Med3C Dr. D.L.

Reyes – Ovarian Ca Gyne

Course: Gynecology Week: 16

Lect urer: Dr. DL Reyes Topic: Ovarian Neoplasias
Source: L ecture, HO, Compre Gyne

Neoplas tic Diseases of the Ovary

DIFFERENTIAL DIAGNOSIS OF ADNEXAL MASS
Organ Cystic Solid Diagnostic Evaluation in the Presence of an
Ovary Functional cyst Neoplasm Adnexal Mass
Neoplastic cyst Benign • Complete physical examination
Benign≈ Malignant • Ultrasonography
Malignant • Colonoscopy or Barium enema, if symptomatic
Endometriosis • Intravenous pyelography, if indicated
Fallopian Tubo-ovarian abscess Tubo-ovarian abscess • Imaging studies – Chest X-ray, CT Scan or MRI
tube Hydrosalphinx Ectopic pregnancy • Tumor markers – Ca-125, HE4, CEA, AFP, β-hCG, LDH
Parovarian cyst Neoplasm • Laparoscopy, Laparotomy
Uterus Intrauterine pregnancy Pedunculated or
in bicornuate uterus intraligamentous myoma Non-Ovarian Causes of Apparent Adnexal Mass
Bowel Sigmoid or cecum Diverticulitis • Diverticulitis
distended with gas or Ileitis • Tubo-ovarian abscess
feces Appendicitis • Carcinoma of the colon or sigmoid
Colonic cancer • Pelvic kidney
Misc Distended bladder Abdominal wall • Uterine or intraligamentous myoma
Pelvic kidney hematoma or abscess
Urachal cyst Retroperitoneal
neoplasm

OVARIAN TUMORS

Symptoms Frequency of Ovarian Neoplasm (WHO Classification)

• Initially are asymptomatic Class Frequency
• Lower abdominal discomfort (%)
• Pelvic pain Epithelial stromal 65 Most common
• Dyspareunia (common epithelial)
• Abdominal enlargement tumors
• Frequent urination Germ cell tumors 20-25
nd
2 most common ovarian
• Constipation neoplasm; contain cells that
recapitulate embryonic
Indications for Surgery (often b/c they suggest malignancy): tissues (ectoderm,
• Ovarian cystic structure >5 cm that has been observed 6-8 mesoderm, endoderm)
weeks without regression Sex cord-stromal 6 Class of ovarian tumors in
• Any solid ovarian lesions tumors w/c constituents of ovary
• Any ovarian lesion with papillary vegetation on the cyst wall or testes are recapitulated
• Any adnexal mass >10 cm Lipid (lipoid) cell <0.01 Histologically resemble the
• Palpable adnexal mass in premenarchal or postmenopausal tumors adrenal gland
• Torsion of pedicle or rupture of mass suspected – Gonadoblastoma <0.01 Tumor that arises in
ALWAYS AN INDICATION for exploration abnormal gonads and
consists of sex-cord
stromal elements and germ
cells
Soft-tissue tumors
(not specific to the
ovary)
Unclassified tumors
Secondary
(metastatic) tumors
Tumor-like
conditions (not true
neoplasm)

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Med3C Dr. D.L. Reyes – Ovarian Ca Gyne

EPITHELIAL OVARIAN NEOPLASMS

• Arise from inclusion cysts lined with surface (coelomic) epithelium within the adjacent ovarian stroma

Classified as
• Benign – adenoma
• Malignant - adenocarcinoma
• Intermediate - borderline malignant or low malignant potential (termed adenoma or adenocarcinoma)

Epithelial Ovarian Tumor Cell Types

Tumor Cell Type Approximate Frequency (%)
All Ovarian Neoplasms Ovarian Cancers
Serous 20-50 35-40
Mucinous 15-25 6-10
Endometrioid 5 15-25
Clear cell (mesonephroid) <5 5
Brenner 2-3 Rare

