Eduovisual
Female Reproductive & Breast
Ovarian cancer: presentation, workup, and screening limits
— Ovarian cancer is the deadliest gynecologic malignancy in the US, largely because ~70% of patients present with stage III/IV disease
— Lifetime risk in the general population is ~1.3%; median age at diagnosis is 63 years
— Epithelial tumors account for ~90%, with high-grade serous carcinoma (HGSC) being the dominant histology, now understood to often originate from the fallopian tube fimbria
— Postmenopausal woman with persistent (>2 weeks), new-onset bloating, early satiety, pelvic/abdominal pain, urinary urgency/frequency, or change in bowel habits
— Adnexal mass on exam or incidental imaging in a woman over 50
— Unexplained ascites, pleural effusion, or carcinomatosis on imaging in a female patient — assume ovarian/tubal/peritoneal primary until proven otherwise
— New VTE in an older woman without obvious provoking factor (Trousseau-type presentation)
— BRCA1 (~40% lifetime risk), BRCA2 (~15%), Lynch syndrome (MMR mutations)
— Strong family history of breast/ovarian/colon/endometrial cancer
— Nulliparity, early menarche, late menopause, infertility, endometriosis (clear cell, endometrioid subtypes)
— Postmenopausal hormone therapy (modest)
— Combined OCPs (≥5 years reduces risk ~50%), multiparity, breastfeeding, tubal ligation, salpingectomy
Board pearl: The classic teaching that ovarian cancer is "silent" is outdated — it has a symptom triad of bloating, early satiety, and pelvic/urinary symptoms that is often dismissed as IBS or menopause. On Step 3, a 55-year-old with 3 weeks of bloating and a normal colonoscopy gets a transvaginal ultrasound and CA-125, not a PPI trial.
Key distinction: Functional cysts dominate in premenopausal women; any adnexal mass in a postmenopausal woman is malignant until proven otherwise and warrants imaging plus tumor markers.
— Bloating / increased abdominal size (most common, ~70%)
— Early satiety or difficulty eating
— Pelvic or abdominal pain
— Urinary urgency or frequency
— Sensitivity ~57% early-stage, ~80% advanced; specificity ~90% in women >50
— Ascites producing rapid abdominal girth increase, often without weight gain elsewhere
— Dyspnea from malignant pleural effusion (usually right-sided)
— Constipation, obstipation, or partial small-bowel obstruction from omental caking
— Sister Mary Joseph nodule (periumbilical metastasis), supraclavicular (Virchow) node
— Paraneoplastic: VTE, subacute cerebellar degeneration (anti-Yo), dermatomyositis
— Duration and frequency of GI/urinary complaints — persistence is the red flag
— Family history: first- and second-degree breast, ovarian, fallopian tube, peritoneal, colon, endometrial, pancreatic, prostate cancer; Ashkenazi Jewish ancestry
— Personal cancer history (breast cancer before 50 raises BRCA suspicion)
— Reproductive history: parity, OCP use, infertility, endometriosis
— Postmenopausal bleeding (more suggestive of endometrial, but estrogen-secreting granulosa cell tumors can cause it)
— Virilization or hirsutism — think Sertoli-Leydig tumors
— Precocious puberty in a child → granulosa cell tumor
— Acute pelvic pain with palpable mass in an adolescent → germ cell tumor (dysgerminoma, immature teratoma); check AFP, β-hCG, LDH
Step 3 management: When a postmenopausal woman presents with vague GI symptoms, the workup pivot is: rule out ovarian cancer in parallel with GI workup, not sequentially. Ordering pelvic US + CA-125 alongside colonoscopy avoids the classic 6-month diagnostic delay tested on boards.
Board pearl: Endometriosis history specifically predisposes to clear cell and endometrioid ovarian carcinomas.
— Cachexia, temporal wasting in advanced disease
— Pallor from chronic disease anemia or occult GI involvement
— Tachycardia and orthostasis if dehydrated from poor PO intake or partial bowel obstruction
— Distension disproportionate to weight — fluid wave, shifting dullness suggest ascites
— Omental caking palpable as a firm, rope-like upper-abdominal mass
— Diminished bowel sounds with tympany if partial obstruction
— Sister Mary Joseph nodule — firm periumbilical lesion, pathognomonic for intra-abdominal malignancy spread
— Fixed, solid, irregular, bilateral adnexal mass is the high-risk pattern
— Nodularity in the cul-de-sac (pouch of Douglas) felt on rectovaginal exam — suggests peritoneal seeding
— Cervical motion tenderness usually absent (helps separate from PID)
— Premenopausal: smooth, mobile, unilateral, cystic favors benign functional cyst
— Left supraclavicular (Virchow's) node — abdominal/pelvic malignancy
— Inguinal nodes can be involved in advanced disease
— Decreased breath sounds and dullness at right base → malignant pleural effusion (stage IV by definition if positive cytology)
— Most patients are hemodynamically stable; instability suggests complication: cyst rupture with hemoperitoneum, torsion, or sepsis from bowel perforation
— Acute abdomen + adnexal mass + hypotension in a premenopausal woman → consider ovarian torsion or ruptured ectopic before assuming malignancy
— Lower extremity edema from pelvic mass compressing iliac veins or lymphatics
— Calf swelling/tenderness → DVT (paraneoplastic hypercoagulability)
— Acanthosis nigricans or dermatomyositis as paraneoplastic clues
CCS pearl: On a CCS case with suspected ovarian cancer, your exam orders should include abdominal, pelvic (bimanual AND rectovaginal), lymph node, and breast exams — missing the rectovaginal or supraclavicular check costs points.
