Diagnosis and management of the adnexal mass

Adnexal masses are frequently found in both symptomatic and asymptomatic women. In premenopausal women, physiologic follicular cysts and corpus luteum cysts are the most common adnexal masses, but the possibility of ectopic pregnancy must always be considered. Other masses in this age group include endometriomas, polycystic ovaries, tubo-ovarian abscesses and benign neoplasms. Malignant neoplasms are uncommon in younger women but become more frequent with increasing age. In postmenopausal women with adnexal masses, both primary and secondary neoplasms must be considered, along with leiomyomas, ovarian fibromas and other lesions such as diverticular abscesses. Information from the history, physical examination, ultrasound evaluation and selected laboratory tests will enable the physician to find the most likely cause of an adnexal mass. Measurement of serum CA-125 is a useful test for ovarian malignancy in postmenopausal women with pelvic masses. Asymptomatic premenopausal patients with simple ovarian cysts less than 10 cm in diameter can be observed or placed on suppressive therapy with oral contraceptives. Postmenopausal women with simple cysts less than 3 cm in diameter may also be followed, provided the serum CA-125 level is not elevated and the patient has no signs or symptoms suggestive of malignancy.     

Calcium concretions in the pineal gland of aged rats: an ultrastructural and microanalytical study of their biogenesis

OBJECTIVE: We summarized general principles related to apoptosis and reviewed the current evidence regarding apoptosis in the normal ovary during follicular atresia, ovulation, and corpus luteum formation and regression, and in the polycystic ovary. DATA SOURCES: Published articles and abstracts from national scientific meetings were reviewed. DATA SYNTHESIS: Apoptosis is a physiologic type of cell death that may regulate tissue remodeling. In the ovary, apoptosis occurs in atretic follicles, in the ovarian epithelium at the time of ovulation, and in the corpus luteum. Certain apoptosis-related genes are expressed during follicular atresia, which suggests a role for genes in the regulation of apoptosis in the ovary. In a rat model of polycystic ovaries, apoptosis occurs in both atretric follicles and cysts. CONCLUSIONS: Apoptosis is an important physiologic process in the ovary, and abnormalities in this process may lead to pathologic conditions. The study of ovarian apoptosis is still at an early stage, and further research will uncover the steps in this process.     

Cyclic changes of vasculature and vascular phenotypes in normal human ovaries

In order to study alterations of angiogenesis and blood vessel regression through ovarian cycle in human ovaries we quantitatively examined vascularity in various stages in 24 normal human ovaries. Vascular density (VD; vessel numbers/10(-7) m2) and endothelial area of each vessel (EA; 10(-12) m2/vessel) were evaluated using immunohistochemistry of CD34 and CAS 200 image analysis system. Small-sized vessels were sporadically observed in stroma adjacent to primordial or primary follicles (6.73 +/- 1.83 for VD and 113.58 +/- 21.80 for EA). Formation of capillary network was observed in the theca layer of preantral follicles (PA; 15.28 +/- 2.77 for VD and 113.58 +/- 21.80 for EA), and higher density of the capillary network was detected in non-dominant follicles in follicular phase (ND-F) and dominant follicles (DF; 29.33 +/- 3.84 for VD and 179.69 +/- 41.25 for EA). Dense capillary network was still present in non-dominant follicles in luteal phase (ND-L) and atretic follicles (AF; 26.88 +/- 3.36 for VD and 110.88 +/- 50.53 for EA). After ovulation, developing capillaries were also observed in the luteinized granulosa layers in early corpus luteum (21.95 +/- 2.06 for VD and 167.08 +/- 29.59 for EA). Vessel density markedly increased in mid corpus luteum, reached plateau in late corpus luteum (60.85 +/- 5.92 for VD and 70.99 +/- 15.57 for EA) and remained constant during degenerating corpora lutea. Vascular endothelial growth factor was immunohistochemically observed in the theca cells in PA, ND-F, DF and ND-L in follicular stages, and functioning corpora lutea. Immunoreactivity of intercellular adhesion molecule-1 was detected only in post-capillary venules in early degenerating corpora lutea. These findings suggest that ovarian angiogenesis is a requirement for the early stages of folliculogenesis and luteal growth, and also plays an important role in the process of follicular atresia and luteal regression.     

