Ovarian cancer

Malignant tumor arising from ovarian tissue. Epithelial ovarian carcinoma is by far the most common (~90%), but ovarian cancer also includes germ cell tumors and sex cord–stromal tumors with distinct behaviors.

• Ovarian cancer is the deadliest gynecologic malignancy due to late presentation. It's a high-yield topic because of its vague symptoms, unique tumor markers (CA-125, AFP, β-hCG, etc.), and the need to distinguish subtypes (epithelial vs germ cell vs stromal) on exams.

• Often in a postmenopausal woman with vague GI symptoms: abdominal bloating, early satiety, pelvic or abdominal pain, urinary urgency. Exam may reveal a palpable adnexal mass and possibly ascites. CA-125 is often elevated.
• Young women or teens with a rapidly enlarging pelvic mass. May present with acute pain from torsion or rupture. Tumor markers can be positive (e.g., ↑AFP in yolk sac tumor, ↑β-hCG in choriocarcinoma or embryonal carcinoma, ↑LDH in dysgerminoma).
• Findings of hormone production: e.g., an ovarian mass with estrogen effects (precocious puberty in a girl, or endometrial hyperplasia/postmenopausal bleeding in an older woman) suggests a granulosa cell tumor; virilization (hirsutism, deep voice) suggests a Sertoli-Leydig cell tumor.

1. Always consider patient age. An adnexal mass in a younger patient → evaluate for germ cell tumor (AFP, β-hCG, LDH). In a postmenopausal patient → high suspicion for epithelial carcinoma (CA-125).
2. Use transvaginal ultrasound (TVUS) to characterize any ovarian mass. Benign features: simple, unilocular cyst <5 cm, smooth walls. Suspicious features: solid or complex mass, thick septations, bilateral masses, or ascites.
3. If malignancy is suspected, obtain appropriate imaging (CT scan of abdomen/pelvis +/- chest) for extent, and refer to a gynecologic oncologist for surgical management. Avoid simple cyst aspiration—if the mass is cancer, spillage can spread tumor cells.
4. Check tumor markers preoperatively to guide the differential: CA-125 (especially if postmenopausal), CEA/CA19-9 (mucinous or GI origin), AFP, β-hCG, LDH (if germ cell tumor suspected), Inhibin (granulosa cell tumor). These help narrow the diagnosis but are adjuncts, not definitive.

1. Primary treatment is surgical. For epithelial ovarian cancer, perform surgical staging and debulking: remove the uterus, both ovaries and tubes (TAH-BSO), omentum, and any visible tumor nodules. Goal is to leave no macroscopic disease. (In early-stage young patients wishing fertility, unilateral oophorectomy can be considered if disease is limited.)
2. Nearly all patients will need platinum-based chemotherapy after surgery. Standard regimen for epithelial ovarian carcinoma is combined carboplatin + paclitaxel. For malignant germ cell tumors, use BEP chemo (Bleomycin, Etoposide, Cisplatin), which yields high cure rates. Sex cord-stromal tumors may also receive chemo (often using BEP) if high stage or poorly differentiated.
3. Advanced or high-risk cases often get maintenance therapy after chemo. Examples: Bevacizumab (anti-angiogenic) is often added for stage III-IV disease, and PARP inhibitors (like olaparib) are used especially in patients with BRCA mutations or homologous recombination deficiency to prolong remission.
4. Always involve a gynecologic oncology specialist for suspected ovarian cancer. Appropriate surgical staging and cytoreduction by an expert improves outcomes. In younger patients with malignancy who desire fertility, a fertility-sparing approach (removing only the affected ovary, if early stage) can be done, followed by chemo, with careful follow-up.

• Use the mnemonic "BEAT" for common ovarian cancer symptoms: Bloating, Early satiety, Abdominal pain, Trouble with bladder (urinary urgency). These vague complaints in an older woman should raise concern for ovarian cancer.
• Don't confuse ovarian cancer with Meigs syndrome: a benign ovarian fibroma with ascites and pleural effusion. Meigs can mimic cancer (mass + ascites) but resolves after fibroma removal.

• Postmenopausal woman with any adnexal mass or unexplained ascites is a red flag for ovarian malignancy until proven otherwise – prompt evaluation and referral is warranted.
• CA-125 level very elevated (e.g. >200 U/mL, especially in a postmenopausal patient) strongly suggests an ovarian cancer (though moderate elevations can occur in benign conditions).
• An ovarian mass with acute torsion or rupture can be life-threatening (severe abdominal pain, peritonitis). While not a "malignancy" sign per se, any patient with known ovarian mass who develops sudden severe pain needs emergency surgical assessment (masses >5 cm increase torsion risk).

1. Patient presents with possible adnexal mass (e.g., pelvic exam finding or symptoms) → Transvaginal ultrasound for characterization.
2. If ultrasound suggests a benign cyst (small, simple, likely functional) and patient is low-risk → observe and follow up imaging; consider elective laparoscopic cystectomy if persistent or symptomatic.
3. If ultrasound or clinical factors are suspicious for malignancy (solid components, septations, nodularity, ascites, or patient is postmenopausal) → Measure tumor markers (e.g., CA-125) and obtain cross-sectional imaging (CT scan) as needed → Refer to gynecologic oncology before intervention.
4. Proceed to surgical exploration for definitive diagnosis and treatment. Perform appropriate cancer staging surgery (with frozen section guidance intra-op). If malignancy is confirmed, execute debulking and then plan for adjuvant chemotherapy. If benign, manage accordingly (cystectomy or oophorectomy as needed).

• A 63-year-old woman with increasing abdominal girth, early satiety, and an adnexal mass on exam. Ultrasound shows a solid complex ovarian mass with ascites; CA-125 is markedly elevated → Epithelial ovarian carcinoma (likely high-grade serous).
• An 18-year-old woman with an acute abdominal pain and pelvic mass. Serum AFP is high (or β-hCG is high) → Ovarian germ cell tumor (e.g., yolk sac tumor if AFP, choriocarcinoma if β-hCG). Tumor is often unilateral and rapidly enlarging.
• A postmenopausal woman with a thickened endometrium, postmenopausal bleeding, and an ovarian mass → think granulosa cell tumor (estrogen-secreting sex cord–stromal tumor causing endometrial hyperplasia/carcinoma).