From the Case Records of the Massachusetts General Hospital, we present Case 8-2010: A 22-Year-Old Woman with Hypercalcemia and a Pelvic Mass.
Germ-cell tumors account for about 75% of ovarian tumors in the first three decades; neoplasms of the surface epithelium and tumors of the sex-cord stroma each account for about 10%, and the final 5% are a heterogeneous group, including ovarian involvement by lymphoma or leukemia.
Clinical Pearls
• How do follicle cysts present?
Follicle cysts are frequent near the time of the menarche, in the second decade, but may also occur in the third decade; a follicle cyst would not produce the large, complex mass seen in this patient. Follicle cysts, which have peak occurrences around the times of the menarche and menopause, have a third, minor peak in the neonatal era due to stimulation of the infant ovary by maternal hormones in utero. This can result in dramatic manifestations if the cyst twists or is large enough to be symptomatic in the first weeks of life.
• What tumors that metastasize from other sites should be considered in a younger woman with an ovarian tumor?
Tumors that metastasize to the ovary from another site, which account for an important subgroup of ovarian tumors overall, are rare but are seen more frequently in the second decade than in the first. Nevertheless, there are documented cases of Krukenberg tumors in teenagers, and some neoplasms that are relatively common in children, such as neuroblastoma, may spread to the ovaries in the first or second decade. A metastatic tumor, particularly carcinoma of the breast, would be more likely in a patient in their third decade than in a patient in her first or second decades, although it would still be less likely than a primary ovarian tumor and less
likely than in an older woman.
Table 2. Selected Ovarian Masses and Their Approximate Relative Frequencies in the First Three Decades of Life.
Morning Report Questions
Q: What ovarian mass lesions are particular to pregnancy?
A: Three mass lesions that are particular to pregnancy are a luteoma of pregnancy; hyperreactio luteinalis; and the so-called large, solitary, luteinized follicle cyst of pregnancy and the puerperium. Luteomas of pregnancy are often bilateral and multinodular and composed of large cells with abundant eosinophilic cytoplasm. They often have mitotic activity, which can lead to an erroneous diagnosis of a malignant tumor. Hyperreactio luteinalis, which is typically associated with a pregnancy in which there is an abnormally high level of human chorionic gonadotropin, is almost always bilateral and is multicystic. In contrast to a luteoma of pregnancy, which is typically seen at or near term, hyperreactio luteinalis may be seen at any time during pregnancy. These two lesions regress post partum. Giant follicle cysts are typically seen at term and are almost always a huge unilocular cyst, averaging about 25 cm in maximum dimension.
Q: What is the approximate fertility rate among women who have chemotherapy after a unilateral oophorectomy for a malignant ovarian germ-cell tumor?
A: There are several reports on survival and reproductive outcomes after fertility-conserving surgery for young women with ovarian cancer. Fertility rates appear to be approximately 75% after unilateral oophorectomy, with preservation of the contralateral ovary and uterus, when followed by chemotherapy for malignant ovarian germ-cell tumors.