Managing ovarian masses during pregnancy

The management of adnexal masses during pregnancy can be challenging for the patient and the clinician. The specter of a possible malignancy can sway the decision for intervention versus expectant management. The etiologies of ovarian masses are reflective of the patient's age; and, therefore, benign entities such as functional ovarian cysts, benign cystic teratomas, and serous cystadenomas predominate. In the unusual cases when cancer is present, they are typically germ cell and borderline ovarian tumors, and are commonly low stage and low grade. Ultrasound is the primary modality used to detect ovarian masses and to assess the risk of malignancy. Morphologic criteria more accurately identify benign cysts compared with malignant tumors. Tumor markers are used primarily to monitor disease status after treatment rather than establish the ovarian tumor diagnosis as a result of lack of specificity, because several markers can be elevated inherent to the pregnancy itself (eg, CA-125, beta-hCG). Expectant management is recommended for most pregnant patients with asymptomatic, nonsuspicious cystic ovarian masses. Surgical intervention during pregnancy is indicated for large and/or symptomatic tumors and those that appear highly suspicious for malignancy on imaging tests. The extent of surgery depends on the intraoperative diagnosis of a benign versus a malignant tumor. Conservative surgery is appropriate for benign masses and borderline ovarian tumors. More aggressive surgery is indicated for ovarian malignancies, including surgical staging. Although rarely necessary, chemotherapy has been used during pregnancy with minimal fetal toxicity in patients with advanced-stage ovarian cancer in which the risk of maternal mortality outweighs the fetal consequences.     

The growing teratoma syndrome: a case report and a review of the literature

Abstract.   Tangjitgamol S, Manusirivithaya S, Leelahakorn S, Thawaramara T, Suekwatana P, Sheanakul C. The growing teratoma syndrome: a case report and a review of the literature. Int J Gynecol Cancer 2006; 16(Suppl. 1): 384–390.
We present the case of a 5-year-old girl with ovarian immature teratoma, which recurred a few months after an incomplete surgical staging. The recurrent masses, located in the upper abdomen and lower pelvis, were accompanied by rise in levels of serum alpha-fetoprotein. The patient and her parents refused surgical resection of these recurrent masses; therefore, chemotherapy was promptly given. After multiple cycles of chemotherapy, all the masses remained stable in size despite normalization of the tumor marker. Subsequent complete resection of the masses showed only mature teratoma (MT) component without any residual malignant germ cell tumor. The patient was disease free for 2 years, when another episode of recurrence developed as a 5-cm mass in the perihepatic area. The third laparotomy revealed a tumor mass, histologically composed of only MT tissue. She is now doing well without any evidence of the disease, 24 months after the last surgery.     

Intracystic evaluation of tumor markers in benign and malignant ovarian pathology

OBJECTIVE: To evaluate, in patients with benign and malignant ovarian cysts, serum samples and ovarian intracystic fluids for the presence of tumor markers such as CA 125, CA 15.3, tissue polypeptide antigen (TPA), CA 19.9 and the carcinoembryonic antigen (CEA). MATERIAL AND METHOD: We studied overall 64 patients with ovarian pathology. Sixteen patients were affected by functional cysts, 28 women by benign cystic tumors and 20 by cystoadenocarcinomas. RESULTS: Average serum levels of all but CA 15.3, TPA and CEA tumor markers of benign cystic ovarian tumors were higher than those of functional cysts. All but CA 19.9 mean intracystic fluid markers levels were more elevated in benign tumors than in functional cysts. In patients with malignant cystic tumors, all but CEA mean serum marker levels were higher than those of benign tumors; furthermore even all mean intracystic levels of markers were more elevated than those of benign tumors. CONCLUSION: This study confirmed the high positivity of tumor markers such as CA 125, CA 15.3, TPA, CA 19.9 and CEA in both the serum and intracystic fluid of patients with malignant epithelial ovarian tumors.     

Keimzelltumoren des Ovars

This review deals with relevant aspects of ovarian germ cell tumors. Malignant ovarian germ cell tumors are rare, aggressive, and chemosensitive tumors of young women. The chances for cure are close to 100% for lower stages and approximately 80% for higher stages. Prognostic factors include staging, residual tumor after surgery, histological type, and tumor markers like AFP and HCG: fertility-sparing surgery followed by polychemotherapy containing platinum is currently the state of treatment. In stage I and in completely resected tumors two to three courses of chemotherapy are recommended. In higher stages and in residual disease after surgery, four courses could be applied. Even in higher stages a fertility-sparing surgical approach is feasible. In stage IA disease surveillance is a safe option. If the patient relapses, chemotherapy will then be commenced. Even in this case the chances of survival are high. Second-look surgery is not necessary.     