A. SEROUS Ciliated epithelial cells that B. MUCINOUS Epithelial cells filled with mucin,
resemble those of the fallopian resembling cells of the endocervix or
tube intestinal cells
1. Serous Occur primarily during reproductive 1. Mucinous Primarily during reproductive years
cystadenoma years cystadenoma
2. Borderline types Occur in women 30-50 years 2. Borderline types
3. Serous Occur in women older than 40 years 3. Mucinous Usually in 30- to 60-year age range
cystadenocarcinoma cystadenocarcinoma

Pseudomyxoma  peritonei  
• Complication of mucinous tumors
• Transformation of peritoneal mesothelium to a mucin secreting epithelium
• Continuous secretion of mucus resulting in accumulation in peritoneal cavity of gelatinous material
• Evacuation at operation is followed by reaccumulation (no definitive tx/cure) L
Treatment
• Repetitive surgical evacuation
• Long-term nutritional support

Type Serous Mucinous

Subtype Serous cystadenoma Mucinous cystadenoma
Charac • Primarily during reproductive years • Primarily during reproductive years
• Complication: pseudomyxoma peritonei (see above)
Gross • Papillary projections on the surface • May become huge (>300 lbs)
• Inner cyst wall are mostly smooth • Round or ovoid, smooth capsule usually translucent or
bluish to whitish gray
• Interior divided by discrete septa into locules containing
clear, viscid fluid

Micro • Low columnar epithelium with occasional cilia • Lining epithelium is tall, pale staining secretory type with
• Psammoma bodies nuclei at basal pole, rich in mucin
o Small granules, end product of degeneration of papillary
implants
o Indicative of functional immunologic response & of a
benign mass (well-differentiated)

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Med3C
Type C. Clear Cell Carcinomas
Charac • Most clear cell neoplasms of the
ovaries are carcinomas
• Contain cells with abundant glycogen
• Most common to be assoc with
paraneoplastic hypercalcemia
• Relationship w/endometriosis is
strongest
• Endometriotic implants are
commonly present in close proximity
to tumor or elsewhere in the pelvis or
abdomen
Gross • Tumors range up to 30 cm dm;
mean ~15 cm
• Cut surfaces reveal a thick-walled
unilocular cyst with multiple yellow-
beige fleshy nodules (excrescences)
protruding into the lumen
• Multiloculated cystic mass with cysts
containing watery or mucinous fluid
Micro • Solid pattern - sheets of polyhedral
cells w/abundant clear cytoplasm
separated by delicate fibrovascular
septae or dense hyalinized fibrotic
stroma
• Tubulopapillary pattern - often
columnar cells w/hobnail
appearance, w/nucleus protruding
from papillae, gland, or cyst into the
lumen
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Dr. D.L. Reyes – Ovarian Ca
D. Endometrioid Adenocarcinoma
• Most endometrioid ovarian neoplasms
are carcinomas
• Consists of cells resembling those of the
endometrium
• Most arise from the surface epithelium of
the ovary
• Smooth outer surface
• On cut section, solid and cystic, w/ cysts
containing friable smooth masses &
bloody fluid
• Well-differentiated endometrioid
adenocarcinoma accounts for majority
of cases
• Charac by a confluent or cribriform
proliferation of glands lined by tall
stratified columnar epithelium with
sharp luminal margins
• Mitotic figures are commonly seen
• Squamous differentiation in up to 50%
of cases
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Gyne
E. Brenner Tumor
• Arise from Walthard cell rests
• Nearly all are benign but
there are scattered reports of
malignant Brenner; assoc
endometrial hyperplasia
• Treatment: simple excision
• Grossly identical to a
Fibroma of Ovary
• Marked hyperplastic
fibromatous matrix
interspersed with nest of
epithelioid cells
• Epithelioid cells show “coffee
bean” pattern c/b longitudinal
grooving of nuclei
• Transitional epithelial cell type,
charac by a relatively uniform
population of stratified cells with
ovoid nuclei displaying nuclear
grooves, name d/t resemblance
to urothelium
Med3C Dr. D.L. Reyes – Ovarian Ca Gyne

