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.

Overview

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
  • Women in reproductive age (15 -45 y/o)
+/– +/–
  • High level of estrogen +/–
  • In US we may see a >3 cm simple cyst with no internal echo and with posterior acoustic enhancement
  • simple cyst with no internal echo or septa
  • NA
  • History/imaging
  • It is associated with hyperestrogenism and endometrial hyperplasia
Theca lutein cysts
  • Women in reproductive age (15 -45 y/o)
+/– +/–
  • Depends on the underlying etiology
  • In US we may see bilaterally enlarged ovaries with multiple cysts
  • Multiple bilateral cysts
  • theca interna cell Hyperplasia
  • History/imaging
  • It is associated with hydatidiform moles, choriocarcinoma, diabetes mellitus and clomiphene intake (ovulation induction)
Serous cystadenoma/carcinoma
  • >55 y/o
  • Bilateral
  • Most common ovarian neoplasm
Mucinous cystadenoma/carcinoma
  • >55 y/o
  • It may cause pseudomyxoma peritonei
Endometrioma
  • Women in reproductive age (15 -45 y/o)
+ + +/– +
  • hyperintensity on T1-weighted images and a hypointensity on T2-weighted images
  • Powder burn hemorrhages
  • Chocolate cyst
  • Laprascopy
  • It may cause infertility
Teratoma
  • 10-30 y/o
+/– +/–
  • High level of HCG and LDH
  • In US we may see cystic adnexal mass with mural components and echogenic lesion due to calcification
  • The iceberg sign
  • Dot-dash pattern
  • We may see evidence of fat components
  • All three germ layers cell
  • Biopsy
  • It may cause ovarian torsion
  • May content thyroid tissue and cause hyperthyroidism
  • In plane radiography we may see calcification due to the presence of tooth in the tumor
Dysgerminoma
  • in the second to third decade of life
+ +/– +/–
  • High level of HCG and LDH
  • Hypercalcemia
  • Multilobulated solid masses
  • We may see ovarian mass with septation which are hyperintense on T1 and hypo or isointense on T2 imaging
  • Sheets fried egg appearance cells
  • Biopsy
  • Same as male seminomas
Yolk sac tumor
  • Young children
  • Male infants
+ +
  • High levels of AFP
  • In US we may see a combination of echogenic and hypoechoic components
  • Ovarian mass with hemorrhagic areas
  • Yellow appearance
  • Hemorrhagic
  • Schiller-Duval bodies (glomeruli like structures)
  • Biopsy
  • The other name is ovarian endodermal sinus tumor
Fibroma
  • >50 y/o
  • Pulling sensation in the groin
+/– +/–
  • High levels of CA-125
  • In CT scan we may see a unilateral mass with poor contrast enhancement
  • Low signal intensity on T1 and T2
  • We may see scattered hyperintense areas due to edema or cystic degeneration
  • Spindle-shaped fibroblast
  • Biopsy
  • It may cause Meigs syndrome (ovarian fibroma, ascites, and hydrothorax)
  • It may cause ovarian torsion
Thecoma
  • >50 y/o
+/–
  • Postmenopausal bleeding
  • High level of estrogen
  • In US we may see non-specific ovarian mass
  • We may see evidence of endometrial hyperplasia due to increased level of estrogen
  • Hyperintense on T2
  • T1 intensity depends on the amount of fibrous tissue (fibrous tissue lead to hypointensity)
  • Lipid-laden stromal cells with pale, vaculolated cytoplasm
  • Biopsy
  • We may see endometrial cancer as e result of hyper-estrogenism
  • We may see ovarian fibrothecoma (mixture of fibroma and thecoma)
Granulosa cell tumor
  • 50-60 y/o
+
  • Postmenopausal bleeding
+/–
  • High level of estrogen and progestron
  • We may see inhibin, calretinin, and Ki-67 on the surface of granulosa cell tumor cells
  • In US we may see solid, cystic, or multiloculated solid and cystic mass
  • We may see solid, cystic, or multiloculated solid and cystic mass
  • Call-Exner bodies
  • Biopsy
  • In postmenopausal women may cause breast tenderness
Sertoli-leydig cell tumor
  • 15 to 35 y/o
+/–
  • In US we may see unilateral Well-defined hypoechoic lesion
  • Low T2 signal intensity
  • areas of high signal intensity
  • Lydig cells (Polygonal pink cells with eosinophilic cytoplasm
  • Sertoli cells (clear vacuolated cytoplasm)
  • Biopsy
Brenner tumor
  • >55 y/o
+/–
  • In US we may see hypoechoic solid mass and calcification
  • Hypointense on T2 because of fibrous content
  • Yellow/pale appearance
  • Transitional cell tumor (resembles bladder)
  • Coffee bean nuclei on H&E
  • Biopsy
  • Most of the times it's an accidental finding
Krukenberg tumor
  • >55 y/o
+/– +/–

