Ovarian immature teratoma

Introduction to ovarian immature teratoma The malignant degree of ovarian immature teratoma is very high, and ovarian malignant germ cell tumors account for 5-15% of ovarian malignant tumors. After treatment with a combination chemotherapy regimen, the survival rate has increased from 10-20% in the past to over 95%. basic knowledge The proportion of illness: 0.001% Susceptible people: women Mode of infection: non-infectious complication:

Ovarian immature teratoma etiology

(1) Causes of the disease

Ovarian immature teratoma consists of mature and immature embryonic tissues from the three germ layers, which may be characterized by one embryonic layer that is immature or incompletely differentiated, and may also be expressed as (two to three germ layer differentiation immature). Mature and immature tissues are often mixed.

(two) pathogenesis

1. Gross: The tumor is mostly a unilateral massive mass. The contralateral ovary can be combined with a benign teratoma. The capsule is smooth, but often has adhesion to the surrounding tissue or tears during surgery. The cut surface is mostly solid, with There are cystic areas; occasionally the capsule is the main body, the capsule wall has a solid area, the solid area is soft, delicate, bleeding, necrosis, variegated and colorful, sometimes see bone, cartilage, hair or brain tissue; The cystic area is usually filled with a slurry, mucus or jelly.

2. Microscopically: composed of mature and immature tissues from the three germ layers; ectoderm is mainly nerve tissue and skin, mesoderm is fibrous connective tissue, cartilage, bone, muscle and undifferentiated mesenchymal tissue are more common, endoderm Mainly glandular structure, sometimes visible bronchial or gastrointestinal epithelium, these tissues are at different stages of maturity, no organ-like arrangement, immature tissue mainly refers to neuroepithelial tissue, can form a chrysanthemum group or neural tube structure (Figure 1 ), can also be diffused into pieces.

According to the content of this neuroepithelium in tumors, some scholars have proposed a classification method for immature teratoma, which has important significance for the treatment and prognosis.

Level 0: All are mature organizations.

Grade I: There are a small number of immature tissues (mainly glial and primordial mesenchyme), and there is nuclear division and less neuroepithelial. Each slice is limited to 1/40-fold field of view.

Grade II: There are more immature tissues, but the neuroepithelial does not exceed 3/40-fold field of view in each section.

Stage III: There are a large number of immature tissues, and the amount of neuroepithelial in each section accounts for 4 or more/40-fold field of view, and often merges with the sarcomatoid interstitial.

This pathological grading method has been widely used. Some scholars have proposed that the neuroepithelial mass in each section accounts for 10% of the grade I, accounting for 10% to 33% for grade II, and more than 33% for grade III, in order to reduce the grade. Inconsistency, recently Norris et al. proposed to combine this classification into low-grade and high-grade malignant, ie, grade I without chemotherapy and grade II and III requiring postoperative chemotherapy. These classification methods must be based on adequate materials. Above, the area should be taken according to the maximum diameter of the tumor in a different area of the naked eye. If the tumor is >20cm, at least 20 pieces of tissue should be taken.

The morphology and tissue grade of the metastases may be different from those of the primary tumors. Some of them form many nodules of different sizes on the surface of the peritoneum. Under light microscopy, they are well-differentiated glia, called peritoneal glioma. The implanted nodules are benign, and the primary tumor can resolve itself after resection.

Ovarian immature teratoma prevention

Regular physical examination, early detection, early treatment, and good follow-up.

Ovarian immature teratoma complications Complication

Ovarian immature teratoma is implanted in the abdominal cavity, metastasized, infected, and tissue adhesions.

Ovarian immature teratoma symptoms Common symptoms Abdominal pain Ascites intraperitoneal implantation

Common symptoms are abdominal mass, abdominal pain, etc., due to the high incidence of abdominal implants, 60% have ascites, and due to ascites to lose body weight, weight loss, most patients with normal menstruation and fertility.

The incidence of ovarian immature teratoma metastasis is high, ranging from 32% to 58%. The most common metastatic sites are pelvic and abdominal peritoneum, omentum, liver surface, diaphragm, and intestinal tract. Membrane and mesentery, most of the metastases are surface implanted, lymph node metastasis is not uncommon. Peking Union Medical College Hospital has performed pelvic lymph node and abdominal aortic lymph node resection in 17 cases of ovarian immature teratoma, 5 cases have lymph node metastasis, accounting for 29.4. %, these 5 cases were clinical stage III cases with extensive intra-abdominal metastasis. Only 3 cases had lymph node dissection in stage I clinical stage, no lymph node metastasis was found, and 9 cases of autopsy materials in Norris (1976) group. 4 cases had lymph node metastasis, FIG0 stage was more in stage I and stage III, and in stage III cases, the clinical pathological process was different because of the different tissue types of metastases, such as if the metastases were all glial, ie In glial peritoneal gliomatosis, the extensive scattered small foci left after the removal of the primary ovarian tumor can often disappear on its own, or the patient can survive with the tumor without disappearing. The prognosis is good. Therefore, it has been suggested that only those with glia in the abdominal cavity should not be classified as stage III. If the metastatic lesion in the abdominal cavity is a pathological grade I or above tumor, the operation will not be cut or effective chemotherapy will be performed, and the condition will continue to deteriorate. Even death, so the prognosis of FIG0III patients is closely related to the tissue type and pathological grade of intraperitoneal metastases.