Histological examination of ovaries and uteri from cows with cystic ovaries

Sections were cut from 486 cysts taken from 260 pairs of cystic ovaries which had been collected during an abattoir survey. The linine of the cysts was examined for the presence of granulosa, basement membrane, theca and luteinisation. Sections of the uteri were examined and the nature of the surface epithelium, the thickness of the endometrium and the activity of the uterine glands were recorded. In those cysts associated with a corpus luteum both granulosa and luteinisation were seen less often than in other cysts. Of the 486 cysts examined 111 (22-84 per cent) had luteinisation, the others had none. Luteinisation was most often encountered when granulosa was absent. The thickness of theca was greater in cysts than in normal follicles and was thickest in thick walled cysts associated with a corpus luteum. The majority of uteri (81-9 per cent) were normal and only in 4-78 per cent was "swiss chese" dilation of the glands seen. Thirteen cases of mucometra were seen and these are discussed in detail.     

The ovary. Computed tomography and magnetic resonance imaging

CT and MR imaging can both contribute valuable clinical information in women with benign and malignant ovarian masses; the superior soft tissue contrast and multiplanar capabilities provided by MR imaging make it a valuable tool to evaluate the normal ovary, polycystic ovaries, endometriosis, and disorders of sexual differentiation. CT is currently the recommended modality to stage ovarian carcinoma, and peritoneal implants as small as 5 mm can be visualized. With the addition of contrast-enhanced images to conventional MR sequences, however, improved visualization of intratumoral architecture has also allowed for accurate MR characterization of benign versus malignant ovarian masses. Fat saturation techniques used with conventional MR sequences can also be used for definitive characterization of benign fat-containing teratomas and differentiate these tumors from hemorrhagic ovarian cysts or endometriomas. Finally, the detailed visualization of the normal-sized ovary on MR images provided by both the body coil and the new phased-array coil allows detection of the normal ovaries, ovarian follicles, and ovarian cysts throughout the premenopausal and postmenopausal years. Findings of polycystic ovarian syndrome, which cannot be evaluated by CT, are characteristic on MR images. MR is unparalleled in the evaluation of disorders of sexual differentiation because MR images can depict ectopic and normally positioned gonads and provide multiplanar depiction of the other pelvic organs and perineum as well. CT and MR imaging can provide valuable and specific clinical information about the ovary and benign and malignant ovarian disease.     

Magnetic resonance imaging of bovine ovaries in vitro

A sample of 20 bovine ovaries were imaged in vitro using nuclear magnetic resonance (NMR) techniques to determine the visibility of various physiologic structures. In particular, the possibility of using NMR imaging to differentiate atretic follicles from physiologically selected and ovulatory follicles was examined. Five of the 20 ovaries were preserved in formalin, whereas the remaining 15 were preserved in a saline solution and imaged within 18 hours of death. Images weighted by T1 and T2 proton spin relaxation rates were obtained along with some three-dimensional (3-D) data sets acquired via a fast imaging with steady-state precession technique. Physiologically different structures were easily identified in the images from their morphology, especially in the 3-D images. Weighting by T1 and T2 was able to separate structures in the fresh ovaries in the following manner. Atretic and "cohort" follicles appear dark in T1-weighted images and bright in T2-weighted images. Ovulatory follicles appear bright in both T1- and T2-weighted images, whereas prephysiologic selection follicles present an intermediate brightness in T1-weighted images and appear dark in T2-weighted images. The corpus luteum appears bright in T1-weighted images and dark in T2-weighted images, whereas cysts in the corpus luteum appear dark in T1-weighted images and bright in T2-weighted images. The varying brightness of the follicles at different stages of development is hypothesized to be related to different hormone and protein concentrations in the follicular fluid. For example, it is known that physiologically selected preovulatory follicles contain high concentrations of estrogens in a viscous follicular fluid. The increased viscosity may occur only when the follicle fluid contains high concentrations of estrogen and contributes to bright T1-weighted images. The possibility of using nuclear relaxation-weighted NMR imaging for the study of follicular dynamics and other ovarian biology therefore shows great promise.     

