eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Oncology

Ovarian Dysgerminomas: Differential Diagnoses & Workup

Author: Allan Y Wu, MD, Director, The Midwest Women's Specialty Group; Adjunct Clinical Professor, Department of Molecular Biology, The Terre Haute Center for Medical Education, Indiana University School of Medicine
Coauthor(s): Chad M Michener, MD, Assistant Professor, Obstetrics/ Gynecology and Women's Health Institute, Section of Gynecologic Oncology, The Cleveland Clinic
Contributor Information and Disclosures

Updated: Oct 7, 2008

Differential Diagnoses

Ectopic Pregnancy

Other Problems to Be Considered

Gastrointestinal

Colorectal cancer
Bowel/omental adhesions
Diverticula
Fecal impaction
Low-lying cecum

Genitourinary

Pelvic abscess
Uterine fibroids
Torsed ovary
Hydrosalpinx (salpingitis isthmic nodosum)
Retroperitoneal tumor
Bladder distention
Pelvic kidney
Urachal cyst

Workup

Laboratory Studies

• Regardless of the clinical environment, obtain a urine pregnancy test. This test should be mandatory in any woman of reproductive age who presents with abdominopelvic symptoms.
• Document a guaiac test during the physical examination.
• Because dysgerminoma tumors affect women of a reproductive and sexually active age, cultures for gonorrhea and chlamydia and a wet mount are indicated at the time of speculum examination, especially if patients experience abdominopelvic pain. In this way, sexually transmissible diseases may be detected and treated before surgery.
• The standard workup for suspected GCTs requires alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (bHCG) levels because these agents have endocrine activity. Dysgerminomas (a germ cell subtype) are an exception to this rule. The absence of an elevated AFP or bHCG does not exclude the diagnosis of dysgerminomas because they rarely produce hormones. In extremely rare cases, dysgerminomas can become infiltrated with syncytiotrophoblastic giant cells, which produce human chorionic gonadotropin. Regardless, if the differential diagnosis includes dysgerminoma, AFP and bHCG levels are highly recommended.
• Useful tumor markers for dysgerminomas
  • bHCG
  • AFP
  • Lactate dehydrogenase (LDH)
  • Cancer antigen 125 (CA-125)
  • These markers can also be used for postoperative follow-up care or for tracking the success of adjuvant therapy.

Imaging Studies

• Imaging should never replace a careful history and physical examination in evaluating a patient with an ovarian mass. The initial approach should be an attempt to determine the nature and extent of the mass. Transvaginal ultrasound is a good preliminary imaging modality to determine if the mass is ovarian and, more importantly, if it has any malignant features (eg, thickened septations, solid and cystic components). Free abdominal fluid and bilateral masses heighten the suspicion of malignancy.
• Secondary imaging studies are used to rule out metastasis.
• Chest radiographs are performed to rule out pulmonary spread.
• Depending on the age of the patient, a preoperative mammogram is suggested to rule out primary metastasis if no study was performed 6-12 months before surgery.
• Body imaging with CT scanning and MRI can be of value in patients with GI or genitourinary signs of obstruction. In these cases, additional studies also include the following:
  • Barium enema
  • Upper GI series
  • Colonoscopy
  • Intravenous pyelography (IVP)
• Bedside ultrasonography concomitant with the physical examination, although helpful, is not indicated as a routine screening test.

Procedures

Dysgerminomas, like all ovarian cancers, can be staged only surgically. Because 5% of all stage Ia tumors can have occult microscopic disease on the contralateral ovary, performing a biopsy of the other ovary is recommended highly, especially if the ovary is enlarged or appears abnormal.

Histologic Findings

Grossly, dysgerminomas have a solid texture, with a tan, fleshlike appearance. Microscopically, dysgerminoma cells are round and ovoid and contain an abundance of clear cytoplasm secondary to glycogen buildup. The nuclei are irregularly shaped and contain more than one prominent nucleolus. These cells tend to coalesce, forming cords and sheets that are identified easily through low-power magnification. Granulocytic and lymphocytic infiltration within the intervening fibrous stroma also can be observed. Interestingly, cystic teratomas occasionally have small nests of dysgerminomatous tissue and vice versa. Additional assays detecting transcription factors GATA-4, Ihh, and BMP-2 may also prove useful in differentiating between dysgerminoma and other germ cell tumors.

Staging

International Federation of Gynecology and Obstetrics (FIGO) staging

• Stage I - Limited to ovaries
  • Ia - Limited to one ovary
  • Ib - Limited to both ovaries
  • Ic - Ascites with malignant cells on peritoneal washings or extension beyond the capsule in either Ia or Ib
• Stage II - Pelvic extension
  • IIa - Involvement of uterus or fallopian tubes
  • IIb - Extension to the bladder or rectum
  • IIc - Stage IIa or IIb but with positive peritoneal washings
• Stage III - Peritoneal implants outside of pelvis
  • IIIa - Microscopic seeding of abdominal surfaces
  • IIIb - Abdominal peritoneal implants smaller than 2 cm
  • IIIc - Abdominal implants larger than 2 cm or positive lymph nodes
• Stage IV - Distant metastases
  • Pleural effusions - Must confirm with positive cytology to be deemed stage IV
  • Any involvement of the liver parenchyma
• During laparotomy, obtain a biopsy from the contralateral ovary because 5% of all stage Ia cancers established by gross inspection have occult microscopic disease on the opposite ovary. Some advocate leaving the opposite ovary undisturbed if it is of normal size or appearance.

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