Ovarian immature teratoma

　　Ovarian immature teratoma is composed of mature and immature embryonic tissues from the three germ layers, which can manifest as immature or incomplete differentiation of a single germ layer, or (2-3 germ layers with immature differentiation). Mature and immature tissues are often mixed.
　　Grossly, the tumor is often a large unilateral mass, with the opposite ovary possibly associated with a benign teratoma. The capsule is smooth, but often adherent to surrounding tissue or torn during surgery. The cut surface is mostly solid, with cystic areas; occasionally, there are those with cysts as the main component, with solid areas in the cyst wall. The solid area is soft and delicate, with hemorrhage, necrosis, and a polychromatic appearance, sometimes with bone, cartilage, hair, or brain tissue; the cystic area is usually filled with serous, mucous, or jelly-like substances.
　　Microscopically, it is composed of mature and immature tissues from the three germ layers; the ectoderm is mainly neural tissue and skin, the mesoderm is often seen in fibrous connective tissue, cartilage, bone, muscle, and undifferentiated mesenchymal tissue, and the endoderm is mainly tubular glandular structures, sometimes with bronchial or gastrointestinal epithelium. These tissues are at different stages of maturation and do not have organ-like arrangement. Immature tissue mainly refers to neural epithelial tissue, which can form glomeruli or neural tube structures, and can also spread in sheets.
　　According to the amount of this neural epithelium in the tumor, some scholars have proposed a grading method for immature teratoma. This grading is of great significance for the judgment of treatment and prognosis.
　　Grade 0: All tissue is mature.
　　Grade I: There is a small amount of immature tissue (mainly glioma and primitive mesenchyme), with nuclear division visible. Neural epithelium is scarce, limited to only 1/40 times field of view in each section.
　　Grade II: There is a large amount of immature tissue, but the neural epithelium does not exceed 3/40 times field of view in each section.
　　Stage III: There is a large amount of immature tissue, with the amount of neural epithelium in each section accounting for 4 or more/40 times field of view, and it often merges with sarcomatous stroma.

　　Immature teratoma of the ovary is prone to peritoneal implantation, metastasis, infection, and tissue adhesion. When cancer cells invade beyond the serosa, they can fall off to the surface of other organs in the peritoneal cavity, causing peritoneal implantation and spread. Peritoneal implantation and metastasis is a complex biological process, commonly occurring in the omentum, mesentery, bladder rectal凹, uterine rectal凹, etc., and is more common around the pelvic Douglas pouch (rectouterine pouch); it can be felt as a hard mass during vaginal examination, or it can be widely implanted in the peritoneal cavity, forming cancerous peritonitis.

　　Common symptoms of immature teratoma of the ovary include abdominal mass, abdominal pain, etc. Due to the high incidence of peritoneal implantation, 60% have ascites. And due to ascites, the body constitution is consumed and weight is reduced. The menstrual and reproductive functions of most patients are normal.
　　The characteristic of immature teratoma of the ovary is a high incidence of metastasis, ranging from 32% to 58%. The mode of metastasis often spreads along the peritoneum. Therefore, the most common sites of metastasis are the peritoneum and peritoneal cavity of the pelvis and abdomen, omentum, liver surface, diaphragm, serosal and mesenteric of the intestines, etc. Most of the metastatic foci are surface implantation. Lymph node metastasis is also not uncommon.

　　The etiology of immature teratoma of the ovary is not yet fully clear, therefore there is no effective preventive measure. Young women should try to have regular physical examinations, early detection and early treatment, and good follow-up, with a better prognosis.

　　The diagnosis of immature teratoma of the ovary can be made without difficulty according to its onset age, abdominal mass, rapid progression of the disease, and other symptoms, combined with the following examinations.
　　Firstly, laboratory examination:It is mainly the determination of tumor markers.
　　1. Serum alpha-fetoprotein (AFP)
　　2. Serum chorionic gonadotropin (HCG)
　　3. Neuron-specific enolase (NSE)
　　Secondly, other auxiliary examinations:Ultrasound examination, abdominal radiography, laparoscopic examination, and histopathological examination.

　　It is very important to adjust the diet for patients with immature teratoma of the ovary. After surgery, clinical symptoms often include deficiency of both Qi and blood, malaise of the spleen and stomach, both nutrient deficiencies and organ dysfunction. Therefore, in the diet and treatment, it is necessary to pay attention to appropriately supplementing nutrition and calories, providing high-protein and high-vitamin foods, and regulating the function of the spleen and stomach, invigorating the stomach Qi, restoring the chemical source, and strengthening the foundation of postnatal development. In terms of food selection, in addition to milk and eggs, general patients should eat more fresh vegetables and fruits, supplement proteins and various vitamins. The diet of patients should be light, and avoid or eat less high-dose lactose and excessive animal fat. Several diet therapy recipes suitable for patients with immature teratoma of the ovary are recommended.
　　1. Solanum nigrum sugar tea:15 grams of Solanum nigrum, 30 grams of麦饭石, boil the juice and add sugar to drink as tea.
　　2. Safflower and hawthorn meat:The safflower seed plate is 60 grams, the juice is taken and boiled with pork 60 grams, and hawthorn 30 grams.
　　3.逍遥mantis crab (Leigong crab):Eat the meat of the逍遥mantis crab cooked, and grind its shell into powder, 2g per day, three times a day, taken orally.
　　4. Sunflower flowers:Two sunflower flower petals, topped with 30 goji berries, 10 walnuts, 30g of meat slices, and appropriate seasonings, steamed for consumption.
　　5. Pork pancreas for removing tumors:One pork pancreas, cleaned, steamed and sliced after adding wine, for consumption. During chemotherapy, patients often have poor appetite and obvious gastrointestinal reactions. The selection of medicinal diet should be light and delicious, with the main function of reducing nausea and vomiting.

