A 73-year-old woman comes to the office due to increasing abdominal girth. She also has constipation and decreased appetite that has worsened progressively for the last 6 months. On physical examination, the abdomen is distended and nontender, and there is a palpable right adnexal mass. The patient undergoes a right oophorectomy, and gross and microscopic examinations of the specimen are shown in the exhibit. Which of the following markers is most likely to be elevated in this patient?
Malignant ovarian neoplasms | ||
Histologic type | Diagnosis | Key features |
Epithelial | Serous |
|
Mucinous |
| |
Germ cell | Dysgerminoma |
|
Endodermal sinus |
| |
Stroma | Granulosa cell |
|
Sertoli-Leydig |
| |
AFP = alpha-fetoprotein; LDH = lactate dehydrogenase. | ||
Patients with ovarian cancer can present with a pelvic mass, ascites, and peritoneal metastasis that result in decreased appetite, abdominal distension, and bowel or bladder changes (eg, constipation, urinary frequency).
Ovarian cancer has 3 histologic types: epithelial, germ cell, and sex cord–stromal. Epithelial ovarian cancer is the most common subtype, and histologic findings include anaplasia of epithelial cells with invasion into the stroma, multiple papillary formations with cellular atypia, and occasional psammoma bodies.
Epithelial ovarian cancer is associated with elevated cancer antigen 125 (CA-125) levels. CA-125 is a protein expressed and released by cells from the peritoneum and müllerian structures (eg, uterus, fallopian tubes) that surround the ovaries. Conditions that irritate or stimulate these cells, either benign (eg, endometriosis) or malignant (eg, epithelial ovarian cancer), cause CA-125 levels to rise. Therefore, in patients with an ovarian mass, an elevated CA-125 level often indicates a rapid-growth tumor irritating the peritoneal tissue or other pelvic structures.
(Choice A) Serum alpha-fetoprotein levels may be increased in patients with hepatocellular carcinoma and ovarian germ cell tumors (eg, endodermal sinus [yolk sac] tumor). Endodermal sinus tumors of the ovary demonstrate Schiller-Duval bodies, which resemble glomeruli.
(Choices B and E) β-hCG is elevated in normal pregnancy, gestational trophoblastic disease (eg, hydatidiform mole, choriocarcinoma), and germ cell tumors (eg, dysgerminomas). Dysgerminomas may also secrete lactate dehydrogenase and have distinctive "fried-egg" cells with large, round nuclei surrounded by clear cytoplasm.
(Choice D) Granulosa cell tumors of the ovary are sex cord–stromal neoplasms that secrete estrogen and inhibin. Pathology findings include Call-Exner bodies with atypical granulosa cells containing coffee-bean nuclei.
(Choice F) Testosterone is secreted by Sertoli-Leydig cell tumors of the ovary. These rare sex cord–stromal neoplasms typically appear as tubules composed of Sertoli cells with interspersed eosinophilic Leydig cells and surrounding fibrous stroma.
Educational objective:
Epithelial ovarian cancer is the most common ovarian malignancy. Histologic findings include anaplasia of epithelial cells with invasion into the stroma and multiple papillary formations with cellular atypia. Epithelial ovarian tumors are associated with elevated cancer antigen 125, which can be used as a serum marker for this condition.