BORDERLINE TUMOR OF THE OVARY

• AKA: Atypical Proliferative Tumor of the Ovary (APT) or Prognosis
Ovarian Tumor of Low Malignant Potential (LMP) • Longer survival than invasive forms:
• Epithelial ovarian tumors with histologic and biologic features o 5-year survival rate of all stages = 97%
intermediate between clearly benign and clearly malignant o 10-year survival rate of all stages = 89%
ovarian neoplasms
• Malignant cells DO NOT invade the stroma of the Management
ovary
• Complete surgical extirpation of the tumor
• Slower growth rate than invasive ovarian carcinomas
• Constitute ~15-20% of epithelial ovarian cancers
Unilateral involvement Bilateral involvement
• Commonly found in younger women
• Salpingo-oophorectomy is • Total abdominal
preferred over Cystectomy hysterectomy with BSO
Most common varieties
• Thorough evaluation of the • Peritoneal fluid cytology
• Serous
other ovary • Partial omentectomy
• Mucinous
• Peritoneal fluid cytology
• Partial omentectomy
Histologic criteria for diagnosis
1. Stratification of the epithelial lining of the papilla
Criteria for Conservative Therapy
2. Formation of microscopic papillary projection or tufts arising
1. Confirmed to be Stage IA
from the epithelial lining of the papillae
2. Extensive histologic sampling of the tumor confirms it to be
3. Epithelial pleomorphism
borderline tumor
4. Atypicality
3. Contralateral ovary appears normal
5. Mitotic activity
4. Biopsy specimens of areas of omental or peritoneal nodularity
6. No stromal invasion present
are negative
• Note: At least 2 of these features must be present to qualify
5. Results of peritoneal cytologic tests are negative for tumor
as borderline
cells

Advanced stage
• Complete surgical extirpation of the tumor
• Same as bilateral involvement plus:
o Pelvic lymphadenectomy
o Tumor debulking
o Extensive biopsy of any peritoneal or omental
implants
o The role of chemotherapy is still controversial

OVARIAN CARCINOMA

Epidemiology
Epithelial Ovarian Cancers
Ovarian Cancer in the Philippines • Constitute 85-90% of ovarian cancers
• 5th leading site among women 5%. • Histologic distribution in USA:
• In 2010, there will be 2,165 new cases and 1,016 deaths. o Serous cystadenocarcinomas = 42%
• Incidence starts rising steeply at age 40. o Mucinous cystadenocarcinoma = 12%
2010 Cancer Facts and Figures o Endometrioid carcinoma = 15%
o Undifferentiated carcinoma = 17%
Primary Ovarian Neoplasms Related to Age o Clear cell carcinoma = 6%
• In general, more than half of ovarian carcinomas occur in
women older than 50. Risk Factors for EPITHELIAL Ovarian Cancer
• The risk of malignancy in a primary ovarian tumor increases to
approximately 33% in women older than 45, whereas it is less Putative Assoc of ↑ing and ↓ing Risks of Ovarian EPITHELIAL Ca
than 1 in 15 for women 20-45 years of age. Increases   Decreases  
Age Breast-feeding
Type <20 yr 20-50 yr >50 yr
Diet Oral contraceptives
(%) (%) (%)
Family history Pregnancy
Coelomic epithelium 29 71 81 Industrialized Tubal ligation and hysterectomy with
Germ cell 59 14 6 country ovarian conservation
Specialized gonadal- 8 5 4 Infertility
stromal Nulliparity
Non-specific mesenchyme 4 10 9 Ovulation
Ovulatory drugs
Talc (?)

