Ovarian cancer differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D.

Differentiating [Disease name] from other Diseases

Diseases		Clinical manifestations							Para-clinical findings				Gold standard	Additional findings
		Age of onset	Symptoms			Physical examination
									Lab Findings	Imaging		Immunohistopathology
			pelvic/abdominal pain or pressure	vaginal bleeding/discharge	GI dysturbance	Pleural effusion	Fever	Tenderness		CT scan/US	MRI
Gynecologic
Ovarian	Follicular cysts						–							It is associated with hyperestrogenism and endometrial hyperplasia
	Theca lutein cysts						–				Bilateral Multiple			It is associated with hydatidiform moles and choriocarcinoma
	Serous cystadenoma/carcinoma	>55 y/o					–				Bilateral			Most common ovarian neoplasm
	Mucinous cystadenoma/carcinoma	>55 y/o					–							It may cause pseudomyxoma peritonei
	Endometrioma		+				–		Iron deficiency anemia Elevated levels of serum cancer antigen-125 Increased levels of interleukin 1, chemoattractant protein-1, and interferon gamma	Complex mass on US Increased Doppler flow because of increased vascularture It may present with catamenial pneumothorax, hemothorax, and lung nodules in CT scan.	hyperintensity on T1-weighted images and a hypointensity on T2-weighted images Powder burn hemorrhages	Chocolate cyst	Laprascopy	Infertility
	Teratoma	10-30 y/o					–		High level of HCG and LDH					It may cause ovarian torsion May content thyroid tissue and cause hyperthyroidism
	Dysgerminoma			+			–		High level of HCG and LDH Hypercalcemia			Sheets fried egg appearance cells	Biopsy	Same as male seminomas
	Choriocarcinoma	During or after pregnancy					–		High level of B-hCG			Trophoblastic tissue origin columns and sheets of trophoblastic tissue invading uterine muscle and blood vessels		It is associated with bilateral Theca lutein cysts Cannonball metastases to the lungs May cause hemoptysis
	Yolk sac tumor	Young children Male infants					–		High levels of AFP			Yellow appearance Hemorrhagic Schiller-Duval bodies (glomeruli like structures)	Biopsy	The other name is ovarian endodermal sinus tumor
	Fibroma		Pulling sensation in the groin				–					Spindle-shaped fibroblast		It may cause Meigs syndrome (ovarian fibroma, ascites, and hydrothorax)
	Thecoma			Postmenopausal bleeding			–		High level of estrogen
	Granulosa cell tumor	50-60 y/o		Postmenopausal bleeding			–		High level of estrogen and progestron			Call-Exner bodies	Biopsy	In postmenopausal women may cause breast tenderness
	Sertoli-leydig cell tumor						–							Virilization
	Brenner tumor									In US Hypoechoic solid mass Calcification		Yellow/pale appearance Transitional cell tumor (resembles bladder) Coffee bean nuclei on H&E
	Krukenberg tumor				+						Bilateral	GI adenocarcinoma metastases Mucin-secreting signet cell
Tubal	tubo-ovarian abscess						+							fever and vaginal discharge
	Ectopic pregnancy
	Hydrosalpinx													infertility
	Tuberculosis salpingitis						+/–
	Epithelial carcinoma
	serous tubal intraepithelial neoplasm
Uterine	Myoma
	Sarcoma
	Pregnancy			+/−
Non-gynecologic
GIT	Appendiceal abscess	NA	+	–	+	+	+/–	+	Leukocytosis	Fluid collection in the appendicular region appendicolith may be visualized.	Fluid collection in the appendicular region appendicolith may be visualized.	NA	Imaging/history	The most common complication of acute appendicitis
	Appendiceal neoplasm	60-70 y/o for adenocarcinoma, 30-50 y/o for carcinoid tumors	+	–	+	+	–	+/–	In adenocarcinoma type we may have high levels of CEA and CA 19-9 In carcinoid type we may see high levels of chromogranin A, 5-HIAA and Ki67	In CT scan we may see: Soft tissue thickening and Cystic lesion with Internal septation Wall irregularity Calcification Periappendiceal fat stranding	Soft tissue mass in the appendix We may see invasion to other structures	Gray/yellowi color Cystic structures with angiolymphatic invasion	Biopsy	It is associated with: MEN1 Syndome Ulcerative colitis Neurofibromatosis type 1 HNPCC Smoking
	Diverticular abscess	>50 y/o	+	–	+	+	+/–	+	Leukocytosis	Ill-defined lesion with air and fluid inside Adjacent bowel loop wall thickening Smudged mesenteric fat	We may see a lesion with air and fluid inside	NA	Imaging/history	Diverticular abscess happens in almost 30-40% of patients with diverticulitis
	GI neoplasm	>50 y/o	+	–	+ (abdominal pain Intestinal obstruction and bleeding in small bowel cancer)?	–	–	+/–	Anemia Positive Fecal occult blood test High levels of CEA and CA 19-9	In CT scan we may see luminal narrowing, intestinal wall thickening,intussusception, bowel obstruction, hepatic metastases, intestinal perforation,enlarged lymph nodes	We may see tumor mass and the extension of tumor to other structures We may see metastasis to the liver, lung and brain	Based on the sub-type we may have different histopathological feature (for more information click here)	Biopsy	It is associated with smoking, positive family history, processed meat, low fiber diet, lynch Syndrome and familial adenomatous polyposis They have apple core lesion on barium enema xray
Renal	Pelvic kidney	NA	−/+ In case of sever hydronephrosis or renal stone we may have pelvic pain	–	−	−	−	−	−	In sonography we may see normal appearing kidney in pelvic position We may see renal calculi	We may see normal kidney structure Renal calculi	NA	Imaging	It may cause hypertension It may cause tract infection (UTI), obstruction, and renal calculi. It may be associated with (RCC)
Others	Retroperitoneal sarcoma	40-50 y/o	+	–	+ Gastrointestinal symptoms, such as early satiety, obstruction	−	−	−	Mild leukocytosis. It may cause hypoglycemia because of production of insulinlike substances	We may see irregular solid, semisolid, liquefactive areas and patchy necrosis on CT scan	We may see retroperitoneal involement and degree of tumor extenstion We may see liver and lung metastasis	There are two types: liposarcoma and leiomyosarcoma In liposarcomas we may see background of adipocytes with scattered lipoblasts, and inflammatory cell infiltrate In leiomyosarcoma we may see smooth muscle cells	Biopsy	May cause lower extremity edema, Serous ascites we should perform chest CT scan to rule out pulmonary metastases

check sites of cancer that may metastasize to the ovaries (eg, stomach, colorectal, breast)

check rectum, liver, spleen, lungs, inguinal or supraclavicular lymph nodes for ovary metastase