Reproductive: Ovarian Cancer

Question 1

When should you think ovarian cancer?

Answer 1

• Complex cystic mass (thick septations, enhancing mural nodule, etc.)
• Solid adnexal masses with variable necrosis
• Ancillary findings (ascites, lymphadenopathy, metastatic disease)

Question 2

Next step: ovarian cyst with many thin septations

Answer 2

Surgery consult

Question 3

Next step: ovarian cyst with enhancing mural nodule on CT

Answer 3

Surgery consult

Question 4

Next step: ovarian cyst with non-enhancing mural nodule on CT

Answer 4

MRI (to see if the mural nodule is a dermoid plug)

Note: If not a dermoid plug, then get a surgery consult.

Question 5

What are the most common types of ovarian cancer?

Answer 5

• Serous cystadenoma (most common)
• Endometroid (2nd)
• Mucinous cystadenoma (3rd)

Question 6

Answer 6

Think serous ovarian cystadenoma

Note: Large, unilocular cystic lesion with few septations centered in the adnexal region.

Question 7

What percentage of serous ovarian tumors are benign?

Answer 7

60%

Note: 15% are considered borderline, and the rest are malignant serous cystadenocarcinoma.

Question 8

Ovarian cystadenoma with ascites…

Answer 8

Think cystadenocarcinoma with metastatic disease (70% have peritoneal involvement at the time of diagnosis)

Question 9

Answer 9

Think mucinous cystadenoma

Note: Large adnexal multilocular cystic lesion.

Question 10

Imaging features that favor serous over mucinous cystadenoma

Answer 10

• Unilocular with fewer septations
• Papillary projections (nodule with blood flow)

Note: Mucinous cyst adenomas are usually multilocular and don’t have papillary projections as frequently.

Question 11

What percentage of endometroid ovarian cancer are bilateral?

Answer 11

15%

Question 12

What percentage of pts with endometroid ovarian cancer also have endometrial cancer at the time of diagnosis?

Answer 12

25%

Note: In these cases the endometrial cancer is the primary and the ovarian tumor is actually a met.

Question 13

Ovarian mass and endometrial thickening…

Answer 13

• Endometrial cancer with mets to the ovary
• Granulosa-theca cell cancer (with endometrial hyperplasia secondary to estrogen production)

Question 14

Differential for a “big fucking mass” in the abdomen of an adult

Answer 14

• Ovarian masses (mucinous, serous, etc.)
• Desmoids (think Gardner syndrome)
• Sarcomas

Question 15

Imaging features of an ovarian fibroma

Answer 15

Similar to a uterine fibroid:

• Hypoechoic solid mass on US
• T1 and T2 dark on MRI
• T2 dark rim on MRI

Question 16

Do fibromas commonly have calcifications?

Answer 16

No, calcifications are rare in fibromas/fibrothecomas

Question 17

Ascites, pleural effusion, and benign ovarian tumor (usually a fibroma)…

Answer 17

Meigs syndrome

Question 18

Answer 18

Think ovarian fibromatosis

Note: This is the “black garland” sign.

Question 19

Ovarian fibromatosis

Answer 19

A rare condition where there is benign tumor-like enlargement of the ovaries due to fibrosis. It is also associated with mental fibrosis and sclerosing peritonitis.

Note: This usually presents around age 25.

Question 20

Brenner tumor

Answer 20

A fibrous epithelial tumor of the ovary seen in women in their 50s-70s

Note: This will be T2 dark like fibromas, but often have calcifications (80%) that fibromas rarely have.

Question 21

Ovarian mass that it T2 dark and contains calcifications…

Answer 21

Think Brenner tumor

Question 22

Struma ovarii

Answer 22

A subtype of ovarian teratoma that contains thyroid tissue and classically appears as a multilocular cystic and solid mass with an intensely enhancing solid component

Question 23

Ovarian mass in a pt with new hyperthyroidism or thyroid storm…

Answer 23

Thin struma ovarii (ovarian teratoma containing thyroid tissue)

Question 24

What are the most common primary cancers in the setting of ovarian mets?

Answer 24

• Colon
• Gastric
• Breast
• Lung
• Contralateral ovary

Question 25

Krukenburg tumor

Answer 25

Metastatic ovarian tumors from a GI primary (usually gastric)