questions 8

Ovarian Cancer

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Topic updated on 09/09/17 3:09pm

Snapshot
  • Ms. Jenson, a 66-year-old women presents with abdominal distention. She underwent menopause 17 years ago and has never had children. She had a pelvic mass but her PAP smear is atrophic. A pelvic ultrasound is performed.
Introduction
  • Ovarian cancer is the fifth most common type of cancer in women
  • Second most common gynecologic cancer behind endometrial cancer (25%)
  • Ovarian cancer is the leading cause of gynecological cancer deaths
  • Risk factors
    • family history
    • increased number of ovulatory cycles
      • infertility
      • nulliparity
      • > 50 yrs
        • cancer < 50 yrs more likely to be benign
      • OCP use is protective because it reduces ovulatory cycles
  • Associated conditions
    • BRCA1 and BRCA2 positivity
      • also increases breast cancer risk
    • cancer syndromes
      • HNPCC
      • Peutz-Jeghers
    • Turner syndrome
  • Tumor types
    • pregnancy luteoma 
      • rare, benign solid tumor often bilateral presenting with symptoms of virilization (or may be asymptomatic) during pregnancy
      • regresses post-partum
        • observation is the most common management
    • germ cell
      • most commonly seen in adolescents due to embryologic remnants
        • subtypes
          • dysgerminoma
            • most common malignant germ cell neoplasm
              • equivalent to male seminoma
            • seen commonly in Turner syndrome
            • histology shows sheets of uniform cells
            • serology shows ↑ hCG and LDH
          • yolk sac (endodermal sinus) tumor
            • aggressive malignancy of ovaries in young girls
              • aslo seen in testes, sacrococcygeal area of young children
            • yellow, friable, solid masses
              • note: like egg yolk
            • histology shows Schiller-Duval bodies
              • resemble glomeruli/yolk sac
            • serology shows ↑ AFP
          • teratoma
            • large majority of ovarian germ cell tumors
            • mature teratoma ("dermoid cyst")
              • most frequent benign ovarian tumor
            • immature teratoma
              • aggressively malignant
            • contain cells from many different tissue types
              • teeth, hair, ect.
              • struma ovarii
                • contains functional thyroid tissue
                • hyperthyroidism present
    • sex cord stromal
      • may produce hormones (androgens, estrogens)
      • mostly benign
      • subtypes
        • thecoma-fibroma
          • histology shows spindle-shaped fibroblasts
          • associated with Meigs' syndrome/triad 
            • ovarian fibroma, ascites, and right pleural effusion
            • fluid abnormalities regress with removal of tumor
          • pulling sensation in groin
        • Sertoli-Leydig cell tumor
          • virilization secondary to secretion of androgens 
          • histology shows cystals of Reinke containing cells
        • granulosa-theca cell tumor
          • hyperestinism secondary to secretion of estrogens
            • may result in precocious puberty in kids
            • may result in endometrial hyperplasia in adults
          • histology shows Call-Exner bodies  
            • small follicles filled with eosinophilic secretions
    • surface-derived
      • most common tumor type
      • CA125 positivity 
      • malignant types can seed peritoneal cavity
      • subtypes
        • serous cystadenoma
          • commonly bilateral
          • benign
          • histology shows fallopian tube-like epithelium
        • serous cystadenocarcinoma
          • commonly bilateral
          • malignant
          • histology shows psammoma bodies
            • also seen in papillary masses of thyroid, meningiomas
        • mucinous cystadenoma
          • multilocular cyst
          • benign
          • histology shows intestine/endocervix-like tissue
        • mucinous cystadenocarcinoma
          • malignant
          • pseudomyxoma peritonei
            • intraperitoneal accumulation of mucinous material
            • may be from ovarian or appendiceal tumors
        • Brenner tumor
          • benign
          • histology shows transitional epithelium
            • similar to Bladder
    • metastasis
      • breast
      • gastric (Krukenberg/Signet ring tumors)
Presentation
  • Symptoms
    • usually asymptomatic until late in the course of the disease
    • ascites
      • key feature
    • distension
    • early satiety
    • constipation
      • secondary to compression of intenstine
    • SOB
    • signs of hyperestinism/virilization
      • if tumor is hormone secreting type
  • Physical exam
    • palpable abdominal mass/ovaries
      • usually cancer in post-menopausal women
Evaluation
  • Pelvic ultrasound is useful in identifying and characterizing an ovarian tumor 
  • Pre-operative work-up in a patient with suspected ovarian cancer should include the following:
    • baseline CA-125 level
    • CT abdomen/pelvis for staging
    • chest radiograph to assess for lung metastases 
    • mammogram to detect a possible primary breast cancer or metastases
    • pap smear
    • colonoscopy / fecal occult blood testing, particularly if the patient is experiencing GI symptoms
Prognosis, Prevention, and Complications
  • Very poor prognosis

 



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Qbank (2 Questions)

TAG
(M3.ON.48) A 61-year-old female presents to her gynecologist with complaints of increasing abdominal distension over the last 3 months as well as more recent onset of early satiety and constipation over the last several weeks. A pelvic exam is performed and is significant for a sizable right ovarian mass. Pelvic ultrasound is then conducted and confirms the presence of a right ovarian mass. Her physician suspects cancer and would like to pursue a work-up. Baseline serum CA-125 level, CT abdomen/pelvis, chest radiograph, mammogram, and a pap smear are obtained. Which of the following should also be included in this patient's work-up? Topic Review Topic

1. Baseline serum CEA level
2. Serum CA 19-9 level
3. Fine needle aspiration of pelvic mass
4. Colonoscopy
5. CT Chest

PREFERRED RESPONSE ▶
TAG
(M2.ON.251) A G0 57-year-old female presents to her gynecologist complaining of lower abdominal pain, early satiety, and urinary frequency of 2 weeks duration. She used oral contraceptive pills (OCPs) for several years during her twenties and thirties, and entered menopause at age 45. Surgical history is notable for a myomectomy 20 years ago. Family history reveals that her mother died of lung cancer. Laboratory results demonstrate markedly elevated CA-125. A pelvic CT scan is shown in Image A. Which of the following in this woman's history is a risk factor for ovarian carcinoma? Topic Review Topic
FIGURES: A          

1. Family history of lung cancer
2. Nulliparity
3. Oral contraceptive use
4. Myomectomy
5. Early menopause

PREFERRED RESPONSE ▶
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