Based on their origin, ovarian tumors can be classified into three groups. Epithelial tumors, at about 60% of all tumors but making up 85% of the malignant ones, constitute the largest group; germ cell tumors (second group) and sex cord-stromal tumors (third group), together with metastatic tumors, make up the remainder [1] [2]. Dysgerminomas make up a third of malignant germ cell tumors, although they constitute only 2% of ovarian tumors [3]. Dysgerminomas correspond to the seminomas of the testis.

Dysgerminomas present with the general symptoms of adnexal tumors: tenderness and pain in the pelvic or lower abdominal area [1], feeling of fullness and early satiety, and urinary problems. Abdominal enlargement can be the consequence of hemoperitoneum or the presence of a large mass [3].

Usually present unilaterally - with about 10-20% being bilateral- and present as firm masses. These are fast growing tumors, although with excellent prognosis [3] [4].

Dysgerminoma mainly occurs in young women; those with abnormal gonads, for example with Swyer syndrome (XY gonadal dysgenesis), have an increased risk of developing dysgerminomas.

It is composed of undifferentiated germ cells, with occasional granulomas and lymphocytes being present. About five percent have syncytiotrophoblastic giant cells present, which secrete lactate dehydrogenase, alkaline phosphatase [3], and human chorionic gonadotropin (HCG) [2]. Thus, in these cases, serum HCG may be elevated, but otherwise hormonal problems are not characteristic of dysgerminomas [4].

• Abdominal Lymphadenopathy

  One month later, she developed a right pelvic mass along with abdominal lymphadenopathies, peritoneal carcinomatosis, left breast mass, and left axillary node. Cytology of the breast mass was suggestive of a pure dysgerminoma. [ncbi.nlm.nih.gov]

• Virilization

  Certain subtypes may occasionally be associated with isosexual precocity, dysgenetic gonads, virilization, hyperthyroidism or carcinoid syndrome (see this term). [orpha.net]

  These cells are known for their hormonal function which may lead to virilization or feminization of the opposite sex. CD56 has been proposed to identify sex cord tumors and to follow response to treatment as a marker. [lecturio.com]

  […] production Sex cord-stromal tumors of the ovary 5–10% of all ovarian tumors Estrogen producing : granulosa cell tumor and theca cell tumor Androgen producing: Sertoli-Leydig cell tumor Occurs very rarely; 20% malignant transformation Production of androgens virilization [amboss.com]

  The tumors typically produce androgens, and clinical virilization is noted in 70–85% of patients. [academic.oup.com]

  Two thirds of children with these tumors present with endocrine abnormalities, such as precocious pseudopuberty, virilization, or menstrual irregularities. [glowm.com]

• Breast Mass

  One month later, she developed a right pelvic mass along with abdominal lymphadenopathies, peritoneal carcinomatosis, left breast mass, and left axillary node. Cytology of the breast mass was suggestive of a pure dysgerminoma. [ncbi.nlm.nih.gov]

• Adnexal Mass

  These symptoms, along with the sonographic findings of a large, solid lobulated adnexal mass in young women, strongly suggest an ovarian dysgerminoma in the differential diagnosis. [nebraska.pure.elsevier.com]

  In a setting of sonographically indeterminate adnexal masses, MR imaging is used as a problem-solving tool. [ncbi.nlm.nih.gov]

  Figure 2 Pelvic CT findings—large cystic left adnexal mass (large anteroposterior diameter of 85.6 mm). [casereports.bmj.com]

  Adnexal mass during pregnancy: a review[J]. Am J Perinatol. 2015 ;32(11): 1010 – 6. doi: 10.1055/s-0035-1549216. [tandfonline.com]

• Amenorrhea

  Therefore the occurrence of post-radiotherapy amenorrhea, characterized by high serum gonadotropin levels, should not always be considered pathognomonic of precocious menopause. [ncbi.nlm.nih.gov]

  This gene is located on the Y chromosome (p11.31); mutations at this site result in phenotypic females with müllerian external genitalia, underdeveloped (streak) internal gonads, amenorrhea, and rudimentary development of breasts, pubic hair, and axillary [emedicine.medscape.com]

  Some ovarian cancers secrete hormones leading to a variety of symptoms: Amenorrhea Hirsutism Precautious puberty Postmenopausal bleeding Irregular uterine bleeding. Emergent complications due to ovarian cysts include rupture and torsion. [lecturio.com]

• Bladder Distention

  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 [csh.org.tw]

• Primary Amenorrhea

  Dysgerminoma is the most common malignant ovarian germ‐cell tumor diagnosed in pregnancy 2, and may also be discovered in patients investigated for primary amenorrhea, in which case it may be associated with gonadal dysgenesis and gonadoblastoma 6. [obgyn.onlinelibrary.wiley.com]

If a pelvic mass is detected, tests for pregnancy and sexually transmitted diseases, as background information, should be obtained in reproductive age women. Determination of lactate dehydrogenase and HCG levels may help in the diagnosis in cases where these are elevated.

