Ovary tumor
Ovarian tumors

Authors: Shahrzad Ehdaivand, M.D. (see Authors page)

Revised: 19 May 2016, last major update May 2012

Copyright: (c) 2003-2016, PathologyOutlines.com, Inc.

PubMed Search: ovarian tumor general
Definition / General
  • #5 cause of cancer death in women (after lung, breast, colon, pancreas); incidence has not changed recently (15,500 estimated US deaths in 2012, American Cancer Society)
  • 80% benign (usually ages 20-45 years)
  • 90% of malignancies are carcinoma, 80% have spread beyond the ovary at diagnosis
  • Note: in one study, 15% of ovarian specimens required additional clinical information, which caused an altered diagnosis / revised report (Arch Pathol Lab Med 1999;123:615)
  • Risk factors for carcinoma: BRACA1 or BRCA2 mutations, childhood gonadal dysgenesis, clomiphene use, family history, hereditary nonpolyposis colon cancer, long term estrogen replacement therapy, nulliparity, older age (US National Cancer Institute)
  • Negative risk factors: history of oral contraceptives, possibly fimbraectomy, pregnancy before age 25, prophylactic oophorectomy, tubal ligation

  • BRCA1 or BRCA2 mutations:
    • Cause 5-10% of ovarian carcinomas
    • 16% with these mutations develop tumors, usually serous cystadenocarcinomas
    • Occult tumors in 4.5% of prophylactic salpingo-oophorectomies (Cancer 2007;109:1784); may be detectable only by examining entire ovary (Am J Surg Pathol 2001;25:1283, Am J Surg Pathol 2006;30:1222)
    • BRCA1+ tumors are usually not borderline or mucinous (Hum Pathol 2000;31:1420)
    • Higher risk of BRCA1 or BRCA2 mutation if ovarian carcinoma (any age), breast cancer (any age), early onset breast cancer
    • BRCA1 prevalence is 1-2% in US Ashkenazi Jews, 0.24% in other US whites (Cancer Epidemiol Biomarkers Prev 2004;13:2078)
    • Note: 1-2% of patients undergoing prophylactic oophorectomy develop peritoneal adenocarcinoma, which resembles papillary serous carcinoma of ovary clinically and histologically

  • Origin:
    • Surface coelomic epithelium (particularly from fallopian tube), which gives rise to fallopian tubes, endometrium, endocervix (Am J Surg Pathol 2010;34:433)
    • Germ cells which migrate to ovary from yolk sac
    • Stroma of ovary, which includes the sex cords, forerunners of endocrine apparatus

  • Symptoms:
    • Abdominal enlargement, increased pressure on adjacent organs, lower abdominal pain
    • Occasionally causes bilateral diffuse uveal melanocytic proliferation, a paraneoplastic syndrome in which uveal melanocytes proliferate and cause blindness (Am J Surg Pathol 2001;25:212)

  • Serum markers:
    • CA-125
      • A high molecular weight glycoprotein discovered in 1981 (J Clin Invest 1981;68:1331)
      • Elevated serum levels are somewhat sensitive but not specific for ovarian carcinoma
      • Not recommended as a screening test (JAMA 2011;305:2295), because it has relatively high false positive rate in premenopausal women

    • HE4: Human epididymis protein 4
      • Secreted glycoprotein found in glandular epithelium of reproductive tract (male and female), distal renal tubules, respiratory epithelium, salivary glands
      • May be more sensitive than CA125
      • Elevated in 1/3 of the 20% of women with tumors that do not overexpress CA125
      • Estimated sensitivity of 87% vs. 80% for CA12; also more specific than CA125

    • ROMA score
      • A multiple marker bioassay utilizing HE4 and CA125; separates patients into high and low risk categories

  • Metastatic spread from primary ovarian tumors:
    • Often contralateral ovary or pelvic peritoneum
    • Sister Joseph’s nodule: umbilical metastasis, may be first manifestation of disease
    • Metastases are associated with ascites, intestinal obstruction, ureteral involvement and hydronephrosis
    • Primary tumors are often positive for WT1, ER, PR, CA125, CK7; negative for CK20, GCDFP-15, CEA (except mucinous tumors, Am J Clin Pathol 2002;117:745, Am J Clin Pathol 1997;107:12)

  • Coexistence with uterine carcinoma:
    • Uncommon
    • May reflect metastases from uterus or ovary or two independent tumors; can differentiate with molecular techniques (Am J Clin Pathol 1996;105:350, Clin Cancer Res 2008;14:5840)
    • Overall excellent prognosis (Asian Pac J Cancer Prev 2006;7:234), better than metastatic disease
    • Metastasis from endometrial tumor to ovary is more likely if multinodular, bilateral, small ovarian tumors, tubal lumen involvement is present, deep myometrial invasion or myometrial vascular invasion is present (Hum Pathol 1985;16:28)
    • Tumors with endometrioid appearance in uterus and ovary are probably independent, have excellent prognosis
    • Metastases from cervix to ovary likely if bilateral ovary involvement, extensive extracervical disease and microscopic type is unusual for ovary, such as squamous or small cell
    • Other tumor histology often signifies metastases with poor prognosis
Diagrams / Tables

Images hosted on PathOut server:

Peritoneal route of spread of ovarian cancer

Lymph nodes draining ovaries

Case Reports
  • Must examine peritoneal cavity for proper staging
  • Benign or borderline tumors: unilateral salpingo-oophorectomy
  • Malignant tumors: bilateral salpingo-oophorectomy with total abdominal hysterectomy
  • Chemotherapy is generally recommended if greater than stage IB
Gross Images

Images hosted on PathOut server:

Twisted infarcted solid ovarian tumor

Ruptured ovarian carcinoma

Cytology Description
  • Staging incorporates presence of malignant cells in washings or ascites fluid
  • Serous / endometrioid carcinomas more often have positive cytology than other carcinomas, particularly if high grade
Cytology Images

Images hosted on PathOut server:

Ovarian carcinoma cells in cervical aspirate

Ovarian tumor cells and psammoma body in vaginal-cervical smear

Ovarian carcinoma cells in peritoneal fluid

Ovarian carcinoma cells in ascitic fluid

Differential Diagnosis
  • Reactive mesothelial cells