GYNECOLOGY

3.4 Neoplastic Diseases of the Ovary (Rey H. Delos Reyes, MD, FPOGS)
Date: March 21, 2016
FEU-NRMF MEDICINE BATCH 2017
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Differential Diagnosis of Adnexal Mass Soft-tissue tumors (not specific to the ovary)
ORGAN CYSTIC SOLID Unclassified tumors
Ovary Functional cyst Neoplasm Secondary (metastatic) tumors
Neoplastic cyst Benign Tumor-like conditions (not true neoplasm)
Benign, Malignant Malignant Germ cell Tumors 2nd most common ovarian neoplasm; Contain cells
Endometriosis that recapitulate embryonic tissues (ectoderm, mesoderm, endoderm)
Fallopian Tubo-ovarian abscess Tubo-ovarian abscess Sex Cord Stromal Tumors - A class of ovarian tumors in which the
tube Hydrosalphinx Ectopic pregnancy constituents of the ovary or testes are recapitulated
Parovarian cyst Neoplasm Lipoid Cell Tumors - Histologically resemble the adrenal gland
Uterus Intrauterine pregnancy in Pedunculated or Gonadoblastoma - tumor that arises in abnormal gonads and consists
bicornuate uterus intraligamentous myoma of sex-cord stromal elements and germ cells
Bowel Sigmoid or cecum
distended with gas or
Diverticulitis
Ileitis, Appendicitis
EPITHELIAL OVARIAN NEOPLASM
feces Colonic cancer
Arise from inclusion cysts lined with surface (coelomic)
Misce- Distended bladder Abdominal wall hematoma epithelium within the adjacent ovarian stroma
llaneous Pelvic kidney or abscess Classified as:
Urachal cyst Retroperitoneal cancers o Benign (adenoma)
o Malignant (adenocarcinoma)
Diagnostic evaluation in the presence of an adnexal mass o Intermediate (Borderline malignant or Low malignant
Complete physical examination potential)
Ultrasonography Tumor Cell Type Approximate Frequency (%)
Colonoscopy or Barium enema, if symptomatic All Ovarian Neoplasms Ovarian Cancer
Intravenous pyelography, if indicated Serous 20-50 35-40
CT Scan or MRI Mucinous 15-25 6-10
Endometrioid 5 15-25
Laparoscopy, Laparotomy
Clear cell <5 5
(mesonephroid)
Symptoms Brenner Tumor 2-3 Rare
Initially are asymptomatic
Lower abdominal discomfort SEROUS TUMORS
Pelvic pain
Composed of ciliated epithelial cells that resemble those of the
Dyspareunia
fallopian tube
Abdominal enlargement
Frequent urination
Constipation Serous Cystadenomas Reproductive years
*Symptoms in relation to impingement d/t enlarging mass Borderline types Women 30-50 years
Serous cystadenocarcinoma Women older than 40 years
Indications for Surgery
Ovarian cystic structure >5 cm that has been observed 6-8 SEROUS CYSTADENOMAS
weeks w/o regression (physiologic cyst regress 6-8 weeks) Gross Microscopic
Any solid ovarian lesions (considered malignant except Papillary projections on Low columnar epithelium
Fibroma of ovary and Brenner Tumor generally benign) the surface with occasional cilia
Any ovarian lesion with papillary vegetation on the cyst wall Inner cyst wall are mostly Psammoma bodies
(generally malignant) smooth (indicates poor prognosis)
Any adnexal mass >10 cm (rarely physiologic cyst attain large Multicystic, smooth Small granules, end
size) capsule product of degeneration
Palpable adnexal mass in premenarchal or postmenopausal of papillary implants
(physiologic cyst is d/t ovulation) Indicative of functional
Torsion or rupture suspected immunologic response

Frequency of Ovarian Neoplasm (WHO Classification) MUCINOUS TUMORS

CLASS FREQUENCY (%) Consist of epithelial cells filled with mucin, resembling cells of
Epithelial stromal (Common epithelial) 65 the endocervix or intestinal cells
tumors
Germ cell tumors 20-25
Sex cord-stromal tumors 6
Mucinous Cystadenoma Primarily during reproductive years
Lipid (lipoid) cell tumors <0.01 Borderline types
Gonadoblastoma <0.01 Mucinous Usually in 30 to 60-year age range
Cystadenocarcinoma