Key distinction: A mobile, unilateral, cystic, <5 cm mass in a 25-year-old vs a fixed, bilateral, solid, with ascites mass in a 65-year-old — the second demands urgent oncologic workup, not repeat ultrasound in 6 weeks.
— Modality of choice for any adnexal mass
— Malignant features: solid components, thick septations (>3 mm), papillary projections, internal vascularity on Doppler, size >10 cm, bilaterality, ascites
— Benign features: simple anechoic cyst, thin wall, no septations, <5 cm in premenopausal women
— O-RADS lexicon stratifies risk (0–5) and drives next steps
— CA-125 — most useful in postmenopausal women; elevated in ~80% of epithelial ovarian cancers but only ~50% of stage I
— False positives in premenopausal women: endometriosis, fibroids, PID, pregnancy, menstruation, cirrhosis, any peritoneal inflammation
— HE4 + CA-125 → ROMA score for risk stratification
— Multivariate index assay (OVA1) can supplement
— AFP — yolk sac tumor, embryonal carcinoma, immature teratoma
— β-hCG — choriocarcinoma, dysgerminoma, embryonal carcinoma
— LDH — dysgerminoma
— Inhibin B, AMH — granulosa cell tumor
— Testosterone, DHEAS — Sertoli-Leydig
— CBC (anemia, thrombocytosis is a paraneoplastic marker), CMP, LFTs, coags, type and screen
— Pregnancy test in any reproductive-age woman before imaging or intervention
— Albumin and prealbumin for nutritional baseline pre-op
— CT abdomen/pelvis with IV + oral contrast for staging once malignancy suspected — assesses omental caking, peritoneal implants, lymphadenopathy, liver mets, hydronephrosis
— CT chest if pleural effusion, supraclavicular nodes, or advanced disease
— MRI pelvis if mass is indeterminate on US
Board pearl: Do NOT biopsy a suspected ovarian primary percutaneously if it appears resectable — risk of tumor seeding upstages disease. The diagnostic tissue comes from surgical staging/cytoreduction.
Step 3 management: In a premenopausal woman, an isolated mildly elevated CA-125 (e.g., 60 U/mL) is not diagnostic — repeat after menses, consider endometriosis, and use US morphology to drive decisions.
— Surgical exploration is both diagnostic and therapeutic for a suspicious adnexal mass
— Approach: exploratory laparotomy (or minimally invasive if early-stage and surgeon-experienced) with frozen section
— If frozen confirms malignancy → proceed to comprehensive staging in the same operation
— Paracentesis with cytology only if non-surgical candidate or to confirm malignancy before neoadjuvant chemotherapy
— Total hysterectomy + bilateral salpingo-oophorectomy (TH-BSO)
— Omentectomy (infracolic minimum)
— Peritoneal washings, multiple peritoneal biopsies (paracolic gutters, diaphragm, pelvis)
— Pelvic and para-aortic lymphadenectomy
— Appendectomy for mucinous tumors (rules out appendiceal primary)
— Maximal cytoreduction (debulking) to <1 cm residual ("optimal"), ideally to no visible disease ("complete R0")
— Stage I: confined to ovaries/tubes
— Stage II: pelvic extension
— Stage III: peritoneal spread beyond pelvis or retroperitoneal nodes (most common at diagnosis)
— Stage IV: distant mets — IVA pleural effusion with positive cytology, IVB parenchymal or extra-abdominal
— Germline BRCA1/2 testing for every patient, regardless of family history
— Somatic BRCA1/2 and homologous recombination deficiency (HRD) testing — drives PARP inhibitor eligibility
— Lynch syndrome testing (MMR/MSI) if histology suggests endometrioid or clear cell or family history fits
— Refer to genetic counseling before and after testing
— Considered when optimal primary cytoreduction is not feasible (extensive disease, poor performance status, comorbidities)
— Requires histologic or cytologic confirmation first (image-guided biopsy of omental cake or paracentesis)
— Typically 3 cycles platinum/taxane → interval debulking → 3 more cycles
Board pearl: Every newly diagnosed epithelial ovarian cancer gets germline BRCA testing — this is a guideline-level recommendation, not a family-history-triggered one.
CCS pearl: Order "gynecologic oncology consult" early — referral to a gyn-onc surgeon improves survival versus general gynecologists or general surgeons.
