Ovarian Neoplasms

Ovarian Neoplasms
433OBGYNteam@gmail.com
Objectives :
• List the differential diagnosis of an ovarian mass.

• Mention the classification of ovarian neoplasms.
• Compare between functional ovarian cysts, benign ovarian tumours and ovarian
cancers in terms of:
Etiology & risk factors
Cell type of origin
Characteristic clinical features
Findings in diagnostic investigations
Management options
Describe staging of primary carcinoma of the ovary
1.List the differential diagnosis of an ovarian mass :
First , what is adnexal mass ?
in gynecology it is anything next to the uterus usually involving the fallopian tubes and ovaries .
Second , Any ovarian mass it could be :

when the patient presents with adnexal mass :
- You have to take a detailed history and do
 Gynecologic : pregnancy test to exclude ectopic pregnancy
- You must do a pelvic exam .
• Ovarian cyst
• Malignant neoplasms
• Benign neoplasms - Premenarche girls the ovaries should not be
• Ectopic pregnancy palpable
- Reproductive age women normally the ovary is
• Leiomyoma palpable about have of the time .
• Tubo-ovarain abscess - Menopausal women the ovaries usually not
palpable.
 Nongynecologic : - 25% of ovarian tumors in postmenopausal
women are malignant .
- 10% of ovarian tumors in reproductive age
• Appendicitis women are malignant
• Diverticular abscess - Pelvic ultrasound is the primary component of
• Gastrointestinal carcinoma evaluation of an adnexal mass
• Peritoneal cyst
2.Mention the classification of ovarian neoplasms :
The main classification of ovarian
masses :
 Functional cysts
 Benign ovarian neoplasm
 Malignant ovarian neoplasm
⁃ Ovarian cancer is the 5th most common cause of cancer death in USA .
⁃The highest mortality rate among gynecological malignancies, 55% of patients
will die with in 5 years of diagnosis .
3.Compare between functional ovarian cysts, benign
ovarian tumors and ovarian cancers:
3.1 functional ovarian cysts
The most common cause of a simple cystic mass in the reproductive age years is a physiologic cyst (luteal or
follicular cyst). During the reproductive years the ovaries are functionally active, producing a dominant
follicle in the first half of the cycle and a corpus luteum after ovulation in the second half of the menstrual
cycle. Either of these structures, the follicular or corpus luteum, can become fluid-filled and enlarged,
producing a functional cyst.
 Clinical Features :
• Follicular cyst : • Corpus luteum cyst :
- Asymptomatic - Cause pain
- Simple - Cause delayed menses
- Can reach 15 cm in diameter - Smaller than the follicular cyst
- Regress during the sub-sequent menstrual cycle
In general , a functional cyst is mobile, unilateral and not associated with

ascites
 Diagnosis :
• Qualitative �-human chorionic gonadotropin (�-hCG) test: If negative, this will rule out pregnancy.
• Sonogram: A complex mass on ultrasound appearance is incompatible with a functional cyst ( if the
cyst < 10 cm , mobile and unilateral )
• Surgical exploration : If the adnexal cystic mass is solid or complex, fixed, size >10 cm and bilateral
 Management :
Observation :
- If the sonogram shows a simple cyst it is probably benign but careful follow-up is needed. Follow-up
examination should be in8-12 weeks, at which time the functional cyst should have spontaneously
resolved.
- If the CA-125 titer normal and Risk for malignancy index (RMI ) is low .
Surgical exploration :
- If the cyst solid, fixed, painful and has high RMI
- In case of torsion
- Hemorrhagic cyst
 Protective factors :
Oral contraceptive medication can be used to help prevent further functional cysts from forming
CALCULATION OF THE RISK FOR MALIGNANCY

INDEX FOR AN OVARIAN MASS
3.2 Benign ovarian neoplasms
25% of adnexal masses in the reproductive age women are benign
 There are three histological cell types they give arise to benign ovarian
neoplasms :  Serous (the most common benign neoplasms )
resembles fallopian tube epithelium
Epithelial cell types the  Mutinous resembles endocervical epithelium
largest class of neoplasms  Endometriod resembles carcinomas of the
endometrium.
 mature cystic teratoma ( Dermoid) :