JOSE TORRES III, RN, EMT 1

 MUCINOUS CYSTADENOMAS ENDOMETRIOID ADENOCARCINOMA
Gross Microscopic Most endometrioid ovarian neoplasms are carcinomas
May become huge (>300 Lining epithelium is tall, Consists of cells resembling those of the endometrium
lbs) pale staining secretory Most arise from the surface epithelium of the ovary (usually
Usually unilocular type with nuclei at basal solid)
Round or ovoid, smooth pole, rich in mucin
capsule usually translucent Associated with recurrent Gross Microscopic
or bluish to whitish gray bowel obstruction Smooth outer Well-differentiated endometrioid
Interior divided by discreet Supports a primary surface adenocarcinoma accounts for the
septa into locule appendiceal origin On cut section, majority of cases
containing clear, viscid therefore appendectomy they are solid Characterized by a confluent or
fluid is indicated and cystic, with cribriform proliferation of glands
*resemble intestinal lining, investigate intestines, maybe a mets and not a the cysts lined by tall stratified columnar
primary tumor containing epithelium with sharp luminal
friable smooth margins
Pseudomyxoma Peritonei masses and Mitotic figures are commonly seen
Transformation of peritoneal mesothelium to a mucin bloody fluid Squamous differentiation is present
secreting epithelium (a dreaded complication) in up to 50% of cases
Continuous secretion of mucus resulting in accummulation in
peritoneal cavity of gelatinous material Cribriform proliferation
Most common cause of death is malnutrition that requires lined by tall columnar
several operations, dictum is do not rupture the tumor, remove epithelium with SHARP
it intact to prevent contact to peritoneum and prevent luminal margins
complication
Evacuation at operation is followed by reaccummulation
Treatment
o Repetitive surgical evacuation
o Long term nutritional support

CLEAR CELL CARCINOMA BRENNER TUMOR

Most clear cell neoplasms of the ovaries are carcinomas
Contain cells with abundant glycogen
Most common epithelial ovarian neoplasm to be associated
with paraneoplastic hypercalcemia
Relationship with endometriosis is strongest among all types
of ovarian carcinoma
Endometriotic implants are commonly present in close
proximity to the tumor or elsewhere in the pelvis or abdomen
Arise from Walthard cell rests (most commonly found in the
connective tissue of the Fallopian tubes, but also seen in the
mesovarium, mesosalpinx and ovarian hilus)
Treatment: Excision
o Conservative management for desirous of pregnancy:
Unlateral Salphingo Oophoectomy
o Post menopausal: TAHBSO
Grossly identical to a Fibroma of the ovary (Fibroma is under
Sex cord-stromal tumor)

Gross Microscopic Microscopic

Tumors range up to 30 Solid pattern is characterized Marked hyperplastic fibromatous matrix interspersed with
cm in diameter with by sheets of polyhedral cells nest of epithelioid cells
mean of about 15 cm with abundant clear Epithelioid cells show coffee bean pattern caused by
Cut surfaces reveal a cytoplasm separated by longitudinal grooving of nuclei
thick-walled unilocular delicate fibrovascular septae Nearly all are benign but there are scattered reports of
cyst with multiple or dense hyalinized fibrotic malignant Brenner; associated endometrial hyperplasia
yellow-beige fleshy stroma The transitional epithelial cell type, characterized by a
nodules protruding into In tubulopapillary pattern, relatively uniform population of stratified cells with ovoid
the lumen cells are often columnar with nuclei displaying nuclear grooves, is named because of its
Multiloculated cystic a hobnail appearance, with resemblance to urothelium
mass with cysts the nucleus protruding from
containing watery or the papillae, gland, or cyst
mucinous fluid into the lumen

