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Updated: Dec 27 2021

Ovarian Cancer

  • 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
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