Regulation of angiogenesis by hypoxic stress: from solid tumours to the ovarian follicle

The preovulatory follicle provides a unique physiological example of rapid growth accompanied by neovascularization, two processes that are generally characteristic of pathologies such as wound repair or malignancy. During the hours preceding ovulation, follicular growth is accompanied by elevated levels of messenger RNA for vascular endothelial growth factor (VEGF). Angiogenic activity, mediated by VEGF, is manifested in the peripheral blood vessels surrounding the follicle, that show capillary sprouting and increased vascular permeability. Following ovulation, rapid infiltration of capillaries through the follicular wall is essential for the formation of the corpus luteum. In this review we compare the preovulatory follicle with a popular model of avascular solid tumour growth, namely the multicellular tumour spheroid, in particular the role of hypoxic stress in the regulation of angiogenesis in both systems.     

Concentration of vascular endothelial growth factor (VEGF) in the serum of patients with suspected ovarian cancer

As a promoter of angiogenesis, vascular endothelial growth factor (VEGF) is believed to play a pivotal role in tumour growth and metastasis. The aim of this study was to determine the value of preoperative serum VEGF levels in the early diagnosis of ovarian cancer and in the differential diagnosis of adnexal masses. We examined preoperative serum VEGF levels in healthy women (n = 131), patients with benign ovarian cysts (n = 81) and in ovarian cancer patients (n = 44) by using an ELISA (R&D Systems, Minneapolis, MN, USA). A logistic regression model was carried out to determine the influence of VEGF and CA 125 on the probability of malignancy. VEGF revealed a significant influence on the odds of presenting with malignancy vs healthy women (P = 0.001). At 363.7 pg ml(-1), VEGF achieved a sensitivity of 54% and a specificity of 77%. With respect to the differentiation between benign cysts and ovarian cancer, CA 125 (P < 0.0001) but not VEGF (P = 0.229) predicts the presence of malignancy in a multivariate model. In conclusion, VEGF does not appear to be a useful tool in the early diagnosis of ovarian cancer or for indicating the absence or presence of malignancy in patients with an adnexal mass.     

Angiotensin II receptors and angiotensin II stimulation of ciliary activity in human fallopian tube

Using an antibody (6313/G2) directed against a specific sequence in the extracellular domain of the type 1 angiotensin II receptor (AT1), we demonstrated the presence of angiotensin II (AII) receptors in human fallopian tube. Immunoperoxidase staining for AT1 receptor showed positive staining in the epithelium of the tubal mucosa. The intensity of staining varied depending upon the hormonal status at the time of salpingectomy, being strongest in the proliferative phase of the ovarian cycle and weakest after menopause. Ligand binding assay confirmed that the AII receptor concentration was highest in the mucosa of fallopian tubes from premenopausal women. Mucosa from the ampullary segment had higher concentrations of AII receptor than the fimbrial and isthmic segments in both premenopausal and postmenopausal women. Displacement studies using specific AII receptor subtype antagonists showed that approximately 60% of the total activity could be displaced by CGP42112B (type 2 specific) and 40% by losartan (AT1 specific). Immunoblotting confirmed that the antibody detected a protein of approximately 60 kDa. Functional studies showed that AII had a stimulatory action on tubal ciliary beat frequency, but had no significant effect on myosalpingseal activity. This effect was achieved at nanomolar concentrations of AII; further increases in the AII concentration were without additional effect. The stimulatory effect of AII was inhibited by the specific AT1 antagonist losartan, whereas the type 2 antagonist, CGP42112B, had no effect. The data demonstrate that AII may play an important role in ovum transport and fertility.     

