Ovarian Neoplasms
What are the most common types of ovarian cancer?
75% diagnosed at advanced stage, 90% are epithelial tumors. Germ cell tumors are more common in patients < 10 years old.
What are risk factors for developing ovarian cancer?
90% of ovarian cancer is sporadic and not inherited, but family history is the most significant risk factor. Multiple relatives with breast or ovarian cancer increases risk: Refer these patients for genetic counseling. Individuals in families with familial cancer syndromes have 20-60% risk of developing ovarian cancer. Other risk factors: nulligravidity (or infertility), early menarche, late menopause, endometriosis.
What is the most likely etiology of an adnexal mass in children and adolescents?
Adnexal masses occur less frequently in children and adolescents than in reproductive-age women. However, when an adnexal mass is found in this patient population, there is a significant likelihood of adnexal torsion or an ovarian malignancy (approximately 10 to 20 percent). Germ cell tumors are the most common type of ovarian cancer in children and adolescents.
What is an adnexal mass?
An adnexal mass (mass of the ovary, fallopian tube, or surrounding connective tissues) is a common gynecologic problem. In the United States, it is estimated that there is a 5 to 10 percent lifetime risk for women undergoing surgery for a suspected ovarian neoplasm. Adnexal masses may be found in females of all ages.
What are risk factors for ovarian cancer?
An increased risk of EOC is associated with: increasing age, infertility, endometriosis, polycystic ovarian syndrome, use of an intrauterine device, and cigarette smoking (for mucinous carcinomas).
How should you treat an adnexal mass?
Asymptomatic premenopausal patients with simple ovarian cysts < 10 cm in diameter can be observed or placed on suppressive therapy with oral contraceptives. Postmenopausal women with simple cysts < 3 cm in diameter may also be followed, provided the serum CA 125 level is not elevated and the patient has no signs or symptoms suggestive of malignancy. If the cyst is > 3 cm or the CA 125 is elevated, further evaluation is necessary.
What are Brenner tumors?
Brenner tumors are rare, non-germ cell tumors of the surface epithelial-stromal type, which appear encapsulated and pale yellow-tan in color. Most tumors are benign and unilateral, and are histologically similar to transitional epithelium found in the bladder. On histology, the cells of Brenner tumors appear to have coffee-bean shaped nuclei.
A 65-year-old woman is undergoing a general examination. On your exam, you note a fullness in the left adnexa. Which of the following conditions would be reassuring that the finding is benign? A. multiloculated cyst noted on ultrasound B. Elevated CA 125 level C. Simple cyst measured at 2.5 cm as seen on ultrasound D. Elevated CEA level
C. Simple cyst measured at 2.5 cm as seen on ultrasound Adnexal masses are commonly encountered in women. In premenopausal women, physiologic follicular cysts and corpus luteum cysts are the most common adnexal masses. Ectopic pregnancy can occur and should be considered. Other causes for masses in this age group include endometriomas, polycystic ovaries, tubo-ovarian abscesses, and benign neoplasms. Malignant neoplasms become more frequent with increasing age. In postmenopausal women with adnexal masses, neoplasms must be considered, along with leiomyomas, ovarian fibromas, and other lesions such as diverticular abscesses. Measurement of serum CA 125 is an appropriate test for assessing postmenopausal women with pelvic masses. Asymptomatic premenopausal patients with simple ovarian cysts < 10 cm in diameter can be observed or placed on suppressive therapy with oral contraceptives. Postmenopausal women with simple cysts < 3 cm in diameter may also be followed, provided the serum CA 125 level is not elevated and the patient has no signs or symptoms suggestive of malignancy. If the cyst is > 3 cm or the CA 125 is elevated, further evaluation is necessary.
What tumor marker is used for ovarian cancer?
CA-125 is elevated in ovarian cancer and other benign ovarian lesions. It is used to assess response to treatment and evaluation of recurrence of ovarian cancer.
What is choriocarcinoma?
Choriocarcinoma is a rare ovarian germ cell tumor that can develop during or after pregnancy in the mother or baby. Malignancy arises usually in the placenta, but sometimes in the ovary. Malignant trophoblastic tissue will show no chorionic villi, while the frequency of theca-lutein cysts increases. Hematogenous spread to the lungs is common. The most effective tumor marker is increased hCG level and most cases are preceded by a hydatidiform mole.
