastasis and pleural effusion; Liver metastasis needs to involve liver parenchyma. Second, differential diagnosis 1. Pelvic endometriosis The adherent ovarian masses and rectocele concave nodules formed by pelvic endometriosis are similar to ovarian malignant tumors. Endometriosis is often a patient of childbearing age with progressive dysmenorrhea, which varies with the aggravation of menstrual cycle and infertility. Abdominal cavity or laparotomy should be performed when necessary to confirm the diagnosis. 2. Pelvic inflammatory mass Pelvic inflammatory disease can form a solid and irregular fixed mass, or inflammatory infiltration of connective tissue around uterus into pelvic wall (frozen pelvic cavity) is similar to ovarian malignant tumor. Patients with pelvic inflammatory mass often have a history of induced abortion, ring removal and postpartum infection. The symptoms are fever, lower abdominal pain, long course of disease, obvious tenderness in Shuanghe town, and the tumor has shrunk after anti-inflammatory treatment. If necessary, the mass can be examined by acupuncture cytology or pathology. 3. Paratuberculosis or peritoneal tuberculosis often has a history of tuberculosis, and has symptoms such as emaciation, low fever, night sweats, less menstrual flow and amenorrhea. Peritoneal tuberculosis ascites showed adhesive mass, which showed high position. B-ultrasound and X-ray gastrointestinal radiography are helpful for the diagnosis of this disease. 4. According to the history of liver cirrhosis, liver function test results, pelvic examination whether there is a mass, ascites characteristics (cancer cells found), it is not difficult to identify. Do ultrasound, CT and other examinations when necessary. 5. Differential diagnosis of benign and malignant ovarian tumors The course of ovarian benign tumors is long, and the masses gradually increase, often occurring on one side, with good mobility, soft texture, smooth surface, complete capsule and more cysts. The patient is generally in good condition. On the contrary, ovarian malignant tumor has short course of disease, fast growth, poor activity, hard texture and unsmooth surface. After triple diagnosis, it can be known that the tumor has papillary nodules, accompanied by edema of the whole body or lower limbs, cachexia and blood in the abdomen. If there is ascites, you can pump water for cytological examination. If possible, further diagnosis can be made by laparoscopy and laparotomy. Treatment methods 1. Basic treatment plan Once the ovarian malignant tumor is diagnosed, whether it is early or late, it should be treated by surgery as soon as possible, supplemented by chemotherapy, radiotherapy and Chinese medicine. If it is in the advanced stage, the tumor is large, with extensive metastasis and serious adhesion, chemotherapy and traditional Chinese medicine can be used to shrink the tumor first, improve the immunity of the body, and prepare for surgical treatment, which can improve the success rate of surgery. Attach importance to the comprehensive treatment of traditional Chinese and western medicine: the treatment principle of ovarian malignant tumor is mainly surgical treatment, supplemented by chemotherapy and radiotherapy. But we must master it flexibly according to the different conditions of patients, so as to eliminate swelling and sliding to the maximum extent.
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