Hobnail appearance, nucleus

protruding into the lumen

JOSE TORRES III, RN, EMT 2

BORDERLINE TUMOR OF THE OVARY Frequency of Ovarian Neoplasm (WHO Classification)
a.k.a Atypical Proliferative Tumor of the Ovary (APT) or Ovarian In general, more than half of ovarian carcinomas occur in
Tumor of Low Malignant Potential (LMP) women older than 50.
The risk of malignancy in a primary ovarian tumor increases to
Histologic criteria for Diagnosis (Atleast 2 of these features) approximately 33% in women older than 45, whereas it is less
Stratification of the epithelial lining of the papilla than 1 in 15 for women 20-45 years of age
Formation of microscopic papillary projection or tufts
arising from the epithelial lining of the papillae Putative Associations of Increasing and Decreasing Risks of
Epithelial pleomorphism Ovarian Epithelial Carcinoma
Atypicality INCREASES DECREASES
Mitotic activity Age Breast-feeding
Diet Oral contraceptives
No stromal invasion present (most important)
Family history Pregnancy
*Frankly Invasive ovarian cancer if there is stromal invasion Industrialized country Tubal ligation and hysterectomy
Infertility with ovarian conservation
The malignant cells do not invade the stroma of the ovary Nulliparity
Constitute approximately 15-20% of epithelial ovarian cancers Ovulation
Slower growth rate than invasive ovarian carcinomas Ovulatory drugs
Longer survival than invasive forms Talc (?)
o 5-year survival rate of all stages = 97%
o 10-year survival rate of all stages = 89% RISK FACTORS
Most common varieties (Serous, Mucinous) GENETIC
Commonly found in younger women A strong family history of either breast or ovarian cancer is the most
important risk factor for the development of epithelial ovarian cancer
10 to 15% of all epithelial cancers have a hereditary predisposition
Management
Breast - ovarian cancer family syndrome
Complete surgical extirpation of the tumor o The lifetime risk of ovarian cancer in women with a germline
Unilateral involvement mutation in BRCA1 approaches 40%
o Salpingo-oophorectomy is preferred over Cystectomy o In women with BRCA2 germline mutation, the lifetime risk
o Thorough evaluation of the other ovary ranges from 10 to 20%
o Peritoneal fluid cytology Site-specific ovarian cancer
o Partial omentectomy o linked to BRCA 1 mutation
Bilateral involvement o there is excess of ovarian CA but not breast CA
Hereditary Non-Polyposis Colon Cancer (HNPCC) Syndrome or Lynch
o TAHBSO (Usually for >45 y/o or postmenopausal)
Syndrome II
o Peritoneal fluid cytology o This accounts for only approximately 1% of all ovarian
o Partial omentectomy cancers
o The cumulative incidence is 12%
Criteria for Conservative Advanced Stage REPRODUCTIVE
Therapy Parity and Pregnancy
Confirmed to be Stage IA Complete surgical Increasing parity >5 ( five or more ) reduces the risk (but increased
risk in cervical cancer
Extensive histologic extirpation of the tumor
AGE AT MENARCHE AND MENOPAUSE
sampling of the tumor Same as bilateral
Ages at menarche and menopause are weak predictors on risk of
confirms it to be borderline involvement plus: epithelial ovarian cancer
tumor o Pelvic LACTATION
Contralateral ovary lymphadenectomy Confers protection against ovarian cancer risk most significant
appears normal o Tumor debulking with duration of 18 months or more
Biopsy specimens of areas o Extensive biopsy of EXOGENOUS HORMONES
of omental or peritoneal any peritoneal or Use of fertility drugs (Clomiphene Citrate = Side Effect: Multiple
nodularity are negative omental implants ovulation)
Results of peritoneal o The role of The use of fertility drugs does not increase the risk for ovarian cancer.
cytologic tests are negative chemotherapy is An increased risk was seen only in association with borderline serous
tumors
for tumor cells still controversial
USE OF OCP USE OF HRT
Use of oral contraceptives Long-term use of unopposed
OVARIAN CARCINOMAS confers long-term protection estrogen and of estrogen plus
against ovarian cancer progestin (sequential) are
In the Philippines, 5th leading site among women 5% (breast >
associated with increased
cervical > lung > colon > ovary) ovarian cancer risk
In 2010, there will be 2,165 new cases and 1,016 deaths GYNECOLOGIC RELATED CONDITION AND SURGERY
Incidence starts rising steeply at age 40 Endometriosis
o Increased risk of epithelial ovarian cancer particularly
Primary Ovarian Neoplasms related to Age: the endometrioid and clear cell types
TYPE <20 yr (%) 20-50 yr (%) >50 yr(%) Pelvic Inflammatory Disease
Coelomic epithelium 29 71 81 o Positively associated; increased risk with epithelial
Germ cell 59 14 6 ovarian cancer
Specialized gonadal- 8 5 4 Polycystic Ovarian Disease
stromal o Less extensively evaluated but points to an increased
Non-specific mesenchyme 4 10 9 risk (due to high hormonal level)
*Specialized gonadal stromal tumor 4th most common type, occur in many Tubal Ligation and hysterectomy
age group, usually in perimenopausal and postmenpausal o reduction in the risk for ovarian cancer
o risk reduction to a less degree

