Ovarian Tumors

Question 1

Concerning characteristics of a pelvic mass

Answer 1

Worry about pelvic mass if >8cm, solid or cystic+solid, nodular, multilocular, + doppler flow, bilateral

Question 2

3 categories of ovarian tumors

Answer 2

Epithelial, germ cell, or stroma.

Question 3

Metastatic ovarian tumors

Answer 3

Usually GI tract (Krukenberg), breast, endometrium

Usually spreads via direct exfoliation; can be lymphatic too, more rarely hematogenous

Question 4

Epithelial tumors (65-70%)

Answer 4

20+ years (esp older)

Serous cystadenocarcinoma, mucinous, endometriod, clear cell, Brenner, undifferentiated

Question 5

Germ cell tumors (15-20%)

Answer 5

0-25+ years

Teratoma, dysgerminoma, endodermalsinus tumor, choriocarcinoma,embryonal carcinoma

Question 6

Sex cord stromal (5-10%)

Answer 6

All ages

Granulosa-theca cell tumors, Sertoli-Leydig cell tumors, fibromas

Question 7

What is the most common ovarian tumor?

Answer 7

Epithelial is #1 most common

Question 8

Etiology of epithelial ovarian tumor

Answer 8

Thought to be 2/2 chronic uninterrupted ovulation → malignant transformation

Question 9

Risk factors for epithelial ovarian tumor

Answer 9

Early menarche, infertility, late menopause, nulliparity, delayed childbearing, increasing age
10-15% have familial syndrome (e.g. BRCA 1>2 or HNPCC)

Question 10

Protective factors for epithelial ovarian tumor

Answer 10

OCPs are protrective (50% if on OCP x 5yrs), also tubal ligation / hysterectomy

Question 11

Symptoms of epithelial ovarian tumor

Answer 11

Asx or vague, nonspecific complaints (lower abd pain, bloating, distention, early satiety, other GI sx, urinary frequency / dysuria / pelvic pressure when more advanced, ascites if later)

Question 12

Physical exam findings of epithelial ovarian tumor

Answer 12

Fixed, solid, irregular pelvic mass +/- ascites.

Question 13

Epithelial ovarian tumor met to umbilicus

Answer 13

Sister Mary Joseph nodule

Question 14

Diagnosis of epithelial ovarian tumor

Answer 14

Pelvic U/S; CT/MRI can be helpful too, then look for mets / other primaries (barium enema, IVP, etc)
Get a CA-125.
If wondering about other types of tumors, alpha-fetoprotein, LDH, hCG too.

Question 15

Staging of epithelial ovarian tumor

Answer 15

Surgical (TAHBSO, omentectomy, peritoneal washings, Pap smear of diaphragm, sampling of pelvic / periarotic lymph nodes).
Many present in stage III/IV (2/2 vague symptoms) and 5-yr survival low.
Goal is optimal debulking (no tumor > 1cm left behind)

Question 16

Treatment of epithelial ovarian tumor

Answer 16

Usually do adjuvant carboplatin + paclitaxel
If optimal debulking achieved, can do intraperitoneal chemo if tolerated
CA-125 elevated in 80% epithelial tumors - not for screening, but to track tx /recurrence
Can also get CT scans to follow serially

Question 17

Most common type of epithelial ovarian tumor

Answer 17

Most common type: serous cystadenocarcinoma, but types can vary from borderline to high malignancy

Question 18

Germ Cell ovarian tumor

Answer 18

Most grow rapidly, limited to one ovary, stage I at time of diagnosis, curable!
95% benign

Question 19

Symptoms of germ cell ovarian tumor

Answer 19

Capsule distention → pain, hemorrhage, necrosis → acute pelvic pain; can also torse / rupture

Question 20

Dysgerminoma

Answer 20

No differentiation (totipotent)
Most common malignant germ cell tumor
Uniquely radiosensitive! but still do chemo (better fertility)
LDH= tumor marker

Question 21

Embryonalcarcinoma

Answer 21

Starting to differentiate towards:
Endodermal sinus tumor
Choriocarcinoma
Teratoma

Question 22

Endodermal sinus tumor

Answer 22

Differentiation: Extraembryonic (yolk sac)

AFP = tumor marker

Question 23

Choriocarcinoma

Answer 23

Differentiation: Trophoblastic (placental)

hCG = tumor marker

Question 24

Teratoma

Answer 24

Differentiation: Embryonic (fetal)
Benign cystic mature teratoma = dermoid cyst = most common germ cell tumor!
Cystic, has skin / hair / teeth /etc
Do a cystectomy for definitive dx & to r/o malignancy!
Immature teratoma = malignant version

Question 25

Treatment for benign germ cell ovarian tumors

Answer 25

For benign tumors (mature teratomas) → cystectomy or oophorectomy

Question 26

Treatment for malignant germ cell ovarian tumors

Answer 26

For malignant tumors, unilateral salpingo-oophorectomy if fertility desired, or TAH/BSO Everything except stage IA dysgerminomas / immature teratomas gets multiagent chemo Usually BEP = bleomycin, etoposide, cisplatin=Platinol Can follow response with tumor markers Dysgerminomas are uniquely radiosensitive - but often still do combo chemo to protect fertility

Question 27

Sex cord-stromal tumors

Answer 27

Generally low grade, don’t recur, usually unilateral Treatment with unilateral sapingooophorectomy No role for chemo or radiation in these tumors

Question 28

Granulosa-Theca cell tumors

Answer 28

Are #1 (70%) Can happen at any age Functional: can make lots of estrogens → endometrial hyperplasia, cancer 2/2 stimulation! See Call-Exner bodies (pathognomonic) - with grooved “coffee-bean nuclei”

Question 29

Symptoms of Granulosa-Theca cell tumors

Answer 29

Can cause precocious puberty, feminization, menstrual irreg, secondary amenorrhea, postnemopausal bleeding 2/2 high estrogen

Question 30

Diagnosis of Granulosa-Theca cell tumors

Answer 30

High estradiol, inhibin A/B

Question 31

Sertoli-Leydig cell tumors

Answer 31

Are more rare Mostly in women < 40 Like the ovary grew a little pair of testicles: making androgens Sx: see virilizing effects (breast atrophy, hirsutism, deepend voice, etc) + oligo / amenorrhea.

Question 32

Ovarian fibroma

Answer 32

Derived from mature fibroblasts, not functional | Can be a/w ascites: tumor + ascites + right hydrothorax = Meigs syndrome

Question 33

Fallopian tube cancers

Answer 33

Really rare, usually adenocarcinoma, Behave like ovarian cancer (peritoneal spread, ascites) More frequently in caucasians, BRCA ½, nullips, infertility

Question 34

Symptoms of fallopian tube cancers

Answer 34

Usually asymptomatic Classic = “Latzko’s triad”, profuse watery discharge + pelvic pain + pelvic mass but only in 15% Hydrops tubae profluens (intermittent hydrosalpinx) = spontaneous or pressure-induced watery / blood tinged vaginal discharge that makes abdominal mass shrink

Question 35

Work up of fallopian tube cancer

Answer 35

Pelvic U/S, CA-125 can be up, cervical cytology rarely shows malignancy Usually dx @ surgery (since so rare); stage surgically

Question 36

Treatment of fallopian tube cancer

Answer 36

Treat like epithelial ovarian carcinoma (TAHBSO, omentectomy, cytoreduction, peritoneal sampling, LN sampling, etc) and then carboplatin + paclitaxil