BLOCK XI: ALTERATIONS IN SEXUAL FUNCTION AND REPRODUCTION – TRANS NO.

06

PELVIC MASS
DRA. AQUITANA

LEGEND
RED (BOLD)-Important terms/terms emphasize by tutors
BLUE - Audio Addendums
PURPLE - Mnemonics/Transcriber’s Notes
GREEN – Footnotes of the MS Powerpoint

PELVIC MASSES
INTRODUCTION
Mass in the pelvis diagnosed by physical examination (by the patient
or the attending physician) or found incidentally during diagnostic
imaging studies
● Source of pelvic masses
o Any structure in or abutting the pelvis may be the
source of enlargement, distention or neoplasia,
resulting in the formation of a mass.
HISTORY
● Potential sources of pelvic masses:
● Last menstrual period
o You should do a thorough examination and history
● Menstrual irregularities
because not all pelvic masses are gynecologic or ● Pain
obstetrical. o character, frequency, location
o Central Nervous System
● Gastrointestinal symptoms
▪ Meningocoele
● Urinary and bowel changes
o Urinary Tract
● Fever
▪ Pelvic kidney o May be associated with an abscess or an
▪ Neurogenic bladder
inflammatory condition
▪ Bladder malignancy ● Weight loss or loss of appetite
o Vascular / Lymphatic
▪ Hemangioma A. Ob / Gyne History
▪ Aneurysm ● Gravidity / parity
▪ Lymph node enlargement ● Details of obstetric history
o Gastrointestinal ● Pelvic surgery
▪ Appendiceal abscess ● Pelvic infections
▪ Diverticular abscess ● Menstrual history
▪ Gastrointestinal tumors or malignancy ● Previous Pap Smear history
o Retroperitoneal / Peritoneal Masses o Try to ask for the result, if they were
▪ Peritoneal inclusion cyst given medicines, or if there was a need
▪ Retroperitoneal mass - fibrosarcoma for referral
▪ Endometriosis implants B. Urinary History
o Reproductive Organs ● Frequency
▪ Pregnancy - In or out of uterus ● Hematuria
(intrauterine or ectopic) - For patients in ● Incontinence
the reproductive age group you still ● Voiding patterns
have to think of pregnancy as a possible C. Gastrointestinal
diagnosis for a pelvic mass ● Increased girth
▪ Cornual ectopic pregnancy / interstitial ● Nausea / vomiting
type ● Bowel dysfunction
- Located at the proximal portion of ● Tarry stools / blood in stools
fallopian tube, already at the ● Diarrhea / constipation (esp. in obstructive
junction masses)
- Repair may not be possible so D. Vascular
hysterectomy would be the ● Known aneurysm or hemangioma
treatment for this case E. Developmental
▪ Cervical mass - benign or malignant ● Congenital anomalies - Vaginal septum
▪ Uterine mass - benign or malignant ● Neurologic motor problems
▪ Parametrial mass - benign or malignant F. Past History
- In the border of the pelvic organs ● Stroke, diabetes, medications, malignancy
▪ Adnexal mass - benign or malignant G. Family History
● Diabetes, Malignancy
 BLOCK XI | Pelvic Masses

