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