C h a p t e r 4 0
Disorders of the Female Genitourinary System
1037
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.
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.
Germinal
follicle
Germ cell
Serosal epithelium
Benign—Dermoid cyst
Malignant—Yolk cell tumor
Choriocarcinoma
Gonadal stroma
Benign—Fibroma
Malignant—Granulosa cell
tumor
Sertoli-Leydig cell
tumor
Benign—Serous cystadenoma
Mucinous cystadenoma
Malignant—Serous adenocarcinoma
Mucinous adenocarcinoma
Endometrioid carcinoma
Transitional cell carcinoma
Layers of
the follicle
Granulosa
Theca interna
Theca externa
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.)