PHYSICAL EXAMINATION
A. Abdomen
● Inspection:
o scars (ask what operation was done),
o abdominal enlargement
● Auscultation:
o bowel sounds
Rectovaginal Examination
● Percussion
● Palpation
o if there is a mass, note for
· tenderness,
· guarding,
· fluid wave,
· assess size of abdominal
organs
B. Pelvis
● Inspection Speculum Exam
● Speculum examination
o Necessary to visualize presence of DIAGNOSTIC TESTS
lesions in the cervix or the vaginal wall A. Blood work
● Internal examination / bimanual examination a. Complete blood count (CBC)
o Bimanual examination: b. Pregnancy test
· two examining fingers are c. Urinalysis (UA)
inserted in the vaginal canal, d. Occult blood (px w/ hx f blood in stool)
in order to aide us in trying to e. Blood culture
determine the consistency, B. Radiologic studies
mobility of the mass, an a. Abdominal and vaginal sonogram
abdominal hand should be b. Computed tomography (CT)
placed within the level of the c. Magnetic Resonance Imaging (MRI)
pelvic area so that upon d. Barium enema
palpation of internal e. Bone scan
examination simultaneously f. Renal sonogram / intravenous pyelogram (IVP)
the abdominal hand is trying C. Colonoscopy and/or cystoscopy
to palpate for the pelvic mass a. should be performed if all above are inconclusive
o Rectovaginal examination
· If 2 fingers are already in the BENIGN PELVIC MASSES
vagina, remove one ENDOCERVICAL POLYP
examining finger and insert it - Most common benign cervical lesion
in the rectum and try to see - Types: Endocervical canal (endocervical polyp) or ectocervix
the integrity of rectovaginal (cervical polyp)
septum, palpate for masses - Endocervical polyps are more common than the cervical
o Rectal examination -Done esp. in polyps.
px with no hx of sexual contact. - Lined by columnar or squamous epithelium, depending on
the site of origin and the degree of squamous metaplasia
- Descrption: purple to cherry red
- 80% are of the adenomatous type. The ff are the other
types:
o Cystic
o Fibrous
o Vascular
o Inflammatory
o Fibromyomatous
▪ Often there is ulceration of the stalk’s
Bimanual Examination -Determine size of uterus and pelvic masses most dependent portion
- Multiparous women
- 40 to 50’s
- Important manifestations :
o Leukorrhea
o Bleeding on contact (vaginal spotting after coitus,
bear in mind polyps)
o Treatment thru excision of the base (polypectomy)
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o If it is too broad or bleeding ensues, the base may
be treated with chemical cautery, electrocautery,
or cryocautery.
PARATUBAL CYST
Polyp (most common on speculum exam, protuding reddish mass)
Endocervical Polyp
NABOTHIAN CYST
- Retention cyst of endocervical columnar epithelium covered
by metaplasia
- Produced by the spontaneous healing process of the cervix
- Transformation zone of the cervix is in an almost constant
process of repair, squamous metaplasia, and inflammation.
o may cause blockage of orifice thus enlargement
(Like pimples on the cervix; non-malignant; just inform px)
PELVIC INFLAMMATORY DISEASE
CERVICAL STENOSIS
- Involves internal os
- Fluid (eg. Blood) inside uterine cavity
- May also be d/t atrohy during menopause or any procedure
done to the cervix (eg. Biopsy)
- Treatment
o Cervical dilators (to address the narrowing of the
cervix)
o Laminaria tents (absorb water then dilate)
o CO2 laser
BLOCK XI | Pelvic Masses
- An adnexal mass
- Thin walled
- Smooth
- Contains fluid
- Majority are benign
- Here is another common incidental finding: A benign
paratubal cyst.
- Sometimes such simple cysts are found adjacent to ovary
and are called parovarian cysts.
- They are filled with clear serous fluid and lined by flattened
cuboidal epithelium.
- Incidental finding in UTZ and IE
- Hydatid cysts of Morgagni (specific variant of paratubal
cyst)
o If pedunculated and near the fimbrial end of the
oviduct
o More than 5cm
o Excision if symptomatic
- At operation (ie. Laparotomy), the oviduct is often found
stretched over a large paratubal cyst.
o The oviduct should not be removed in these cases
because it will return to normal size after the
paratubal cyst is excised. Just observe.
- If the patient is in the reproductive age who is complaining
of foul smelling yellowish vaginal discharge, presents with
vaginal bleeding, and fever, you might want to get a sample
of vaginal discharge and send it in the lab
- Most common cause: Neisseria gonorrhea, Chlamydia
trachomatis (Gram negative intracellular diplococci). Do
gram stain.
- PID - polymicrobial in nature (combination of bacteria,
seldom monomicrobial)
- Not all PIDs are sexually transmitted however that is still the
most common
- Inflammation in tissue
- Capillary oozing
- Small blood vessel erosion
- Vulvitis, vaginitis, cervicitis, endometritis
- vaginal bleeding / spotting, foul-smelling discharge
(esp in young adolescent px, screen for PID. You
may just be treating the UTI but the problem is
PID)
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PID is also known as Acute salpingitis or tuboovarian
abscess (not able to delineate the ovary and fallopian tube, the
abscess is already in the fallopian tube)
o pain, tenderness, generalized signs and symptoms
of infection
o The mainstay treatment would be antibiotic, not
all pids require surgery (oral antibiotics for
ambulatory px/ opd; hospitalize px if with severe
pid, nulliparous and px cant be seen in a regular
basis)
o The problem that you would face would be after
the pid because as it heals there may be scarring,
the damage would be permanent
o For the infection to be treated explain and treat
both the patient and his/her partner (prevent
pingpong effect, treat the px and the partner to
Smooth muscle tumors of the uterus are often multiple. Seen here are
prevent infection)
submucosal, intramural, and subserosal leiomyomata of the uterus
Left FT: Normal Right FT: Inflammed
LEIOMYOMA
- AKA: myoma, fibroid, fibromyoma
- Most Common Types
o Submucosal-bleeding, most problematic (most
bleeding)
o Intramural - globular
o Subserous- knobby contour, nodular
o Intraligamentary(broad ligament)
▪ Can damage ureter during hysterectomy
BLOCK XI | Pelvic Masses
o Cervical
o Pedunculated- from serous form
o Parasitic- from pedunculated form
▪ Detached subserous myoma that can be
found in other organ near the uterus
- Major site of myoma : Isthmus of uterus
- Can also have vascular leiomyoma (walls of blood vessel has
smooth muscle)
o Source of the neoplastic smooth muscle tumor
- Start as intramural myoma, uterine myoma may grow
towards the endometrial cavity (submucous) then may grow
a stalk and prolapse into the cervix (px comes w/ mass in
intercoitus --> differentials: Polyps or myoma)
- Larger the myoma, the more an abnormal karyotype will be
detected (esp. In intarmural myoma).
- Estrogen and progesterone receptors are found in higher
concentrations in uterine myomas
- Usually single
- Highest levels of aromatase (estrogen synthetase) in myoma
cells (more estrogen receptors)
- Leiomyoma not related with leiomyosarcoma (rare
malignancy)
- Usually present in nullipara – more prone to grow and
become symptomatic
- Smoking decreases incidence
o due to decreased estrogen
- 40 to 50 percent asymptomatic (most px are asymptomatic)
- Grossly
o Sharply circumscribed, discrete,round,firm,gray-
white tumors varying in size from small nodules to
massive tumors that fill the pelvis
- Microscopic
o Spindle shaped cells
- Types of degeneration
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 BLOCK XI | Pelvic Masses
o Hyaline-most common(65%) ▪ Danazol
o Mildest form of degeneration ▪ aromatase inhibitors
o Myxomatous(15%) ▪ Antiprogesterone RU 486(Mifepristone)
o calcific(10%) ● Blocks the synthesis or action
o Red or carneous of progesterone
▪ Acute form - Surgical
▪ Infarction o Myomectomy- preserve fertility
● Severe pain and localized o hysterectomy-no plan of pregnancy
peritoneal irritation o power morcellation-microscopic
● Best treated nsaids for 72 ▪ discouraged for older women due to risk
hours of malignancy
o Cystic/hydropic degeneratuin ▪ only encouraged to young women
o Fatty degeneration ▪ Use of medical device to break uterine
- Risk factors: fibroids into pieces so they can be
o Increasing age removed thru a small incision in the
o Early menarche abdomen
o Low parity
o Use of Tamoxifen
ADENOMYOSIS
o Obesity - Presence of ectopic endometrial glands and stroma in the
o Familial predisposition uterine myometrium
- 30 percent incidence
- Symptomatic at ages 35-50 yrs
- Break of basalis layer or trauma
- Increased parity
- Diffuse involvement of both anterior and posterior walls of
the uterus
- Is a clinical dx and can only be confirmed by pathologic
review
- Presence of adenomyoma- an adenomyosis that appear as
focal mass
- The posterior wall is usually involved more than the anterior
wall
Here is a very large leiomyoma of the uterus that has undergone
- Manifestations
degenerative change and is red (so-called "red degeneration"). Such
o Menorrhagia
an appearance might make you think that it could be malignant.
o Dysmenorrhea
Remember that malignant tumors do not generally arise from benign
tumors. o Enlarged uterus and tender (boggy ,soft)
- Symptoms o Ultrasound-
o Menorrhagia (AUB) ▪ Thickened walls
o Will depend on site-submucous ▪ Honeycomb appearance
▪ Intramural can also have bleeding - Management
/chronic pelvic pai o GnRH agonist
o Dyspareunia o Progesterone(lessen bleeding)
o Dysmenorrhea o Progesterone containing iud
o Pelvic pressure (constipation) o Cyclic hormones
o Acute pelvic pain –torsion of pedicle o Prostaglandin synthetase inhibitors
o Infarction o Surgical
o Degeneration ▪ Hysterectomy
o Urgency of urination
o Hydroureter (unilateral/bilateral)
o Infertility
- Management:
o monitor size of myoma esp during pregnancy
▪ Can cause to sudden preterm labor
o Medical tx -bleeding to disappear
▪ Gnrh agonist eg luprolex
● Reduced uterine vol and size
● Once stopped lesion will grow
again
▪ Medoxyprogesterone acetate(dmpa)
● Creating a pseudomenopause
state to inhibit estrogen thus
not allowing the myoma to
grow
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 BLOCK XI | Pelvic Masses
o Peritoneum
- Aberrant endometrial tissues are hormonally dependent on
high estrogen levels
- Disease of reproductive age group
- Ovaries enlarged, tender, fixed to the broad ligament or
lateral pelvic sidewall

ENDOMETRIOMA
ENDOMETRIAL POLYP - At laparoscopy the appearance of endometriosis is quite
- Treatment: variable.
o Polypectomy or hysterectomy - It can take one of the following appearances:
▪ Localized overgrowths of endometrial o Blue or black powder-burn lesions
glands and stroma that project beyond o Red, blue, white or non-pigmented lesions
the surface of the endometrium o Scarring and peritoneal defects
▪ Wide range of bleeding patterns - o Ovarian cysts
menorrhagia, premenstrual and
postmenstrual spotting

HEMATOMETRA
- Collection or retention of blood in the uterus
- With cyclic menstruation
o Vaginal canal distends, cervix dilates leading to
formation of hematometra
- Etiology
o Imperforate hymen - bluish bulge at the introitus
o Transverse vaginal septum
o Previous gynecologic procedures
▪ Scaring
- Clinical presentation
o Cyclic pain
o Amenorrhea
o Abdominal pain mimicking acute abdomen
o Difficulty with urination or defecation

ENDOMETRIOSIS
- Presence of endometrial glands and stroma outside of uterus
- Most frequent sites:
o Ovaries (most common site)
o Pelvic viscera

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 BLOCK XI | Pelvic Masses
size and, if they rupture, can cause abdominal pain.