— Risk of Malignancy Index (RMI) = US score × menopausal score × CA-125
— ROMA = HE4 + CA-125 + menopausal status
— O-RADS US categories 4–5 → high risk → refer to gyn-onc
— Indications for referral to gyn-onc (ACOG/SGO): elevated CA-125 (postmenopausal: any elevation; premenopausal: >200), ascites, abdominal/distant mets, family history, fixed/nodular pelvic mass
— Simple cyst <10 cm in premenopausal woman → observe with repeat US in 8–12 weeks
— Simple cyst <1 cm in postmenopausal woman with normal CA-125 → can be observed
— Persistence, growth, complex features, or rising CA-125 → surgery
— Premenopausal complex masses >5 cm, postmenopausal complex masses of any size → surgery
— Stage IA/IB, grade 1, favorable histology → surgery alone may suffice; in young patients desiring fertility, unilateral salpingo-oophorectomy with staging can be considered
— Stage IC, grade 2–3, clear cell, or higher → surgery + adjuvant platinum/taxane chemotherapy
— Stage II–IV → maximal cytoreduction + chemotherapy ± maintenance therapy
— Unresectable stage III/IV → NACT → interval debulking → adjuvant chemo
— Residual disease after surgery — strongest modifiable factor
— Stage, grade, histology (clear cell and mucinous are platinum-resistant)
— BRCA mutation status — paradoxically better response to platinum and PARP inhibitors
— Performance status, age, CA-125 nadir and rate of decline
Step 3 management: For a 28-year-old with a stage IA grade 1 mucinous ovarian cancer who wants future pregnancy → fertility-sparing unilateral salpingo-oophorectomy with comprehensive staging is acceptable; she does NOT mandatorily lose her uterus and contralateral ovary.
Key distinction: "Optimal" cytoreduction = <1 cm residual; "complete" = no visible disease. Complete R0 is the new survival benchmark and should be the surgical goal whenever feasible.
— Carboplatin (AUC 5–6) + paclitaxel (175 mg/m² IV q3 weeks) × 6 cycles
— Dose-dense weekly paclitaxel an option in selected patients
— Intraperitoneal (IP) chemotherapy historically used for optimally debulked stage III; largely supplanted by IV regimens + bevacizumab/PARP maintenance in current practice
— HIPEC (hyperthermic intraperitoneal chemo) at interval debulking can be considered
— Added to carboplatin/paclitaxel and continued as maintenance for high-risk stage III or stage IV disease
— Improves PFS; modest OS benefit in highest-risk subsets
— Toxicities: hypertension, proteinuria, GI perforation, impaired wound healing, thromboembolism, posterior reversible encephalopathy syndrome (PRES)
— Hold ≥4 weeks before and after surgery to avoid wound complications
— Olaparib, niraparib, rucaparib after response to first-line platinum chemotherapy
— Olaparib + bevacizumab for HRD-positive tumors (PAOLA-1)
— Olaparib monotherapy for BRCA-mutated tumors (SOLO-1) — durable PFS benefit
— Niraparib is the only PARP approved regardless of biomarker status, with lower efficacy in BRCA wild-type/HRD-negative
— Adverse effects: myelosuppression (especially niraparib — thrombocytopenia), fatigue, nausea, rare MDS/AML (<1%)
— CBC with diff, CMP, audiogram (cisplatin only), echocardiogram if cardiac history
— Discuss fertility preservation with reproductive-age patients before chemo initiation
— Vaccinations updated, central access (port) placement
— Anti-emetic prophylaxis (5-HT3 + dexamethasone + NK1 antagonist for high-emetogenic regimens)
Board pearl: Every newly diagnosed epithelial ovarian cancer patient gets germline + somatic BRCA and HRD testing to guide PARP inhibitor maintenance — this is the single most impactful pharmacologic decision of the disease course.
Step 3 management: Bevacizumab + new-onset hypertension → don't stop it reflexively; add or intensify antihypertensives (ACEi preferred for concurrent proteinuria) and continue therapy unless BP uncontrolled or proteinuria >2 g/day.
— Performed by gynecologic oncologist (improves survival vs. general gyn/surgery)
— Goal: complete gross resection (R0); optimal defined as <1 cm residual
— Procedures may include: TH-BSO, omentectomy, pelvic/para-aortic lymphadenectomy, peritoneal stripping (including diaphragm), bowel resection with anastomosis, splenectomy, partial hepatectomy, appendectomy
— Mucinous tumors mandate appendectomy and colonoscopy to exclude GI primary
— After 3 cycles of NACT in patients not initial surgical candidates
— Followed by 3 more cycles of adjuvant chemotherapy
— HIPEC at time of IDS improves OS in selected patients (carboplatin/cisplatin-based)
— Eligible: stage IA, grade 1–2, non-clear cell, young patient desiring fertility, normal contralateral ovary
— Unilateral salpingo-oophorectomy + comprehensive staging (omentum, nodes, washings)
— Plan for completion surgery after childbearing in select cases
— Risk-reducing bilateral salpingo-oophorectomy (RRBSO): BRCA1 by age 35–40, BRCA2 by 40–45, after childbearing complete
— Reduces ovarian/tubal/peritoneal cancer risk by ~80% and breast cancer risk in premenopausal women
— Discuss surgical menopause consequences: vasomotor symptoms, bone loss, cardiovascular risk, sexual dysfunction
— Short-term HRT until natural menopause age is generally safe after RRBSO in BRCA carriers without breast cancer history
— Opportunistic salpingectomy at hysterectomy or tubal sterilization is now recommended for all women (population-level prevention)
— Paracentesis for symptomatic ascites; tunneled peritoneal catheter for recurrent ascites
— Thoracentesis or PleurX for malignant effusion
— Bowel obstruction: trial of NG decompression, octreotide, dexamethasone; surgical bypass or venting gastrostomy if refractory
— Ureteral stents or nephrostomy for obstructive uropathy
CCS pearl: When ordering surgery on a CCS case, consult gyn-onc before laparoscopy or laparotomy for any suspected malignancy — sending the patient to a general gynecologist who does an unstaged BSO triggers a downstream survival hit and likely a points deduction.
