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Snapshot
  • A 68-year-old woman presents to her gynecologist with pelvic pain and discomfort. Her symptoms are associated with a bloated sensation with increased urinary frequency. She became menopausal at the age of 52. Pelvic examination is notable for an adenxal mass. CA-125 levels are elevated. A transvaginal ultrasound demonstrates an ovarian mass concerning for malignancy. Preparations are made for surgical resection to establish a tissue diagnosis.
Introduction
  • Overview
    • malignant neoplasm originating from the ovaries 
  • Epidemiology
    • incidence
      • second most common gynecologic malignancy
      • mean age of diagnosis is 69
      • 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 
          • > 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 (12)
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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(M2.ON.4672) A 58-year-old female presents to her primary care physician with complaints of fatigue, shortness of breath, weight gain, and increased abdominal bloating over the last month. She also reports intermittent chest pains, and she has had trouble buttoning her pants, which have been feeling abnormally tight, over the last several weeks. Her vital signs are as follows: T 37.0, HR 104, BP 128/75, RR 18, SpO2 95%. Physical examination is significant for the following findings: dullness to percussion and decreased breath sounds of the right middle and lower lobes; palpation of a solid, 8 cm unilateral right-sided pelvic mass; shifting dullness on percussion of the abdomen; visible fluid-wave. A chest radiograph is performed and shows a right-sided pleural effusion. A CT scan of the abdomen-pelvis is obtained and shown in Figure A. Which of the following ovarian tumors is most commonly associated with this patient's presentation? Review Topic

QID: 107189
FIGURES:
1

Serous cystadenocarcinoma

40%

(10/25)

2

Dysgerminoma

8%

(2/25)

3

Fibroma

40%

(10/25)

4

Endodermal sinus tumor

4%

(1/25)

5

Immature teratoma

0%

(0/25)

M2

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SUBMIT RESPONSE 3

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(M3.ON.48) A 61-year-old woman presents to her primary care physician with complaints of increasing abdominal distension over the last 3 months, as well as more recent onset of early satiety and constipation over the last several weeks. She has a past medical history of obesity and diabetes. She states she feels more distended in her abdomen but has lost 10 pounds this past month. The patient has a 20 pack-year smoking history and was an alcoholic with her last drink 7 years ago. Her father died of colon cancer at the age of 62 and her mother died of breast cancer at the age of 45. She takes naproxen and ibuprofen for joint and back pain. Her temperature is 97.4°F (36.3°C), blood pressure is 120/81 mmHg, pulse is 83/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is notable for an elderly woman who has muscle wasting and a distended abdomen. Ultrasound is performed as seen in Figure A of the left lower quadrant of the abdomen. Which of the following is the most likely diagnosis? Review Topic

QID: 103071
FIGURES:
1

Alcoholic cirrhosis

0%

(0/0)

2

Colon cancer

0%

(0/0)

3

Non-alcoholic fatty liver disease

0%

(0/0)

4

Ovarian cancer

0%

(0/0)

5

Perforated viscus

0%

(0/0)

M2

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(M2.ON.1) A 38-year-old G4P3 African American woman presents to her OBGYN for a routine prenatal check up. She denies any problems, except that she's noticed increased acne and dark hair on her face lately. She also thinks her hair might be falling out around her temples. Her physical exam is notable for a gravid uterus and possible left ovarian mass palpated on bimaual exam. Transvaginal ultrasound reveals bilateral solid ovarian masses as seen in Figure A (R adnexa only shown). What is the most appropriate next step in treatment? Review Topic

QID: 105171
FIGURES:
1

Immediate chemotherapy

0%

(0/14)

2

Delayed chemotherapy following delivery

7%

(1/14)

3

Immediate surgery

7%

(1/14)

4

Delayed surgery following delivery

14%

(2/14)

5

Reassurance; repeat ultrasound following delivery

64%

(9/14)

M2

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