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Ovarian Cancer Differential Diagnoses

  • Author: Andrew E Green, MD; Chief Editor: from Memorial Sloan-Kettering - Yukio Sonoda, MD  more...
 
Updated: Jun 16, 2016
 
 

Diagnostic ConsiderationsOvarian cystsEvaluation of adnexal massesOther problems

An ovarian cyst is a fluid-filled sac in an ovary. Ovarian cysts can develop from the neonatal period to postmenopause but most occur during infancy and adolescence, which are hormonally active periods of development. With the more frequent use of ultrasonography in recent years, the diagnosis of ovarian cysts has become more common.

The normally functioning ovary produces a follicular cyst six to seven times each year. In most cases, these functional masses are self-limiting and resolve within the duration of a normal menstrual cycle. In rare situations, they persist longer or become enlarged. At this point, they represent a pathological condition.

For more information, see Ovarian Cysts.

Adnexal masses present a diagnostic dilemma; the differential diagnosis is extensive, with most masses representing benign processes.[29, 30, 31] However, without histopathologic tissue diagnosis, a definitive diagnosis is generally precluded. Physicians must evaluate the likelihood of a pathologic process using clinical and radiologic information and balance the risk of surgical intervention for a benign versus malignant process.

Since ovaries produce physiologic cysts in menstruating women, the likelihood of a benign process is higher. In contrast, the presence of an adnexal mass in prepubertal girls and postmenopausal women heightens the risk of a pathologic etiology.

A review by Suh-Burgmann and Kinney suggests that surgical evaluation of adnexal masses is appropriate in the following circumstances[31] :

  • Symptomatic masses
  • Masses associated with other signs of malignancy (eg, elevated cancer antigen 125 [CA125] levels in a postmenopausal patient, ascites)
  • Women at high genetic risk for ovarian cancer
  • Large masses (>10 cm), which are less likely to regress, have a higher risk of symptoms, and are often more difficult to characterize on ultrasound

Ultrasound features associated with malignancy include the following[31] :

  • Irregular solid tumor
  • Ascites
  • At least four papillary projections
  • Irregular multilocular solid tumor ≥10 cm
  • Very strong intratumoral blood flow

These authors note that measurable benefits of monitoring are realized within the first year of observation. If an adnexal mass is small, lacks suspicious ultrasound features, and remains stable, the likelihood of malignancy and therefore, the potential benefit of observation wanes with time, while potential harms increase.[30]

A systematic review concluded that pelvic magnetic resonance Imaging (MRI) with contrast is the preferred advanced second imaging test for assessment of ultrasound-indeterminate adnexal masses. In particular, the high specificity of MRI in this setting provides confident identification of many benign lesions.[32]

A study of a second-generation multivariate index assay designed to improve the detection of ovarian cancer in women undergoing surgery for a pelvic mass found that a single cut-off separated high and low risk of malignancy regardless of patient menopausal status, with a specificity of 69% and positive predictive value of 40%. The assay includes five markers: CA125, apolipoprotein A-1, follicle-stimulating hormone, and human epididymis protein 4.[33]

For more information, see Adnexal Tumors.

Other problems to be considered in the differential diagnosis of ovarian cancer include the following:

  • Appendiceal tumors
  • Benign lesions of the uterine corpus
  • Bladder distention/urinary retention
  • Bowel/omental adhesions
  • Colon cancer
  • Embryologic remnants
  • Fecal impaction
  • Gastric adenocarcinoma
  • Hydrosalpinx/pyosalpinx
  • Low-lying cecum
  • Metastatic gastrointestinal carcinoma
  • Ovarian torsion
  • Pelvic abscess
  • Pelvic kidney
  • Peritoneal cyst
  • Retroperitoneal mass
  • Urachal cyst
  • Uterine anomalies
  • Uterine fibroids

Differential Diagnoses

 
 
Contributor Information and Disclosures
Author

Andrew E Green, MD Consulting Staff, Northeast Georgia Medical Center

Andrew E Green, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Society of Gynecologic Oncology, American Society of Clinical Oncology

Disclosure: Nothing to disclose.

Coauthor(s)

Agustin A Garcia, MD Associate Professor of Medicine, University of Southern California Keck School of Medicine

Agustin A Garcia, MD is a member of the following medical societies: European Society for Medical Oncology, American Society of Clinical Oncology

Disclosure: Nothing to disclose.