Board pearl: Bowel involvement at debulking with bowel resection is acceptable and survival-improving if it achieves R0 status.
— Comprise nearly half of new diagnoses but historically undertreated
— Geriatric assessment (G8, CARG score) before chemotherapy planning — guides intensity
— Functional status and comorbidities, not age alone, predict treatment tolerance
— Single-agent carboplatin can be considered if poor performance status; combination still preferred when tolerable
— Higher risk of bevacizumab toxicities (HTN, GI perforation, thromboembolism) — weigh carefully
— Carboplatin dosing by Calvert formula: dose = AUC × (GFR + 25)
— Use measured GFR (24-hour urine or cystatin C) rather than estimated when possible — overestimated GFR causes overdosing and severe myelosuppression
— Cisplatin generally avoided if CrCl <60 mL/min due to nephrotoxicity; switch to carboplatin
— PARP inhibitors require dose reduction in moderate-to-severe renal impairment (niraparib, rucaparib)
— Hydration and electrolyte repletion (Mg, K) critical with any platinum
— Paclitaxel — extensively hepatically metabolized; dose reduce or hold for elevated bilirubin and transaminases
— Olaparib: dose adjust in moderate hepatic impairment; avoid in severe
— Bevacizumab: no formal hepatic dosing adjustments, but caution with significant hyperbilirubinemia
— ECOG 3–4 → consider best supportive care, hospice referral, palliative chemo (single-agent liposomal doxorubicin or weekly paclitaxel) if any chemotherapy at all
— Routine palliative care co-management from diagnosis improves QOL and may improve survival
— Bevacizumab contraindicated in recent arterial thromboembolism, severe uncontrolled HTN, recent surgery
— Baseline echo if anthracycline-containing salvage regimens (liposomal doxorubicin) planned in patients with cardiac history
Step 3 management: A 78-year-old with stage IIIC ovarian cancer, CrCl 45, and ECOG 2 — do NOT default to "she's too old." Order a geriatric assessment, dose carboplatin by Calvert with accurate GFR, and consider holding bevacizumab if frailty or GI involvement.
Key distinction: Calvert formula uses GFR + 25, not GFR alone — using eGFR-MDRD overdoses; 24-hour CrCl or measured GFR is preferred.
— ~1–2% of pregnancies have an adnexal mass on first-trimester US
— Most are functional cysts or mature teratomas; resolve spontaneously
— Persistent masses >6 cm, complex features, or rising markers → surgical evaluation in second trimester (16–20 weeks) when organogenesis complete and uterus small enough for safe access
— Ovarian cancer in pregnancy is rare (~1:10,000–50,000); most are germ cell, borderline, or stromal tumors in younger patients
— Avoid in first trimester (teratogenic — methotrexate, alkylators)
— Platinum/taxane regimens reasonably safe in second and third trimesters
— Plan delivery at term when possible; avoid chemotherapy within 3 weeks of delivery (neonatal cytopenias)
— Predominantly germ cell tumors: mature teratoma (most common, benign), dysgerminoma, yolk sac tumor, immature teratoma
— Present with abdominal pain, palpable mass, precocious puberty (granulosa), or torsion
— Mark with AFP, β-hCG, LDH, inhibin
— Fertility-sparing surgery is the norm; germ cell tumors are highly chemosensitive (BEP: bleomycin/etoposide/cisplatin)
— BRCA1/2: HGSC predominantly; risk-reducing BSO timing as noted
— Lynch syndrome (MLH1, MSH2, MSH6, PMS2): endometrioid and clear cell histology; consider risk-reducing hysterectomy + BSO at age 40 or after childbearing
— Peutz-Jeghers: sex cord tumor with annular tubules (SCTAT)
— Li-Fraumeni: rare ovarian involvement
— Universal genetic counseling referral for any epithelial ovarian cancer patient or first-degree relative
— Generally avoid in serous and endometrioid histologies due to estrogen sensitivity
— Granulosa cell tumors are estrogen-producing, so HRT contraindicated
— Vaginal estrogen for severe GU syndrome can be considered cautiously after multidisciplinary discussion
Board pearl: Adolescent with rapidly enlarging painful adnexal mass and markedly elevated LDH → dysgerminoma until proven otherwise; mirrors testicular seminoma biology, exquisitely chemo/radio-sensitive.
Step 3 management: Pregnant patient at 14 weeks with persistent 8-cm complex adnexal mass → schedule surgery at 16–20 weeks, not immediate intervention and not waiting until postpartum.