JOSE TORRES III, RN, EMT 3

 ENVIRONMENTAL MOST FREQUENT PRESENTING SYMPTOMS OF OVARIAN CANCER
Obesity Symptom Relative Frequency
o Adult & early adulthood confer an increased risk of ovarian Abdominal swelling/enlargement XXXX
cancer Abdominal pain XXX
Cigarette smoking Dyspepsia XX
o Increases the risk for the development of mucinous Urinary frequency XX
epithelial ovarian cancer but not the other histologic types Weight change X
o Stopping smoking returns the risk to normal in the long term Symptoms are vague and not specific for ovarian cancer
Alcohol consumption A high index of suspicion is warranted in all women between the ages
o No association between moderate alcohol intake and of 40 to 69 years who have persistent gastrointestinal symptoms that
ovarian cancer risk cannot be diagnosed
Dietary factors
o High meat and fat intake may increase the risk of epithelial NON-OVARIAN CAUSES OF APPARENT ADNEXAL MASS
ovarian cancer Diverticulitis
Physical activity Tubo-ovarian abscess
o Weak to modest protection against epithelial ovarian cancer Carcinoma of the colon or sigmoid
Caffeine and tea intake Pelvic kidney
o Ovarian cancer risk is not very well-established Uterine or intraligamentous myoma
o Tea may reduce the risk of epithelial ovarian cancer
Talc and others (No causal relationship)
DIAGNOSIS
ETIOLOGY Screening and early detection tools
Periodic pelvic Examination
Theory of Incessant Ovulation
Sonography
The risk of EOC is related directly to the number of
Biomarkers (e.g. CA 125)
uninterrupted ovulatory cycles
Conclusion: There is NO evidence available yet that the
Early menarche, late menopause
current screening modalities can be used effectively for
Tubal ligation, hysterectomy
widespread screening for ovarian cancer

Diagnostic Evaluation of Adnexal Mass

Complete physical examination
Appropriate imaging studies, Tumor markers
o Chest X-ray, Ultrasonography, CT scan, MRI, Ca-125, HE4,
CEA, AFP, BhCG, LDH
Colonoscopy or barium enema study, if symptomatic

Tumor Markers in Ovarian CA

Carcinoma Antigen 125 80% Ovarian Epith Ca, less in mucinous
(CA-125) types
Gonadotropin Hypothesis
Increased in tubal, endometrial, lung,
Exposure of ovarian epithelium to persistently high levels of breast and pancreatic cancers
pituitary gonadotropins Increased in benign conditions
FSH promote the growth of epithelial ovarian cancer cells in (Endometriosis, Peritoneal
vitro inflammation including PID,
Breastfeeding, pregnancy, OCPS, Fertility pills Leiomyoma, Pregnancy, Hemorrhagic
ovarian cysts, Liver disease)
Specificity appears better for increased
values in postmenopausal patients
Human Epidydimis Epithelial ovarian CA
protein 4 (HE4)
Carcino-embryonic associated with Mucinous Carcinoma
antigen (CEA)
Alpha-feto protein (AFP) Germ cell Tumors
Lactic dehydyhrogenase
(LDH)
Human chorionic
gonadotrophin (hCG)
SIGNS AND SYMPTOMS
CHARACTERISTICS IN BENIGN AND MALIGNANT OVARIAN TUMORS DIAGNOSTIC TECHNIQUES
Clinical Finding Benign Malignant Routine pelvic examination detect only 1 ovarian cancer in
Unilateral XXX X 10,000 asymptomatic women
Bilateral X XXX Routine laboratory test are not of great value in the diagnosis
Cystic XXX X of ovarian tumors
Solid X XXX The major value of laboratory tests is in ruling out other pelvic
Mobile XXX XX disorders
Fixed X XXX Surgical exploration is the ultimate test as to the nature of the
Irregular X XXX disorder
Smooth XXX X
Additional diagnostic methods: CT scan, MRI, Barium Enema or
Ascites X XXX
Colonoscopy
Cul-de-sac Nodulations 0 XXX
*Differential dx in cul-de-sac nodulations Endometriosis, Endometrial
Cyst, Endometrioid Carcinoma