Klinik, Symptomatik und Therapiestrategien bei Keimzelltumoren des Ovars

Ovarian germ cell tumors (GCT) in children and adolescents constitute a heterogeneous group of tumors that develop from totipotent primordial germ cells. Their clinical behavior varies between benign tumors such as teratomas and highly aggressive and metastatic tumors such as choriocarcinomas. In order to achieve reliable diagnosis and to enable prospective scientific analysis it is necessary to obtain reference histopathologic evaluation. Histologic differentiation, clinical course and response to chemotherapy strongly correlate with production of tumor markers AFP and β-HCG, in this age group, have to be measured prior to surgery in every ovarian tumor. Radiographic assessment with sonography, computerized tomography or nuclear resonance imaging have to consider areas of potential local spread and characteristic metastatic sites. Therapy of malignant ovarian GCT follows a multimodal approach. The introduction of platin-based chemotherapy represents a significant breakthrough in adjuvant treatment. Nevertheless, therapy must always aim for complete local tumor control, which in most cases can be achieved with laparotomic ovariectomy or adnectomy. In locally advanced and metastatic tumors, preoperative chemotherapy may help to obtain complete resection. In general, prognosis of malignant ovarian GCT in children and adolescents can be considered favorable, if patients are treated according to current standards. Future prospective studies should aim for optimized stratification of therapy on the basis of clinical, histologic and molecular-biologic parameters.     

The value of cancer antigen-125 as a tumor marker in malignant germ cell tumors of the ovary

The value of cancer antigen-125 (CA-125) as a tumor marker for malignant germ cell tumors (MGCT) of the ovary was investigated and compared with the other recognized tumor markers (human chorionic gonadotrophin (hCG), alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA) and lactate dehydrogenase (LDH) isoenzymes. In the 10 months following June 1984, 4 new cases with MGCT and 1 patient with active disease on treatment were evaluated. In all cases prior to planned surgery the levels of CA-125 were significantly elevated. The serum values ranged from 154 to 617 U/ml (normal less than 20 U/ml). In 1 case (pure dysgerminoma) CA-125 was the only tumor marker. In 3 patients (2 mixed germ cell tumors and 1 immature teratoma) serum LDH (LD 1, 2, and 3) was elevated, and AFP was elevated in 1 of these. In the fifth case (mixed germ cell tumor), on treatment, serum AFP was used to monitor the disease. Four patients underwent cytoreductive surgery followed by combination chemotherapy. The changes in the serum levels of CA-125 paralleled those of the other tumor markers while on therapy. In our experience CA-125 is an invaluable indicator of the clinical status of the patient and could be a new tumor marker in patients with MGCT.     

The diagnostic value of multiple tumor markers in malignant ovarian neoplasms

Ovariancanceristhemostfrequentcauseofdeath fromgynecologicalcancer.Almost90%ofpatientsare diagnosedwithmetastaticdiseaseinthepelvisorabdo menandforthesepatients5yearsurvivalratesareless than30%.Incontrast,thesmallproportionofpatients diagnosedwithstageIovariancancerconfinedtotheo varieshavea5yearsurvivalrateinexcessof90%[1].Tumormarkerisakindofsubstancecorrelatedwiththe occurrenceoftumor.Itarisesfromthetumortissue,ex istsinthetumor,orexcretesintobloodorotherbody fluid[2].Nowadaysmorethan100ki…     

卵巢卵黄囊瘤手术和化疗后自然周期体外受精-胚胎移植成功分娩一例并文献复习

卵巢卵黄囊瘤属卵巢恶性生殖细胞肿瘤,占卵巢恶性肿瘤的1%。由于卵巢恶性生殖细胞肿瘤多见于儿童及年轻女性,故保存生育能力是关键。卵巢卵黄囊瘤对化疗药物敏感,手术联合术后辅助化疗是标准治疗方案。对于对侧卵巢和子宫未受肿瘤累及,并且有生育需求的患者均应行保留生育功能的手术。但肿瘤本身、手术和放化疗均可能造成患者不孕,术后可能需要借助辅助生殖技术助孕,本文通过1例卵巢卵黄囊瘤患者手术和术后化疗后行自然周期-体外受精-胚胎移植(NC-IVF-ET)的个案报道和文献复习,探讨卵巢卵黄囊瘤患者的生育助孕策略。     