— Malignant bowel obstruction (MBO) — most common cause of death; partial or complete, often multifocal
— Initial management: NPO, NG decompression, IV fluids, octreotide (reduces secretions), dexamethasone, antiemetics; surgical bypass or venting gastrostomy if irreversible
— Malignant ascites — repeated paracentesis, tunneled drain for refractory cases; albumin replacement debated
— Pleural effusion — thoracentesis, PleurX catheter; pleurodesis less common in advanced disease
— VTE — markedly elevated risk; therapeutic anticoagulation with LMWH or DOAC (apixaban, rivaroxaban now preferred per guidelines unless GI primary or thrombocytopenia)
— Hydronephrosis from pelvic mass or peritoneal disease → ureteral stents or percutaneous nephrostomy
— Cachexia — nutritional consult, appetite stimulants (mirtazapine, megestrol); avoid TPN in end-stage disease
— Carboplatin hypersensitivity — typically after >6 cycles, IgE-mediated; pre-medicate or desensitize, or switch to cisplatin/oxaliplatin
— Paclitaxel peripheral neuropathy — cumulative, often dose-limiting; duloxetine for painful neuropathy; avoid gabapentin if ineffective
— Neutropenic fever — broad-spectrum antibiotics within 1 hour of recognition; G-CSF prophylaxis for high-risk regimens
— Bevacizumab GI perforation — sudden severe abdominal pain, sepsis; CT confirms; surgical emergency
— PARP inhibitor myelosuppression — weekly CBC initially, dose adjust; MDS/AML risk with cumulative exposure
— Surgical complications — anastomotic leak, ileus, wound infection, VTE; bevacizumab held perioperatively
— Depression, anxiety, fear of recurrence (FOR) common; screen at every visit
— Sexual dysfunction from surgical menopause and treatment effects
— Financial toxicity — social work and patient navigator involvement
Board pearl: Bowel obstruction in known ovarian cancer ≠ adhesions until proven otherwise — assume disease progression, image with CT, and involve gyn-onc and palliative care early.
CCS pearl: Suspected neutropenic fever → CBC, blood and urine cultures, CXR, start empiric cefepime or piperacillin-tazobactam immediately — do not wait for ANC result.
— Any postmenopausal woman with an adnexal mass and elevated CA-125
— Premenopausal woman with CA-125 >200, ascites, lymphadenopathy, distant mets, or strong family history
— Suspicious O-RADS 4–5 lesions
— Improves survival — should occur before surgical intervention, not after pathology returns
— Gynecologic oncology (surgeon and medical), pathology, radiology, genetic counseling, palliative care, nutrition, social work, fertility specialist when relevant
— Bowel obstruction with intractable vomiting or signs of ischemia
— Neutropenic fever
— Symptomatic large-volume ascites or pleural effusion requiring intervention
— Acute pain crisis from disease progression
— Hypercalcemia, hyponatremia (SIADH), or severe electrolyte disturbance
— Active VTE requiring titration and observation
— Postoperative complications: ileus, fever, anastomotic concern
— Sepsis with hemodynamic instability (often from bowel perforation or central line infection)
— Tumor lysis-like presentations are rare in ovarian cancer but watch in highly chemosensitive germ cell tumors
— Massive PE with hemodynamic compromise — consider thrombolysis or thrombectomy
— Respiratory failure from large pleural effusion or pneumonitis (rare with these regimens)
— Postoperative cardiopulmonary instability
— ECOG 3–4, multiple lines of chemo failure, refractory MBO, platinum-resistant or refractory disease
— Early palliative care integration from diagnosis improves QOL and may extend survival (Temel-type data)
— Hospice when prognosis <6 months and goals shift to comfort
— Post-debulking discharge — wound care, VTE prophylaxis (often 4 weeks of LMWH after major pelvic surgery for cancer), bowel function monitoring
— Communication between gyn-onc, primary care, and chemotherapy infusion center on follow-up scans, CA-125 trends, and toxicity management
Step 3 management: New ovarian cancer diagnosis on outpatient imaging → same-week gyn-onc referral, do not order biopsy or schedule local hospital surgery; ensure germline genetic counseling referral simultaneously.
Board pearl: 4 weeks of post-discharge LMWH prophylaxis after major pelvic cancer surgery is guideline-supported and frequently tested.
— Functional cysts (follicular, corpus luteum) — premenopausal, simple, resolve in 6–8 weeks; observe
— Mature cystic teratoma (dermoid) — fat, calcifications, hair on imaging; surgical removal due to torsion risk
— Endometrioma — "chocolate cyst," homogeneous low-level echoes; endometriosis history; raises CA-125 modestly
— Theca lutein cysts — bilateral, multilocular, associated with molar pregnancy or ovarian hyperstimulation
— Low malignant potential, no stromal invasion
— Younger patients, better prognosis
— Often serous or mucinous; surgical resection sufficient for most
— Fertility-sparing surgery acceptable in early stage
— Germ cell tumors (dysgerminoma, yolk sac, immature teratoma, choriocarcinoma) — younger patients, elevated AFP/β-hCG/LDH
— Sex cord-stromal tumors (granulosa cell, Sertoli-Leydig, fibroma)
— Granulosa cell tumor — estrogen secretion, postmenopausal bleeding or precocious puberty, Call-Exner bodies, inhibin marker
— Sertoli-Leydig — virilization, elevated testosterone
— Fibroma → Meigs syndrome (fibroma + ascites + right pleural effusion, benign)
— Krukenberg tumor — metastatic signet-ring cell adenocarcinoma to ovary, typically from gastric primary; bilateral
— Tubo-ovarian abscess (TOA) — fever, leukocytosis, bilateral adnexal tenderness; can mimic malignancy on imaging
— Hydrosalpinx — fluid-filled tube from prior PID
— Ectopic pregnancy — reproductive-age woman with positive β-hCG; ALWAYS check β-hCG before assuming malignancy
— Pedunculated fibroid — can mimic adnexal mass on exam
— Endometrial cancer with adnexal extension
— Cervical cancer with parametrial involvement
Key distinction: Meigs syndrome (benign fibroma + ascites + pleural effusion + elevated CA-125) can mimic advanced ovarian cancer perfectly — resection of fibroma resolves all findings, including the markedly elevated CA-125.
