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
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI 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/LFemale: 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/mLFemale: 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/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative 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/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 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/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 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/minFemale: 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 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 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 ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + (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: A 1 Mature teratoma 15% (20/131) 2 Increased CA 19-9 tumor marker 19% (25/131) 3 Endometrial hyperplasia 53% (69/131) 4 Vaginal atrophy 11% (14/131) 5 Pregnancy 1% (1/131) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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% (1/80) 2 Metastatic lung cancer 5% (4/80) 3 Metastatic ovarian cancer 10% (8/80) 4 Meigs syndrome 82% (66/80) 5 Nephrotic syndrome 0% (0/80) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK