Question:

A 53-year-old woman, gravida 2 para 2, comes to the office due to right-sided pelvic pain that has worsened over the past 3 months. She has a history of severe dysmenorrhea that resolved following her last menstrual period a year ago. The patient reports having disruptive hot flushes since menopause and is now experiencing bloating and a decreased appetite. She had a cesarean delivery and bilateral tubal ligation at age 35 and has a remote history of pelvic inflammatory disease in her 30s. The patient has no other medical conditions. Temperature is 36.7 C (98 F) and blood pressure is 110/70 mm Hg. Leukocyte count is 8,200/mm³. Β-hCG is undetectable. Pelvic ultrasonography shows a 7-cm right ovarian mass with solid components, thick septations, and a moderate amount of peritoneal fluid. Which of the following is the most likely explanation for this patient's findings?

Abnormal proliferation of tubal or ovarian epithelium

Development of a cuboidal, nonciliated epithelial lined cyst

Ectopic implantation of endometrial glands

Excessive growth of well-differentiated germ cells

Obstruction from fluid accumulation in the fallopian tube

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Epithelial ovarian carcinoma
Clinical presentation	Acute: shortness of breath, obstipation/constipation with vomiting, abdominal distension Subacute: pelvic/abdominal pain, bloating, early satiety Asymptomatic adnexal mass
Laboratory findings	↑ CA-125
Ultrasound findings	Solid mass Thick septations Ascites
Management	Exploratory laparotomy

This patient with pelvic pain, bloating, and a decreased appetite has a complex adnexal mass (ie, solid components and thick septations) with ascites on imaging, which is worrisome for advanced-stage epithelial ovarian carcinoma (EOC).

The ovary is composed of multiple different cell lineages, each of which can result in different malignancies (eg, granulosa cell tumors arise from stromal cells, yolk sac tumors arise from germ cells). EOC is the most common subtype of ovarian cancer and is thought to arise from the ovarian surface epithelium.

Recent studies have revealed that the majority of EOC tumors are most histologically and molecularly similar to fallopian tube epithelium. For most cases, epithelial ovarian carcinogenesis is thought to originate from the dysplastic/malignant tubal epithelium that spills secondarily onto the surface of the ovary (creating the appearance of ovarian origin), the peritoneum, and the omentum. Salpingectomies remove the entire tube (not just a portion) and markedly reduce the risk of EOC (up to 40% risk reduction). For other cases of EOC, the ovarian surface epithelium is thought to undergo malignant transformation after sustained damage with persistent ovulation, which is why suppression of ovulation (ie, oral contraceptive pills, pregnancy) protects against the development of EOC.

(Choice B) Cystadenomas are among the most common benign neoplasms that arise from the ovary. They are often simple, round, and fluid-filled cysts lined by cuboidal, nonciliated epithelium closely resembling the ovarian surface epithelium.

(Choice C) Endometriomas, a common cause of pelvic pain in premenopausal patients, are ovarian cysts that arise from implanted ectopic endometrial glands on the ovarian surface. Ultrasonography demonstrates a homogenous cyst with internal echoes (eg, "ground glass") rather than a complex mass with septations in a postmenopausal patient.

(Choice D) Mature cystic teratomas, or dermoid cysts, are benign ovarian tumors that arise from multiple germ cell layers. On ultrasound, they have hyperechoic nodules and calcifications; although they can have solid components, they do not exhibit multiple septations or cause ascites.

(Choice E) A hydrosalpinx is caused by fluid accumulation in a fallopian tube due to blockage by either adhesions (eg, pelvic inflammatory disease) or surgery (eg, bilateral tubal ligation). Ultrasound demonstrates a mass separate from the ovary rather than an ovarian tumor.

Educational objective:
Epithelial ovarian cancer can present as a complex adnexal mass with pelvic pain, decreased appetite, and bloating. Ovarian carcinogenesis often involves the abnormal proliferation of the tubal epithelium that secondarily involves the ovary and peritoneum.