Ovarian cancer: Clinical sciences

Ovarian cancer is the second most common gynecologic cancer after endometrial cancer, and the leading cause of gynecologic cancer death. The three main types of ovarian cancer are germ cell tumors which arise from primordial germ cells; sex cord or stromal cell tumors that arise from supporting tissues of the ovary; and epithelial cell tumors, which come from the mesothelium that covers the ovary.

The majority of ovarian malignancies are epithelial cell tumors, which primarily occur in older patients. Due to their vague symptoms, they are usually diagnosed at a later stage. Germ cell and sex cord or stromal cell tumors commonly occur among younger patients. They might produce hormones that cause symptoms of pregnancy, precocious puberty, abnormal bleeding, or virilization; and are therefore diagnosed at an earlier stage.

When a patient presents with a chief concern suggesting ovarian cancer, the first step is to perform a focused history and physical examination. Patients often report a history of abdominal or pelvic pain or bloating, and possibly a decrease in appetite, early satiety, or a change in bowel habits. The physical examination reveals an abdominal, pelvic, or adnexal mass and sometimes abdominal or pelvic tenderness, or abdominal distension. With these findings, suspect an adnexal mass and obtain a pelvic ultrasound.

Here’s a clinical pearl! When reproductive-age patients present with abdominal or pelvic symptoms, be sure to assess for pregnancy with an hCG. Keep in mind that some germ cell tumors produce hCG which may result in a false positive pregnancy test. Also, a diagnosis of pregnancy does not exclude malignancy.

Okay, if the ultrasound reveals a thin, anechoic, smooth walled cyst that is less than 10 centimeters without septations, internal blood flow, or solid components, the probable diagnosis is a benign adnexal mass. In this case, manage the patient expectantly with serial ultrasounds. However, if the patient has severe or persistent pain or if the mass increases in size, consider surgical intervention.

On the other hand, the ultrasound may demonstrate a complex mass, possibly greater than 10 centimeters in diameter. The mass may contain septations or loculations and solid components such as mural nodules, as well as increased internal doppler flow. There might also be evidence of pelvic free fluid. These findings are suggestive of an ovarian malignancy.