Using these rules the reported sensitivity was 95%, specificity 91%, positive likelihood ratio of 10.37 and negative likelihood ratio of 0.06.
The morphology index (MI) presently used in the University of Kentucky Ovarian Cancer Screening Trial was published initially by Ueland and colleagues and is illustrated in Figure 49.3. Both morphologic complexity and tumor volume, as calculated by the prolate ellipsoid formula, were related directly to the risk of malignancy Morphologic abnormalities were easy to categorize, and interobserver variation was minimal. Risk of malignancy varied from 0.3% in ovarian tumors with a MI of <5 to 84% in tumors with a MI >=8. Using a MI >=5 as indicative of malignancy, the following statistical parameters were observed: sensitivity 0.981, specificity 0.808, PPV 0.409, and NPV 0.997. Therefore, morphologic indexing is a relatively accurate and cost-effective method to predict risk of malignancy in an ovarian tumor.
Wenever possible conservative or minimally invasive surgery is preferred to preserve endocrine and reproductive function.
BOTs form a separate entity within the group of ovarian tumours
BOTs can be divided according to their epithelial characteristics as serous (50%),mucinous (46%), and mixed, endometrioid, clear cell, or Brenner tumors (3.9%). Serous BOTs are bilateral in 30% of patients and can be associated with extraovarian lesions (so-called implants) in 35%. These implants can be invasive or noninvasive depending on their microscopic appearance, which will in turn inﬂuence therapeutic options. Mucinous BOTs are classiﬁed as intestinal (85%) or endocervical/Mullerian type (15%) depending on the nature of the epithelial lining. They can be associated with pseudomyxoma peritonei (10%), necessitating a thorough investigation of the GI tract with special attention to the appendix because this can be the primary tumor origin. Presenting symptoms of borderline ovarian tumors Borderline tumors, as with other ovarian tumors, are difficult to detect clinically until they are advanced in size or stage. In one study, the most common presenting symptoms were abdominal pain, increasing girth or abdominal distention, and abdominal mass. Approximately 23% of patients were asymptomatic.
Without comprehensive surgical staging, the prognosis for an individual patient is difficult to predict. Many clinicians group stages II-IV together for prognostic consideration. Important component is description of the type of implants, as these have significant prognostic value. Preoperatively, borderline tumors are often presumed to be either benign or malignant ovarian masses; however, as with other ovarian masses, staging is performed surgically. Many sources recommend complete staging if a borderline tumor is found. Current guidelines include biopsy specimens of the pelvic peritoneum (cul-de-sac, pelvic wall, and bladder peritoneum), abdominal peritoneum (paracolic gutters and diaphragmatic surfaces), omentum, intestinal serosa and mesentery, and retroperitoneal lymph nodes (pelvic and para-aortic).
Surgical removal of BOTs is the cornerstone in the management of BOTs, but a lot of debate exists on the extent of the staging procedure and the surgical approach. Lately, the use of laparoscopy and conservative surgery, which is deﬁned as surgery with complete staging but with preservation of the uterus and at least part of one ovary (Fig 1), is gaining popularity. However, the question arises about whether this management is appropriate or whether we should be more cautious.
Classification of ovarian tumors
Dr Anusha Rao P
• Normal size 5 x 3 x 3cm
• Variation in dimensions can result from
– Endogenous hormonal production(varies with age
and menstrual cycle)
– Exogenous substances, including OCs, GnRH
agonists, or ovulation-inducing medication, may
DIFFERENTIAL DIAGNOSIS OF ADNEXAL MASS
ORGAN CYSTIC SOLID
OVARY Functional cyst, Neoplastic cyst,
Benign, Malignant, Endometriosis
FALLOPIAN TUBES Tubo-ovarian abscess
UTERUS Intrauterine pregnancy in a bicornuate
BOWEL Sigmoid or caecum distended with gas
Appendicitis, Colonic cancer
MISCELLANEOUS Distended bladder, Pelvic kidney,
Abdominal wall hematoma or
Lifetime Risk of ovarian neoplasm
• A woman has 5–10% lifetime risk of
undergoing surgery for a suspected ovarian
• 13–21% of these will be found to be have an
Functional ovarian cysts
• Follicular cysts
• Corpus luteum cysts
• Theca lutein cysts
• Luteomas of pregnancy
By far the most common clinically detectable
enlargements of the ovary in the reproductive years.
All are benign and usually asymptomatic.
II. Sex cord tumors:
• Granulosa-stromal cell tumors, theca cell
III. Lipid cell tumors
IV. Germ cell tumors:
• Endodermal sinus tumor
• Embryonal ca.
VI. Soft tissue tumors (not specific to ovary)
VII. Unclassified tumors
VIII. Secondary tumors
IX. Tumor-like conditions
Simple ultrasound-based rules for the
diagnosis of ovarian cancer.
Ultrasound Obstet Gynecol2008
• Asymptomatic – accidentally discovered on USG
• Chronic pattern of pain, increasing abdominal girth over months or weeks.
• Associated with secondary symptoms of anorexia, nausea, vomiting,
• Could be associated with primary or secondary amenorrhea, menstrual
irregularities, virilization, precocious puberty
• Become acutely symptomatic if undergoes torsion, rupture or
Benign ovarian neoplasms are indistinguishable clinically from malignant
• Abdominal and vaginal examination and the
presence or absence of local lymphadenopathy
– Cystic Vs solid
– Mobile Vs fixed
– Smooth Vs irregular
– Cul-de-sac nodules
– Rapid growth rate
• Pattern recognition is superior to all other scores.
• Subjective evaluation of ovarian masses based on pattern
recognition can achieve sensitivity of 88% to 100% and specificity of
62% to 96%.
