Primary ovarian neoplasms are tumours that arise from the ovaries, fallopian tubes, or peritoneum. Malignant ovarian tumours are one of the deadliest cancers because they present with vague symptoms and are often diagnosed late.
Classification of ovarian tumours
| Category | Description | Examples |
|---|---|---|
| Ovarian epithelial tumours (65 – 70%) | These are derived from the ovarian surface epithelium. They are slow growing and usually advanced at diagnosis (Stage IIIC is the most common stage). They are associated with BRCA mutations. | Serous cystadenoma, serous cystadenocarcinoma, mucinous cystadenoma, mucinous cystadenocarcinoma, endometriod carcinoma, clear cell carcinoma, and Brenner tumour |
| Ovarian germ cell tumors (< 15 – 20%) | These are derived from germ (egg) cells. They are common in women < 20 years old and are rapidly growing. They are commonly diagnosed at stage 1 | Immature teratoma, mature teratoma, monodermal teratoma, dysgerminoma, endodermal sinus tumour, choriocarcinoma, embryonal carcinoma, and polyembryoma |
| Sex cord-stromal tumours (5 – 10%) | These are derived from hormone producing cells in the interstitium of the ovary. They produce hormones which cause symptoms that may not be seen with other tumours. | Granulosa-theca tumour, sertoli-leydig tumour, and fibroma |
Benign vs malignant ovarian masses
| Benign ovarian mass | Malignant ovarian mass | |
|---|---|---|
| Size | < 8cm | > 8cm |
| Consistency | Cystic | Solid or mixed |
| Solid component | None | Nodular or papillary |
| Sepatations | None or single | Multilocular and thick |
| Doppler | Negative | Positive |
| Laterality | Unilateral | Bilateral |
| Associated features | Calcification | Ascites, peritoneal metastases, and lymphadenopathy |
Ovarian tumor markers
| Tumor | Tumor marker |
|---|---|
| Epithelial | CA-125 |
| Dysgerminoma | LDH |
| Endodermal sinus tumor | AFP |
| Choriocarcinoma | hCG |
| Embryonal carcinoma | AFP + hCG |
Staging ovarian cancer by surgical laparotomy
| Diagnosis | 5-year survival | ||
|---|---|---|---|
| Stage I | Confined to ovaries | 28% | 92% |
| IA | 1 ovary | ||
| IB | 2 ovaries | ||
| IC | 1 or 2 ovaries + Capsule rupture/Tumor at suface/Malignant ascites | ||
| Stage II | 1 or 2 ovaries + pelvic extension | 8% | 70% |
| IIA | Uterus/Tubes | ||
| IIB | Other pelvic organs | ||
| IIC | A/B with Malignant ascites | ||
| Stage III | 1 or 2 ovaries + Peritoneal Mets/Regional lymph nodes | 50% | 39% |
| IIIA | Micro peritoneal mets | ||
| IIIB | Macro < 2cm peritoneal mets | ||
| IIIC | Macro > 2cm peritoneal mets/ regional LNs mets | ||
| Stage IV | Distant mets beyond peritoneal cavity | 13% | 17% |
- Risk factors
- Advanced age (postmenopausal)
- Family history of ovarian or breast cancer
- Nulliparity
- Early menarche
- Late menopause
- Obesity
- Endometriosis
- Smoking
- Hormone replacement therapy
- Perineal talc use
- Protective factors
- Oral contraceptives
- Multiparity
- Breastfeeding
- Tubal ligation
- Salpingectomy
- Associated conditions
- BRCA1/BRCA2 mutations
- Li-Fraumeni syndrome (TP53)
- Peutz-Jeghers syndrome (STK11)
- Lynch syndrome
- Signs and symptoms
- Asymptomatic until advanced
- Vague lower abdominal pain
- Abdominal distension
- Bloating
- Early satiety
- Pelvic pressure
- Increased frequency and urgency
- “Sister Mary Joseph Nodule” represents metastasis to umbilicus
- Meigs Syndrome
- Ovarian tumor
- Ascites
- Right hydrothorax
- Physical exam finding
- Solid, fixed, irregular pelvic mass
- Investigation
- Ultrasoun dis the first line investigation
- Multiple septations
- Cystic and solid components
- Larger than cysts > 7cm
- Neovascularization
- CA-125 titres for post-menopausal women
- Abdominopelvic CT to planning treatment
- Laparotomy for staging and treatment
- Ultrasoun dis the first line investigation
- Treatment
- ≤ Stage IB
- Laparotomy
- Peritoneal washings or aspiration of free ascitic fluid
- Palpation of peritoneal surfaces
- Extrafascial hysterectomy and BSO
- Unilateral SO can be done for young women with cancer confined to one ovary
- Peritoneal biopsy
- Pelvic and infrarenal para-aortic lymphadenectomy
- ≥ Stage IC
- Chemotherapy (platinum based)
- Dialysis or nephrostomy tubes for hydronephrosis
- Follow-up with regular pelvic exams and CA-125 titres
- ≤ Stage IB