Recurrence and reversal of malignancy:

Recurrence rate

The recurrence rate of immature ovarian teratoma is high, and the recurrence rate of tumor is closely related to adjuvant chemotherapy after surgical resection. Patients with adequate VAC or PVB combined chemotherapy within 4 weeks after surgery rarely relapse, but no chemotherapy. Or the chemotherapy drugs and methods used are not appropriate, the recurrence rate is very high, up to 66.7% ~ 93.8% (Table 1), the tumor has a tendency to relapse repeatedly, 25 recurrence tumors in Peking Union Medical College Hospital have recurrence after surgery 10 For example, 40%, the third operation, of which 1 case received the 4th and 5th surgery due to recurrence, most of the recurrence sites in the pelvic and abdominal cavity, accompanied by liver recurrence 14 For example, 56% of the relapsed cases, 11 of 14 cases were large liver surface implants (8-20 cm in diameter), and 1 case of recurrent tumors in the lungs. The recurrence time was 5-12 months, and there were also after surgery. There was a rapid recurrence in 3 months, and 1 case was 7 years after the initial treatment and recurrence. Caldas (1992) also reported that 1 case of recurrence occurred 11 years after primary tumor resection and chemotherapy. Between the diaphragm and the diaphragm, there is a large grade 0 teratoma during reoperation. There is, until the patient has symptoms of oppression come to treatment.

2. Reversal of the degree of recurrence

The ovarian recurrent immature teratoma has the characteristics of transformation from immature to mature. The results of 62 repeated operations of 25 recurrent tumors in Peking Union Medical College Hospital revealed the biological behavior of this benign transformation, in these 62 surgical resections. In the tumor, most of the primary tumors differentiated into grade 2, and a few were grade 3 or grade 1. In the recurrent tumor, except for 2 cases of short recurrence, the tumor grade was not transformed, and most of the other were benign transformation. O grade, individual grade 1, foreign countries have had reports on the reversal of malignant degree of immature teratoma, but all cases were reported in 1 case or 2 cases. No large sample group analysis has been performed to confirm However, some scholars have found that 11 cases and 1 case of mature teratoma in the abdominal cavity were diagnosed in 22 cases and 3 cases of immature teratoma after surgery and chemotherapy. Mature teratoma is also the result of benign transformation of immature teratomas.

3. Factors that contribute to the malignant reversal of tumors

(1) Time factor: The pathological grade of recurrent tumor is closely related to the time interval from the first operation. Most of the patients within 1 year are immature, so the tumor cells in the short-term recurrence are still poorly differentiated. The later, beyond a certain time interval, that is, the degree of malignancy gradually decreases with the passage of time, and the tumor tissue is matured and differentiated. The regular tendency of transformation from immature to mature resembles the development and growth of a normal embryo, and has a mature development. The natural tendency, and this mature development requires a certain time course. Other authors report that there are not many cases of recurrent immature teratoma, but it also reveals the time regularity of this pathological grade reversal.

(2) The effect of chemotherapy: Disaia has reported that the reversal of the malignant degree of ovarian immature teratoma is due to the influence of chemotherapy, but there are also 3 cases of recurrence of 4 cases of recurrent tumors without chemotherapy in Peking Union Medical College Hospital, Benjamin. The reported case of reversal has not been treated with chemotherapy. Of course, the number of cases reported in these cases is small, and the role of chemotherapy cannot be completely denied. Gersh-enson (1986) has suggested that because chemotherapy inhibits immature tissue components in tumors, The well-differentiated mature tissues persisted, but we have seen several cases of tumor resection of multiple recurrent tumors on the surface of the liver and spleen or between the liver and the spleen, or those who have not undergone biopsy due to technical difficulties. All of the recurrent tumors were grade 2 or grade 3 immature teratomas. The components of mature teratoma were not seen. After continuous chemotherapy, the unresectable tumors continued to grow after a certain time interval. Surgery, surgery is still a giant tumor on the surface of the liver, but the pathological examination is all mature components, pathological differentiation into grade 0 tissue, and the first surgical biopsy did not see level 0 tissue It is difficult convincing positive transformation which must be the result of inhibition of chemotherapy, tumors and not natural transformation.

