Ch 18 : Female Reproductive System: Ovary and Ovarian Tumors

Question 1

Describe the composition of the ovarian follicle, the production of estradiol, and its effect on ovulation . What endometrial phases correspond to each segment of the follicle’s action?

Answer 1

The follicle has a central oocyte, an inner ring of Granulosa cells, and an outer ring of theca cells.
LH from the anterior pituitary stimulates the theca cells to produce androgen, which goes to the granulosa cells
FSH stimulates granulosa cells to convert androgen to estradiol – proliferative phase –
Estradiol stimulates the LH surge, leading to ovulation – secretory phase of endometrial cycle

Question 2

What happens to the follicle after ovulation?
Effect of hemorrhage into this structure?
What can remain following the cycle?

Answer 2

Residual follicle is the corpus luteum, which secretes progesterone (secretory phase).
Effect of hemorrhage – hemorrhagic corpus luteal cyst, esp. during early pregnancy
Degeneration of follicles result in follicular cysts.

Question 3

A young woman comes to your office. She is obese, and in her patient history, she describes trouble getting pregnant and irregular menstrual cycles. She has facial hair, and you find that her blood glucose is highly elevated.
From this presentation, what disorder is this, and what would you predict about her FSH and LH levels?
What would this imbalance lead to?
What is the mechanism for her hirsutism ?

Answer 3

Polycystic ovarian disease (PCOD) –
Increased LH, low FSH (LH:FSH>2)
Multiple ovarian follicular cysts result from the imbalance
Increased LH production leads to increased androgen from theca cells, resulting in increased body hair.
Androgen is also converted to estrone in adipose tissue – estrone feedback decreased FSH, resulting in cystic degeneration of follicles – and high levels of estrone increase endometrial carcinoma risk.

Question 4

Describe the three cell types in the ovary

From which can tumor arise?

Answer 4

Surface epithelium, germ cells (oocyte), and sex cord-stroma (granulosa and theca cells)
All of them , or metastasis

Question 5

This most common type of ovarian tumor is derived from? What is embryologically produced by this tissue?
Most common subtypes of these tumors?

Answer 5

The coelomic epithemium lining the ovary- produces the lining of the fallopian tube (serous), endometrium, and endocervix (mucinous)
Serous (watery fluid) and mucinous (mucinous fluid). Both are usually cystic, and can be benign, malignant, or borderline.

Question 6

Describe a benign ovarian tumor?
Malignant
Borderline
Effect of the BRCA1 mutation, and management decision of many carriers?

Answer 6

Cystadenoma – composed of a single cyst with a simple flat lining, most commonly arising in premenopausal women (30-40 yr old) –

Cystadenocarcinoma – complex cysts with thick shaggy lining – usually for post menopausal women (60-70)-

Borderline – in between – better prognosis than malignant, but have metastatic potential.
BRCA1 - increased risk of serous carcinoma of ovarian and fallopian tube –
BRCA1 carriers often get prophylactic salpingo-oophorectomy (ovary and fallopian tube) and prophylactic mastectomy

Question 7

Describe some of the less common subtypes of surface epithelial tumors?
Surface epithelial tumors – how do they present? Prognosis- Spread
Serum marker for treatment response, and screening for recurrence?

Answer 7

Endometrioid and Brenner (transitional) –
Endometrioid tumors – endometrial like glands, usually malignant – postmenopausal
May arise from endometriosis, 15% of tumors are associated with independent (separate) endometrial carcinoma (endometrioid type)
Brenner (transitional) tumors – composed of bladder like epithelium, benign
Surface epithelial tumors present with vague abdominal pain and compression type symptoms, like urinary frequency.
Prognosis is poor for surface epithelial cancers – worst of female genital tract cancers
Epithelial carcinomas usually spread locally, especially to peritoneum
CA-125 is a good marker

Question 8

2nd most common type of ovarian tumor, common in women of reproductive age?
What are the most common types?

Answer 8

Germ cell tumor –
Subtypes mimic tissues produced by germ cells –
Fetal tissue = cystic teratoma and embryonal carcinoma
Oocytes = dysgerminoma
Yolk sac – endodermal sinus tumor
Placental tissue – choriocarcinoma

Question 9

Describe a cystic teratoma –
What can change its status from benign to malignant?
Name for a teratoma composed of thyroid tissue?