JOSE TORRES III, RN, EMT 4

ROLE OF ULTRASOUND IN OVARIAN CA Conservative surgery: Unilateral Salpingo-Oophorectomy (for those
Ultrasound helped to define criteria to allow conservative desirous of pregnancy, if then she completes reproductive desire,
follow-up and the risk of malignancy of some adnexal masses perform the standard surgery)
Scoring systems have been proposed and parameters used are: Criteria (must meet all criteria)
o Unilocular or complex cysts Stage IA
o Papillary projections Well-differentiated tumor
o Regular and smooth septa and/or cytstic walls Peritoneal fluid cytology is negative for malignant cells
o Echogenicity Omentum and peritoneal biopsies are negative for metastasis
o Doppler color-enhanced flow Young woman desirous of pregnancy
Used to characterize ovarian mass as benign or malignant,
rather than for screening STAGING
STAGE 1: Confined to Ovaries
ULTRASOUND FINDINGS SUGGESTIVE OF OVARIAN CA 1A Tumor limited to 1 ovary, capsule intact, no tumor on
Irregular borders surface, negative washings (fluid cytology)
Papilations 1B Involves both ovaries otherwise like IA
Thick septations 1C Tumor limited to 1 or both ovaries
Ascites 1C 1 Surgical spill (ruptured intraop)
Matted bowel
1C 2 Capsule rupture before surgery or tumor on
*Best procedure to determine if benign or malignant is histologic finding,
Request intraoperatively for frozen section, which is an immediate
ovarian surface
evaluation of the tumor just to indicate if benign or malignant 1C 3 Malignant cells in the ascites or peritoneal
washings (positive fluid cytology)
TREATMENT STAGE 2: Tumor involves 1 or both ovaries with pelvic extension
Staging is surgical and based on the operative findings at the (below pelvic brim) or primary peritoneal cancer
commencement of the procedure 2A Extension and/or implant on uterus and/or Fallopian
Surgery tube
Removal of all resectable disease 2B Extension to other pelvic intraperitoneal tissues (below
Interval debulking surgery linea terminalis or pelvic inlet; beyond is stage3/4)
STAGE 3: Tumor involves 1 or both ovaries with cytologically or
Standard Surgical Procedure (REMEMBER) histologically confirmed spread to the peritoneum outside the
Total abdominal hysterectomy with bilateral salpingo- pelvis and/or metastasis to the retroperitoneal LN
oophorectomy 3A Positive retroperitoneal LN and/or microscopic
Bilateral lymph node dissection metastasis beyond the pelvis
Paraaortic lymph node dissection/ sampling/palpation 3A - 1 Positive retroperitoneal LN only
Infracolic omentectomy 3A 1 (I) Mets < or = 10 mm
Random biopsy of abdominal peritoneum in early-stage 3A 1 (II) Mets > 10 mm
disease 3A - 2 Microscopic, extrapelvic (above the brim)
Tumor debulking in advanced disease peritoneal involvement (+/-)
retroperitoneal LN
Staging Laparotomy 3B Macroscopic, extrapelvic, peritoneal mets < or = 2cm
Midline longitudinal incision (+/-) retroperitoneal LN, includes extension to the
o To properly evaluate abdomen if there are mets, do capsule or liver/spleen
not perform low transverse or low cut 3C Macroscopic, extrapelvic peritoneal mets > 2cm (+/-)
Peritoneal fluid cytology retroperitoneal LN, includes extension to capsule of
Systematic exploration of the abdominal cavity liver/spleen
TAHBSO STAGE 4: Distant metastasis excluding peritoneal metastasis
Infracolic omentectomy (removal of omentum below 4A Pleural effusion with positive cytology
transverse colon) 4B Hepatic and/or splenic parenchymal metastasis,
Lymph node evaluation (Pelvic and Para aortic) metastasis to extraabdominal organs (including
Random biopsy of abdominal peritoneum and suspicious areas inguinal LN and LN outside the abdominal cavity)
Tumor debulking (ideally not more than 1 cm, the bigger
implant, the poorer prognosis) Other major recommendations/considerations
Histologic type including grading should be designated at staging
Post-operative Adjuvant therapy Primary site (ovary, Fallopian tube or peritoneum) should be
Chemotherapy designated where possible
o Most common adjuvant used Tumors that may otherwise qualify for stage I but involved with dense
o Depends on the stage, tumor grade and histologic adhesions justify upgrading to stage II if tumor cells are histologically
proven to be present in the adhesions
type
o Limiting factor: Toxicity ROUTES OF SPREAD
o Epithelial : Carboplatin and Paclitaxel (or Docetaxel) Ceolomic spread (most common)
o Germ Cell Tumor and SCT : Bleomycin, Etoposide and o Spread through the peritoneal surfaces of both the parietal
Cisplatin ( BEP ), Vincristine, Actinomycin D and and intestinal areas, as well as the under surface of the
Cisplatin ( VAC ) diaphragm; epith of ovary and abd cavity are the same
Radiation therapy (for early disease confined to pelvis) Lymphatic route (2nd most common)
Immunotherapy (still in experimental stage) o Para-aortic nodes are at risk through lymphatics that run
parallel to the ovarian vessels (lungs)
Hematogenous spread (most common evidence: bone mets/
microscopic evidence of lymphovascular space involvement)