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Med3C Dr. D.L. Reyes – Ovarian Ca Gyne

Genetic  
• A strong family history of either breast or ovarian II.    Site-­‐specific  ovarian  cancer    
cancer is the most important risk factor for the • Linked to BRCA 1 mutation
development of epithelial ovarian cancer. • Excess of ovarian CA but not breast CA
• ~10-15% of all epithelial ca have hereditary predisposition.
III.  Hereditary  Non-­‐Polyposis  Colon  Cancer  (HNPCC)  Syndrome  or  Lynch  
I.  Breast  -­‐  ovarian  cancer  family  syndrome   Syndrome  II    
• Lifetime risk of ovarian cancer in women w/germline mutation • Accounts for only ~1% of all ovarian cancers.
o BRCA1 approaches 40%. • Cumulative incidence is 12%.
o BRCA2 ranges 10-20%.

Hormone Related Relation to Risk

Reproductive Factors (Parity & Reduces if ↑parity ≥5
Pregnancy)
Lactation Confers protection against; most significant with duration of 18+ mos
Use of OCP Confers long-term protection against
Age at menarche and menopause Weak predictors
Exogenous Hormones (fertility DOES NOT ↑ risk except in assoc w/borderline serous tumors.
drugs)
Use of HRT Increased if long-term use of unopposed estrogen and/or estrogen plus progestin (sequential).
Gynecologic Related Cond’n & Surgery Relation to Risk
Tubal Ligation and hysterectomy Ligation confers reduction; hysterectomy also but to a less degree.
Polycystic Ovarian Disease Less extensively evaluated but points to an increased risk.
Endometriosis Increased esp endometrioid and clear cell types.
Pelvic Inflammatory Disease Positively associated
Environmental & Lifestyle Relation to Risk
Physical Activity At best a weak to modest protection against
Caffeine and Tea intake Caffeine: not very well-established
Tea: may reduce risk
Alcohol Consumption (moderate) NO association
Talc (perineal) and others NO causal relationship
Dietary factors (high meat, fat) May increase
Obesity (early adult, adult) Increased
Cigarette smoking (current/active) Increased for devt of MUCINOUS epithelial ovarian cancer but not the other histologic types;
cessation returns risk to normal in long term

Etiology of Ovarian Cancer

Theory of “Incessant Ovulation”
• Risk of EOC is related directly to the number of uninterrupted
ovulatory cycles
• Surface epithelium is ruptured and undergoes rapid
proliferation and repair
• Invagination of the surface epithelium into the underlying
stroma forming inclusion cysts
• Epithelium lining these inclusion cysts undergoes neoplastic
transformation under the influence of oncogenic factors
• ↑: Early menarche, late menopause
• ↓: Tubal ligation, hysterectomy

Gonadotropin Hypothesis
• Exposure of ovarian epithelium to persistently high levels of
pituitary gonadotropins
Clinical Presentation
• FSH promote growth of epithelial ovarian cancer cells in vitro
• Increase gonadotropin levels
Characteristics in Benign and Malignant Ovarian Tumors
• Promotes estrogen biosynthesis in the ovarian stroma Clinical Finding Benign Malignant
• Causes abnormal proliferation of the adjacent epithelium Unilateral +++ +
• ↑: Breastfeeding, pregnancy, OCP’S Bilateral + +++
• ↓: Fertility pills? Cystic +++ +
Solid + +++
Routes of spread Mobile +++ ++
• Ceolomic spread – thru peritoneal surfaces of both the Fixed + +++
parietal and intestinal areas, as well as the under surface of Irregular + +++
the diaphragm. Smooth +++ +
• Lymphatic route - para-aortic nodes are at risk through Ascites + +++
lymphatics that run parallel to the ovarian vessels Cul-de-sac - +++
• Hematogenous spread Nodulations

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Med3C Dr. D.L. Reyes – Ovarian Ca Gyne