The most important feature to determine is whether or not the tumor is malignant. After the physical characterization of the mass, the initial imaging method is a transvaginal ultrasound. Four sonographic features that distinguish between benign and malignant pelvic masses have been proposed [5], according to which malignancy is suggested by solid material in the tumor, the presence and location of flow on color doppler imaging, free intraperitoneal fluid, and thick septations within the tumor. The most significant association with malignancy was found in cases where a solid component was present; masses that had no solid component, or had strongly hyperechoic solid parts, were almost invariably benign [5]. Necrosis inside the solid mass was also an indicator of the malignant condition [1]. Another study found papillary projections, the most reliable predictor [6].

Most authors agree that no single sonographic feature has a strong enough diagnostic value for malignancy, and a number of scoring systems have been proposed to predict disease based on morphological features [6]. Technical improvements, such as 3-dimensional ultrasonography, which help in characterizing both the internal structure of the adnexal masses as well as their vascularization, lead to better judgment [7] [8]. Combining imaging results obtained with different sonographic systems for both morphology and vascularity of the masses also increases the accuracy of diagnosis [6].

Magnetic resonance imaging performs better than either ultrasonography or computed tomography in diagnosing malignant features in ovarian tumors (although not in extraovarian pelvic masses). However, ultrasonography detected abdominal spread with higher specificity than the other two imaging methods in few cases [9].

Surgery is not just a treatment, but also an important tool for characterizing the tumor and establishing the spread of the disease, and so contributes diagnostic information for follow-up therapy [3].

• Right Pleural Effusion

  Chest X-ray showed massive right pleural effusion. Abdominopelvic CT scan showed a left adnexal solid mass and ascites. [ncbi.nlm.nih.gov]

  Meigs’ syndrome is the triad of right pleural effusion, ascites and abdominal mass mostly in ovarian sex cord/stromal tumor. It is most commonly found in fibroma but can also occur in granulosa cell tumors and sometimes even in Brenner’s tumor. [lecturio.com]

• Pneumoperitoneum

  Science ], [Google Scholar] Remarkably, as recommended by the European Society of Gynecological Oncology (ESGO), these are 4 prerequisites for surgical interventions during pregnancy as follows: a maximal laparoscopic procedure time of 90 minutes, a pneumoperitoneum [tandfonline.com]

• Ovarian Mass

  We describe three cases of ovarian dysgerminoma in which color Doppler sonography demonstrated multilobulated solid ovarian masses with prominent flow signal in the fibrovascular septa. [ncbi.nlm.nih.gov]

  Subsequent MRI revealed solid, enhancing right ovarian mass concerning for malignancy. Transvaginal ultrasound again showed the mass as well as para-aortic lymphadenopathy. [academic.oup.com]

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2. Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST. CT and MR imaging of ovarian tumors with emphasis on differential diagnosis. Radiographics. 2002 Nov-Dec;22(6):1305-1325.
3. Ajao M, Vachon T, Snyder P. Ovarian dysgerminoma: a case report and literature review. Mil Med. 2013 Aug;178(8):e954-945.
4. Pectasides D, Pectasides E, Kassanos D. Germ cell tumors of the ovary. Cancer Treat Rev. 2008 Aug;34(5):427-441.
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8. Kurjak A, Kupesic S, Sparac V, Prka M, Bekavac I. The detection of stage I ovarian cancer by three-dimensional sonography and power Doppler. Gynecol Oncol. 2003 Aug;90(2):258-64.
9. Kurtz AB, Tsimikas JV, Tempany CM, et al. Diagnosis and staging of ovarian cancer: comparative values of Doppler and conventional US, CT, and MR imaging correlated with surgery and histopathologic analysis-report of the Radiology Diagnostic Oncology Group. Radiology. 1999 Jul;212(1):19-27.