Ovarian Cancer - Oncology - Medbullets Step 2/3

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 Ovarian biopsy indication to confirm the diagnosis and specify 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

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