What is cystoadenocarcinoma?
Cystadenocarcinoma is the most common type of malignant ovarian tumor, often detected late in patients. Tumors arise from ovarian surface epithelium and are either of serous or mucinous type. Serous-type comprises 45% of ovarian tumors and are often bilateral with psammoma bodies. Mucinous tumors have mucus-secreting epithelium and mucinous material may travel to and accumulate in the peritoneal cavity. BRCA-1 and Lynch syndrome are hereditary risk factors, and increased CA-125 is a common indication for ovarian cancer.
What are cystadenoma tumors?
Cystadenoma tumors arise from ovarian surface epithelium and are the most common type of benign ovarian tumor. There are two types, serous and mucinous. Serous-type tumors comprise 45% of ovarian tumors, are commonly bilateral and are characterized by unilocular cysts lined smoothly by serous fluid-secreting epithelium. Mucinous-type tumors have multilocular cysts lined by mucus-secreting epithelium.
How is ovarian cancer diagnosed?
Diagnosis of ovarian cancer starts with a physical examination (including a pelvic examination), a BLOOD TEST (for CA-125 and sometimes other markers), and transvaginal ultrasound.
What is a dysgerminoma?
Dysgerminoma is a rare malignant germ-cell tumor often found in young adults, equivalent to seminoma found in males. Tumors show sheets of uniform cells that are similar to primordial germ cells and have gross and microscopic features similar to those of seminomas. Turner syndrome is a risk factor, and elevated LDH and hCG are common tumor markers.
How is ovarian cancer treated?
Early stage: TAH-BSO plus selective lymphadenectomy Surgery: tumor debulking Serum CA-125 levels used to monitor treatment progress Chemotherapy: Taxol + Cisplatin or Carboplatin.
What is the most likely etiology of an adnexal mass in a pregnant woman?
Ectopic pregnancy and luteomas - These occur solely during pregnancy. Corpus luteum cysts - These persist longer during pregnancy and thus are likely to reach a larger size and may become hemorrhagic, rupture, or undergo torsion. Theca lutein cysts - These are most likely to occur in women with ovarian hyperstimulation due to ovulation induction for infertility or gestational trophoblastic disease.
What is the most likely etiology of an adnexal mass in a postmenopausal woman?
Excluding malignancy is the main priority in postmenopausal women with an adnexal mass (the average age of diagnosis of ovarian cancer in the United States is 63 years old).
What are fibromas?
Fibromas are unilateral, spherical tumors composed of fibroblasts. Fibromas often occur in concurrence with ascites and hydrothorax in a condition called Meigs syndrome. Most tumors contain a thecoma component, made of plump spindle cells containing lipid droplets. These may be referred to as fibromathecomas. Patients may often present with a pulling sensation in the groin.
What urgent conditions must be assessed in a patient with an adnexal mass?
First trimester bleeding or pain -Ectopic pregnancy Acute pelvic or abdominal pain -Adnexal torsion -Ruptured or hemorrhagic ovarian cyst Fever -Tubo-ovarian abscess
What are granulosa cell tumors?
Granulosa cell tumors, also known as granulosa-theca cell tumors, are potentially malignant yellow-white masses arising from granulosa cells. Tumors are often estrogen-producing, increasing risk of endometrial carcinoma. Unopposed excess estrogen exposure in younger patients can result in precocious puberty, while adults may experience abnormal uterine bleeding. Call-Exner bodies are hallmark cellular characteristics.
What are Krukenberg tumors?
Krukenberg tumors are caused by metastasis to the ovaries from a separate primary location. This is thought to occur through retrograde lymphatic spread, and tumors often present bilaterally. Common primary tumor sources include metastases from both gastric and breast malignancies, although gastrointestinal malignancy at the pylorus is the most frequent source. Microscopically, mucin-secreting signet cells are a defining characteristic of this tumor type.
How does ovarian cancer present clinically?