(3) Cytogenetic examination: Gibas (1993) reported a pathological grade of ovarian immature teratoma, although after chemotherapy, but after 1 year, there was tumor recurrence in the abdominal cavity and mediastinum. The pathological examination was Mature teratoma, primary tumor and recurrent tumor are different in histology. The former is an immature teratoma and the latter is a mature teratoma. However, the karyotype of the primary and recurrent foci is completely cytogenetic analysis. The same, all chromosome 4 is haplotype and chromosome 1 pseudo-bicentric, indicating that although the recurrence of tumor after chemotherapy has benign transformation, but its karyotype has not changed, still maintain the malignant karyotype of the primary tumor, this A case of cytogenetics can show that the benign transformation of tumors is not due to the selective inhibition of chemotherapy destroying the undifferentiated immature teratoma, leaving the mature teratoma to continue to grow, so, regarding the malignancy of immature teratoma The degree of reversal mechanism remains to be explored.

4. Clinical significance of the degree of malignancy reversal

This malignant reversal of ovarian immature teratoma has not been discovered in the past because the pathology of grade 2 and grade 3 tumors is extremely malignant and grows rapidly, often recurring within six months after surgery, so most authors The pathological grade of the reported recurrent tumor is still the same as that of the primary tumor, and if the tumor relapses, the operation is abandoned, and the patient dies in a short period of time, so there is no chance to observe the transformation of the tumor grade, so only the tumor with repeated recurrence is performed multiple times. Surgical resection allows the patient to survive for a period of one year or more, and the biological characteristics of tumor transformation may be revealed.

Understanding the biological behavior of the malignant degree of immature teratoma reversal has the following practical value:

(1) Understanding the benign transformation of tumors can make us full of confidence and courage for advanced or recurrent tumors, and take all measures to actively treat the patients to prolong the life of the patients, so that the tumors have enough time to mature and transform into benign.

(2) To understand the time required for benign transformation of immature teratoma is about 1 year, the pathological grade of recurrent tumor can be estimated according to this time rule. As a reference for treatment, if it is estimated that it is a mature teratoma, Chemotherapy is used. Because mature teratoma is not sensitive to chemotherapy, continuing chemotherapy can only increase the suffering of patients and does not help tumors.

(3) It is not necessary to perform a second laparotomy after the completion of chemotherapy, because the condition in the abdominal cavity can be estimated according to the time rule. The time is more than 1 year, even if there are residual tumors or recurrent tumors, it is already mature. Therefore, understanding The benign transformation of immature teratomas is of great significance for guiding clinical practice.

Examination of ovarian immature teratoma

1. Serum alpha-fetoprotein (AFP) Peking Union Medical College Hospital has tested the serum AFP of 23 patients with ovarian immature teratoma. The result is 56.6% negative, and the other 43.5% of the cases are positive, but the serum AFP level is much higher than Ovarian yolk sac tumor is low, ovarian yolk sac tumor is mostly 10,000 or tens of thousands of ng/ml before the primary tumor is resected, and 7 of 10 cases with immature teratoma positive reaction 1500ng/ml, the other 3 cases were 3200ng/ml, 4000ng/ml and 8000ng/ml. These 3 cases had poor tumor maturity and more undifferentiated neuroepithelial cells. They were pathological grades 2 and 3, so they were presumed to be immature. A small amount of AFP in the serum of patients with teratoma may be due to the secretion of a small amount of AFP in the endoderm tissue of immature teratomas. The other may be a mixed type of germ cell malignant tumors, which may be mixed in immature teratomas. There is a small amount of yolk sac tumor component, which can synthesize trace AFP. Due to incomplete pathology, this small amount of yolk sac tumor component has not been found.

2. Serum chorionic gonadotropin (HCG) 16 cases of ovarian immature teratoma have been tested for serum HCG in Peking Union Medical College Hospital. Only 1 case of serum HCG value is slightly higher than normal, while the other 15 cases have no serum HCG value. High phenomenon.

3. Neuron specific enolase (NSE) Ovarian immature teratoma often contains mature or immature nerve cells, so sometimes NSE can be measured in serum, which has reference significance for the diagnosis of this disease.

B-ultrasound, abdominal radiography, laparoscopy, histopathological examination.

Diagnosis and differentiation of ovarian immature teratoma

diagnosis

Ovarian immature teratoma is not difficult to make a diagnosis based on the age of onset and the abdomen mass, rapid development of the disease, etc., combined with the above examination.

Differential diagnosis

Ovarian immature teratoma should be differentiated from yolk sac tumor and choriocarcinoma.

The material in this site is intended to be of general informational use and is not intended to constitute medical advice, probable diagnosis, or recommended treatments.