Updated: 8/21/2019

Ovarian Tumors

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Snapshot
  • A 70-year-old woman presents with lower extremity edema and early satiety. She also reports pelvic discomfort. She underwent menopause at 50 years of age. Pelvic examination is notable for an adnexal mass. CA-125 levels are noted to be elevated with transvaginal ultrasound demonstrating an ovarian mass concerning for malignancy.
Introduction
  • Overview
    • malignant neoplasm originating from the ovaries
  • Epidemiology
    • incidence
      • second most common gynecologic malignancy
      • most common gynecologic malignancy that results in death
    • risk factors
      • BReast CAncer gene (BRCA) 1 (chromosome 17) or 2 (chromosome 13) mutation
      • early menarche
      • family history
      • nulliparity
      • infertility
      • endometriosis
      • polycystic ovarian syndrome
      • hereditary nonpolyposis colorectal cancer (HNPCC) syndrome
        • also known as Lynch syndrome
    • protective factors
      • breast feeding
        • decreases the risk of breast and ovarian cancer
      • oral contraceptive pills
      • chronic anovulation
  • Associated conditions
    • BRCA 1 or 2 mutations
    • Lynch syndrome
Presentation
  • Symptoms
    • asymptomatic (in early stages of the disease)
    • pelvic and/or abdominal pain
    • bloating
    • urinary urgency or frequency
    • vaginal bleeding
  • Physical exam
    • adnexal mass
      • highly concerning in postmenopausal women since their ovaries should be atrophic
Imaging
  • Pelvic ultrasound (e.g., transvaginal or transabdominal ultrasound)
    • indication
      • imaging study of choice
        • transvaginal ultrasound
          • premenopausal and postmenopausal women with a pelvic mass
        • transabdominal ultrasound
          • young, not sexually active, prepubescent adolescent with a pelvic mass
    • findings
      • ovarian mass; however, its not specific for ovarian cancer
        • suggestive findings include
          • > 10-cm mass
          • irregularity
          • presence of ascites
Studies
  • Serum labs
    • CA-125 (cancer antigen 125) 
      • sensitivity and specificity for ovarian cancer is highest in postmenopausal women with a pelvic mass
      • note that other conditions can increase CA-125 levels
        • endometriosis
        • uterine leiomyoma
        • pelvic inflammatory disease
  • Histology
    • indication
      • to confirm the diagnosis and specific the ovarian tumor subtype
        • can arise from the surface epithelium, germ cells, or sex cord stromal tissue
    • ovarian tumor subtypes
      • surface epithelium tumors
        • benign
          • serous cystadenoma (most common benign ovarian neoplasm) 
            • contains fallopian tube-like epithelium
          • mucinous cystadenoma
            • contains mucus-secreting epithelium
          • endometrioid tumor
            • tubular glands that resemble the endometrium
              • may arise in the setting of endometriosis
              • "chocolate cyst"
        • malignant
          • serous cystadenocarcinoma (most common malignant ovarian neoplasm)
            • contains psammoma bodies 
          • mucinous cystadenocarcinoma
            • may be metastatic from gastrointestinal or appendiceal tumors
            • pseudomyxoma peritonei
              • may result in mucinous accumulation in the peritoneum
      • germ cell tumors
        • benign
          • mature cystic teratoma
            • contains elements from all 3 germ cell layers
              • e.g., hair, teeth, and sebum 
            • monodermal form can present as hyperthyroidism due to the presence of thyroid tissue (struma ovarii) 
        • malignant
          • dysgerminoma 
            • "fried egg" cell appearance
            • associated with increased LDH and hCG levels
            • equvalent to seminoma in males
          • immature teratoma
            • contains fetal tissue and neuroectoderm
          • yolk sac tumor (ovarian endodermal sinus tumor)
            • can be yellow and friable
            • Schiller-Duval bodies in 50% of cases 
            • associated with increased AFP levels 
      • sex cord stromal tumor
        • benign
          • fibroma
            • spindle-shaped fibroblasts
            • associated with Meigs syndrome 
              • triad of ovarian fibroma, ascites, and hydrothorax
          • thecoma
            • may produce estrogen, leading to postmenopausal bleeding
        • malignant
          • granulosa cell tumor 
            • often produces estrogen, leading to postmenopausal bleeding, precocious puberty, and breast tenderness
            • Call-Exner bodies 
              • haphazard organization of granulosa cells around eosinophilic fluid 
      • other
        • benign
          • Brenner tumor 
            • transitional cells, resembling bladder epithelium
            • "coffee bean" nuclei 
        • malignant
          • Krukenber tumor
            • mucin-secreting signet cell adenocarcinoma
              • secondary to metastatic gastrointestinal cancer
Differential
  • Leiomyoma
    • differentiating factors
      • whorled pattern of smooth muscle in the uterus
Treatment
  • Ovarian cancer
    • treatment depends on the stage, nodal status, and pathology
    • e.g., bilateral salpingo oopherectomy
Complications
  • Ascites
  • Malignant pleural effusion
  • Bowel obstruction
  • Metastasis
 

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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
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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%

(1/84)

2

Metastatic lung cancer

5%

(4/84)

3

Metastatic ovarian cancer

10%

(8/84)

4

Meigs syndrome

82%

(69/84)

5

Nephrotic syndrome

1%

(1/84)

M1

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PREFERRED RESPONSE 4

(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%

(22/151)

2

Increased CA 19-9 tumor marker

21%

(32/151)

3

Endometrial hyperplasia

52%

(78/151)

4

Vaginal atrophy

10%

(15/151)

5

Pregnancy

1%

(1/151)

M1

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PREFERRED RESPONSE 3
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