Endodermal sinus tumor of the ovary: a case series with flow cytometric DNA content analysis

Endodermal sinus tumors (EST) are rare germ cell ovarian malignancies occurring primarily in young women. A retrospective review of the Magee-Womens Hospital tumor registry revealed eight cases of pure EST and two mixed tumors in which the EST component was predominant. Mean patient age was 18.2 years. Abdominal pain was the most common presenting symptom and a pelvic mass was palpable in all patients. Four patients are currently alive and well with no evidence of disease. All were treated with surgery and combination chemotherapy. Flow cytometric DNA content analysis of paraffin-embedded tumor tissue identified similar aneuploid cell populations in three of five tumors analyzed with relative peak positions of 1.72, 1.62, and 1.70. The management of women with endodermal sinus tumor remains controversial with regard to type of chemotherapy employed and the use of second-look laparotomy. The prognosis role of flow cytometric DNA content analysis is yet to be determined.     

青少年卵巢肿瘤的临床病理分析

目的:探讨青少年卵巢肿瘤的临床病理特点。方法:回顾性分析67例20岁以下的青少年卵巢肿瘤患者的临床表现、诊断、病理和治疗。结果:临床症状以腹痛、腹部包块为主,肿瘤扭转率高。良性肿瘤41例,交界性3例,恶性23例;组织学类型以生殖细胞肿瘤最多。恶性肿瘤中65.2%为FIGOI期。除8例恶性患者进行了肿瘤细胞减灭术外,其余59例均进行了保留生育功能的手术。15例恶性肿瘤患者术后化疗。单因素分析显示仅化疗方案影响生存期,BEP优于VAC。结论:青少年卵巢肿瘤的临床病理特点与成人不同,首选保留生育功能的手术,BEP是恶性患者的一线化疗方案。     

Ovarian masses during adolescence: clinical, ultrasonographic and pathologic findings, serum tumor markers and endocrinological profile.

This retrospective study was undertaken to assess the epidemiological and clinical features, laboratory findings, preoperative work-up, surgical treatment and pathologic findings in adolescents with ovarian cysts. All adolescents who were referred to our institution and had been operated on because of a diagnosed ovarian mass, from January 1997 to June 2003, were included in this study. Forty-four cases of women with an ovarian mass were retrospectively analyzed. These patients, aged between 12 and 21 years, had 47 ovarian masses (three patients had bilateral lesions), of which 49% were non-neoplastic and 51% were neoplastic. Of the neoplastic lesions, 62.5% were germ cell tumors, 20.8% were epithelial and 16.7% were sex cord-stromal tumors. Of the neoplastic tumors, 95.8% were benign while 4.2% were malignant. Procedures included 30 operative laparoscopies (68.20%) and 14 exploratory laparotomies (31.8%). Simple excision of the ovarian cyst was performed in 39 cases (88.6%). According to our study, most of the adolescents with an ovarian cyst underwent an operation because of a neoplastic lesion. The majority of ovarian tumors occurring in adolescents are non-epithelial in origin, and germ cell tumors are the most common histological type. Ultrasound examination is one of the most important diagnostic tools. Preoperative diagnostic approach of these patients should always include careful history taking, physical examination, imaging and evaluation of serum assays. Gynecologists who care for young girls must be familiar with the differential diagnosis of ovarian masses whose surgical treatment should be conservative when appropriate, so that hormonal status and future fertility are not compromised in this group of patients.     

The diagnostic value of multiple tumor markers in malignant ovarian neoplasms

Objective:To study the diagnostic value of multiple tumor markers in malignant ovarian neoplasm.Methods:Sera obtained from 430 patients with ovarian masses (110 cases were malignant ovarian tumors,320 cases were benign ovarian tumors) before operation,and from 50 healthy women as control.Serologic examination of tumor markers included CA125,TSGF,SA,CEA,AFP,HCG and Fer.Results:The serum levels of CA125,TSGF,SA and Fer in patients with ovarian cancer were higher than those in patients with benign ovarian tumors (P<0.05),also in control group (P<0.05).In the diagnostic value of application for malignant ovarian neoplasm,CA125,TSGF and SA were better than the others.The sensitivity,specificity and accuracy in diagnosis of ovarian cancer were 86.4%,82.8%and 83.7% respectively for CA125 alone,78.2%,81.3%and 80.5% for TSGF alone,74.5%,81.9%and 80.0% for SA alone,whereas 95.5%,45.6%and 58.4% for multiple tumor markers combined in which 1 or more indices showed positive,93.6%,80.6%and 84.0% for that in which 2 or more indices showed positive,and 87.3%,90.3%and 89.5% for that in which 3 or more indices show positive.Conclusion:multiple tumor markers examination could improve the diagnosis of ovarian cancer,and examination of CA125,TSGF and SA combined is most ideal.     

