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 ETIOLOGY 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