Most Frequent Presenting Symptoms of Ovarian Cancer

Symptom Relative frequency Additional diagnostic methods
• CT scan
Abdominal swelling XXXX
• MRI
Abdominal pain XXX • Barium enema or Colonoscopy
Dyspepsia XX
Urinary frequency XX Prognosis
Weight change X Prognostic Factors
• Note: Sx are vague and not specific for ovarian cancer • Tumor stage
• A high index of suspicion is warranted in all women btwn ages • Tumor grade
of 40-69 yo w/persistent GI sx that cannot be diagnosed. • Cell type
• Amount of residual tumor after resection
Diagnostic Techniques
Routine pelvic Detect only 1 ovarian cancer in 10,000 asx Treatment
exam women • Staging is surgical and based on the operative findings at
Routine lab test Not of great value in dx of ovarian tumors; the commencement of the procedure
Major value is in ruling out other pelvic dsos
Surgical Ultimate test as to nature of dso Staging Laparotomy
exploration • Midline longitudinal incision
• Peritoneal fluid cytology
Tumor Markers in Ovarian Cancer • Systematic exploration of the abdominal cavity
• Carcinoma Antigen 125 (CA-125 ) – for epithelial tumors • TH with bilateral salpingo-oophorectomy
• Human Epidydimis protein 4 (HE4) – better than CA-125 • Infracolic omentectomy
• Carcino-embryonic antigen (CEA) – better for mucinous • Lymph node evaluation (Pelvic and Para aortic )
• Alpha-feto protein (AFP) – for germ cell tumors • Random biopsy of abdominal peritoneum & suspicious areas
• Lactic dehydyhrogenase (LDH) – for germ cell tumors • Tumor Debulking
• Human chorionic gonadotrophin (hCG) – for germ cell tumors
Treatment options
CA  125  and  Ovarian  Cancer   Surgery    
• Expressed in ~80% of ovarian epithelial cancers but less • Removal of all resectable disease
frequently by mucinous types • Interval debulking surgery
• ↑in tubal, endometrial, lung, breast and pancreatic cancers Post-­‐operative  or  Adjuvant  therapy  
• Increased in benign conditions • Chemotherapy
o Endometriosis • Radiation therapy
o Peritoneal inflammation, including PID • Immunotherapy
o Leiomyoma
o Pregnancy Conservative surgery
o Hemorrhagic ovarian cysts • Unilateral Salpingo-Oophorectomy
o Liver disease Criteria  
• Better specificity for increased values in postmenopausal pts ü Stage IA
ü Well-differentiated tumor
Role of Ultrasound in Ovarian Cancer ü Peritoneal fluid cytology is negative for malignant cells
• Helped to define criteria to allow conservative follow-up ü Omentum and peritoneal biopsies are negative for metastasis
and risk of malignancy of some adnexal masses ü Young woman desirous of pregnancy
• Scoring systems have been proposed; parameters used:
o Unilocular or complex cysts Stage Specific Treatment
o Papillary projections Stage I: tumor confined to ovaries
o Regular and smooth septa and/or cystic walls • IA. Limited to one ovary
o Echogenicity o No tumor on surface
o Doppler color-enhanced flow o Negative washings
• Used to characterize ovarian mass as benign or o Capsule intact
malignant, rather than for screening o No ascites present containing
• IB: Both ovaries
Ultrasound  Findings    Suggestive  of  Ovarian  Malignancy   o Rest same as above
• Irregular borders • IC: 1 or both ovaries
• Papilations o IC1: Surgical spill
• Thick septations o IC2: Capsule rupture before surgery or tumor on surface
• Ascites o IC3: Malignant cells in ascites or peritoneal washes
• Matted bowel

Ultrasound and Ovarian Cancer

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Med3C Dr. D.L. Reyes – Ovarian Ca Gyne

Stage II: Tumor involves 1 or both ovaries with pelvic extension
(below pelvic brim) or primary peritoneal cancer
• IIA: Extension and/or implant on uterus and/or fallopian tubes
• IIB: Extension to other pelvic intraperitoneal tissues
Other major recommendations
• Designate
o Histologic type including grading - at staging
o Primary site (ovary, Fallopian tube or peritoneum) -
where possible
• Tumors that may otherwise qualify for stage I but involved
with dense adhesions justify upgrading to stage II if tumor
cells are histologically proven to be present in the adhesions