JOSE TORRES III, RN, EMT 5

SURGICAL FINDING OF BENIGN AND MALIGNANT OVARAN NEOPLASM Staged surgically as with epithelial types
Findings Benign Malignant Certain histologic types secretes a specific tumor marker
Surface papilla Rare Very common A single tumor may contain a mixture of histologic types
Intracystic papilla Uncommon Very common
Solid areas Rare Very common Treatment
Bilaterality Rare Common Surgery
Adhesions Uncommon Common
o Extent of primary surgery is dictated by the findings at
Ascites (100ml or Rare Common
surgery and the reproductive desires
more)
Necrosis Rare Common
USO = if preservation of fertility is desired
Peritoneal implants Rare Common THBSO = if childbearing has been completed
Capsule intact Common Infrequent Chemotherapy
Totally cystic Common Rare o Tremendous advances have been made that even in
advanced malignancies an excellent chance at long
Prognostic Factors term control cure
Tumor stage (most important prognostic indicator) Radiotherapy (Rarely used today)
Tumor grade (well diff, mod, poorly)
Cell type (Clear cell poorer prognosis) SEX CORD STROMAL TUMORS OF THE
Amount of residual tumor after resection (Ideally < 1 cm)
o Large tumors non vascularized chemo will OVARY
take time to penetrate tumor Originate from the ovarian matrix
o It is better to leave multiple small tumors Consist of cell from the embryonic sex cord and mesenchyme
because it is well vascularized and chemo will Incidence increasing in the 5th, 6th and 7th decades
penetrate the tumor easily o Also cases in 1st and 2nd decade of life
Approximately 90% of hormonally active ovarian tumors
Have propensity for indolent growth, tend to recur late
GERM CELL TUMORS OF THE OVARY Granulosa Theca Cell Tumor estrogen producing; if they occur
Classification of Germ Cell Neoplasm of the Ovary in postmenopausal, would have endometrial carcinoma;
Dysgerminoma (most common malignant; most younger children would have precocious puberty
radiosensitive; Tumor marker: LDH and hCG) Masculinizing ovarian tumors hirsutism, amenorrhea
Endodermal sinus tumor (poorest prognosis; Tumor marker:
AFP, rarely alpha1-antitrypsin) MANAGEMENT
Embryonal carcinoma (AFP/hCG) Surgery is adequate treatment in most cases
Polyembryoma (AFP/hCG) o USO = for those who are desirous of fertility
Choriocarcinomas (hCG) preservation and are Stage Ia
Teratomas (most common) o THBSO = for advanced stage and older women
o Immature (Solid, Cystic, or both; Tumor marker: AFP, Stage IC or higher
LDH, CA-125) o Adjuvant therapy: Radiation or Chemotherapy
o Mature
Solid --------------------------------------------------------------------------
Cystic
Mature cystic teratoma (Dermoid cyst) - (most Case 1
common; usually benign)
A 55 year old, postmenopausal woman consulted because of
Mature cystic teratoma (Dermoid cyst) with
malignant transformation rapid abdominal enlargement associated with weight loss of 8
o Monodermal or highly specialized lbs of 2 months duration.
Struma ovarii Pertinent PE findings are: palor, abdominal girth of 89 cm with
Carcinoid positive fluid wave and shifting dullness, with a vague pelvo
Struma ovarii and carcinoid abdominal mass.
Mixed forms (tumors composed of types in any combination)
Pelvic exam:
o Normal external genitalia, Parous vagina
o Cervix: firm, close and slightly movable, the lower pole of a
mass is palpable at the cul-de-sac which seems solid and
slightly movable.
o The uterus and adnexa can not be fully assessed because of
the massive ascites
What is your diagnosis? Ovarian New Growth, probably
Malignant
Basis of your diagnosis?
o Rapid enlargement of the mass
o Weight loss
o Massive ascites
97% are benign and only 3% are malignant o Solid mass with limited mobility
Most occur in young women What diagnostic work-up/s will you request and why?
Mostly in the 2nd and 3rd decades of life o Ultrasonography: Transvaginal and Transabdominal