Board pearl: Bilateral solid ovarian masses + signet-ring cells on path = Krukenberg → workup the stomach with EGD; do not stop at "ovarian cancer."
— Colon cancer with pelvic mass extension or peritoneal carcinomatosis — colonoscopy if symptoms or mucinous histology
— Appendiceal mucinous neoplasm → pseudomyxoma peritonei (gelatinous ascites); appendectomy mandatory in mucinous ovarian tumors to rule this out
— Diverticular abscess — left-sided, fever, leukocytosis, CT shows inflammatory mass
— Crohn disease with phlegmon — chronic GI symptoms, terminal ileal involvement
— Gastric cancer with Krukenberg metastasis — bilateral ovarian masses + GI symptoms
— Pelvic kidney — incidental imaging finding mimicking a mass
— Bladder diverticulum or large urachal cyst
— Lymphoma involving ovary or pelvic nodes — B symptoms, diffuse lymphadenopathy; biopsy distinguishes
— Leukemic infiltration — rare
— Pelvic congestion syndrome — chronic pelvic pain, dilated pelvic veins on imaging
— Ovarian vein thrombosis — postpartum or post-surgical, right-sided abdominal pain, low-grade fever
— Pelvic tuberculosis — endemic regions, ascites with elevated CA-125, peritoneal nodularity that perfectly mimics ovarian carcinomatosis; adenosine deaminase in ascitic fluid helps
— Actinomycosis (IUD-associated) — pelvic mass with sulfur granules
— Cirrhosis with portal hypertension — SAAG ≥1.1
— Heart failure — bilateral pleural effusions, elevated BNP
— Nephrotic syndrome — proteinuria, hypoalbuminemia
— Peritoneal carcinomatosis from other primaries — pancreas, breast, lung
— Severe deep infiltrating endometriosis can mimic peritoneal carcinomatosis; CA-125 may be elevated; biopsy if any doubt
Key distinction: Ascites with SAAG ≥1.1 points to portal hypertension (cirrhosis, heart failure); ascites with SAAG <1.1 and high protein points to peritoneal disease — malignancy, TB, pancreatitis. CA-125 elevation alone does NOT distinguish malignant from inflammatory peritoneal processes.
Board pearl: Young woman from a TB-endemic region with ascites, elevated CA-125, and peritoneal nodularity → think pelvic TB before ovarian cancer; quantiferon and ADA in ascitic fluid before laparotomy.
— PARP inhibitor maintenance after first-line platinum response — olaparib (BRCA+), olaparib/bevacizumab (HRD+), niraparib (any) — for up to 2–3 years
— Bevacizumab maintenance alone or with PARP for high-risk stage III/IV
— Continue until disease progression or unacceptable toxicity
— No survival benefit to intensive surveillance (no CT or CA-125 routinely) per multiple trials
— Acceptable schedule: clinic visit q3 months × 2 years, q6 months years 3–5, annually thereafter
— Symptom-driven imaging; CA-125 only if previously elevated and patient/clinician agree that rising marker would change management
— Discuss the MRC OV05 trial finding — earlier chemotherapy for CA-125 rise without symptoms did not improve survival but worsened QOL
— BRCA1: RRBSO at age 35–40, after childbearing
— BRCA2: RRBSO at age 40–45
— Lynch syndrome: RRBSO + hysterectomy at 40 or after childbearing
— Opportunistic salpingectomy at hysterectomy/sterilization for all women — population-level prevention
— Combined OCPs reduce ovarian cancer risk substantially even in BRCA carriers (slightly raises breast cancer risk — net benefit individualized)
— Surgical menopause management: vasomotor symptoms, vaginal dryness, sexual health
— Bone density (DEXA) at baseline after BSO, every 1–2 years
— Cardiovascular risk modification — accelerated risk after premature menopause
— Age-appropriate cancer screening — colon, breast, cervical (cervical screening can usually stop after total hysterectomy for benign indication, but continue if cancer history)
— Vaccinations updated; annual flu, COVID, pneumococcal per age, HPV/zoster as indicated
— Exercise, weight management, smoking cessation, alcohol moderation
— Fear of recurrence support, survivorship clinics, peer groups
Step 3 management: A BRCA1 carrier completes childbearing at 34. Counseling: RRBSO by age 40, consider short-course HRT (non-breast-cancer history) until ~51 to mitigate surgical menopause harms, and annual breast MRI alternating with mammography starting at 25–30.
Board pearl: Routine post-treatment CA-125 surveillance does NOT improve survival and can drive overtreatment — discuss explicitly with patients.