Answer 9

Mature Germ cell tumor (most common in females, often bilateral) – composed of fetal tissue from 2-3 embryological layers (skin, bone, hair, etc.) –
Benign tumor – if there’s immature tissue (neural most common) or somatic malignancy (squamous cell carcinoma of skin) – can have malignant potential
Struma ovarii –

Question 10

Describe a dysgerminoma
Testicular counterpart
Prognosis
Serum marker

Answer 10

Tumor composed of large cells with clear cytoplasm and central nuclei – resemble oocytes - - most common malignant germ cell tumor
Seminoma in males – common germ cell tumor
Good prognosis, responds to radiotherapy
Serum LDH may be elevated

Question 11

Descirbe an endodermal sinus tumor – who’s most at risk?
Serum marker
Histological findings

Answer 11

Malignant yolk sac mimic tumor – most common germ cell tumor in children –
Serum marker – afp elevated –
Schiller duval bodies (glomerulus like structures – seen on histology

Question 12

Choriocarcinoma - describe it
Size and spread
Marker
Response to therapy

Answer 12

Choriocarcioma is malignant tissue composed of trophoblasts and synctiotrophoblasts that mimics placental tissue with absent villi
Small hemorrhagic tumor with hemotogenous spread
High B hCg is characteristic (from synctiotrophoblasts) – may lead to thecal cysts in ovary
Poor response to chemo

Question 13

Embryonal carcinoma – describe it, and its behavior

Answer 13

Malignant tumor composed of large primitive cells

Aggressive with early metastasis

Question 14

Granulosa-theca cell tumor – what does it produce, and what will be its effects before puberty, during reproductive years, and after menopause?
Behavior?

Answer 14

GT tumor is a neoplastic proliferation of granulosa and theca cells, which often produces estrogen.
Before puberty - precocious puberty
Reproductive years – menorrhagia (uterine bleeding at regular intervals) or metrorrhagia (uterine bleeding at irregular intervals)
Post menopause (most common time for GT tumor) – endometrial hyperplasia with postmenopausal uterine bleeding
Malignant, but with little risk of metastasis

Question 15

Sertoli leydig cell tumor – what is it (composition), what does it produce, and what is it associated with

Answer 15

SL cell tumor – composed of sertoli (tubule forming) cells and leydig cells (between tubules) with characteristic reinke crystals
May produce androgen, associated with hirsutism and virilization

Question 16

Fibroma – what is it, how would it present, and how to resolve it?

Answer 16

Benign tumor of fibroblasts

Associated with pleural effusions and ascites (Meigs) – resolves with removal of tumor

Question 17

Krukenberg tumr – what is it – how to distinguish from primary carcinoma?

Answer 17

KT – metastatic mucinous tumor involving both ovaries – usually due to metastatic gastric carcinoma (diffuse type) –
Bilaterality helps to distinguish metastases from primary mucinous carcinoma of the ovary, unilateral

Question 18

Pseudomyxoma peritonei – what is it, and what causes it?

Answer 18

Massive amount of mucus in the peritoneum, due to mucinous tumor of the appendix – usually with metastasis to the ovary

Question 19

Association card –

In a vignette - Young woman, reproductive age woman, post menopausal woman - what is the stereotypic tumor?

Answer 19

Young woman – 15-30 – germ cell
Reproductive – benign surface epithelial tumor
Post menopausal – malignant surface epithelial tumor

Question 20

Tumor occurring after menopause, often bilateral, usually confined to ovary or pelvis, may have areas of squamous differentiation, resembles the endometrium histologically?

Answer 20

Endometrioid adenocarcinoma

Question 21

Functional ovarian tumor, usually of postmenopausal women, usually benign, lipid rich, related to fibromas, contain cells that can secrete estrogens or androgens?

Answer 21

Thecoma

Question 22

Dysmenorrhea, pelvic pain that occurs with menstruation, bleeding, repeated hemorrhage that leads to scarring – what do you think?

Answer 22

Endometriosis – benign endometrial glands and stroma outside the uterus