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Cancer Of Ovary

Ultrasound Characteristic of benign vs Malignant Ovarian Tumors

Physical examination

Benign tumor

 Malignant tumor



Fixed, large and multi locilated



Solid or firm





Smooth on PN examination

Nodular on PN examination



Usually < 10 cm size

Any size


< 2 mm thickness

Multiple septations > 3 mm in size


Seen in teratoma

Usually absent

Omental caking







Unilateral cyst with no

Solid areas with adhesion,



rupture may occur.


Capsule intact

Capsule is breached

Risk of Malignancy index (RMI) Scoring Systems

Feature RMII Score RMI2 Score
Ultrasound features: 0 = None 0 = None
• Multilocular cyst 1 = One abnormality 1 = One abnormality
• Solid areas 3 =Two or more abnormalities 4 = Two or more abnormalities
• Bilateral lesions
• Ascites
• Intra-abdominal metastases
Premenopausal 1 1
Postmenopausal 3 4
CA125 U/mL U/mL
RMI score == Ultrasound score x Menopausal score x CA125 level in U/mL

Risk Factors for developing Ovarian Cancer
N = Nulliparity
O = Ovulation induction by Clomiphene/ Gonadotropins
C = Cackasian
H = Family history
I = Increased age (> 60)
L = Late menopause, early menarche
D = Delayed child bearing

Women with first degree relative with ovarian cancer have a 5% lifetime risk of developing the disease and those with two first degree, relatives with ovarian cancer have a 7% risk.
Women with BRCA gene mutations have a life time risk of breast cancer of 82%,
BRCA 1 → Ovarian cancer 25-60%
BRCA2 → Ovarian cancer 15-25%

In women with BRCA 1 and BRCA2 mutations, chances of ovarian cancer can be reduced by prophylactic bilateral Salpingo oopherectomy on completion of childbearing or 35 years of age.

Classification of Ovarian Cancer

Ovarian Cancer


Frequency (%)


Age Group


Celomic epithelium


Serous, mucinous

endometrioid, clear cell,

Brenner undifferentiated



(45+ years)







Sex cord stromal

Gonadal stromal


Granulosa cell tumor,

Sertoli-Leydig tumor

Reproductive (20-40





Germ cell tumors

Primitive germ cells


Dysgerminoma, endodermal

sinus tumor, embryonal,

teratoma, chorio CA


(15-20 years)













Serous cyst adenoma accounts for 40%of ovarian tumors, it is bilateral in 40%cases, and it can turn malignant (adenocarcinoma) in 40% cases. It is the MC ovarian tumor.


Mucinous cyst adenoma is the largest benign ovaria; tumor.

Extra Edge:

  • Only 19% of ovarian cancers (epithelial cancers) are recognised while disease is localised stage approx 70% are diagnosed in stage III.
  • Symptoms - Nonspecific like bloating, early society, weight loss, constipation, arorexia.
  • Physical examination - Most I portant sign is presence of a pelvic mass.

Etiology of Epithelial Ovarian Cancer


Theory of incessant ovulation = the more the ovulation, the more the risk

Risk factors:

  • Advancing age (average age 60 years)
  • Early menarche and late menopause
  • Family history of ovarian cancer
  • Incessant ovulation (greater risk if more ovulatory cycles)
  • Personal / family history of breast CA
  • Multiple cycles of gonadotropins/clomiphene citrate for ovulation induction
  • Talc and asbestosis
  • Low parity

Hereditary Breast, Ovarian Cancer

  • Most hereditary ovarian CA is associated with mutations in BRCA 1 (tumor-suppressor gene) gene located on
  • Chromosome 17. Small proportions have mutations in BRCA 2 gene located on chromosome 13.
  • The mutations are inherited in an autosomal-dominant pattern.
  • Hereditary ovarian CAs occur in women approximately 10 years younger than those with nonhereditary tumors














Lynch II Syndrome


It includes multiple adenocarcinomas and involves a combination of familial colon CA (Lynch I); a high-rate of ovarian, endometrial, breast CAs; and hereditary nonpolyposis coli. It is associated with DNA-mismatched repaired gene abnormalities.

