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)
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(M1.ON.13.1) 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? Tested Concept

QID: 101235
1

Metastatic colon cancer

1%

(1/88)

2

Metastatic lung cancer

5%

(4/88)

3

Metastatic ovarian cancer

9%

(8/88)

4

Meigs syndrome

83%

(73/88)

5

Nephrotic syndrome

1%

(1/88)

L 2 D

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(M1.ON.13.1) 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? Tested Concept

QID: 100501
FIGURES:
1

Mature teratoma

15%

(25/166)

2

Increased CA 19-9 tumor marker

21%

(35/166)

3

Endometrial hyperplasia

53%

(88/166)

4

Vaginal atrophy

8%

(14/166)

5

Pregnancy

1%

(1/166)

L 1 D

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