Serum lactic dehydrogenase as a tumor marker in dysgerminoma

Dysgerminoma is the most common malignant germ cell tumor in young women. The management of advanced-stage dysgerminoma challenges the gynecologic oncologist to achieve maximal survival, while maintaining childbearing potential. Radiation therapy has been extremely successful in curing dysgerminoma, but ovarian conservation is usually not possible. In contrast, various chemotherapeutic regimens have achieved high cure rates with continued ovarian function. Diagnosing recurrent dysgerminoma promptly so that salvage therapy can be initiated is important when conservative management has been employed. While alpha-fetoprotein and human chorionic gonadotropin have proven useful as tumor markers in some types of germ cell tumors, they have not been useful in patients with dysgerminoma. Serum lactic dehydrogenase (LDH) levels are known to be elevated in some patients with dysgerminoma. We treated a patient with Stage IIIC dysgerminoma whose initial serum LDH level was markedly elevated. After unilateral salpingo-oophorectomy with pelvic and paraaortic lymphadenectomy, followed by four cycles of VAC chemotherapy, her LDH level returned to normal. Her LDH level rose with disease recurrence and returned to normal again with salvage BEP chemotherapy. This is the first report to document the utility of serial LDH measurements in detecting disease recurrence in patients with ovarian dysgerminoma.     

The value of tumor markers in a mixed tumor, mucinous and neuroendocrine carcinoma of the ovary

Serum CA125 is frequently used to monitor the treatment response and to detect early recurrence during the follow-up of patients who have epithelial ovarian tumors. In this report, the level of serum CA125 and urinary 5-hydroxyindole acetic acid of a patient with a carcinoid tumor which occurred in association with a mucinous adenocarcinoma of the ovary is described. The level of serum CA125 decreased despite the presence of a clinically progressive tumor. There was a rise of the 5-hydroxyindole acetic acid level 16 weeks before pelvic recurrence was detected clinically. This indicates that it was the neuroendocrine component, and not the mucinous component of the tumor, that was not responsive to the chemotherapy. The problem of using tumor markers to monitor patients with mixed tumors is discussed.     

Ovarian masses during adolescence: clinical,ultrasonographic and pathologic findings,serum tumor markers and endocrinological profile

This retrospective study was undertaken to assess the epidemiological and clinical features, laboratory findings, preoperative work-up, surgical treatment and pathologic findings in adolescents with ovarian cysts. All adolescents who were referred to our institution and had been operated on because of a diagnosed ovarian mass, from January 1997 to June 2003, were included in this study. Forty-four cases of women with an ovarian mass were retrospectively analyzed. These patients, aged between 12 and 21 years, had 47 ovarian masses (three patients had bilateral lesions), of which 49% were non-neoplastic and 51% were neoplastic. Of the neoplastic lesions, 62.5% were germ cell tumors, 20.8% were epithelial and 16.7% were sex cord–stromal tumors. Of the neoplastic tumors, 95.8% were benign while 4.2% were malignant. Procedures included 30 operative laparoscopies (68.2%) and 14 exploratory laparotomies (31.8%). Simple excision of the ovarian cyst was performed in 39 cases (88.6%). According to our study, most of the adolescents with an ovarian cyst underwent an operation because of a neoplastic lesion. The majority of ovarian tumors occurring in adolescents are non-epithelial in origin, and germ cell tumors are the most common histological type. Ultrasound examination is one of the most important diagnostic tools. Preoperative diagnostic approach of these patients should always include careful history taking, physical examination, imaging and evaluation of serum assays. Gynecologists who care for young girls must be familiar with the differential diagnosis of ovarian masses whose surgical treatment should be conservative when appropriate, so that hormonal status and future fertility are not compromised in this group of patients.     