- Lining closely packed layer of round, plump granulosa cells,

with the spindleshaped cells of the theca interna deeper in
the stroma
- Also known as follicular hematomas
- Seen in young regular menstruating women
- Manifestations
o Tenesmus –cramping rectal pain
o Transient Pelvic tenderness
- Clinical Presentation: o Deep dyspareunia
o Chronic pelvic pain o Menstrual irregularity
▪ may be due to accumulated blood o Abnormal Uterine Bleeding
o Infertility – if there is scarring o Vague, dull sensation or Pelvic
o Dysmenorrhea heaviness
o Dyspareunia – if it is implanted in the vagina - Management
o Since this disease is seen during menstruation, it o observe only
is hormonally dependent so you can treat it o resolves in 4 to 8 wks
medically but there is no guarantee yet of high o repeat UTZ in 2-3 months
possibility of cure for endometriosis o CA-125 post menopausal

OVARIAN MASSES CORPUS LUTEUM CYST

- Reproductive age group 20 to 45 - Occurs after ovulation
- 80 to 85% benign - 3 cm or more
- Always do frozen section due to risk of malignancy - Can occur w/ normal endocrine fxn
- Frozen section - Prolonged progesterone
o Patho lab procedure to perform rapid microscopic - May rupture
analysis of a specimen often used in oncological - Higher risk if at right ovary
surgery - Halban Syndrome:
- Malignancy o Persistently functioning corpus luteum cyst with
o Children -50 to 60% abnormal vaginal bleeding
- Diagnostic
o UTZ
▪ Benign
- Cystic ,mobile,smooth,unilateral
▪ Malignant
- Bilateral, solid, fixed, irregular,
(+) ascites

NON-NEOPLASTIC
FUNCTIONAL CYST - The corpus luteum secretes progesterone which induces a
- Follicular cysts secretory endometrium.
- Most common - It normally regresses in 14 days unless it is rescued by
- Responds to FSH and LH increasing concentrations of human chorionic gonadotropin
- Usually from unruptured follicles from a pregnancy
- 3cm to 15cm - HALBAN'S CLASSIC TRIAD
- Thin walled, unilocular o Delay in a normal period followed by
o But can be multiple spotting
- Easily ruptures o Unilateral pelvic pain
- Watery clear liquid o Small, tender, adnexal mass
- Management:
SIMPLE FOLLICAULAR CYST o Cystectomy

THECA LUTEIN CYST

- Least common
- Multilocular and bilateral
- Hyperreactio luteinalis
o Development of multiple luteinized follicular cysts
- High HCG
- Associated with
o Pregnancy
o H-mole
Follicle cysts. Here is a benign cyst in an ovary. This is probably a - Confirmed by ultrasound
follicular cyst. Occasionally such cysts may reach several centimeters in - Management
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 BLOCK XI | Pelvic Masses
o Treatment is conservative because these cysts
gradually regress
▪ Do not puncture - risk of haemorrhage
▪ Delivery - pregnancy or mole
- Luteoma of pregnancy
o Hyperplastic reaction of the ovarian theca lutein
cells

Bilateral Mature Cystic Teratoma

BENIGN NEOPLASTIC
DERMOID CYST/ MATURE TERATOMA/ BENIGN
CYSTIC TERATOMA
- 46xx Chromosomal makeup
- 15% Risk of torsion-most frequent
o Especially dermoid
- Manifests as pain
o Sensation of pelvic pressure Open Mature Cystic Of Ovary. A Ball Of Hair And Mixture Of Tissue
- Malignant component
o Squamous carcinoma of the ovary is rare and ENDOMETRIOMAS
usually arises in mature cystic teratoma or - Most common causes of enlargement of the ovary
dermoid - Is an often painful disorder in which tissue that normally
- Bilateral lines the inside of your uterus — the endometrium — grows
- Associated with outside your uterus
o Thyrotoxicosis - Chocolate cyst
o Carcinoid Syndrome o Blood accumulates every menstrual cycle
o Autoimmune Hemolytic Anemia - Large cysts are usually bilateral
- Tangled masses of hair, cartilage, teeth - Manifestations
- ROKITANSKY TUBERCLE or dermoid plug - o Pelvic pain
o Solid protuberance projecting into the cyst cavity o Dyspareunia
you can find MOLAR tooth,bone o Infertility
- Diagnostic - Diagnostic
o UTZ o Laparoscopy
- Management o Ultrasound
o Cystectomy - Treatment:
o o Medical vs surgical
TERATOMA/ DERMOID CYST o It will depend on the situation of the patient
- Unilocular cyst (<15cm)
- is a tumor made up of several different types of tissue, such
as hair, muscle, teeth, or bone
- Contain sebaceous glands, teeth, hair, nervous tissue,
cartilage, bone, resp & intestinal & thyroid tissue
- Long pedicle, heavy & easily undergo torsion
- Histologically, a variety of mature tissue elements may be
found.
- Most common presentaTion is acute onset of pain &sudden
onset nausea

- At laparoscopy the appearance of endometriosis is quite

variable. It can take one of the following appearances:
o blue or black powder-burn lesions
o red, blue, white or non-pigmented lesions
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 BLOCK XI | Pelvic Masses
o scarring and peritoneal defects
o ovarian cysts
*pictures same with endometrioma at benign pelvic masses

BRENNER’S TUMOR/ TRANSITIONAL CELL TUMOR

- Solid but benign(fibrous tissue)
- Are an uncommon subtype of the surface epithelial-stromal
tumor group of ovarian neoplasms. The majority are benign,
but some can be malignant.
- Presence of nests of transitional epith embedded in a dense
fibrous stroma This is the cut surface of a fibroma. Such neoplasms slowly enlarge
- Coffee bean nucleus over the years
o Due to indentation in the nucleus
- With concurrent serous or mucinous cystadenoma of the NON-EPITHELIAL OVARIAN TUMOR
ipsilateral ovary NON-EPITHELIAL OVARIAN CANCER
- Slow growing - 10% of all ovarian cancers
- Management - Includes the following tumor types:
o Excision o Germ cell origin
o Sex cord-stromal origin
o Metastatic cancers to the ovary
o Variety of extremely rare ovarian cancers,
sarcomas, lipoid cell tumors