JOSE TORRES III, RN, EMT 6

 Differentiate solid from cystic, detect omental and liver
metastasis
Differentiate between ascites and intracystic fluid
o Hematologic exams: CBC and Platelet count, Blood
chemistries
o MRI or CT Scan
Detect other organ involvement also LN involvement
Case 2
A 60 y/o nulligravid underwent exploratory laparotomy because
of an ovarian mass. Intraoperative finding were: the ovary was
enlarged to 12 x 9 cm with papillary excricences on the surface;
the uterus, both tubes and contralateral ovary was grossly
normal; omentum was studded with 1 cm nodular lesions; the
abdominal peritoneum, liver and diapragm are free of tumor.
What is the Stage of Ovarian Cancer? Ovarian Cancer, Stage IIIB
Case 3
A 45 y/o G1P1 underwent exploratory laparotomy because of an
ovarian mass. Intraoperative finding were: the ovary was
enlarged to 20 x 11 cm with smooth external surface, which on
cut section showed multiple papillary growths; the uterus, both
tubes and contralateral ovary was grossly normal; omentum
was grossly normal but showed metastatic cells on microscopic
examination; the abdominal peritoneum, liver and diapragm are
free of tumor. PFC was positive for malignant cells.
What is the Stage of Ovarian Cancer? Ovarian Carcinoma, Stage
IIIA
Exercise!
1-2 Differentiate physiologic and non-physiologic cyst
3-4 Give 2 symptoms of ovarian tumors
5-6 Give 2 indications for surgery in ovarian tumors
7 Based on WHO classification, what is the most common type of
ovarian tumor?
8 What is the most common type of epithelial ovarian tumor?
9 What is the second most common epithelial ovarian cancer?
10 Describe pseudomyxoma peritonei
11-12 Give 2 benign solid ovarian tumors
13-14 Give 2 histologic criteria for diagnosis of borderline ovarian
tumor
15-16 Give 2 protective factors for ovarian cancer
17 Describe or characterize incessant ovulation theory
18 Give 1 example of benign condition with elevated CA-125
19 What is the most common route of spread of ovarian cancer?
20 What is the most important prognostic indicator in ovarian
cancer?
21 What is the most common germ cell tumor?
22-23 Give 2 tumor markers in germ cell tumors
24 What is the cell of origin of sex cord stromal tumors?
25 What age group is sex cord stromal tumor commonly found?

Case 4
A 19 year old nulligravid consulted because of abdominal
enlargement of 1 month duration. Pertinent PE findings:
abdomen is globularly enlarged with a solid, movable non-
tender mass about 8 x 10 cm. Rectal exam showed an
unenlarged uterus with a right adnexal mass, predominantly
solid with cystic areas, movable and nontender.
What is your impression? Ovarian Newgrowth probably
malignant, probably Germ Cell Tumor
What work-up/s is/are necessary to arrive at a proper
diagnosis?
o Ultrasonogram
o Tumor markers: AFP, hCG, LDH
o Blood exams
What is the management?
o Exploratory laparotomy, USO with Frozen section of the ovary
If malignant: lymphadenectomy, PFC, Infracolic
omentectomy, random biopsy of peritoneum, adhesions
and suspicious areas for metastasis

*No questions will be asked on the parameters of the scoring

system in ultrasound but questions will be asked on the findings
suggestive of malignancy
*Doc will not ask on staging specifically the complicated stage 3A Thank you Hannah Adrias for the recording
and Paulo Sales for helping me find it!

Special thanks to Doyenne Sadicon for my typist! <3

JOSE TORRES III, RN, EMT 7