Samina Ahmed, MD Fellow, Division of Oncology, Department of Medicine, University of Southern California, Keck School of Medicine

Samina Ahmed, MD is a member of the following medical societies: American Society of Clinical Oncology

Disclosure: Nothing to disclose.

Chief Editor

from Memorial Sloan-Kettering - Yukio Sonoda, MD Associate Professor, Weill Cornell Medical College; Associate Attending Surgeon, Gynecology Service, Department of Surgery, Memorial Hospital for Cancer and Allied Diseases; Associate Member, Memorial Sloan-Kettering Cancer Center

from Memorial Sloan-Kettering - Yukio Sonoda, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Medical Association, Society of Gynecologic Oncology, Society of Laparoendoscopic Surgeons, AAGL, American Society of Clinical Oncology, International Gynecologic Cancer Society, Japanese Medical Society of America, Korean American Medical Assocation

Disclosure: Nothing to disclose.

Acknowledgements

Robert P Edwards, MD Professor, Department of Obstetrics, Gynecology, and Reproductive Science, University of Pittsburgh; Vice-Chair, Clinical Affairs, Director, Ovarian Cancer Center of Excellence, Magee-Womens Hospital of University of Pittsburgh

Robert P Edwards, MD is a member of the following medical societies: American Association for Cancer Research, American College of Obstetricians and Gynecologists, American College of Surgeons, American Medical Association, and Society for Gynecologic Investigation

Disclosure: Nothing to disclose.

C William Helm, MB, BCh, MA, FRCS(Edin), FRCS Professor, Division of Gynecologic Oncology, Saint Louis University School of Medicine

C William Helm, MB, BCh, MA, FRCS(Edin), FRCS is a member of the following medical societies: American College of Obstetricians and Gynecologists, European Society of Gynaecologic Oncology, and International Gynecologic Cancer Society

Disclosure: ThermaSolutions, Inc Grant/research funds Research Registry of patients treated with hyperthemic intraperitoneal chemotherapy; Sanofi-Aventis, Inc Grant/research funds Support for and investigator initiated research study of HIPEC for consolidation in ovarian cancer; ThermaSolutions, Inc Honoraria Speaking and teaching; UpToDate Royalty Online Text Book Chapters; Genzyme, Inc Honoraria Speaking and teaching

Warner K Huh, MD Professor, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Senior Scientist, Comprehensive Cancer Center, University of Alabama School of Medicine

Warner K Huh, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Society of Clinical Oncology, Massachusetts Medical Society, and Society of Gynecologist Oncologists

Disclosure: MERCK Consulting fee Consulting; ROCHE PHARMA/DIAGNOSTICS Consulting fee Consulting; INTUITIVE SURGICAL Proctor Fee Consulting; Qiagen Consulting fee Consulting

Karen Loeb Lifford, MD Director of General Gynecology, Associate Program Director, Department of Obstetrics and Gynecology, Instructor, Brigham and Women's Hospital, Harvard Medical School

Karen Loeb Lifford, MD is a member of the following medical societies: Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Michel E Rivlin, MD Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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An enlarged ovary with a papillary serous carcinoma on the surface.
Metastases from epithelial ovarian carcinoma involving the omentum.
Inside of a large, smooth-surfaced tumor replacing the ovary. Final histologic studies indicated the tumor was a mucinous carcinoma of low malignant potential. Note the multiple cysts with thick septa between. This tumor was extensively sectioned and was a mucinous carcinoma of low malignant potential.
Granulosa cell tumor excised from a woman aged 44 years. Note the yellowish tumor that has eroded through, onto the surface of the ovary.
This photo shows a granulosa cell tumor, with the cut surface showing classic features of a hemorrhagic cyst and yellowish solid component.
Mature cystic teratoma of the ovary exhibiting multiple tissue types.
Mature cystic teratoma of the ovary with hair, sebaceous material, and thyroid tissue.
Dr. Oliver Zivanovic, MD, PhD, discusses the role of hyperthermic intraperitoneal chemotherapy in ovarian cancer. Courtesy of Memorial Sloan-Kettering Cancer Center.
Dr. Oliver Zivanovic, MD, PhD, demonstrates hyperthermic intraperitoneal chemotherapy for ovarian cancer. Courtesy of Memorial Sloan-Kettering Cancer Center.
 
 
 
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