Ovarian cancer

Question 1

What is stage 1 ovarian cancer?

Answer 1

confined to the ovary or fallopian tubes

Stage 1A: limited to 1 ovary or tube, capsule intact, negative cytology

Stage 1B: both ovaries/tubes involved. capsule intact, tubal surface free.

Stage 1C1: +surgical spill
Stage 1C2: +capsule ruptured or tumor on ovarian/fallopian tube surface
Stage 1C3: positive washings.

Question 2

What is stage 2 ovarian cancer?

Answer 2

spread to pelvis below pelvic brim or primary peritoneal cancer

stage 2A: spread/implants to uterus
Stage 2B: spread to over pelvic intraperitoneal tissues.

Question 3

What is stage 3 ovarian cancer?

Answer 3

positive microscopically peritoneal metastasis outside pelvis or positive retroperitoneal nodes (pelvic or para-aortic).

3A: +retroperitoneal nodes
3A1: + nodes only
3A2: microscopic spray outside pelvis (above pelvic brim)

3B: macroscopic peritoneal spread beyond pelvis <2cm
3C: macroscopic peritoneal spread >2cm, capsule of liver/spleen

Question 4

What is stage 4 ovarian cancer?

Answer 4

Distant metastasis (Excludes peritoneal mets)

4A: pleural effusion with + cytology
4B: parenchymal disease (eg liver, spleen) +/- extra abdominal disease

Question 5

What are features that increase changes of malignancy?

Answer 5

Old age
bilateral mass
solid
complex
excrescences (papillary projections)
septations
bloody fluid
size >10cm
duration (persistent mass, DOES NOT reduce w/ menses or OCP)

Question 6

What is the differential diagnosis for a solid tumor?

Answer 6

Fibroid
Thecoma
Fibroma
Brenner
Granulosa cell tumor
Dysgermimoma

Question 7

What is the differential diagnosis for a cystic tumor?

Answer 7

Functional cyst
Serous and mutinous tumor
Mature cystic teratoma
Endometrioma

Question 8

Rates of bilaterally of ovarian tumors

Answer 8

germ cell tumor (5-10%), exception is gonadoblastoma (40%)
- Fibroma 10%
- Serous carcinoma 66%
Mutinous carcinoma 20%
- Krukenberg 100% (mets from GI tract)
-Epithelial ovarian cancers: 20-25%, most are mets from one ovary (primary). Serous more likely to be bilateral than mucinous

• Mucinous adenoma: 0%
• Mucinous adenocarcinoma 10%
• Serous adenoma 10%
• Serous adenocarcinoma 66%

Question 9

What is Ca-125?

Answer 9

tumor marker for serous epithelial tumors

Causes of false positives:
- appendicitis, cholecystitis, PID, fibroids, endometriosis, diverticulosis (anything ends in “itis” or “osis”

Causes of false negatives: CEA - mucinous epithelial tumors, 50% of stage 1 epithelial ovarian malignancies have normal Ca-125!

Question 10

What is AFP?

Answer 10

endodermal sinus tumors (yolk sac) and embryonal tumors

Question 11

What is HCG?

Answer 11

Choriocarcinoma, embryonal carcinoma, dysgermimoma

Question 12

What is estrogen?

Answer 12

Granulosa cell tumor

Question 13

What are androgens?

Answer 13

theca, fibroma, sertoli-leydig cell

Question 14

What is inhibin?

Answer 14

Granulosa cell tumor

Question 15

What is LDH

Answer 15

dysgermimoma

Question 16

What is the criteria for a borderline tumor?

Answer 16

Epithelial stratification
Papillations
Nuclear atypia
NO STROMAL INVASION

Question 17

What is a dysgermimoma?

Answer 17

Most common type of malignant germ cell tumor.
- “fried eggs” on histo path: lymphocyte infiltrated storm w/ large vesicular cells

Chemosensitive - BEP regimen (bleomycin/etoposide/cisplatin).

2/3 diagnosed at Stage 1A

tx=USO and limited staging to spare fertility since most of patient are young/desirous of fertility. follow w/ serial tumor markers (LDH and hCG).

10-15% can be bilateral.

Question 18

What is a granulosa cell tumor?

Answer 18

Histology: call-exner bodies. Coffee bean nuclei (also seen in Brenner tumor).
- secretes estrogen and inhibin
- low malignant potential, arises from sex cord stromal cells.
- surgery alone=tx, most are stage 1A.

Question 19

Random

Answer 19

ovarian cancers associated with dysgenic gonads in presence of Y chromosome: dysgermimoma & gonadoblastoma.

Any HUGE ovarian tumor likely to be a benign mucinous cyst adenoma.

• cancer=breach of basement membrane.

Question 20

What are coffee bean nuclei associated with?

Answer 20

Granulosa cell tumor/Brenner tumor

Question 21

What are Schiller Duval bodies associated with?

Answer 21

Endodermal sinus tumor (yolk sac)

Question 22

What are call-exner bodies associated with?

Answer 22

Granulosa cell tumor (call-girl!)

Question 23

What are psamomma bodies associated with?

Answer 23

low-malignant potential tumors
serous tumors (body builders are serious!)
clear cell

Question 24

What does “cellular proliferation w/ nuclear atypia” suggest?

Answer 24

low malignant potential tumor

Question 25

What are sex cord stromal ovarian tumors?

Answer 25

3-5% of ovarian tumors
- Granulosa cell (call Exner, coffee bean nuclei)
- Fibroma (thecoma elements, w/ Meig syndrome)
- Thecoma (produce estrogen)
- Sertoli-Leydig (testicular gonad, crystal of Reinke, testosterone production)
- Lipid cells (testosterone)
- Gonadoblastoma (both ovarian + testicular components, patients who have dysgenetic gonads like Turner’s, MALIGNANT)

Question 26

What are germ cell tumors?

Answer 26

1/3 of all ovarian neoplasms. most common gyn malignancy in pre-adolescents.
most are unilateral, do fertility sparing surgery - USO.
- Dermoid (mature cystic teratoma)=most common subtype.

• Malignant:
• dysgermimoma
• yolk sac tumor
• immature teratoma
  Others: Choriocarcinoma, endodermal sinus, gonadoblastoma (malignant only if associated dysgermimoma elements)

Question 27

How do you workup pt with constipation, bloating, poor appetite. pelvic uS w/ complex mass and elevated CA-125?

Answer 27

• workup for mets: CT/MRI, CXR, CMP
• refer to gyn onc
• if concern for cancer, on imaging, need laparoscopy for adequate staging.