— CBC + CMP before each cycle — neutrophils, platelets, renal/hepatic function
— CA-125 each cycle — track response; >50% decline expected, normalization predicts better outcomes
— Cycle-by-cycle toxicity grading (CTCAE) — neuropathy, fatigue, GI, alopecia, hypersensitivity
— Mid-treatment CT imaging typically after 3 cycles (especially in NACT to confirm response before interval surgery)
— Bevacizumab: BP at each visit, urine protein/creatinine (hold if ≥2 g/24h)
— PARP inhibitor: weekly CBC first 1–2 months, then monthly; LFTs
— H&P including pelvic exam q3 months × 2 years, q4–6 months years 3–5, annually thereafter
— Educate patient on return-precaution symptoms: persistent bloating, early satiety, pelvic pain, urinary symptoms, weight loss, new VTE
— Imaging only for symptoms or rising markers
— No survival benefit from routine surveillance imaging
— Peripheral neuropathy — chronic; duloxetine for painful neuropathy
— Cardiotoxicity if anthracyclines were used — surveillance echo
— Secondary malignancies (MDS/AML) — counsel about persistent cytopenias prompting hematology referral
— Surgical menopause: DEXA, lipids, vasomotor symptom management
— Lymphedema after pelvic node dissection — physical therapy referral
— Recurrence is common (~70% of advanced disease) — frame expectations realistically
— Platinum-sensitive recurrence (>6 months from last platinum) → re-treat with platinum-based combo + PARP maintenance
— Platinum-resistant recurrence (<6 months) → single-agent (PLD, weekly paclitaxel, topotecan, gemcitabine) ± bevacizumab; consider clinical trials
— Discuss clinical trial enrollment at every transition point
— Advance care planning discussions early, not at terminal phase
— First-degree relatives of any BRCA-positive patient → genetic counseling and testing
— Lynch families → multi-organ screening protocols
Step 3 management: Post-chemo patient calls 6 months later with new abdominal bloating + CA-125 of 80 (was normal) — order CT abdomen/pelvis and refer to gyn-onc; do NOT just trend the marker.
Board pearl: Platinum-free interval >6 months = platinum-sensitive recurrence — eligibility for retreatment with platinum doublet and maintenance PARP.
— BRCA and other hereditary testing must include pre-test counseling: implications for relatives, insurance (GINA protects health insurance but not life, disability, or long-term care insurance), psychological impact
— Patients have the right to refuse testing; alternatively, tumor-only somatic testing can guide therapy without disclosing germline status — discuss this option
— Disclosure to family members is the patient's responsibility, not the physician's, but offer support (cascade testing letters, referral)
— Reproductive-age patients must be offered fertility consultation BEFORE chemotherapy or surgery — failure to do so is a documented gap and a Step 3-favored testable point
— Options: oocyte/embryo cryopreservation, ovarian tissue cryopreservation, GnRH agonist (debated efficacy)
— Document the discussion and patient's decision
— Possibility of conversion from staging to full debulking including bowel resection, splenectomy, ostomy must be discussed and consented preoperatively
— "Reasonable patient" standard for what risks to disclose
— In a young woman with possible early-stage disease, fertility-sparing options must be presented even if not the surgeon's default
— Highest-risk handoffs: post-debulking discharge (VTE, wound, bowel function), chemotherapy hand-offs between hospital and outpatient infusion, transition to hospice
— Medication reconciliation at each transition — anticoagulants, antiemetics, opioids, hormone therapy
— Communicate CA-125 trend, imaging results, and pathology to PCP and infusion team in writing
— Early palliative care integration — improves QOL, may extend survival
— POLST/MOLST forms before crises
— Avoid futile chemotherapy in last 30 days of life — a quality measure for oncology
— Hospice eligibility when prognosis <6 months
— Chemotherapy ordering safety: two-pharmacist verification, BSA recalculation each cycle, CrCl recalculation for carboplatin
— Neutropenic precautions education
— VTE prophylaxis continuation across care settings — common error point at discharge
Step 3 management: A 31-year-old with stage IC clear cell ovarian cancer is rushed to surgery without fertility counseling. Even if surgery is medically appropriate, the missed fertility discussion is a documented standard-of-care failure — Step 3 expects you to delay non-emergent surgery for reproductive consultation.
Board pearl: GINA does not protect life, disability, or long-term care insurance — patients deserve to know this before germline BRCA testing.