Anatomical features of cystic ovaries in cattle found during an abattoir survey

During an abattoir survey, 8071 bovine genitalia were examined. Cysts of 2-5 cm or larger were found on one or both ovaries in 307, an incidence of 38 per cent. The cysts were arbitrarily classified anatomically into eight groups according to the number present and their texture, whether thin or thick walled, and to the presence or absence of a corpus luteum. The weight and dimensions of the cysts were recorded and any abnormalities of the genital tracts were noted. Ninety-six specimens (30-67 per cent) were associated with a corpus luteum and 217 (69-33 per cent) had no corpus luteum. One hundred and sixty eight tracts (53-67 per cent) had single cysts and in 145 (46-33 per cent) they were multiple. The incidence of multiple ovulations was higher in the cystic ovaries which had corpora lutea than in the non-cystic population. The incidence of ovaro-bursal adhesions in the cystic population was three times higher than in that found in the genitalia which had no cysts and it is possible that this resulted from trauma during rectal palpation.     

Contribution of Doppler color ultrasonography to the screening and surveillance of ovarian hyperstimulation syndrome

Color and power Doppler producing ovarian vascular mapping allows to realize a new functional approach of ovarian hyperstimulation syndrome (OHS); local vascular factors (ovarian angiogenesis, increase in cappillary permeability) released by hCG injection (LH effect) have in fact an important part in this syndrome. Vaginal Doppler sonography allows: -before induction, to predict potential risk of hyperstimulation: polycystic ovaries, spontaneous stromal hypervascularization; -in monitoring of ovulation stimulation, to reduce risk of multiple pregnancy and to detect early hyperstimulation, decision of hCG injection depends on number of follicles able to be fertilized (> 15 mm) and luteinized (> 10 mm); -to assess severity of OHS and search complications: ascites, hydrothorax, ovarian torsion and deep venous thrombosis. So OHS prevention imposes a monitoring by Doppler sonography and estradiol assay of all cycles induced by gonadotropins.     

Analysis of blood vessel maturation processes during cyclic ovarian angiogenesis

Cyclic angiogenic processes in the ovarian corpus luteum (CL) of monovulatory species are characterized by distinct phases of blood vessel growth, vessel maturation, and vessel regression. To characterize molecular and cellular systems that may play a role in regulating blood vessel maturation, we have (a) analyzed the spatiotemporal expression of vascular endothelial growth factor (VEGF) and its receptors VEGF-R1 (Flt-1) and VEGF-R2 (Flk-1) throughout the ovarian cycle, (b) examined the recruitment of pericytes during vessel maturation, and (c) quantitatively measured the ratio of angiopoietin-2 (Ang-2) to angiopoietin-1 (Ang-1) throughout the ovarian cycle. The data indicate that the VEGF/VEGF-receptor system is expressed not only during ovarian angiogenesis, but also with similar intensity in the nonangiogenic midstage CL. In fact, VEGF is expressed through most of the ovarian cycle, only being down-regulated during luteolysis, which leads to regression of the CL neovasculature. Pericytes are recruited soon after the induction of CL angiogenesis following the front of invading endothelial cells. Based on a double-staining immunohistochemistry technique, we developed a microvessel maturation index (MMI) that reflects the percentage of the capillary neovasculature that is associated with pericytes. The MMI in the angiogenic corpus rubrum is approximately 0.60. This value is not significantly higher in the nonangiogenic midstage CL but increases to close to 0.90 during CL regression. Lastly, an RT-PCR analysis of Ang-1 and Ang-2 expression revealed that both molecules are expressed throughout the ovarian cycle. The quantitative Ang-2/Ang-1 ratio does, however, change from 1.34 in the angiogenic CL and 1.07 in the midstage CL to 7.59 during CL regression, reflecting the strong overexpression of Ang-2 over Ang-1 during blood vessel regression. Taken together, the data support a model of a transiently maturated vasculature in the midstage CL, which is characterized by VEGF and pericyte contact-mediated endothelial cell survival and an induction of blood vessel regression during luteolysis that is characterized by the down-regulation of VEGF and the up-regulation of Ang-2.     

