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Ovarian cysts and tumors: Pathology review

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Questions

USMLE® Step 1 style questions USMLE

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A 61-year-old woman, gravida 2 para 2, comes to the clinic due to pelvic discomfort and fatigue over the past 6 months. The patient was previously healthy, other than a history of polycystic ovarian syndrome. Menarche occurred at age 12, and menopause occurred 2 years ago. Both of the patient’s children were delivered via Cesarean sections due to personal preference. Family history is significant for breast cancer in her cousin at age 56 and colon cancer in her father at age 55. Vitals are within normal limits. BMI is 35 kg/m2. On physical examination, the abdomen is bloated, and shifting dullness is present. Pelvic examination reveals a left-sided adnexal mass. The patient undergoes a hysterectomy and bilateral salpingo-oophorectomy, followed by adjuvant chemotherapy. A pathohistological analysis is consistent with serous cystadenocarcinoma of the ovary. Which of the following is the most significant risk factor for this patient’s condition?

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Yifan Xiao, MD

65-year-old Rebecca presents to the clinic with several months of abdominal discomfort, bloating, and a change in bowel habits. Her past medical history is significant for endometriosis. Menarche was at age 10 and menopause at age 57. She has never been pregnant. On physical examination, a slightly painful nodule is palpated around the umbilicus. Transvaginal ultrasound showed a large, irregular cyst with heterogeneous fluid in her right ovary. Later that day, 6-year-old Gloriana is brought to the office by her mother, who is worried that her daughter is more “womanly” and taller than the other girls her age. Over the last few months, she has also occasionally complained of vague abdominal pain. Physical examination reveals coarse pubic hair and significant breast enlargement. The child’s height is also in the 96th percentile. Laboratory studies also showed increased inhibin b levels.

Based on the initial presentation, Rebecca and Gloriana’s symptoms are caused by some form of ovarian mass. Broadly speaking, ovarian masses include ovarian cysts and tumors. Starting with ovarian cysts, these are fluid-filled sacs on or in the ovaries and can be classified into simple and complex cysts.

Simple cysts are generally small, they contain a clear serous liquid, and have a smooth internal lining. The classic example is a follicular cyst which is a dominant follicle that fails to rupture before ovulation and keeps growing. This can happen, if say, the normal surge of LH that causes ovulation just doesn’t happen during a given menstrual cycle. In fact, follicular cysts are the most common type of ovarian mass in young individuals.

For your test, remember that if you encounter multiple follicular cysts, they are usually associated with polycystic ovary syndrome, or PCOS. This is caused by a dysfunction in the hypothalamic-pituitary-ovarian axis that causes chronic anovulation, which may lead to amenorrhea, or absent menstruation, and excess androgen production, which may lead to hirsutism.

Sources

  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Williams Gynecology, Fourth Edition" McGraw-Hill Education / Medical (2020)
  4. "Schwartz's Principles of Surgery" F.C. Brunicardi (2018)
  5. "Oral contraceptives for functional ovarian cysts" Cochrane Database of Systematic Reviews (2014)
  6. "Diagnosis and management of ovarian cyst accidents" Best Practice & Research Clinical Obstetrics & Gynaecology (2009)
  7. "A Comprehensive Review of Ovarian Serous Carcinoma" Advances In Anatomic Pathology (2019)