— CA-125 — epithelial (especially serous)
— CEA — mucinous (also rules out GI primary)
— AFP — yolk sac, embryonal, immature teratoma
— β-hCG — choriocarcinoma, dysgerminoma, embryonal
— LDH — dysgerminoma
— Inhibin B / AMH — granulosa cell
— Testosterone, DHEAS — Sertoli-Leydig
— HGSC — most common, p53-mutated, originates in fallopian tube fimbria, BRCA-associated
— Endometrioid and clear cell — endometriosis-associated, ARID1A mutations
— Mucinous — often unilateral, large; rule out GI primary; appendectomy mandatory
— Brenner tumor — transitional cell-like, usually benign
— Granulosa cell — Call-Exner bodies, estrogen-producing, late recurrences (10+ years)
— Sertoli-Leydig — Reinke crystals, virilization
— Dysgerminoma — ovarian counterpart of seminoma, exquisitely chemosensitive
— Yolk sac tumor — Schiller-Duval bodies, AFP
— Choriocarcinoma — β-hCG, hemorrhagic, lung metastases
— Meigs: fibroma + ascites + pleural effusion (benign)
— Pseudo-Meigs: ascites/effusion with other ovarian tumors
— Krukenberg: bilateral signet-ring mets, usually gastric
— Pseudomyxoma peritonei: appendiceal/ovarian mucinous neoplasm with gelatinous ascites
— Sister Mary Joseph nodule: periumbilical metastasis
— Trousseau syndrome: migratory thrombophlebitis with visceral malignancy
— USPSTF Grade D recommendation against screening average-risk asymptomatic women — TVUS and CA-125 do not improve mortality and cause harm via unnecessary surgery
— No general-population screening exists
— High-risk (BRCA, Lynch): TVUS + CA-125 q6 months age 30–35 until RRBSO — not proven to reduce mortality but offered while awaiting surgery
— Best "screening" for BRCA carriers = risk-reducing salpingo-oophorectomy
Board pearl: The single highest-yield Step 3 fact: no screening test for ovarian cancer is recommended in the general population (USPSTF Grade D). Ordering routine CA-125 + TVUS in an asymptomatic average-risk woman is the wrong answer every time.
— 62-year-old woman, 6 weeks of bloating, early satiety, mild urinary urgency, normal colonoscopy 1 year ago
— Best next step: TVUS + CA-125
— Distractor: repeat colonoscopy, empiric PPI, reassurance
— 50-year-old asymptomatic woman, no family history, requests "ovarian cancer screen"
— Correct answer: counsel that screening is not recommended (USPSTF Grade D)
— Distractor: order CA-125, order TVUS annually
— 68-year-old with 6-cm complex adnexal mass, CA-125 220, ascites on CT
— Best next step: referral to gynecologic oncologist for surgical staging
— Distractors: percutaneous biopsy (wrong — risks seeding), general surgery referral, observation
— 27-year-old with stage IA grade 1 endometrioid ovarian cancer desiring future pregnancy
— Best management: unilateral salpingo-oophorectomy with comprehensive staging, preserve uterus and contralateral ovary
— Distractor: TH-BSO, refuse fertility preservation
— 36-year-old BRCA1+ woman, 2 children, no cancer history
— Recommend: RRBSO by age 35–40 after childbearing
— Distractors: surveillance only with TVUS/CA-125, prophylactic OCPs only
— Woman with bilateral solid ovarian masses, signet-ring cells on biopsy
— Next step: EGD/colonoscopy to evaluate GI primary, especially gastric
— 55-year-old with ovarian mass, ascites, right pleural effusion, CA-125 elevated
— Pathology: fibroma → diagnosis is Meigs syndrome (benign)
— Patient 18 months out from completing carboplatin/paclitaxel, now rising CA-125 with new peritoneal nodules
— Platinum-sensitive recurrence → re-treat with platinum doublet ± PARP maintenance
— Newly diagnosed stage IIIC HGSC, germline BRCA1 mutation, R0 debulking, completed 6 cycles carbo/taxol with normalized CA-125
— Olaparib maintenance for ~2 years
— 14 weeks pregnant, 7-cm complex adnexal mass persisting from first trimester
— Surgery at 16–20 weeks (second trimester window)
Board pearl: When the stem says "asymptomatic average-risk woman wants ovarian screening," the answer is always counseling against screening — never order CA-125 or TVUS.
Ovarian cancer is a postmenopausal, often late-stage epithelial malignancy whose evaluation hinges on TVUS + CA-125 in symptomatic women, gyn-oncology referral for staging/debulking, platinum-taxane chemotherapy with PARP/bevacizumab maintenance guided by universal BRCA/HRD testing, and the explicit recognition that population screening is NOT recommended (USPSTF Grade D).
— Suspect in any postmenopausal woman with >2–3 weeks of bloating, early satiety, pelvic/urinary symptoms, or any complex adnexal mass — screening of average-risk women is contraindicated
— Diagnose with TVUS + CA-125 (HE4/ROMA optional), CT for staging, and surgical exploration with frozen section rather than percutaneous biopsy in resectable disease; gyn-onc referral improves survival
— Treat with maximal cytoreduction (R0 goal) + carboplatin/paclitaxel × 6; add bevacizumab for high-risk stage III/IV; PARP inhibitor maintenance universally considered after first-line response, especially for BRCA/HRD-positive
— Prevent in BRCA carriers with RRBSO at 35–40 (BRCA1) or 40–45 (BRCA2), opportunistic salpingectomy at any pelvic surgery, and combined OCPs as protective; universal germline testing for every epithelial ovarian cancer patient drives both treatment and family cascade testing
Board pearl: If you remember three things — no screening in average-risk women, TVUS + CA-125 for symptomatic postmenopausal women, and universal BRCA testing with gyn-onc surgical referral — you will answer the vast majority of Step 3 ovarian cancer questions correctly.
Step 3 management: The longitudinal arc — symptom recognition → imaging + markers → gyn-onc referral → staging surgery → chemotherapy → maintenance PARP → symptom-driven surveillance → recurrence stratified by platinum-free interval → early palliative integration — is the entire mental model boards reward.