Porth's Essentials of Pathophysiology, 4e

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Disorders of the Female Genitourinary System

C h a p t e r 4 0

Serosal epithelium

Germ cell

Benign—Serous cystadenoma Mucinous cystadenoma Malignant—Serous adenocarcinoma Mucinous adenocarcinoma

Benign—Dermoid cyst Malignant—Yolk cell tumor Choriocarcinoma

Endometrioid carcinoma Transitional cell carcinoma

Layers of the follicle

Granulosa

Germinal follicle

Theca interna

Theca externa

Gonadal stroma

Benign—Fibroma Malignant—Granulosa cell tumor

Sertoli-Leydig cell tumor

FIGURE 40-16. Classification of ovarian neoplasms based on cell type. (From Mutter GL, Pratt J, Schwartz DA.The female reproductive system, the peritoneum and pregnancy. In: Rubin R, Strayer DS, eds. Rubin’s Pathology: Clinicopathologic Foundations of Medicine. 6th ed. Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams &Wilkins; 2012:888.)

At present, no good screening tests or other early methods of detection exist for ovarian cancer. 41,42 The serum tumor marker CA-125 is a cell surface antigen that can be used in monitoring therapy and recurrences when preoperative levels have been elevated. Despite its role in diagnostic evaluation and follow-up, CA-125 is not cancer or tissue specific for ovarian cancer. Levels also are elevated in the presence of endometriosis, uter- ine fibroids, pregnancy, liver disease, and other benign conditions and with cancers of the endometrium, cervix, fallopian tube, and pancreas. Transvaginal ultrasonogra- phy (TVS) has been used to evaluate ovarian masses for malignant potential. Although TVS has demonstrated high sensitivity and specificity as a screening tool, cost precludes its use as a universal screening method. When ovarian cancer is suspected, surgical evaluation is required for diagnosis, complete and accurate staging, and cytoreduction and debulking procedures to reduce the size of the tumor. The most common surgery involves removal of the uterus, fallopian tubes, ovaries, and omen- tum. Recommendations regarding treatment beyond sur- gery and prognosis depend on the stage of the disease. Women with early-stage disease usually do not require adjuvant treatment; women with intermediate disease or advanced disease can often benefit from chemotherapy using a combination of a platinum compound (cisplatin or carboplatin) and a taxane (paclitaxel or docetaxel). When this combination therapy fails, salvage chemother- apy with newer drugs may prolong survival.

Clinical Features. Until recently it was believed that most cancers of the ovary produce no symptoms. Several studies have now established that symptoms are often present and reported by women before diagnosis, but are nonspecific and therefore difficult to interpret. Symptoms that are believed to have a strong correla- tion to ovarian cancer include increased abdominal size, epigastric distress, early satiety, or bloating as the result of increased pressure from ascites (i.e., fluid in the peritoneal cavity) or involvement of the omentum. Occasionally, women with early-onset disease pres- ent with abdominal or pelvic pain, due to ovarian tor- sion, although most women with early-stage disease are asymptomatic. Because the gastrointestinal manifesta- tions can occur for a variety of reasons, many women self-treat with antacids and other remedies for a time before seeking treatment, and health care providers may dismiss the woman’s complaints as being caused by other conditions, further delaying diagnosis and treat- ment. Recent onset (<12 months) and frequent occur- rence (>12 times per month) of these symptoms should increase the index of suspicion for ovarian cancer and suggest the need for further evaluation. 44 It is not fully understood why the initial symptoms of ovarian can- cer are manifested as gastrointestinal disturbances. It is thought that biochemical changes in peritoneal flu- ids may irritate the bowel or that pain originating in the ovary may be referred to the abdomen and be inter- preted as a gastrointestinal disturbance.