• Clinical science

Ovarian tumors

Summary

The ovaries consist of different kinds of tissue (epithelial, germ cells, and sex cord tissue), which may give rise to benign or malignant tumors. Symptoms depend on the type of tissue affected and range from local abdominal discomfort to endocrinological phenomena caused by hormone-producing tumors. Metastases of other tumors and lymphomas may also affect the ovaries. The most common malignant tumor of the ovaries is serous ovarian cancer, which (with the exception of those who are genetically predisposed) mostly affects older women. The lack of early symptoms of ovarian cancers often delays diagnosis, resulting in an unfavorable prognosis. Ovarian cancers primarily metastasize intraperitoneally and later become noticeable mostly due to increasing abdominal girth caused by malignancy-related ascites. Treatment generally involves radical surgical removal of the tumor and chemotherapy.

Epidemiology

  • Lifetime prevalence of malignant ovarian cancer: 1–2%
  • Peak incidence: 60–70 years
  • Genetic predisposition may play a role in familial incidence and in younger patients (< 30 years) developing tumors.
  • Epithelial ovarian carcinomas account for 70% of all ovarian malignancies.

References:[1][2][3]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Risk factors

References:[4][2][3]

Overview of ovarian tumors

Epithelial Tumors

Epithelial ovarian tumors may be benign, malignant, or borderline!

Germ cell tumors

Sex cord-stromal tumors of the ovary

Metastasis

References:[4][2][3][5][6][7]

Clinical features

General symptoms

The first symptom is often increasing abdominal girth (clothes no longer fit at the waist)!

Specific symptoms

References:[1][2][3][5][6][8]

Diagnostics

Fine needle aspiration cytology is absolutely contraindicated in ovarian tumors because it increases the risk of spreading tumor cells to the peritoneum!

Call your Ex and Grandparents! – Call-Exner bodies are characteristic of Granulosa cell tumors.

Ultrasound workup of ovarian masses
Benign Malignant
Internal structure Uniform, thin walls Irregularly thickened septa
Margins Smooth Indistinct borders; papillary projections
Echogenicity Anechoic Hypoechoic, anechoic, and hyperechoic components
Content Cystic Cystic or solid components
Vascularization Unremarkable Possible central vascularization
Pouch of Douglas Unremarkable Possible free fluid (ascites)

References:[5][6][9]

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Treatment

  • Surgery
    • Frozen section and histology positive for carcinoma: radical surgical staging
      • Removal of the greater omentum
      • Lymphadenectomy
      • Hysterectomy with bilateral salpingo-oophorectomy
      • Appendectomy if involvement is suspected during surgery
      • Biopsy from all noticeable locations/adhesions
    • Frozen section negative for carcinoma: tumor resection, but no surgical staging
  • Chemotherapy
    • Indicated for all patients as adjuvant therapy
    • First-line therapy: carboplatin; polychemotherapy and antimitotics (e.g., paclitaxel)
    • Radiation therapy: rarely used due to the intraperitoneal location and low radiosensitivity of the tumor

Malignant germ cell tumors respond particularly well to polychemotherapy because they are highly aggressive!

References:[5][6]

Prognosis

Ovarian carcinoma

  • Very poor overall prognosis as a result of late diagnosis
  • 5-year survival rate of all ovarian carcinomas: ∼ 30–40%
FIGO Anatomic extension 5-year survival rate
I Limited to one or both ovaries 80–90%
II Infiltration of lesser pelvis 60–70%
III Extension outside pelvis 30–50%
IV Distant metastases 10–20%

References:[5]

Prevention

References:[10]

Special patient groups

Pregnant women

  • Pregnancy luteoma
    • Definition: : rare benign tumors that develop specifically during pregnancy.
    • Clinical features
      • The majority of patients are asymptomatic.
      • When clinically apparent, it typically manifests with symptoms of virilization during pregnancy.
    • Diagnostics: tumor often diagnosed incidentally (during cesarean delivery)
      • Apparent as solid adnexal masses (unilateral or bilateral; usually nodular)
      • The size of the tumor is usually < 10 cm in diameter.
    • Treatment: observation only; regresses spontaneously post-partum
  • Theca lutein cysts

If surgical removal of an ovarian tumor is indicated during pregnancy, surgery should, if possible, be scheduled for after the 10th week of gestation, as the secretion of progesterone by the corpus luteum is essential for the maintenance of the pregnancy. The placenta takes over this function from approximately the 10th week of pregnancy onwards.

References:[11][12][13][14]