GERM CELL TUMORS

- Derived from primordial germ cells of the ovary
- Second most frequent among ovarian neoplasms
- 20-25% of all ovarian tumors
- Is a neoplasm derived from germ cells.
FIBROMA - Germ-cell tumors can be cancerous or benign.
- Solid - Germ cells normally occur inside the gonads (ovary and
- Are benign tumors that are composed of fibrous or testis).
connective tissue. - 1/10th the incidence of the malignant germ-cell tumors of
- With low malignant potential the testis
- Unilateral - Can arise from:
o Unlike adenofibroma which is bilateral
o Gonad from undifferentiated germ cells
- Diameter of a fibroma
o Extragonadal sites: mediastinum and
o Important clinically because the incidence of
retroperitoneum
associated ascites is directly proportional to the
size of the tumor
o very important to take not
- Meig’s syndrome
o is the triad of ascites, pleural effusion, and benign
ovarian tumor (ovarian fibroma, fibrothecoma,
Brenner tumour, and occasionally granulosa cell
tumour)
o Ovarion fibroma
o Ascites
o Hydrothorax
- Manifestation
o Pressure
o Abdominal enlargement
- Management
o Excision
o Total Abdominal Hysterectomy with Bilateral - Most frequent benign tumor: Mature Teratoma
Salpingo-Oophorectomy

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 BLOCK XI | Pelvic Masses
Dysgerminoma Placental alkaline phosphatase
LDH

Histogenesis of Germ cell Tumors

Clinical Features of Germ Cell Tumors:

o Rapidly growing mass
o Subacute pain: distention, hemorrhage, necrosis
o Pressure symptoms
o Menstrual irregularities
o Abdominal distention: ascites
o Palpable adnexal mass
o Signs of ascites, pleural effusion, organomegaly
Diagnosis of Germ Cell Tumors:
o Adnexal mass
o >/= 2 cm in premenarcheal girls
o >/= 8 cm in premenopausal women
- Here are bilateral mature cystic teratomas of the ovaries. o hCG, AFP titers, CBC, liver function tests =test to
- These are a form of ovarian germ cell tumor. be requested
- Histologically, a variety of mature tissue elements may be o Chest X-Ray, karyotype
found. o Preoperative CT Scan, MRI
- These tumors are often called "dermoid cysts" because
They are mostly cystic. DYSGERMINOMA
- Most frequent malignant tumor: - Most common malignant germ cell tumor
o Dysgerminoma - Accounts for about 30-40%
o Immature teratoma - it usually is malignant and usually occurs in the ovary.
o Endodermal sinus tumor - A tumor of the identical histology but not occurring in the
- Usually unilateral EXCEPT for dysgerminoma and immature ovary may be described by an alternate name: seminoma in
teratoma the testis
or germinoma in the central nervous system or other parts
IMMATURE TERATOMA of the body.
Histologic typing of germ cell tumors: - 5-10% in patients younger than 20 years of age
Dysgerminoma Immature - 75% occur between the ages of 10 and 30 years
Mature Solid, cystic - 20-30% cases associated with pregnancy
Teratoma Monodermal and Struma ovarii - Represent abnormal proliferation of the basic germ cell
highly specialized Carcinoid - May co-exist with immature teratoma, chorioCA, EST and
Mixed other extraembryonal lesions
Others
Endodermall Sinus
Tumor
IMMATURE TERATOMA
Embryonal Cancer
Polyembryoma
Choriocancer
Mixed forms

Classification Tumor markers

Embryonal Cancer hCG, AFP
Endodermal sinus cancer AFP
Choriocarcinoma hCG - 5% cases in phenotypic females with abnormal gonad
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 BLOCK XI | Pelvic Masses
o Pure gonadal dysgenesis: 46XY, streak gonads medullary pattern
o Mixed gonadal dysgenesis: 45X/46XY, unilateral ● The second most common germ cell malignancy
streak gonad, contralateral testis ● Resembles tissues derived from the embryo
o Androgen insensitivity syndrome: 46XY ● Consist of immature embryonic structures admixed with
mature elements
- 75% cases are at Stage I
● an immature teratoma contains immature or embryonic
- 85-90% cases are confined to one ovary
structures.
- 10-15% cases are bilateral
● It can coexist with mature cystic teratomas and can
- Rapidly growing constitute of a combination of both adult and embryonic
- 25% cases are metastatic tissue
o Lymphatic system, hematogenous, direct ● 10-20% of all ovarian tumors in women <20
extension ● 50% occur in women between the ages of 10 and 20 years
o Sites: bones, lungs, liver, brain, mediastinum, ● Rarely bilateral
supraclavicular lymph nodes
- Gross:
o 5 to 15 cm
o Slightly bosselated capsule
o Spongy and gray brown on cut surface
- Microscopic:
o Large, round, ovoid or polygonal cells
o With abundant, clear, very pale staining cytoplasm
o Large and irregular nuclei with prominent nucleoli
o Mitotic figures seen ● Grow rapidly, cause pain early
o ● 2/3 confined to ovary
● Pure teratomas don’t produce hCG or AFP
Management ● Pathogenesis: proliferation of a meiotic germ cell
● Diagnosis:
Surgery Unilateral oophorectomy, USO
o Xray, UTZ: calcifications
TAHBSO o No tumor markers
Gross:
If there is a Y chromosome on karyotype: ● Smooth external surface
remove both ovaries ● Predominantly solid maybe cystic
● Necrosis and hemorrhage
Inspect and palpate peritoneal surfaces ● Hair, bone, keratinaceous debris, cartilage
Microscopic:
Lymphadenectomy
● Immature tissues from all 3 germ cell layers
Radiation Dysgerminoma is extremely sensitive ● Immature neural elements are common and may correlate
with outcome
Chemotherapy Allows preservation of fertility Classification:
● Based on the degree of differentiation and quantity of
Tumor markers for ff up monitoring: AFP, BhCG immature tissue
● The amount of undifferentiated NEURAL tissue is of
BEP (bleomycin,etoposide,cisplatin prognostic importance
VBP (vinblastin,bleomycin,cisplatin) Grade 1 <1 LPF with immature neural elements
VAC (vincristine,actinomycin,cyclophosphamide) Grade 2 1 to 2 LPF with immature neural elements
Second look Grade 3 >3 LPF with immature neural elements
operation-
surgery Management :
performed Surgery
after primary Unilateral Oophorectomy, USO, TAHBSO
tx to det Inspect and palpate peritoneal surfaces
whether tumor Hematogenous spread: lungs, liver, brain
cell remain Chemotherapy
For recurrent disease: ● Stage 1a. Gr 1: no adjuvant treatment
● (75% occur within 1st year after primary TX) ● Stage 1a, Gr 2 and up: higher stages , + ascites
** Give adjuvant chemotherapy (VAC, VBP)
● Chemotherapy or radiotherapy
In pregnancy: Radiation: not used as primary treatment
● Stage 1a: remove ovary Second look operation:
● Advanced stage: continuation of pregnancy depends on the ● Not justified in patients who have received adjuvant
AOG chemotherapy
● Chemotherapy may be given in the 2nd and 3rd trimester ● In macroscopic residual disease - of value
Prognosis: ● Sampling of peritoneal lesions and retroperitoneal lymph
● Stage 1a: 95% 5 year disease – free survival nodes:
● Greater possibility of recurrence is seen when: o If mature elements: D/C chemotx
a) Lesion is 10-15cm o If immature elements: alternatives – newer
b) Patient is less than 20 years old regimen, experimental regimens
Prognostic features:
c) Microscopic pattern shows numerous mitosis, anaplasia
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 BLOCK XI | Pelvic Masses
● Grade of lesion no use
● Stage of disease
● Extent of tumor
**The overall 5 year survival for all stages: 70-80%
**The overall 5 year survival for stage 1: 90-95%
The degree or grade of immaturity predicts the metastatic potential
and curability

