Ovarian Tumors

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