Ovarian Tumors - Oncology - Medbullets Step 1

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

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

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