Selenium concentrations in serum, hair and tumor tissue from patients with ovarian tumors

Selenium (Se) concentration was determined in 150 samples of serum, 135 samples of hair and 96 samples of ovarian tissue from patients with malignant or benign ovarian tumors and normal subjects. The serum Se level in patients with malignant ovarian tumors was significantly lower than that in patients with benign ovarian tumors and normal subjects. No difference of Se concentrations of hair among different groups was observed. Se level in malignant ovarian tumor tissue was significantly higher than that in benign ovarian tumor tissue and normal ovarian tissue. The low serum Se level in patients with malignant ovarian tumors was probably the result of protective migration of Se from blood to the cancer tissue.     

The role of tumor markers in gynecologic oncology.

Human chorionic gonadotropin is a highly sensitive and specific tumor marker for gestational trophoblastic neoplasia that accurately reflects tumor volume and the clinical course of disease. In women with endodermal sinus tumors and embryonal carcinomas, alpha-fetoprotein usually is a reliable marker, and it accurately predicts the presence of yolk sac elements in mixed germ cell tumors. CA 125 is the most widely utilized tumor marker presently available for use in patients with epithelial ovarian cancer. It has utility in monitoring therapy and differentiating benign from malignant pelvic masses. Measurement of serial CA 125 levels in postmenopausal women may facilitate screening for occult early stage disease. In the future, monoclonal antibodies that recognize tumor-associated antigens may prove useful for radionuclide imaging.     

Role of Ca-125 in the differential diagnosis of adnexal mass in breast cancer patients

OBJECTIVES: Serum CA-125 is of value in differential diagnosis of benign and malignant adnexal masses, especially in postmenopausal women. In ovarian cancer preoperative CA-125 levels are related to tumor stage, histologic grade, but are not an independent prognostic factor. Design: The aim of our study was to determine CA-125 serum level in women with ovarian tumor treated previously because of breast cancer. MATERIALS AND METHODS: Due to our research, we examined 51 women operated on for adnexal masses in the Department of Oncological Gynaecology in Bydgoszcz, 1996 - 2002. All those patients were treated because of breast cancer previously. RESULTS: In 19 women (37,3%) benign ovarian tumors were found, in 4 cases (7,8) - primary ovarian cancer whereas in 28 patients (54,9%) breast cancer metastases were detected. Based on CA-125 levels before surgery, correlation between CA-125 concentration and malignant histologic type was observed. CONCLUSIONS: 1. Higher CA-125 serum levels were found in a group of patients with metastatic adnexal masses compared to primary ovarian cancer. 2. In a group of women with breast cancer and ovarian tumor, metastatic adnexal masses were observed in more than 50% of cases.     

Dysgerminoma in a patient with a tumor of the neck. Empiric treatment of stage IV dysgerminoma

The evolution of therapy for malignant ovarian germ cell tumors is one of the true success stories in oncology. Treatment outcome has improved greatly thanks to cisplatin-based combination chemotherapy. According to the well-established treatment guidelines for advanced cases, we treated a case of stage IV undifferentiated germ cell tumor in which we were able to preserve the patient's fertility. We concluded that the PEP regimen is an effective treatment for the patient with metastatic germ cell tumor.     

Prognostic factors of patients with yolk sac tumors of the ovary

OBJECTIVE: Our purpose was to evaluate the prognostic factors in yolk sac tumors of the ovary. STUDY DESIGN: We performed a retrospective review of 47 patients with yolk sac tumors of the ovary from 1979 to 1997. RESULTS: Twenty-two patients had pure yolk sac tumors and 25 had germ cell tumors with yolk sac tissue as a component of the disease. The 5-year survival rate in stages I, II, III, and IV was 95%, 75%, 30%, and 25%, respectively. Patients with stage I disease had a more favorable prognosis than those with stage III and IV disease (P <.001). All patients who did not respond to chemotherapy died of this disease within 36 months of the first treatment. Chemotherapy regimens that included cisplatin gave better results than those without cisplatin (P <.05). The difference in prognosis was significant in cases in which the size of residual tumor was <2 cm in diameter (P <.01) and in cases in which ascites was either absent or <100 mL in volume (P <.05). Coexistence of other components of ovarian germ cell tumors in histologic specimens, preoperative serum alpha-fetoprotein level, fertility-sparing surgery, dissection of intrapelvic nodes, and p53 status had no significant correlation with the prognosis in this study. CONCLUSIONS: Staging and tumor-reductive surgery strongly affected the prognosis of this disease. Tumor-reductive surgery is advisable when ascites is minimal. Cisplatin-based chemotherapy after surgery was superior to chemotherapy without cisplatin; however, p53 status seemed to have no impact on chemosensitivity in yolk sac tumors of the ovary.