Germ cell types are derived from the - most common tumor of women of all ages
primary germ cells and that is may contain
relatively deferent structures like hair and - often in pre-menopausal women
bone - demonstrate tissues of all three embryologic cell types
( ectodermal , mesodermal and endodermal )
Stromal cells types benign Fibroma

ovarian neoplasm is derived from specialized
sex-cord stroma of the developing gonads Thecoma
MEIG“’ Syndrome : Benign ovarian fibroma + Ascites + Right pleural effusion

3.2 Benign ovarian neoplasms
 Clinical features :
-The clinical features of benign ovarian tumors are often nonspecific. Except for the functioning ovarian neoplasms (
stromal cell types ), most benign ovarian tumors are asymptomatic unless they undergo torsion or rupture.
-They usually enlarge very slowly, so that an increase in abdominal girth or pressure on surrounding organs is not
perceived until the later stages of growth.
-Any pelvic pain is generally mild and intermittent, unless the tumor twists on its pedicle (torsion), when infarction
may induce severe pain and tenderness.
 Diagnosis :
• transvaginal ultrasonography
• serum CA 125, as part of the RMI (distinguish between benign and malignant masses, particularly in a
postmenopausal patient )
• Laparoscopy (distinguishing between a uterine myoma, a quiescent hydrosalpinx, and an ovarian tumor, but it
will not distinguish between a functional cyst, a benign neoplasm, and an encapsulated malignant ovarian
neoplasm )
 Management :
- Benign epithelial ovarian neoplasms are generally treated by :
• unilateral salpingo-oophorectomy If the patient is young and nulliparous
• total abdominal hysterectomy and bilateral salpingo-oophorectomy if the patient is old and there is suspicion of
malignancy
- Stromal cell neoplasms of the ovary are generally treated by unilateral salpingo-oophorectomy
- Cystic teratomas dermoids a e treated y ovaria yste to y
3.3 Malignant ovarian neoplasms
 There are three histological cell types they give arise to malignant ovarian
neoplasms :
 Serous
Epithelial cell types constant  Mutinous
of 90% of all ovarian malignancies  Clear cell
 endometriod
Dysgerminoma
Germ cell types most common
ovarian cancer in women < 20
Endodermal sinus tumor
Immature teratoma
 granulose cell tumor secrets large

Sex-cord stromal types amount of estrogen
( rare) :  sertolileydig tumor secrets large
amount of androgens
 Clinical features :
-Age : 5th decade of life
Sx :
-abdominal bloating
-abdominal distension
-abdominal or pelvic pain
-early satiety
-the most common symptoms are GI not gynecological symptoms
 Diagnosis :
-It is important to be aware of early warning signs of ovarian cancer
-Radiological imaging : pelvic ultrasound is the best first line test
-CA-125 Levels : most helpful in post-menopausal women with a pelvic mass ( this is because
there are many cases of elevated CA 125 levels in pre-menopausal women for reasons such as :
fibroid, PID and endometriosis which make it less useful )
-CEA (carcinoembryonic antigen) should also be drawn for the possibility of ovarian epithelial
cancer.
- LDH,hCG, and cx-fetoprotein should be drawn for the possibility of germ cell tumors.
- Estrogen and testosterone should be drawn for the possibility of stromal tumors.
- Surgical exploration is definitive next step in the evaluation if there is high suspicion
 Management 432 team work :
 Staging :
Risk factors :
⁃Nulliparity
⁃Primary infertility
⁃Endometriosis
⁃Inherited mutations ( BRCA and HNPCC )
Protective factors :
⁃OCP for at least 5 years
⁃Tubal ligation
⁃Hysterectomy
Helpful link https://youtu.be/Ugm3Fh5VKFc