Comparison of Surgical Findings of Benign & Malignant Ovarian

Findings Benign Malignant
Surface papilla Rare Very common
Intracystic papilla Uncommon Very common
Solid areas Rare Very common
Stage III: Tumor involves 1 or both ovaries with cytologically or
Bilaterality Rare Common
histologically confirmed spread to the peritoneum outside the
pelvis and/or metastasis to the retroperitoneal lymph nodes Adhesions Uncommon Common
• IIIA: (+) Retroperitoneal LN and/or MICROscopic metastasis Ascites (100 ml or more) Rare Common
beyond pelvis Necrosis Rare Common
o IIIA1: (+) Retroperitoneal LN only Peritoneal implants Rare Common
§ IIIA1(i): Mets >10mm
§ IIIA11(ii): Mets >10mm Capsule intact Common Infrequent
o IIIA2: Microscopic, extrapelvic (above the brim) Totally cystic Common Rare
peritoneal involvement ± (+) retroperitoneal LN
• IIIB: MACROscopic, extrapelvic, peritoneal metastasis ≤2 cm ± Intraoperative Findings
(+) retroperitoneal LN. Includes extension to capsule of
liver/spleen
• IIIC: Macroscopic, extrapelvic, peritoneal metastasis >2 cm ±
(+) retroperitoneal LN. Includes extension to capsule of
liver/spleen

Stage IV: Distant metastases – pleural effusion, liver parenchyma

• IVA: Pleural effusion w/(+) cytology
• IVB: Hepatic and/or splenic parenchymal metastasis,
metastasis to extra-abdl organs (incl inguinal LN and LN
outside abdl cavity) Adjuvant therapy
• Chemotherapy
o Depends on the stage, tumor grade and histologic
type
§ Epithelial : Carboplatin and Paclitaxel (or
Docetaxel)
§ Germ Cell Tumor and SCT : Bleomycin,
Etoposide and Cisplatin ( BEP ), Vincristine,
Actinomycin D and Cisplatin ( VAC )
• Radiotherapy
• Immunotherapy

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Med3C Dr. D.L. Reyes – Ovarian Ca Gyne

GERM CELL TUMORS OF THE OVARY

• Derived from germ cells of the ovary
nd
Teratoma
• 2 most frequent type of ovarian neoplasms – 20- • Tissues that recapitulate – ecto-, meso- and endo-derm
25% of all • Usu XX karyotype
• 97% are benign and only 3% are malignant
• Most occur in young women Benign Cystic Teratomas (Dermoids)
nd rd
• Mostly in the 2 and 3 decades of life • THE MOST COMMON germ cell tumor – 25% of all ovarian
• Staged surgically as with epithelial types neoplasms
• Certain histologic types secretes a specific tumor marker • Primarily in reproductive years, but may occur in
• A single tumor may contain a mixture of histologic types postmenopausal & children
• Usually unilateral (except teratomas and dysgerminomas) o ↑Risk for malignancy in postmenopause
• Ability to reproduce adult tissue – skin, bone, teeth, hair,
Box 33-3 WHO Classification of Germ Cell Tumors dermal tissue
*Common • Usu unilateral (10-15% bilateral)
• *Dysgerminoma - Most frequent malignant germ cell • Outside wall smooth
tumor – 45% of malignant GCTs; most • Yellowish appearance c/b sebaceous fatty material
radiosensitive? • Prominent hair
rd
o *Endodermal sinus tumor – 3 most common; • Usu asx
worst prognosis o Pain if torsion or perforation (reactive peritonitis)
o Embryonal carcinoma o Rare, severe complication can occur during
o Polyembryoma pregnancy
o Choriocarcinomas – worst prognosis • Tx: cystectomy or unilateral oophorectomy
o *Teratomas – most common of all o Open laparotomy
§ Immature (Solid, Cystic, or both) o Inspect contralateral ovary
§ Mature o If postmenopausal à TAHBSO
• Solid
• Cystic Treatment options
o Mature cystic teratoma
• Surgery:
(dermoid cyst)
o Extent of primary surgery is dictated by the findings
o Mature cystic teratoma
at surgery and the reproductive desires
(dermoid cyst) with
§ USO = if preservation of fertility is desired;
malignant
one ovary
transformation
• With tumor debulking
o Monodermal or highly specialized
§ THBSO = if childbearing has been
§ Struma ovarii
completed
§ Carcinoid
• Chemotherapy - tremendous advances have been made that
§ Struma ovarii and carcinoid
even in advanced malignancies an excellent chance at long
§ Others
term control cure
• Mixed forms (tumors composed of types in any combination)
• Radiotherapy - rarely used today