Based on underlying malignancy

+/–

Based on underlying malignancy

  • In case of metastatic GI cancers we may see iron deficiency anemia
  • Mostly bilateral, complex ovarian lesion
  • In CT scan we may see evidence of concurrent malignancy in other organs
  • Mostly bilateral, complex ovarian lesion with solid components
  • Internal hyperintensity on T1 and T2 weighted MR images because of mucin
  • Evidence of concurrent malignancy in other organs
  • Mucin-secreting signet cell
  • Imaging/biopsy
  • The most common primary tumor is in colon, stomach, breast, lung, and contralateral ovary.
Tubal tubo-ovarian abscess
  • Young women (15-30 y/o
+ + + +
  • High levels of inflammatory markers
  • Leukocytosis
  • In US we may see multilocular complex lesion mostly bilateral with debry inside
  • We may see a pelvic mass filled with fluid with thick walls
  • hypointense in T1 and heterogeneous in T2
  • In abscess aspiration we may see anaerobic organisms
  • History/imaging
  • The most common risk factors are previous PID, diabetes mellitus, intrauterine device and history of uterine surgery
Ectopic pregnancy
  • Women in reproductive age (15 -45 y/o)
+ + +/– +
  • High level of BhCG
  • Progesterone level ≤5 ng/ml
  • In US we may see empty uterine cavity, tubal ring sign, ring of fire sign (Doppler), extra-uterine fetal heart rate
  • NA
  • NA
  • History/imaging
  • Any women in reproductive age presenting with abdominal pain or amenorrhea should be screened for ectopic pregnancy
Hydrosalpinx
  • NA
+ +/–
  • In US we may see tubal longitudinal folds thickening (cogwheel appearance)
  • In CT scan we may see tubular adnexal lesion with fluid attenuation
  • Dilated Fallopian tube with fluid signal intensity
  • NA
  • Imaging
  • It is associated with endometriosis (haematosalpinx), ovulation induction, pelvic inflammatory disease, post-hysterectomy, tubal ligation, and tubal malignancy
  • It may cause infertility
Salpingitis
  • Women of reproductive age
+ + + +
  • Leukocytosis
  • In US we may see , edematous and thickened endosalpingeal folds
  • NA
  • NA
  • History/physical exam
  • It may cause infertility
Fallopian tube carcinoma
  • >60 y/o
+ + + + +/–
  • High levels of CA125
  • US findings are non specific (complex mass on Fallopian tube
  • We may see papillary projections
  • Low signal on T1
  • In case of hemorrhage inside the tumor we may see high signal intensity on T1
  • Low or of intermediate signal on T2
  • In case of serous fluid inside the tumor we may see high signal intensity on T2
  • Based on the tumor type we may have different biopsy finding
  • Biopsy
  • We may see Latzko triad (abdominal pain, vaginal discgarge, pelvic mass)
Uterine Leiomyoma
  • Women of reproductive age
+ + +/–
  • In chronic cases, we may see mild anemia
  • In US we may see hypoechoic mass with calcification and cystic areas of necrosis or degeneration may
  • Low to intermediate signal intensity on T1 and T2
  • In case of necrosis inside the mass, there might be some high signal lesions on T2
  • Smooth muscle
  • Imaging
  • It may cause infertility
Choriocarcinoma
  • Women in reproductive age (15 -45 y/o)
+ + +/– +
  • High level of B-hCG
  • In US we may see heterogeneous mass infiltrating myometrium
  • Enlarged uterus
  • Necrosis +
  • Hemorrhage +
  • In CT scan we may see evidence of metastasis to brain, lung and other organs
  • We may see an infiltrative uterine mass and thickening of uterine wall
  • Trophoblastic tissue origin
  • columns and sheets of trophoblastic tissue invading uterine muscle and blood vessels
  • Biopsy
  • It is associated with bilateral Theca lutein cysts
  • Cannonball metastases to the lungs
  • May cause hemoptysis
  • We may see passing of grapes like tissue from the vagina
Leiomyosarcoma
  • >55 y/o
+ + +/–
  • Increased uterine size
  • Irregular central zones of low signal intensity (tumor necrosis)
Pregnancy +/− +/− +/−
  • NA
Non-gynecologic
GIT Appendiceal abscess
  • NA
+ + + +/– +
  • NA
Appendiceal neoplasm[1] + + + +/–
  • Soft tissue mass in the appendix
  • We may see invasion to other structures
  • Gray/yellowi color
  • Cystic structures with angiolymphatic invasion
Diverticular abscess
  • >50 y/o
+ + + +/– +
  • 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
Colorectal cancer
  • >50 y/o
+ + +/–
  • We may see tumor mass and the extension of tumor to other structures
Renal

Bladder

Pelvic kidney
  • NA
−/+

In case of sever hydronephrosis or renal stone we may have pelvic pain

  • We may see normal kidney structure
  • NA
  • It may cause tract infection (UTI), obstruction, and renal calculi.
  • It may be associated with RCC
Bladder cancer
  • ≥65 y/o
+
  • isointense compared to muscle in T!
  • slightly hyperintense compared to muscle in T2
Others Retroperitoneal sarcoma[2]
  • 40-50 y/o
+ +

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

  • Bladder tumour–associated antigen (BTA)
  • Nuclear matrix proteins (NMP)
  • Mucin and carcinoembryonic antigen (CEA)

References

  1. Chapter 5: Tumours of the Appendix - IARC. https://www.iarc.fr/en/publications/pdfs-online/pat-gen/bb2/bb2-chap5.pdf Accessed on January 15, 2019
  2. Storm FK, Mahvi DM (July 1991). "Diagnosis and management of retroperitoneal soft-tissue sarcoma". Ann. Surg. 214 (1): 2–10. PMC 1358407. PMID 2064467.

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