Endodermal sinus tumor

● 10% of malignant germ cell tumors
● The third most frequent malignant germ cell tumor of the
ovary
● Also known as:
(Necrotic Variegated Tumor)
o Yolk sac tumor
o Mesonephroma
CHORIOCARCINOMA
o Mesoblastoma of Vitellium
● Pure ovarian choriocarcinoma of germ cell origin is a very
o Teilum tumor
uncommon neoplasm
● May originate as:
o Primary gestational CA associated with ovarian
pregnancy
o Metastatic focus from primary gestational
choriocarcinoma elsewhere in genital tract
o Germ cell tumor differentiating in the direction of
trophoblastic structures
o Same as appearance as gestational
choriocarcinoma metastatic to the ovaries
● Mostly affects those 20 years old
● Recapitulates extraembryonic tissue: yolk sac ● Tumor markers: hCG
● Presents with abdominal or pelvic pain in 75% of cases ● Isosexual precocity occur in about 50% of patients
● Peak incidence 19 years ● Chemotherapy: MAC (methotrexate,actinomycin
● Range of 16 months to 46 years A,chlorambucil),BEP
● AFP elevated in these tumor ● Poor prognosis
● Metastasis by lymphatic system to liver, lungs, peritoneum, Microscopic:
lymph nodes, bowel ● Sheets of anaplastic syncitiotrophoblast and cytotrophoblast
● 15% associated with mature cystic teratomas without chorionic villi
● 100% unilateral
● Secretes AFP and rarely α-1-antitrypsin (AAT)
● Ultrasound findings:
o Large, predominantly cystic mass measuring 20 to
30 cm in greatest diameter § Large, solid, soft
tissue components with low level echoes
intermixed with numerous septations
Gross:
● Soft
● Grayish brown with cystic areas that result from
degeneration
● Capsule usually intact (Hemorrhagic tumor)
Microscopic:
● Presence of endodermal sinus or SCHILLER DUVAL BODIES POLYEMBROYOMA
● Cystic spaced lined with a layer of flattened or irregular ● Extremely rare
endothelium into which projects glomerulus tuft with central ● Composed of “embryoid bodies”
vascular core ● Very young, premenarchal girls with pseudopuberty
● Contains clear, glassy cytoplasm ● Tumor markers: AFP and hCG
Management: ● Chemotherapy: VAC
● Surgical exploration, USO with frozen section
● TAH and contralateral SO – does not appear to alter the
outcome
● Second look laparotomy is NOT done

EMBRYONAL CARCINOMA
● Least differentiated germ cell tumor
● is a relatively uncommon type of germ cell tumour that
occurs in the ovaries and testes.
● Differentiated from choriocarcinoma by its lack of
syncitiotrophoblast and cytotrophoblast
Mixed Germ Cell Tumor
● Occurs in patients between 4 and 28 years old
● Secretes estrogen Dysgerminoma 80%
● Tumor markers: AFP, hCG Endodermal sinus tumor 705
● Treatment: same as Endodermal sinus tumor, radiation is of
Page 12 of 20
 BLOCK XI | Pelvic Masses
Immature teratoma 53% ● Secretes estrogen
Choriocarcinoma 20% ● Are usually unilateral (2% cases are bilateral)
Embryonal Carcinoma 16%

Gross:
(Heterogenous or variegated tumor dye to different components)
Microscopic:
● The most frequent combination: Dysgerminoma +
Endodermal sinus tumor
● Combination chemotherapy: BEP
● Second look operation: Indicated
● The most important prognostic feature: size of primary
tumor and relative amount of its most malignant
component
● Stage 1A >10 cm: 100% survival rate
Features/Clinical Manifestations/Diagnosis:
SEX CORD STROMAL TUMORS
● 5-8% of all ovarian malignancies
● Consist of germ cell and sex cord-stromal elements
● Germ cell resemble dysgerminoma
● “female cells”: granulosa and theca cells
● “male cells”: sertoli and leydig cells
● Smooth, lobulated surface
● Granular and frequently trabeculated
● Yellow or gray-yellow
● Round or ovoid cells with scant cytoplasm and may assume
small clusters or rosette formation around a central cavity:
CALL EXNER BODIES
● The nucleus is compact, finely granular or hyperchromatic
with a groove thus resembling, “coffee bean”
● Other variant patterns include folliculoid, diffuse, cylindroid,
pseudoadenomatous, mixed
● The typical coffee bean nuclei are difficult to see
● Prepubertal: 75% associated with sexual pseudoprecocity
● Reproductive age: menstrual irregularity due to amenorrhea
and cystic hyperplasia
● Postmenopausal: AUB
o 5%: endometrial Ca
o 35-50%: endometrial hyperplasia
● Other signs and symptoms: non-specific
● Tends to be hemorrhagic rupture hemoperitoneum
● Usually stage 1a at diagnosis
● Spreads hematogenously lungs, liver, brain
● Tumor marker: inhibin

Treatment
Surgery USO
TAHBSO
Radiation
Chemotherapy Recurrent or metastatic
Sex Cord Tumors with Annular Tubules. The large tumor has a yellow- BEP
orange sectioned surface(from a patient without the Peutz-Jeghers Progestins or anti estrogens
syndrome).
Prognosis:
Classification ● Prolonged natural history
1. Granulosa-Stromal a. Granulosa cell tumor ● Tendency for late relapse
Cell Tumors b. Tumors in thecoma (fibroma o 10-year survival rates 90%
group) o 20-year survival rates 75%
-thecoma ● Presence of residual disease: most important
-fibroma ● DNA ploidy: an independent prognostic factor
-unclassified ● Residual negative, DNA diploid: 96% 10 year survival rates
2. Androblastomas; a. Well differentiated
sertoli leydig tumors -sertoli cell tumor SERTOLI-LEYDIG TUMORS
-sertoli-leydig cell tumor ● 3rd to 4th decade of life
-leydig cell tumor: hilus cell tumor ● <0.2% of ovarian cancers
b. Moderately differentiated ● Is a group of tumors composed of variable proportions of
c. Poorly differentiated Sertoli cells and Leydig cells.
d. With heterogenous elements ● Produces androgens and clinical virilization in 70-85%
3. Gynandroblastomas ● Increase testosterone, androstenedione, DHEAS
4. Unclassified (dihydroepiandrosterone)
● Low grade malignancies; occasionally poorly differentiated
GRANULOSA STROMAL CELL TUMORS ● <1% cases are bilateral
● Low grade malignancy
● Rarely, thecomas & fibromas: fibrosarcoma
● These tumors are most commonly observed in
postmenopausal women
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 BLOCK XI | Pelvic Masses

Gross: Krukenberg Tumor Of Ovary

● Average size13.5 cm, ranging from 5 to 15cm Metastatic adenocarcinoma to ovary appears as a large mass and
● Variable in appearance but usually do not have much blood
resembles a primary tumor: Seen here extending out of the pelvis at
filled cysts and are almost unilocular
autopsy is a large right ovarian mass. Metastases are also present in
Microscopic:
the lower right portion of liver.
● Tubules were solid or hollow
● Delicate septa were occasionally seen
● The cells usually had pale to occasionally densely
EPITHELIAL OVARIAN CANCER
eosinophilic cytoplasms
Treatment: Classification of Ovarian Neoplasm
● USO Epithelial stromal The most frequent ovarian neoplasm.
● TAHBSO tumors (common Believed to arise from the
● Radiationn or chemotherapy: of marked value epithelial tumors) surface(coelomic) epithelium
Prognosis: Germ cell tumors The second most frequent and the most
● 70-90% 6 year survival common among young women.

