Malignant Ovarian Neoplasms Review

Malignant Disease of the Ovary

Overview

  • Presenter: Beverly Conatser, BSRT, RDMS, RVT

Clinical Signs and Symptoms

  • Median age of diagnosis: 52 years

  • Vague complaints: Often reported by patients but not always specific

  • Symptoms:

    • Pressure or bloating in the abdomen

    • Acute pain which may be due to ovarian torsion

    • Increasing abdominal girth, indicating potential tumor growth

    • Vaginal bleeding, which may suggest abnormal ovarian activity or growth

Laboratory Tests

  • CA 125 tumor-associated antigen:

    • Elevated in 80% of ovarian cancers, indicates malignancy

    • Caveat: High levels are not specific to ovarian cancer; may present in other conditions

  • Other tumor markers:

    • AFP (Alpha Feto-protein) – typically associated with germ cell tumors

    • CEA (Carcinoembryonic Antigen) – associated with cancers including colorectal and breast cancer

    • hCG (Human Choriogonadotropin) – involved in some germ cell tumors

    • LDH (Lactate Dehydrogenase) – can be elevated in various malignancies

Treatment Modalities

  • Survival Rates:

    • Early-stage detection: 90% five-year survival rate

    • Late-stage detection: 25% five-year survival rate

  • Treatment approaches:

    • Multifaceted, tailored to individual patient needs

    • Surgery: For removal of tumors and affected ovarian tissue

    • Chemotherapy: Uses drugs to target and kill cancer cells

    • Radiation therapy: Not commonly used for ovarian cancer, but may be indicated in certain cases

  • Potential metastatic sites:

    • Diaphragm

    • Liver

    • Serosal bowel

    • Colon and its lymph nodes

    • Ovaries

    • Pleura, omentum, and stomach

Sonography Findings

  • Non-specific findings of malignant ovarian tumors include:

    • Large, complex masses

    • Multiseptated structures indicating possible tumor progression

    • Presence of daughter cysts, which are smaller cysts within a larger cystic mass

    • Low resistance Doppler flow pattern, indicating blood flow irregularities

Figure Analysis

  • Figure 10-19:

    • A: T2-weighted image showing a large cystic and solid mass above the uterus

    • B: Shows extensive solid components of the mass, obliterating the connection to the left ovary

  • Imaging specificities include:

    • Size measurements (e.g. a mass of 30 x 13 cm as depicted)

    • Imaging techniques employed (Sonography, HDI 5000, etc.)

Endovaginal Imaging

  • Sonographic Screening Focus:

    • Assessment of size/volume of ovaries

    • Evaluation of echogenicity (appearance on ultrasound)

    • Symmetry considerations between both ovaries

Malignant Ovarian Neoplasms

  • Types of tumors include:

    • Epithelial tumors:

    • Cystadenocarcinoma

    • Adenocarcinoma

    • Endometroid carcinoma

    • Clear Cell carcinoma

    • Sex Cord Tumors:

    • Granulosa-theca cell tumor

    • Sertoli-Leydig cell tumor (Androblastoma)

    • Germ Cell Tumors:

    • Dysgerminoma

    • Teratoma (including Struma ovarii and Choriocarcinoma)

    • Endodermal sinus tumor (yolk sac tumor)

    • Metastatic tumors:

    • Krukenberg tumor

    • Lymphoma affecting the ovary

Epithelial Tumors and Sonographic Findings

Serous Tumors

  • Characteristics:

    • Malignant serous tumors are bilateral in 50% of cases

    • Most common in peri- and postmenopausal women

    • Typically smaller than mucinous tumors

  • Sonographic Findings:

    • Multilocular with multiple papillary projections

    • Occasional echogenic material within lesions

    • Ascites may be present

Mucinous Tumors

  • Incidence:

    • Account for 5-10% of malignant ovarian neoplasms

    • Most common in women aged 40-70 years

    • 15-20% are bilateral

  • Complications:

    • Rupture may cause pseudomyxoma peritonei; gelatinous ascites appearance

  • Sonographic Appearance:

    • Large multiloculated cystic structures (15-30 cm) with echogenic material and papillary excrescences

Specific Cases

  • Cystadenocarcinoma:

    • Thick, irregular walls and septations

    • Presence of ascites and pseudomyxoma peritonei

  • Endometrioid Tumors:

    • 80% malignant; better prognostic outcomes than serous and mucinous types

    • Affects 20-25% of ovarian carcinoma patients

    • Associated endometrial abnormalities in 30% of cases

    • Sonographic Findings:

    • Mixed cystic and solid masses

Clear Cell Carcinoma

  • Prevalence:** 5% of malignant ovarian tumors

    • Mostly found in women aged 50-70 years

    • Up to 20% bilateral occurrences

  • Sonographic presentation:

    • Non-specific complex mass, predominantly solid

Brenner’s Tumor

  • Description:

    • 1-2% of all primary ovarian tumors; typically benign

    • Common in women aged 40-80; most prevalent in those in their 50s

  • Sonographic Findings:

    • Hypoechoic solid mass, may contain calcifications

    • Cystic spaces may resemble an ovarian fibroma

Sex Cord Tumors

Granulosa Cell Tumors

  • 95% are of the adult type; prevalent in postmenopausal women (50-55 years)

  • Associated with estrogen production; may cause abnormal uterine bleeding

  • Sonographic Findings:

    • Small predominantly solid; larger lesions multiloculated and cystic

    • Possible endometrial thickening due to estrogen stimulation

Sertoli-Leydig Tumor (Arrhenoblastoma/Androblastoma)

  • Rarity: Less than 0.5% of ovarian neoplasms

  • Usually unilateral; frequently presents in women <30 years

  • Accounts for 20% malignant risk; produces testosterone, potentially leading to masculinization

  • Sonographic Findings:

    • Solid echogenic masses, similar to granulosa cell tumors

Germ Cell Tumors

Dysgerminoma

  • Characteristics:

    • Arise from primordial germ cells, accounting for 3-5% of ovarian malignancies

    • Predominantly affects women under 30 years; 15% are bilateral

    • Highly malignant but responsive to radiation therapy (5-year survival rate up to 90%)

  • Sonographic Findings:

    • Multilobulated solid masses; size may vary

Endodermal Sinus (Yolk Sac) Tumor

  • Timing: Occurs primarily during young adulthood (20-30 years)

  • Aggressiveness: Highly malignant, with rapid metastasis

  • Serum marker: Increased levels of alpha-fetoprotein (AFP)

  • Sonographic Appearance:

    • Predominantly solid mass with necrotic areas

Teratoma

  • Characteristics:

    • Sizes range from small to 40 cm, typically unilateral

    • Contains multi-tissue types (fat, hair, etc.)

  • Clinical Manifestations:

    • Varies from asymptomatic to severe abdominal pain, pedunculated, and risk of torsion

  • Sonographic Findings:

    • Cystic/complex mass with echogenic components; acoustic shadowing may be present

Struma Ovarii

  • A rare tumor containing thyroid tissue; may cause hyperthyroidism

  • Sonographic Findings:

    • Centralized color flow; solid mass with possible ascites

Teratocarcinoma

  • Rare malignancy featuring varied cystic and echogenic areas

Metastatic Tumors

  • Prevalence: 5-10% of ovarian tumors are metastatic in origin

  • Typical Presentation: Usually bilateral solid masses

  • Common Source Tumors: Breast and gastrointestinal tract cancers

  • Routes of Spread:

    • Direct invasion from uterine/fallopian tube carcinomas

    • Peritoneal fluid carrying malignant cells

    • Hematogenous and lymphatic spread from distant sites

Krukenberg Tumor

  • Definition: Specific type of ovarian cancer resulting from gastrointestinal primary sources, predominantly gastric carcinoma

  • Typical Findings:

    • Rarely distinguished from primary ovarian tumors via imaging

    • Usually bilateral, more common on right in cases of unilateral presentation

  • Sonographic Findings:

    • Bilateral solid, hypoechoic, or complex masses, potentially with ascites