SEX CORD-STROMAL TUMORS OF THE OVARY

• Originate from the ovarian matrix (sex cords of the ovary and
the specialized stroma of developing gonad)
th th th
• Incidence increasing in the 5 , 6 and 7 decades
• Approximately 90% of hormonally active ovarian tumors
• Have propensity for indolent growth, tend to recur late
Management
• Surgery is adequate treatment in most cases
o USO = for those who are desirous of fertility
preservation and are Stage Ia
o THBSO = for advanced stage and older women
• Stage Ic or higher:
o Adjuvant therapy: Radiation or Chemotherapy

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Med3C Dr. D.L. Reyes – Ovarian Ca Gyne

CASES
Case 1 Case 3
• 55 year old, postmenopausal woman A 45 y/o G1P1 underwent exploratory laparotomy because of an
• Consulted because of rapid abdominal enlargement ovarian mass. Intraoperative finding were: the ovary was enlarged
associated with weight loss of 8 lbs of 2 months to 20 x 11 cm with smooth external surface, which on cut section
duration. showed multiple papillary growths; the uterus, both tubes and
• Pertinent PE findings are: pallor, abdominal girth of 89 cm contralateral ovary was grossly normal; omentum was grossly
with positive fluid wave and shifting dullness, with a normal but showed metastatic cells on microscopic examination;
vague pelvo abdominal mass. the abdominal peritoneum, liver and diapragm are free of tumor.
• Pelvic exam: PFC was positive for malignant cells.
• Normal external genitalia, Parous vagina
• Cervix: firm, close and slightly movable, the lower pole of a What is the Stage of Ovarian Cancer? Ovarian Carcinoma, Stage
mass is palpable at the cul-de-sac which seems solid IIIA
and slightly movable.
• The uterus and adnexa can not be fully assessed because of Case 4
the massive ascites. A 19 year old nulligravid consulted because of abdominal
enlargement of 1 month duration. Pertinent PE findings: abdomen
Diagnosis: Ovarian New Growth, probably Malignant is globularly enlarged with a solid, movable non-tender mass about
Basis of diagnosis: 8 x 10 cm. Rectal exam showed an unenlarged uterus with a right
• Rapid enlargement of the mass adnexal mass, predominantly solid with cystic areas, movable and
• Weight loss nontender.
• Massive ascites
• Solid mass with limited mobility What is your impression? Ovarian Newgrowth probably malignant,
probably Germ Cell Tumor
Diagnostic work-up: What work-up/s is/are necessary to arrive at a proper diagnosis?
• Ultrasonography: Transvaginal and Transabdominal Diagnostic work-up:
o Differentiate solid from cystic, detect omental and • Ultrasonogram
liver metastasis • Tumor markers: AFP, hCG, LDH
o Differentiate between ascites and intracystic fluid • Blood exams
• Hematologic exams: CBC and Platelet count, Blood What is the management?
chemistries • Exploratory laparotomy, USO with Frozen section of the ovary
• MRI or CT Scan: o If malignant: lymphadenectomy, PFC, Infracolic
o Detect other organ involvement – also LN omentectomy, random biopsy of peritoneum,
involvement adhesions and suspicious areas for metastasis
Treatment
• Surgery in Ovarian Cancer

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

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