Histologically, they may be composed of

extraembryonic elements or may have
features that resembles any or all of the
three embryonic layers (ectoderm,
mesoderm, and endoderm).

Main cause of ovarian malignancy in

young women, particularly those in their
teens and early 20s
Sex cord-stromal The third most frequent and contain
tumors elements that recapitulate the
constituents of the ovary or testis. These
tumors may secrete sex steroid hormones
or may be hormonally inactive
Lipid (lipoid cell Extremely rare and histologically resemble
tumors the adrenal gland
Gonadoblastoma Consist of germ cells and sex cord stromal
elements. They occur in individuals with
dysgenetic gonads, particularly when a Y
chromosome is present
METASTATIC TUMORS Soft tissue tumors Not specific to the ovary such as
● 5-6% cases hemangioma or lipoma, are extremely
● Source: genital tract, breast, GIT rare and are categorized according to the
● Ovaries and vagina: most common site of metastasis to criteria of soft tissue tumors arising
female genital tract elsewhere in the body
● Four pathways of spread: Unclassified Cannot be placed in any preceding
1. Direct extension (tubal CA, cervical CA, adenoCA) tumors categories. Eg. Small cell carcinoma,
2. Lymphatic metastasis: most common which is highly virulent cancer affecting
3. Hematogenous: non gynecologic, breast Ca primarily young women
4. Peritoneal implantation Metastatic tumors May arise elsewhere in the RT or from
to the ovary distant sited such as bowel /stomach,
KRUKENBERG TUMOR most common is GI malignancies like
● Makes up 30-40% of metastatic CA to ovaries Krukenberg tumors
● Arises in the ovarian stroma Tumor- like Refer to enlargements of the ovary, such
● Composed of mucin filled, Signet-ring cells conditions as the extensive edema, pregnancy
Primary tumor: luteoma, endometriomas, and follicular or
● Most common: stomach luteal cysts, none of which are true
● Less frequent: colon, breast, biliary tract neoplasms
● Rare: cervix and bladder
● Usually bilateral WHO : Frequency of Ovarian Neoplasm
CLASS APPROX
FREQUENCY(%)
Epithelial stromal (common epithelial) 65

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 BLOCK XI | Pelvic Masses
tumors Most frequent
Germ cell tumors 20-25
Sex cord stromal tumors 6
Lipid(lipoid)cell tumors <0.1
Gonadoblastoma <0.1
Soft tissue tumors(not specific to ovary)
Unclassified tumors
Secondary(metastatic)tumors
Tumor-like conditions(not true neoplasm)

Epithelial Ovarian Tumors cell types

Approx frequency %
Cell type All ovarian Ovarian cancers
neoplasm
Serous 20-50 (most 35-40 SEROUS PAPILLARY CARCINOMA
Mucinous common) 6-10
Endometroid 15-25 15-25
Clear cell 5 5
(mesonephroid) <5 rare
Brenner 2-3
Mucinous seldom becomes malignant.

Classification
Classification Description
Benign Adenoma
Malignant Adenocarcinoma
Intermediate form Borderline malignant adenocarcinoma or
tumors of low malignant potential
Papillary Papillae (finger like projections) The tumors are partly solid and partly cystic. The rough-surfaced
Prefix cysts Cystic structures (fluid containing) polypoid tumor has extended (has extensions) through the capsule.
Suffix “fibroma” Adenofibroma, when the ovarian stroma
predominates
SEROUS CYSTADENOMACARCINOMA
(+) Psammoma bodies
SEROUS TUMORS
● MOST FREQUENT ovarian epithelial tumor
● Benign forms (usually)
o occur primarily during the reproductive years
o serous cystadenoma
● Malignant forms
o 40% or more of ovarian cancers and occur in
women older than years of age
o serous cystadenocarcinoma
● Borderline tumors – occur in women 30 to 50 years of
age
● Low-grade (formerly well-differentiated) serous
tumors MUCINOUS TUMORS
o Consist of ciliated epithelial cells that resemble
● Consist of epithelial cells filled with mucin
those of the fallopian tube ● Most are benign (reproductive years)
o Classifying serous ovarian cancers into low (better ● Cells resemble cells of the endocervix or may mimic
prognosis) or high-grade (poor prognosis) cancer intestinal cells, which can pose a problem in the differential
● 2 Histological variants of serous tumors: diagnosis of tumors that appear to originate from the ovary
1. Serous surface papillary carcinoma of the ovary or intestine
o Aggressive tumor with small ovaries that are ● Back to back cysts lined by single layer of mucinous
usually <4 to 5 cm in diameter epithelium: uniform tall columnar cells **
o With extensive disease on the ovarian surface ● Mucinous carcinoma is usually seen in 30s to 60s
and metastatic disease in the abdomen ● Prominent vacuoles containing mucin
2. Primary peritoneal serous adenocarcinoma -
Often difficult histologically to distinguish

Mucinous cystadenoma. The sectioned surface reveals numerous thin-

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 BLOCK XI | Pelvic Masses
walled locules. Immature teratoma(malignant) 2-5
Dysgerminoma 5-10
Other malignant germ cell tumors rare
Sex Cord stromal tumors
Thecoma Rare
Sertoli-leydig cell tumor rare
Granulosa theca cell tumor rare