　　The immature teratoma of the ovary is a highly malignant tumor. If not properly treated, the mortality rate is quite high. If the treatment principles are correctly mastered, this highly malignant tumor can become a completely curable tumor. The treatment principles of immature teratoma are: ①Firstly, tumor cell reduction surgery should be performed to make the remaining tumor ≤2cm in diameter; ②Effective combined chemotherapy must be initiated early after surgery to reduce tumor recurrence and improve survival rate; ③If the above two points cannot be satisfactorily performed, tumor recurrence is often unavoidable. For recurrent tumors, specific plans should be formulated based on the law of reversibility of the malignancy of immature teratoma and different specific situations.
　　First, surgical treatment
　　1. Scope of surgery:During surgery, it should be first thoroughly explored, especially the diaphragm, liver surface, and retroperitoneal lymph nodes, to perform accurate tumor staging. Since the vast majority of tumors are unilateral and the patients are usually very young, it is generally recommended to perform unilateral adnexectomy to preserve fertility.
　　2. Surgical treatment for recurrent tumors:For the recurrent tumors of immature teratoma, surgical resection is still the main treatment, supplemented by effective combined chemotherapy. Recurrent tumors are often large and small masses scattered widely in the abdominal and pelvic cavities. Large or medium-sized tumors located in the liver or between the liver and diaphragm may seem very difficult to resect surgically at first glance, but surgery should not be easily abandoned. With careful and cautious efforts, the removal of the tumor is still feasible. If adhesions are severe and cannot be completely resected, a small amount of tumor tissue can be left, and chemotherapy can be performed after surgery, which can also achieve good results.
　　3. Surgical treatment for residual tumors that have not been completely resected and have transformed into pathological grade 0:For such tumors, treatment can be adjusted according to different situations.
　　①When the tumor is large, involving important organs, and causing symptoms, such as being closely attached to the liver or diaphragm, causing compression symptoms, even affecting respiration and producing a large amount of ascites; or the tumor is located within the mesentery, affecting the peristaltic function of the intestines; or the tumor is closely attached to the pelvic wall, compressing the ureter, etc., early surgery is required to relieve the symptoms.
　　②The patient has undergone multiple major surgical traumas in recent times. Although there are still some pathological grade 0 tumors remaining in the abdominal cavity, the tumors are not large (diameter ≤6cm), and there are no symptoms. It can be observed closely for the time being, and surgery can be scheduled after the physical condition improves.
　　③Due to the presence of pathological grade 0 tumors remaining in the abdominal cavity in some cases, there is still a possibility of malignancy after a certain time interval.
　　Although the chance of mature teratoma transforming into adenocarcinoma or carcinoid and other malignant tumors is not high, once it does, its malignancy is high and the prognosis is poor. Therefore, if the patient's general condition recovers well, it is advisable to try to remove the residual mature teratoma that has transformed into grade O.
　　4. Second Exploration Surgery:For immature teratoma, since there is no sign of tumor recurrence in clinical examination, there is no need to consider a second exploration surgery. Because even if there is residual tumor after the first surgery, due to the tumor's characteristic of benign transformation, it usually transforms into a benign mature teratoma after a certain time interval, grows slowly, and can often be detected by physical examination, B-ultrasound, or CT scan, so there is no need for a second exploration surgery. In recent years, with the application of combined chemotherapy, there have been very few residual cancers, so a second exploration surgery is not recommended.
　　Second, Chemotherapy:Chemotherapy is an essential treatment method for ovarian immature teratoma. Before the advent of combined chemotherapy, the survival rate of immature teratoma was only 20% to 30%. Immediate and early combined chemotherapy after the first surgery can prevent recurrence and improve survival rates. However, when chemotherapy is used improperly and treatment fails, it is still necessary to rely on the biological characteristics of benign transformation of the tumor to perform repeated surgery for recurrent tumors to save the lives of patients.
　　The selection and application of chemotherapy drugs, the total number of treatment courses, and the interval between treatment courses all have certain requirements. If the drugs are not administered according to these requirements, the therapeutic effect cannot be achieved, which is essentially the same as the chemotherapy for ovarian yolk sac tumors. In clinical stage I cases, due to the inaccuracy of surgical staging, such as retroperitoneal lymph node metastasis, simple palpation or biopsy of a few lymph nodes does not necessarily indicate whether there are small or microscopic metastases, and exploration of the diaphragmatic area may also miss some small metastatic nodules. Therefore, it is advisable to still give combined chemotherapy after surgery, but milder combined chemotherapy with fewer treatment courses can be selected. For example, VAC for 6 courses, or BEP, PVB for 3 courses; for those beyond stage I, the following options are available: ① VAC for 12 courses; ② PVB for 6 courses or BEP for 6 courses; ③ VAC for 6 courses after PVB for 3 courses; the selection of drugs and the number of treatment courses can still be appropriately increased or decreased according to the condition. Some people also use single doxorubicin (adriamycin) to treat immature teratoma, with good results.