TEACHING CASE
CASE: A 48 year-old G3P3 woman comes to the office for a health maintenance exam.
She is in good health and has no concerns. She had three normal vaginal deliveries and
underwent a tubal ligation after the birth of her third child 15 years ago. She has no
history of abnormal Pap smears or sexually transmitted infections. Her cycles are regular
and her last menstrual period was 18 days ago. She is not taking any medications. Her
family history is significant for a maternal aunt who was diagnosed with ovarian cancer at
age 60. On examination, she has normal vital signs. Her heart, lung and abdominal exams
are normal. On pelvic examination, she has normal external genitalia, vagina and cervix.
On bimanual exam, she has a slightly enlarged uterus and a palpable 6 cm mobile, non-
tender right adnexal mass which is confirmed on the rectovaginal exam.
1. What is the next step in the management of this patient?
- Pelvic transvaginal ultrasound is essential to evaluate the characteristics of the adnexal mass.
Categorization as to whether this is a simple (cystic) or complex adnexal mass is crucial to the
management.
- If cystic, mobile, and less than 10 cm, observation is reasonable in the pre-menopausal patient who is
asymptomatic (and with no family history of ovarian cancer). A repeat ultrasound in 8-12 weeks will
assist in determining if this is persistent or increasing, at which point surgical exploration would be
advisable. In this case, this is most likely a neoplasm. If the cystic ovary resolves or is smaller, then this
likely represents a functional cyst.
- If the adnexal cystic mass is solid or complex, fixed, size >10 cm, or bilateral, then surgical exploration is
recommended.
- CA125: tumor marker often elevated in women with advanced epithelial ovarian cancer. CA 125 was
developed originally to follow response to chemotherapy treatment (as surrogate marker for response),
but now used to assess for relapsed disease and to triage women with a pelvic mass (to gyn oncologist or
gynecologist for further investigations). Non-specific elevations seen among premenopausal women with
gynecologic and non-gynecologic conditions (endometriosis, fibroids, benign cystic neoplasms,
infection/inflammation, cirrhosis). More likely to be discriminating among postmenopausal women with
adnexal masses.
- Other tumor markers to consider: CEA (mucinous tumors), AFP (yolk sac germ cell tumors), LDH
(dysgerminoma), beta-HCG (choriocarcinoma, mixed germ cell tumors)
2.How would your approach be different if the patient was postmenopausal at 62 years of age?
Any postmenopausal patient with a complex cystic/solid mass requires surgical exploration and removal. If the
cyst is simple in nature, then observation is reasonable provided the patient is asymptomatic, there is no
significant family history of ovarian cancer, and CA125 is normal.
3.You obtain an ultrasound which shows a 6 cm right complex ovarian cyst. What is your differential diagnosis?
Benign:
• Functional cyst (follicular, corpus luteum, theca lutein)
• Endometrioma
• Tubo-ovarian abscess
• Serous/ uci ous cystadenoma
• Gonadal stromal tumors (fibroma/thecoma)
• Ger cell tu ors (teratomas)
Malignant:
• Epithelial tu ors (serous, uci ous, clear cell, endometrioid, Brenner)
• Ger cell tu ors (dysgerminoma, endodermal sinus tumor, immature teratoma)
• Sex cord stro al tu ors (Sertoli-Leydig, Granulosa)
4.What risk factors does this patient have for ovarian cancer?
• This patie t’s risk factors i clude a family history of ovarian cancer.
• Other risk factors include: family history breast cancer, personal history of breast cancer,
BRCA 1/2 genetic mutation, increasing age, nulliparity, infertility
• Protective factors include: oral contraceptive use, tubal ligation, increasing parity
5.List elements of the history and physical examination, which would help support the diagnosis of ovarian
cancer.
 Presenting symptoms for epithelial ovarian cancer include:

• Abdominal discomfort/bloating (50%)
• Gastrointestinal disturbances (20%)
• Urinary symptoms (15%)
• Vaginal bleeding/menstrual irregularities (15%)
• Weight loss (15%)
• Germ cell tumors may present with acute pain. Precocious pseudopuberty and virilization may be
seen with some germ cell and sex cord/stromal tumors.
 Physical exam findings typically include the presence of an adnexal/pelvic mass. In advanced
stages, abdominal distension with ascites and/or an abdominal mass may be noted.
Done By :
Rahma Alshehri
Revised By :
Razan AlDhahri

Ovarian Neoplasms

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Ovarian Neoplasms

• List the differential diagnosis of an ovarian mass.

Second , Any ovarian mass it could be :

In general , a functional cyst is mobile, unilateral and not associated with

CALCULATION OF THE RISK FOR MALIGNANCY

 mature cystic teratoma ( Dermoid) :

Stromal cells types benign Fibroma

MEIG“’ Syndrome : Benign ovarian fibroma + Ascites + Right pleural effusion

 granulose cell tumor secrets large

Helpful link https://youtu.be/Ugm3Fh5VKFc

 Presenting symptoms for epithelial ovarian cancer include:

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