Benign Epithelial Ovarian Tumor: the adnexal mass

> 5 cms Considered abnormal
Age and menstrual status must also be
considered
Mucinous adenocarcinoma. The sectioned surface appears gelatinous, 5 to 8 cm (unilocular) Regular menses and in her 40s,
with extensive hemorrhage and necrosis. functioning ovarian cyst
Women in her 20s or early 30s
ENDOMETRIAL TUMORS observe for two menstrual cycles (and
● Consist of epithelial cells resembling those of the make sure to request for utz on the
endometrium first 5-7 days of MP
● Usually occur in women in their 40s and 50s Women taking OCPs ,observe
● May be seen in conjunction with endometriosis and ovarian 5 to 8 cm More likely to be neoplastic
endometriomas (that is why it is not rare to see ovarian (multilocular)
cancers from patients who had endometriosis when they
were younger) Risk of malignancy
● Endometriosis now is not entirely a benign thing because it ● Rises after the age of 40
can develop into endometrial adenocarcinoma later on (but ● Pre- and postmenopausal women taking tamoxifen for breast
only a little percentage only) cancer
● Arise directly from the surface epithelium of the ovary Transvaginal Ultrasound scan
● Confluent villoglandular epithelial proliferation >5mm ● Reliably detect an ovary >1 cm in diameter
● Preferably with a transvaginal probe
CLEAR-CELL (MESONEPHROID) TUMOR ● Only prefer abdominal or pelvic ultrasound large cysts
● Large vacuoles presence of glycogen ● If the cyst is not large transvaginal ultrasound is preffered
● Cells: abundant clear cytoplasm, polyhedral ● Occasionally, it is discovered that the adnexal mass is
● Contain cells with abundant glycogen and so-called hobnail paraovarian (cyst is not in the ovary but adjacent to the
cells in which the nuclei of the cells protrude into the ovary)
glandular lumen ●
● Identical histologic features are found in the endometrium, ADNEXAL MASS AND OVARIAN CANCER
cervix, and vagina CA 125
● Poor prognosis: very aggressive tumor and present at very ● Tumor marker
late stage ● Very important tumor marker but lacks specificity because
● Not related to diethylstilbestrol (DES) exposure there are some benign conditions in which CA125 is highly
● Occur primarily in women 40s to 70s sensitive
● Highly aggressive ● Expressed by approximately 80% of ovarian epithelial
carcinomas but less frequently by mucinous tumors
● Also increased in endometrial and tubal carcinoma
● Normal range is 0-35 U/ml
● >35 U/mL: considered increased
● Lack of specificity (CA 125 has a lot of false-positives, refer
to Benign Conditions in Which CA-125 has been Found to be
Elevated)
● Specificity appears to be better for increased values in the
postmenopausal patient
● Benign Conditions in Which CA-125 has been Found to be
Elevated:
BRENNER TUMORS 1. Endometriosis
● Consist of cells that resemble the transitional epithelium of 2. Peritoneal inflammation, including pelvic inflammatory
the bladder and Walthard nests of the ovary disease
● Abundant stroma 3. Leiomyoma
4. Pregnancy
Bilaterality of Ovarian Tumors 5. Hemorrhagic ovarian cysts
Type of tumor Occurrence (%) 6. Liver disease
Epithelial tumors Cancer Antigen 125 associations
Serous cystadenoma 10 Cancer
Serous cystadenocarcinoma 33-66 Ovarian, primary peritoneal, fallopian tube
Mucinous cystadenoma 5 Uterine
Mucinous cystadenocarcinoma 10-20 Colon
Endometroid carcinoma 13-20 Breast
Benign brenner tumor 6 Stomach
Germ cell tumor Liver
Benign cystic teratoma (dermoid) 12 Disease
Page 16 of 20

Leiomyomata
Endometriosis
Pelvic infections
Liver,heart,kidney failure
Alcoholism
Peritonitis
Pancreatitis
Condition
Pregnancy
Mild menstrual cycle
USE OF ULTRASOUND SCREENING & CANCER ANTIGEN 125 IN
THE EVALUATION OF THE ADNEXAL MASS
Ultrasound has helped to define criteria to allow conservative
follow-up and the risk of malignancy of some adnexal masses
Scoring system: Lerners and Sasson Scoring
1. Is the finding a simple (unilocular) or complex
(multicystic/multilocular with solid components) cyst?
2. Are there papillary projections?
3. Are the cystic walls and/or septa regular and smooth?
4. What is the echogenicity (tissue characterization)
● Combined transvaginal ultrasonography and normal CA 125
values
o Increased the accuracy of preoperative evaluation
● Transvaginal pulsed Doppler color-enhanced flow studies to
differentiate benign form malignant masses
o Resistance index: measures resistance to flow in
the vessels
o Presumable is low in the presence of
neovascularization that is seen with malignant
tumors
● Three-dimensional (3-D) ultrasonography
o May allow more accurate volume assessments
● Color Doppler 3-D ultrasonography
o May permit better detection of vessel irregularity,
coiling, and branching
● Future possibility: use of contrast media to quantify and
permit earlier detection of abnormal angiogenesis
Ovarian Cancer Screening
● Ovarian cancer is characterized by advanced-stage disease
at diagnosis and high mortality
● Early-stage disease is often curable (Example, in stage IA,
Diagnosis
you can resect the tumor and undergo chemotherapy.
However patients usually ignore it because it is
asymptomatic. They seek consultation when it is already late
and the tumor is vague and symptomatic.)
● Prevention → screening to identify early-stage disease
● Amenable to screening:
o Sufficiently severe (high mortality)
o Have a natural history from latency to overt
disease that is well characterized
o There should be successful outcome if early
disease is treated
● 3 Modalities:
1. Physical examination
2. Biomarkers (such as CA 125),
proteomics/genomics (experimental)
3. Sonography
● Physical Examination
o Least sensitive and specific
o Easiest to implement
o Poor sensitivity limits this intervention as an
effective strategy
● Biomarkers such as CA 125
o Easy to obtain and serial evaluation can be tracked
o A reliable biomarkers of epithelial nonmucinous
ovarian cancer
BLOCK XI | Pelvic Masses
o Limitation of this as a sole strategy for ovarian
cancer screening
● Ultrasonography
o More expensive (actually, it is less expensive
compared to CA 125) and less amenable to
population screening
o Has become increasingly accurate in identifying
early changes within the ovary
o As with single-modality testing, sonography is too
insensitive to be widely used for screening
NON MALIGNANT NEOPLASM
● Most are assymptomatic,unilateral adnexal masses that can
be treated by oophorectomy or occasionally hysterectomy
● Women beyond her reproductive years(>50 y/o):TAHBSO is
usually done
● Vertical incision (tumor be removed intact)
● Frozen section-suspicious of malignancy
● For woman desiring fertility-don’t do hysterectomy
● Mucinous Tumors
o large and reach sizes of > 30 cm
o possible complications: perforation and rupture
---deposit and growth of mucin in the peritoneal
cavity (pseudomyxoma peritonei)
● Adenofibromas
o consist of fibrous and epithelial elements
o epithelial component maybe
serous,mucinous,clear cell,or endometroid
o appearance will depend on the predominant
histologic features:epithelial or fibrous
o managed by simple excision
● Brenners Tumors
o rare and often incidental finding
o in women in their 40s and 50s
o almost always benign and can usually be manage
by oophorectomy
DIAGNOSIS, STAGING, SPREAD AND PRE-
OPERATITVE EVALUATION
● Usually diagnosed by detection of an adnexal mass on pelvic
or abdominal examination
● Unfortunately, the diagnosis is frequently made only after
the disease has spread beyond the ovary
● More than 90% of women diagnosed with ovarian cancer
report symptoms before diagnosis
o Symptoms are vague and not specific for early-
stage disease or even ovarian cancer
o Increased abdominal size, bloating, urinary
urgency, and pelvic pain
o Diagnosis is established by histologic examination
of tumor tissue removed at operation
o Occasionally, the initial diagnosis is suggested by
malignant cells founding ascetic fluid obtained at
paracentesis
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 BLOCK XI | Pelvic Masses

Preoperative Evaluation
● Preoperative workup usual for a major abdominal operation
● CA 125
● CT scan of the abdomen to search for retroperitoneal node
enlargement for parenchymal liver masses
● Barium enema or colonoscopy is performed to evaluate
pelvic and/or gastrointestinal symptoms
● Endoscopic or gastrointestinal radiographic examination is
performed if there is evidence of gastrointestinal bleeding or
the suggestion of any gastrointestinal pathology
Page 18 of 20