Most commonly, EOC presents in a subacute fashion (eg, pelvic or abdominal pain, bloating, gastrointestinal symptoms) in women with either early or advanced disease. -The majority of women have stage III (disease that has spread throughout the peritoneal cavity and/or that involves lymph nodes) disease at diagnosis.
What is the epidemiology of ovarian cancer?
Ovarian cancer is the second most common gynecologic malignancy in developed countries and the third most common gynecologic malignancy in developing countries (cervical cancer is the most common). Ovarian cancer is the second most common gynecologic malignancy and the most common cause of gynecologic cancer death in the United States.
How does the anatomic location help when approaching an adnexal mass?
Ovarian masses include: ●Physiologic cysts (follicular or corpus luteum) ●Benign ovarian neoplasms (eg, endometrioma, mature teratoma [dermoid cyst]) ●Ovarian cancer or metastatic disease from a non-ovarian primary cancer A mass in the fallopian tube may be: ●Ectopic pregnancy ●Hydrosalpinx ●Fallopian tube cancer
What is the appropriate workup for a patient with an adnexal mass?
Pelvic pain or pressure is the most common symptom associated with an adnexal mass. Patients who present with symptoms or findings suggestive of an adnexal mass should undergo pelvic examination and imaging to confirm whether a mass is present. -Rectovaginal examination is performed to allow palpation of the ovary posteriorly.
What is the imaging study of choice when evaluating a patient with an adnexal mass?
Pelvic ultrasound is the imaging study of choice for the evaluation of an adnexal mass. Ultrasound is relatively less expensive than other imaging modalities and its diagnostic performance is similar. Both a transvaginal and transabdominal ultrasound should be obtained in most patients.
What are the predominant ages for diagnosis of ovarian cancer?
Predominant age -Epithelial: mid-50s -Germ cell malignancies: usually observed in patients <20 years of age
What is the pathogenesis of ovarian cancer?
Serous, clear cell, and endometrioid ovarian carcinomas often appear to arise from tissues not normally present in the ovary, such as the fallopian tube, Müllerian inclusion cysts, endometriosis, and endosalpingiosis. Ovarian sex cord-stromal tumors arise from the dividing cells that would typically give rise to specialized gonadal stroma surrounding the oocytes, including granulosa cells, theca cells, Sertoli cells, Leydig cells, and fibroblasts.
What is a teratoma?
Teratoma is classified as a germ cell tumor occurring in the early reproductive years. They are mostly benign and contain tissue from all three germ layers: ectoderm, mesoderm, and endoderm. Tumors may have skin, hair, bone, teeth, and thyroid tissue. A dermoid cyst, or mature teratoma, is the most common ovarian germ tumor and is usually benign. Immature teratoma are aggressively malignant and are made of histologically immature tissue. Struma ovarii is a rare type of benign teratoma composed of mainly thyroid tissue.
What patients are most likely to be affected by ovarian cancer?
The average age at diagnosis of ovarian cancer in the United States is 63 years old.
What is the most likely etiology of an adnexal mass in pre-menopausal women?
The great majority of adnexal masses occur in reproductive-age patients (including postmenarchal adolescents), and most of these masses are benign. This is because the pathogenesis of many benign adnexal masses is associated with reproductive function. Ovarian or fallopian tube cancer is less likely in premenopausal than postmenopausal women, but the possibility of malignancy should be considered in all patients.
What are the most common kinds of ovarian cancer?
The majority of ovarian malignancies (95 percent) are epithelial; the remainder arise from other ovarian cell types (germ cell tumors, sex cord-stromal tumors).
What are protective factors against ovarian cancer?
Use of oral contraceptives: 5 years of use decreases risk by 20%; 15 years by 50%. The progestin component of oral contraceptive preparations (OCPs) may protect against ovarian cancer by regulating apoptosis of the ovarian epithelium.
What is a yolk-sac tumor?
Yolk sac tumor, or endodermal sinus tumor, is the most common germ-cell ovarian tumor found in infants. It is aggressively malignant and presents as a yellow, non-encapsulated mucinous mass. In 50% of cases, glomerulus-like structures called Schiller-Duval bodies can be found in histological examination. AFP is used as a tumor marker.