Updated: 4/4/2018

Ovarian Tumors

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Snapshot
  • A 66-year-old woman presents with abdominal distention and early satiety. She underwent menopause 17 years ago and has never had children. She had a pelvic mass but her PAP smear is atrophic. A pelvic ultrasound is performed.
Introduction
  • Ovarian cancer is the fifth most common type of cancer in women
  • Second most common gynecologic cancer behind endometrial cancer (25%)
  • Ovarian cancer is the leading cause of gynecological cancer deaths
  • Risk factors
    • family history
    • increased number of ovulatory cycles
      • infertility
      • nulliparity
      • > 50 yrs
        • cancer < 50 yrs more likely to be benign
      • OCP use is protective because it reduces ovulatory cycles
  • Associated conditions
    • BRCA1 and BRCA2 positivity
      • also increases breast cancer risk
    • cancer syndromes
      • HNPCC
      • Peutz-Jeghers
    • Turner syndrome
  • There are many tumor types
    • germ cell
      • most commonly seen in adolescents due to embryologic remnants
      • subtypes
        • dysgerminoma
          • most common malignant germ cell neoplasm
            • equivalent to male seminoma
          • seen commonly in Turner syndrome
          • histology shows sheets of uniform cells
          • serology shows ↑ hCG and LDH
        • yolk sac (endodermal sinus) tumor
          • aggressive malignancy of ovaries in young girls
            • also seen in testes and sacrococcygeal area of young children
          • yellow, friable, solid masses
            • note: like egg yolk
          • histology shows Schiller-Duval bodies
            • resemble glomeruli/yolk sac
          • serology shows ↑ AFP
        • teratoma
          • large majority of ovarian germ cell tumors
          • mature teratoma ("dermoid cyst") 
            • most frequent benign ovarian tumor
          • immature teratoma
            • aggressively malignant
          • contain cells from many different tissue types
            • teeth, hair, etc.
            • struma ovarii 
              • contains functional thyroid tissue
              • hyperthyroidism present
    • sex cord stromal
      • may produce hormones (androgens and estrogens)
      • mostly benign
      • subtypes
        • thecoma-fibroma
          • histology shows spindle-shaped fibroblasts
          • associated with Meigs syndrome/triad
            • ovarian fibroma, ascites, and right pleural effusion
            • fluid abnormalities regress with removal of tumor
          • pulling sensation in groin
        • Sertoli-Leydig cell tumor
          • virilization secondary to secretion of androgens
          • histology shows crystals of Reinke containing cells
        • granulosa-theca cell tumor
          • hyperestrinism secondary to secretion of estrogens
            • may result in precocious puberty in kids
            • may result in endometrial hyperplasia in adults
          • histology shows Call-Exner bodies  
            • small follicles filled with eosinophilic secretions  
    • surface derived
      • most common tumor type
      • CA-125 positivity 
      • malignant types can seed peritoneal cavity
      • subtypes
        • serous cystadenoma
          • commonly bilateral
          • benign
          • histology shows fallopian tube-like epithelium
        • serous cystadenocarcinoma
          • commonly bilateral
          • malignant
          • histology shows psammoma bodies
            • also seen in papillary masses of thyroid and meningiomas
        • mucinous cystadenoma
          • multilocular cyst
          • benign
          • histology shows intestine/endocervix-like tissue
        • mucinous cystadenocarcinoma
          • malignant
          • pseudomyxoma peritonei
            • intraperitoneal accumulation of mucinous material
            • may be from ovarian or appendiceal tumors
        • Brenner tumor 
          • benign
          • histology shows transitional epithelium
            • similar to Bladder histology
            • characteristic "coffee ground" appearance 
    • metastasis
      • breast
      • gastric (Krukenberg/Signet ring tumors)
Presentation
  • Symptoms
    • usually asymptomatic until late in the course of the disease
    • ascites
      • key feature
    • distension
    • early satiety
    • constipation
      • secondary to compression of intestine
    • SOB
    • signs of hyperestrinism/virilization
      • if tumor is hormone secreting type
  • Physical exam
    • palpable abdominal mass/ovaries
      • usually cancer in post-menopausal women
Treatment
  • Surgical cytoreduction
    • total abdominal hysterectomy
    • bilateral salpingo-oophorectomy (BSO)
    • removal of pelvic and para-aortic lymph nodes and omentum
  • Chemotherapy
    • combination of platinum (i.e. carboplatin) and non-platinum (i.e. paclitaxel) regimen
  • Radiation
    • reserved for palliation or localized persistent disease after chemotherapy
Prognosis, Prevention, and Complications
  • Very poor prognosis
    • up to 70% of women present at stage III or IV
    • prognosis is strongly associated with the stage at diagnosis
  • USPSTF recommends against routine screening for ovarian cancer
  • In women with familial BRCA mutations and strong family history, prophylactic BSO is effective for reducing the risk of ovarian, fallopian tube, and peritoneal cancers 
    • If surgery refused, recommendation is transvaginal ultrasonography and CA 125 measurement every six months during days 1 through 10 of the menstrual cycle, beginning five to 10 years earlier than the earliest age of diagnosis of ovarian cancer in the family

 

 

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Questions (5)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M1.ON.1) A 52-year-old patient undergoes a biopsy of the ovary, with the results shown in Figure A. Which of the following additional findings would you most expect to see in this patient? Review Topic

QID: 100501
FIGURES:
1

Mature teratoma

15%

(21/141)

2

Increased CA 19-9 tumor marker

19%

(27/141)

3

Endometrial hyperplasia

53%

(75/141)

4

Vaginal atrophy

10%

(14/141)

5

Pregnancy

1%

(1/141)

M1

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PREFERRED RESPONSE 3
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(M1.ON.1) A 40-year-old nulliparous woman with no significant medical history presents to your office with shortness of breath and increased abdominal girth over the past month. The initial assessment demonstrates that the patient has a right-sided hydrothorax, ascites, and a large ovarian mass. Surgery is performed to remove the ovarian mass, and the patient's ascites and pleural effusion resolve promptly. What is the most likely diagnosis? Review Topic

QID: 101235
1

Metastatic colon cancer

1%

(1/81)

2

Metastatic lung cancer

5%

(4/81)

3

Metastatic ovarian cancer

10%

(8/81)

4

Meigs syndrome

83%

(67/81)

5

Nephrotic syndrome

0%

(0/81)

M1

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PREFERRED RESPONSE 4
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