Preoperatively
● Programmed to cleanse the bowel
● Prophylactic board-spectrum antibiotics
● Venous thromboembolism prophylaxis
o Variable compression leg support stockings
o Heparin (fractionated and unfractionated)
Operatively
● May infiltrate the peritoneal surfaces of both the parietal and
intestinal areas, under surface of the diaphragm, particularly
on the right side
● Important to note the paraaortic nodes
● You have to palpate all suspicious areas that may have
infiltration of the tumor and do biopsy. If you have a tumor
along the pelvic peritoneum (stage II).
● Always do biopsy and submit to pathologist to rule out
involvement of cancer and for proper staging.
Prognosis
Related to:
1. Tumor stage (stage I has better prognosis than stage II)
2. Tumor grade (grade I has a better prognosis than grade III)
3. Cell type (Clear-cell tumor has poor prognosis, Endometrioid
Tumor or Serous Tumor has better prognosis)
4. Amount of residual tumor after resection – most important
Carcinoma of the Ovary: Survival by FIGO Stage for Patients
Treated 1990-1992
Carcinoma of the Ovary: Survival by FIGO Stage for Patients
Treated 2004-2010
Cell type
● Epithelia cancers: most common, worst prognosis (more
poorly differentiated and discovered at the higher stage)
● Mucinous and endometrioid tumors: better prognosis
● Transitional cell carcinoma (variant of papillary serous): rare,
more chemosensitive tumor
● Clear-cell cancers: worse prognosis, mitotic activity and
tumor stage
● Tubulocystic pattern: no effect on prognosis
● Aggressive tumors (poorly differentiated tumors like clear-
cell, papillary, serous): propensity for recurrence even in
stage 1 (chemotherapy is necessary to prevent recurrence)
● 1. Tumor is confirmed to be at stage 1A
BRCA1 and BRCA2 mutations
BLOCK XI | Pelvic Masses
● Serous surface papillary carcinoma of the ovary: survival
improved if the patients were treated postoperatively with
combination chemotherapy
● BRCA1 and BRCA2 are human genes that produce
tumor suppressor proteins. These proteins help
repair damaged DNA and, therefore, play a role in
ensuring the stability of each cell’s genetic material.
● Primary peritoneal carcinoma
● Role of this gene that resides on chromosome 17q11: not
clear
● Increase risk of breast and ovarian cancer
● Hereditary ovarian cancer group may have a better
prognosis
Tumor grade
● Major determinant of patient prognosis
o Grade 0 (borderline) tumors: best prognosis
o Grade 3 (poorly differentiated tumors): markedly
worse prognosis
● Low grade tumors generally clustered with LMP neoplasms
● High-grade tumors differentially expressed genes linked to
cell proliferation, chromosomal instability, and epigenetic
silencing
Ploidy of the tumor
● Aneuploidy: negative prognostic factor
● Independent prognostic association with the DNA index and
Sphase fraction (S-phase cells: better prognosis)
Size of residual nodules
● 5 year survival rate
o Stage III tumors that are completely resected:
>30%
o Stage III tumors when resection are incomplete:
10%
● Frequently used categories are microscopic (present on
biopsy, but not grossly), less than 1.0 cm, or greater than
1.0 cm
MANAGEMENT
Borderline Ovarian Tumors (Ovarian Carcinomas Of Low
Malignant Potential)
● 20% of ovarian epithelial cancers
● Excellent prognosis regardless of stage
● Serous and mucinous tumors: most common histologies
● Do not invade the stroma of the ovary
● Slower growth rate than do invasive ovarian carcinomas,
manifested by prolonged survival
● Occur in young women during the reproductive years
● Desirable to ascertain the safety of the conservative therapy
for patients with borderline stage 1A tumors (confined to
one ovary)
● Stages I and II: rare recurrences
● Stage III: 40% 20 year survival rate
● Stage I: unilateral adnexectomy, salpingoooperectomy
Mucinous Borderline Tumors: Excellent Prognosis
● Associated with widespread growth of mucin producing cells
in the peritoneum (pseudomyxoma peritonei) – that is why it
is important to remove the tumor “in toto” or intact
● Associated with recurrent bouts of bowel obstruction
● Appendectomy is indicated
● Tends to recur and to require repeated laparotomy to relieve
bowel obstruction
Conservative Therapy Unilateral Salphingo-Oophorectomy
(Uso) (Preservation Of Childbearing Function)
2. Extensive histologic sampling of the tumor confirms it to be a
Page 19 of 20
 BLOCK XI | Pelvic Masses
borderline tumor effectiveness of chemotherapy
3. The contralateral ovary appears normal
4. Biopsy specimens of areas of omental or peritoneal nodularity
are negative Second-Look Procedures
5. Results of peritoneal cytologic test are negative for tumor cells ● Not usually done
● Second-look laparotomy is performed, it is important to
Invasive Epithelial Carcinoma extensively sample the peritoneal surfaces and lymph nodes
● Primary treatment of ovarian epithelial carcinoma → removal ● Recommend that the operation not be done for those with
of all resectable gross disease low stage tumors
o Ascitic fluid: sent for cytologic evaluation ● Favorable factors for a negative second-look operation:
o Peritoneal washing (pelvis, upper abdomen, and 1. Low tumor grade
right and left paracolic gutters and diaphragm) 2. No residual disease after primary operation
o Biopsy or, preferably, excision of any suspicious 3. Young age (younger than 55 years)
nodules is performed 4. Rapid regression to normal of increased CA
o TAHBSO, appendectomy and infracolic 125 values
omentectomy
o Paraaortic and pelvic lymph node sampling
Quiz:

Matching Type:

Pseudocapsule Myoma
Sciller Duval Endodermal sinus tumor
AUB, infertility Mucous
Knobby Subserous
Signet Ring Krukenberg
Teeath Teratoma
Myoma peritonae Mucinous
Psamomma bodies Serous
Meig Syndrome Fibroma
Blue black powder burn Endometrioma
Honeycomb appreance Adenomyosis
Call exner Granulosa cell tumor
Well-differentiated (Grade 1) ovarian tumors confined to one Polymicrobial PID
ovary (Stage IA) Defeminization Sertoli Leydig
1. Tumor confined to one ovary Estrogen-producing Granulosa
2. Tumor well-differentiated (grade 1) with no invasion of
capsule, lymphatics, or mesovarium
3. Peritoneal washings negative
4. Omental biopsy specimen negative
5. Young women of childbearing years with strong desired
preserve reproductive function TRANSCRIBERS:
**follow the patient closely for any evidence of future ovarian Sarmiento, Jannine Christine Grace
Tovera, Brix Jean
enlargement with vaginal ultrasonography
Trapago, John Mandy
Trinidad, Joanna Marie
Postoperative Management Umiten, Hijanel
1. Chemotherapy
2. Radiation therapy – we do not usually do this in ovarian
cancer
3. Intraperitoneal (IP) radiocolloids
4. Immunotherapy – give immunologic targeted therapy to
increase longevity of lives of cancer patients, however it is
so expensive.

Neoadjuvant Chemotherapy
● Before the operation
● Alternative for patients thought to have substantial operative
risk or preoperative disease distribution that could preclude
optimal cytoreduction
● To allow for an improvement in performance status,
decreasing operative morbidity through less extensive,
surgery, and increasing the opportunity to achieve an
optimal result

Interval Cytoredution
Refers to a secondary attempt at maximal surgery after
surgery and adjuvant chemotherapy. Such therapy improved the
likelihood or subsequent successful resection and subsequent

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