Factors Reducing the Risk of Ovarian Cancer

  • Use of OC pills/DMPA (since they cause anovulation)
  • Multiparity
  • Breast feeding
  • Pregnancy
  • Anovulation

Management Options in High-risk Women (BRCA1/2 Carriers)

  • 6 monthly TVS
  • OCPs (when not interested in fertility)
  • Prophylactic oophorectomy (as soon as family is completed)
  • Annual mammography

Figo Staging for Ovarian Cancer (Surgical)

Stage I

Growth limited to the ovaries

Stage Ia

Growth limited to one ovary; no ascites containing malignant cells

No tumor on the external surface; capsule intact

Stage Ib

Growth limited to both ovaries; no ascites containing malignant cells

No tumor on the external surfaces; capsules intact

Stage Ic

Tumor either stage la or lb but with tumor on the surface of one or both ovaries; or with capsule ruptured; or with ascites present containing malignant cells or with positive peritoneal washings

Stage II

Growth involving one or both ovaries with pelvic extension

Stage IIa

Extension and/ or metastases to the uterus and/ or fallopian tubes

Stage IIb

Extension to other pelvic tissues (includes pelvic L nodes)

Stage IIc

Tumor either stage IIa or Ilb but with tumor on the surface of one or both ovaries; or with capsule(s) ruptured; or with ascites present containing malignant cells or with positive peritoneal washings.

Stage III

Tumor involving one or both ovaries with peritoneal implants outside the pelvis and/ or positive retroperitoneal or inguinal nodes. Superficial liver metastasis and proven malignant extension to small bowel or omentum (all reference to L nodes are with respect to extrapelvic L nodes)

Stage IIIa

Tumor grossly limited to the true pelvis with negative nodes, but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces

Stage IIIb

Tumors of one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces, none exceeding 2 cm in a diameter. Nodes negative

Stage IIIc

Abdominal implants >2 cm in diameter or positive retroperitoneal or inguinal nodes or both

Stage IV

Growth involving one or both ovaries with distant metastasis. If pleural effusion is present, there must be positive cytologic test results to allot a case to stage IV. Parenchymal liver metastasis equals stage IV



  • Superficial liver mets = stage 3
  • Parenchymal liver mets = stage 4
  • Inguinal lymph nodes involvement with CA ovary = stage 3c
  • Inguinal lymph nodes involvement with CA endometrium - stage 4b

Extra Edge:


Inguinal lymph nodes are involved in- Ca ovary-stage IIIC Ca Endometrium-stage IVB Ca Cervix-not involved.

Pseudomyxoma Peritonei:


It is a clinical term used to describe the finding of abundant mucoid or gelatinous material in the pelvis and abdominal cavity. It is most commonly secondary to a well differentiated appendiceal carcinoma. It can also be associated with ovarian mucinous carcinoma or other gastrointestinal primary carcinoma and, less commonly, to a mucocele of the appendix.

Extra Edge:


Ovarian Tumor

Histologic Characteristic

Serous Epithelial tumors

Psammoma bodies

Clear cell tumors

Hobnail cells

Brenner tumors

Walthard cell rests


Large polygonal cells, lymphocytic infiltration, and fibrous septa


Skin, teeth, bones, hair, cartilage, neural tissue, and thyroid

Endodermal sinus tumor

Schiller-Duval bodies

Embryonal carcinoma

Embryoid bodies

Granulosa cell tumors

Cali-Exner bodies

Leydig (hilus) cell tumors

Reinke's crystals

Krukenberg tumor

Signet ring cells

Epithelial Tumors

lmportant Points to Remember: In Epithelial Tumors
  • Malignant epithelial tumours include both cystic and solid types
  • These are bilateral in 50 per cent cases
  • Cystic type is more common than the solid
  • These may arise de novo as malignant or more commonly, they result from malignant changes of benign cystic tumours. Serous. The serous histologic subtype resembles cells of the fallopian tube and is the most common, accounting for over 50% of all malignant ovarian tumors. Approximately one third are malignant, one sixth are LMP, and half are benign.
  • The mean age of patients at diagnosis is 57 years.
  • Psammoma bodies are present in 25 %.
    Mucinous tumors - lined by cells that resemble the cells of the endocervical glands.
  • Primary ovarian mucinous tumors account for 3 % to 4 % of epithelial tumors.
  • Sixty percent of mucinous tumors are stage I, and most are unilateral.
  • They are large, cystic, and multiloculated.
  • CA-125 levels may not be markedly elevated.
  • Poor prognosis than serous variety.
    Endometrioid tumors resemble the histology of the endometrium.
  • Most of them are malignant; 20% may be LMP.
  • Associated with endometrial cancer, and endometriosis.
  • Endometrioid tumors have a better prognosis because of their early stage at diagnosis.
    Clear cell. The most chemoresistant type of ovarian cancer are most commonly associated with paraneoplastic syndromes.
  • Histologically Hobnail-shaped cells are characteristic of the clear cell carcinoma.
  • Brenner tumor - Mostly benign, very rarely malignant.

Germ Cell Tumors

  • Germ cell tumors are generally unilateral except dysgerminoma, which is bilateral in 10-15% cases.
  • In the first two decades of life, 70% of ovarian tumors are germ cell in origin of which one-third are malignant.

Histologic Classification of Germ Cell Tumors of the Ovary

  1. Dysgerminoma (MC malignant germ cell tumor)
  2. Teratoma
    1. Solid
    2. Cystic
      1. Dermoid cyst/mature cystic teratoma (MC benign germ cell tumor)
      2. Dermoid cyst with malignant transformation
      3. Monodermal and highly specialized
        • Struma ovarii
        • Carcinoid
        • Struma ovarii and carcinoid
  3. Endodermal sinus tumor / yolk sac tumor
  4. Embryonal carcinoma
  5. Polyembryoma
  6. Choriocarcinoma
  7. Mixed forms


  • Commonest malignant germ cell tumour" of ovary.
    They are the most common ovarian malignancy detected during pregnancy.
  • Primarily affect young women (average age of incidence is 20 yearsv).
  • Usually unilateral's but they are the only germ cell malignancy with a significant rate of bilateral ovarian involvement - 15 to 20%.
  • Can be found at gonadal as well as extra gonadal sites.
  • Pathologically it is a solid neoplasm with areas of softening due to degeneration. "Consistency is fleshy"
  • Histologically as in seminoma, it mimics the pattern of primitive gonad, lymphocytic infiltration may be seen (good prognostic sign?
  • Clinically as with all germ cell tumours most dysgerminoma are diagnosed at an early stage.
  • Unlike other germ cell tumours it does not secrete AFP and HCG is only rarely secreted, however it secretes LDH and placental alkaline phosphate, which are used as tumour marker of dysgerminoma.
  • M/C, route of spread is via lymphatics but hematogenous and direct spread are also seen.
  • It can metastasise to opposite ovary and an uncommon site of meatastasis seen is lower vertebra.

Management of Dysgerminoma

  • The treatment of early dysgerminoma i.e. Stage IA Surgical - including resection of the primary lesion (unilateral oophorectomy) and proper surgical dissection, without postoperative chemotherapy.
  • Rest all cases - surgery (fertility sparing i.e. removing only the affected ovary or debulking surgery) followed by chemotherapy.


  • The most frequently used chemotherapy regimens for germ cell tumors are:
    • BEP - Bleomycin, Etoposide, Cisplatin (best regime)
    • VBP - Vinblastin, Bleomycin, Cisplatin
    • V AC - Vincristine, Actinomycin, Cyclophopharnide

In case of Recurrent Disease:

If primary treatment was surgery - chemotherapy. can be given (BEP regine).

If primary treatment was chemotherapy -

  • Radiation therapy can be given (Major disadvantages - loss of fertility if pelvic and abdominal irradiation is required).
  • Chemotherapy in the form of POMB - ACE (i.e. Vincristine, bleomycin, cisplatin, etoposide, actinomycin D, methotrexate and syclophasphamide) is given.

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