Angiogenesis and neoangiogenesis

Angiogenesis, the development of new capillary networks from the normal vasculature, is a fundamental process during embryogenesis. In adulthood, angiogenesis contributes to corpus luteum formation, placental implantation and wound healing and is also required in some pathological conditions such as several intraocular syndromes, growth of solid tumors, and metastasis. Many factors are involved in the regulation of neovascularisation among which FGF-2 (fibroblast growth factor-2) and VEGF (vascular endothelial growth factor) are considered as key inducers. Their biological activity is highly controlled by extracellular matrix components and angiostatic factors. Better understanding of the molecular mechanisms regulating angiogenesis should contribute to the development of new molecules to be used for the treatment of neovascularisation-linked diseases.     

Laparoscopic cystectomy of the ovary; results of a new technique

The results of a prospective study of laparoscopic management of ovarian cysts are discussed. This technique of minimally invasive surgery was introduced at the department of Gynaecology of the Leiden University Medical Centre in 1991. Only premenopausal women with unilocular ovarian cysts smaller than 10 cm in diameter and with sonographically benign characteristics were included in this study. In a period of one year, 25 cystectomies and one ovariectomy were performed. 88% of the cysts were initially treated with hormone therapy. Mean age of the patients was 30 years (range: 21-54), average size of the cysts was 6 cm (range: 4-10) and mean operating time was 80 minutes (range: 35-120), there were no complications during operation or in the postoperative period. No laparotomies had to be performed. Three times (11.5%) pathological specimen examination revealed a corpus luteum cyst. The other 23 were non-functional cysts. No carcinoma was detected. The results of this minimally invasive surgery for removal of ovarian cysts are encouraging. Morbidity compared with the conventional cystectomy by laparotomy is low as appears from a shorter hospital stay and quicker recovery. Cystectomy of the ovary, compared with laparoscopic aspiration and fenestration, has a better therapeutic effect and the histological evaluation is more reliable. Persistent, unilocular ovarian cysts, which fulfill the criteria used in our study, are best treated by laparoscopic removal instead of laparotomy.     

Localization of vascular endothelial growth factor in human retina and choroid

OBJECTIVE: To examine the distribution and relative levels of vascular endothelial growth factor (VEGF) in the nondiabetic and preproliferative diabetic human retina and choroid. METHODS: Immunohistochemical localization was performed on frozen sections from cryopreserved postmortem human tissue using a polyclonal antibody against VEGF and a streptavidin peroxidase system. Eyes from 5 subjects without diabetes and 8 subjects with diabetes were examined and analyzed using a 7-point immunohistochemical grading system. RESULTS: In subjects without diabetes, weak or no VEGF immunoreactivity was associated with retinal blood vessels. In subjects with diabetes, we found significantly increased immunoreactivity in the retinal vascular endothelium and blood vessel walls. Vascular endothelial growth factor immunoreactivity was also associated with intravascular leukocytes in subjects with and without diabetes. In the choroid of subjects without diabetes, immunoreactivity was almost exclusively associated with intravascular leukocytes, whereas in diabetic subjects, immunoreactivity was localized within choriocapillaris endothelium, choroidal neovascular endothelium, and migrating retinal pigment epithelium cells. CONCLUSIONS: The observed increase in VEGF immunoreactivity in the diabetic retina and choroid suggests that VEGF may contribute to 2 well-documented events during retinopathy: increased vascular permeability and angiogenesis.     