• Adding doppler does not seem to yield much improvement in the
diagnostic precision, but increases the confidence with which a
correct diagnosis of benignity or malignancy is made.
• Hypoxic tissue in tumors recruit low-resistance, high-flow blood
• Role in evaluating ovarian mass is controversial – as the ranges of
values of RI,PI,MSV between benign and malignant masses overlap.
• To overcome this, vascular sampling of suspicious areas (papillary
projections, solid areas, thick septations) using both 3D USG and
power doppler both has been evaluated and found effective.
• “Chaotic” vascular pattern in malignancy
OTHER IMAGING MODALITIES
• CT, MRI, PET not recommended in the initial evaluation
• CT scan: evaluating
– LN involvement,
– Omental mets, peritoneal deposits, hepatic mets,
– obstructive uropathy
– or a probable alternate primary site when cancer is suspected based
• MRI : differentiating non adnexal pelvic masses (like leiomyomata),
expensive and inconvenient.
• ACOG GUIDELINES 2007
SENSITIVITY SPECIFICITY PPV NPV
61-90% 71-93% 35-91% 67-90%
Most useful when non-mucinous epithelial cancers are present
Elevated in 80% of patients with epithelial ovarian Ca but only in 50% of patients
with stage I disease
Increased sensitivity in post menopausal women esp. when associated with
relevant clinical and USG findings
Cut-off of 30 u/ml, sensitivity of 81% and specificity of 75%
• HE4 is a precursor to the epididymal secretory protein E4 and in normal
ovarian tissue, there is minimal gene expression and production of HE4.
• As a single tumor marker, HE4 had the highest sensitivity for detecting
ovarian cancer, especially Stage I disease.
• Combined CA125 and HE4 is a more accurate predictor of malignancy
than either alone or to any other dual combination of markers
• HE4 levels(>70 pM) were found to be elevated in over half of the patients
with ovarian cancer with normal serum CA125 levels (>35 U/ml)
• HE4 when studied in the premenopausal group of patients was able to
discriminate benign tumors from malignancies
Moore et al. / Gynecologic Oncology, 2008
• ROMA: Risk of Ovarian Malignancy Algorithm
The dual marker algorithm utilizing HE4 and CA125 to calculate a ROMA value
In patients with stage I and II disease, ROMA achieved a sensitivity of 85.3% compared
with 64.7% for RMI
MOORE ET AL, AJOG 2010
• OVA 1:
FDA approved. Combination of 5 immunoassays
CA 125, transthyrettin, apo lipoprotein A1, transferrin, B2 microglobulin
Sensitivity : 93%, specificity: 43% PPV 42% NPV 93%
COMMUN ONCOL, 2010
Asymptomatic simple cysts
<5cms Likely physiological
(do not require follow up)
5-7 cms Yearly USG
>7cm Require further
Ovarian mass in reproductive age group
<5 cms. >/= 5 cms
Persistence or progression
Ovarian mass in childhood:
History and physical examination
Appr. Imaging studies
- Observe and reassess
Solid or solid cystic
MRI and tumor markers
Benign - cystectomy
Ovarian cysts in postmenopausal women:
• Post menopausal gonad atrophies to a size of
1.5 X 1 X 0.5cm on average
• Shouldn’t be palpable on pelvic examination.
• Presence of palpable ovary must alert the
possibility of an underlying malignancy.
• Incidence in asymptomatic post menopausal
1.5% by pelvic examination
3.3% to 14.5% by USG.
obstet gynecol survey, 2002
• Causes -10% functional
90% neoplastic (either benign or malignant)
• It is recommended that ovarian cysts in postmenopausal women
should be assessed using CA125 and transvaginal grey scale
• There is no routine role yet for Doppler, MRI, CT or PET.
TVS 89% 73%
CA 125 81% 75%
• Simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a
low risk of malignancy. It is recommended that, in the presence of a normal
serum CA125 levels, they be managed conservatively.
• Aspiration is not recommended for the management of ovarian cysts in
• It is recommended that a ‘risk of malignancy index’ should be used to select
women for laparoscopic surgery, to be undertaken by a suitably qualified
• It is recommended that laparoscopic management of ovarian cysts in
postmenopausal women should involve oophorectomy (usually bilateral)
rather than cystectomy.
They were not separately classified by the FIGO and the
WHO until the early 1970s.
• Borderline tumors make up approximately 15% of all
epithelial ovarian tumors.
• The mean age of occurrence is approximately 10 years
younger than that of women with frankly malignant
• 2 major histological tumor subtypes
• (bilateral in 30%)
• Could be associated with extraovarian lesion : implants(35%)
– Mucinous (46%)
• Mucinous tumors do not have a clearly defined origin.
– Substantial information indicates that many tumors may
actually originate from the appendix; thus, this organ should
be removed at the time of surgery.
Histology and Cytology
• According to Dietel and Hauptmann, the histology of borderline
tumors is characterized by the following features:
– Epithelial multi-layering of more than 4 cell layers
– Not more than 4 mitoses per 10 high-power field (HPF)
– Mild nuclear atypia
– Increase in nuclear/cytoplasmic ratio
– Slight to complex branching of epithelial papillae and pseudopapillae
– Epithelial budding and cell detachment into the lumen
– No destructive stromal invasion - A major component in
differentiating malignant from borderline tumors
• Comprehensive staging : of significant
prognostic value and is performed surgically
• Borderline ovarian tumors are staged
according to the FIGO classification of ovarian
International Federation Of Obstetrics And
Gynecology (FIGO) staging
FIGO stage Definition
I Tumor confined to the ovary
II Peritoneal implants within the pelvis
III Peritoneal implants beyond the pelvis,
Positive lymph nodes, or both
IV Liver parenchyma involvement, or tumor
beyond the peritoneal cavity