Glioblastoma growth inhibited in vivo by a dominant-negative Flk-1 mutant

Angiogenesis, the sprouting of capillaries from pre-existing blood vessels, is a fundamental process in the formation of the vascular system during embryonic development. In adulthood, angiogenesis takes place during corpus luteum formation and in pathological conditions such as wound healing, diabetic retinopathy, and tumor-igenesis. Vascularization is essential for solid tumour growth and is thought to be regulated by tumour cell-produced factors, which have a chemotactic and mitogenic effect on endothelial cells. Vascular endothelial growth factor (VEGF), a homodimeric glycoprotein of relative molecular mass 45,000, is the only mitogen, however, that specifically acts on endothelial cells, and it may be a major regulator of tumour angiogenesis in vivo. Its expression has been shown to be upregulated by hypoxia, and its cell-surface receptor, Flk-1, is exclusively expressed in endothelial cells. Here we investigate the biological relevance of the VEGF/Flk-1 receptor/ligand system for angiogenesis using a retrovirus encoding a dominant-negative mutant of the Flk-1/VEGF receptor to infect endothelial target cells in vivo, and find that tumour growth is prevented in nude mice. Our results emphasize the central role of the Flk-1/VEGF system in angiogenesis in general and in the development of solid tumours in particular.     

Skin and serum reactivity among humans to histoplasmin in the vicinity of a natural focus of Histoplasma capsulatum var. duboisii

A questionnaire was sent to Alaskan gynecologists to evaluate their practice in regard to prophylactic oophorectomy at the time of hysterectomy. At issue is the possible benefit of prophylactic oophorectomy in the prevention of ovarian cancer. Sixty-seven questionnaires were sent and 42 (63%) were returned completed. The percentage who said they would remove apparently normal ovaries at the time of hysterectomy in premenopausal women is as follows: at 35-39 years, 5%; 40-44, 35%; 45-49, 81% and over 49 years, 95%. In postmenopausal women, 97% would recommend removal of the ovaries. 29% of respondents believe that more than 10% of ovarian cancers could be prevented by prophylactic oophorectomy at the time of hysterectomy.     

Time-dependent vascular regression and permeability changes in established human tumor xenografts induced by an anti-vascular endothelial growth factor/vascular permeability factor antibody

The hyperpermeability of tumor vessels to macromolecules, compared with normal vessels, is presumably due to vascular endothelial growth factor/vascular permeability factor (VEGF/VPF) released by neoplastic and/or host cells. In addition, VEGF/VPF is a potent angiogenic factor. Removal of this growth factor may reduce the permeability and inhibit tumor angiogenesis. To test these hypotheses, we transplanted a human glioblastoma (U87), a human colon adenocarcinoma (LS174T), and a human melanoma (P-MEL) into two locations in immunodeficient mice: the cranial window and the dorsal skinfold chamber. The mice bearing vascularized tumors were treated with a bolus (0.2 ml) of either a neutralizing antibody (A4.6.1) (492 micrograms/ml) against VEGF/VPF or PBS (control). We found that tumor vascular permeability to albumin in antibody-treated groups was lower than in the matched controls and that the effect of the antibody was time-dependent and influenced by the mode of injection. Tumor vascular permeability did not respond to i.p. injection of the antibody until 4 days posttreatment. However, the permeability was reduced within 6 h after i.v. injection of the same amount of antibody. In addition to the reduction in vascular permeability, the tumor vessels became smaller in diameter and less tortuous after antibody injections and eventually disappeared from the surface after four consecutive treatments in U87 tumors. These results demonstrate that tumor vascular permeability can be reduced by neutralization of endogenous VEGF/ VPF and suggest that angiogenesis and the maintenance of integrity of tumor vessels require the presence of VEGF/VPF in the tissue microenvironment. The latter finding reveals a new mechanism of tumor vessel regression-i.e., blocking the interactions between VEFG/VPF and endothelial cells or inhibiting VEGF/VPF synthesis in solid tumors causes dramatic reduction in vessel diameter, which may block the passage of blood elements and thus lead to vascular regression.