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Reproductive module > ✓ 33- Benign and Malignant Ovarian Conditions > Flashcards

✓ 33- Benign and Malignant Ovarian Conditions Flashcards

1
Q

What is the management/follow up plan for ovarian masses?

A
  • < 5 cm → Doesn’t recquire follow up [likely physiological]
  • 5-7 cm → Yearly US
  • > 7 cm → further imaging and surgical intervention
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2
Q

What are the general types of ovarian masses?

A
  1. Functional
  2. Inflammatory
  3. Neoplastic
  4. Other
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3
Q

What are the functional ovarian masses?

A
  1. Follicular cyst
  2. Corpus Luteum cyst
  3. Theca Lutein cyst
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4
Q

What are the inflammatory ovarian masses?

A
  1. Tubo-ovarian masses
  2. Abscess
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5
Q

What are the neoplastic ovarian masses?

A
  1. Benign ovarian mass
  2. Borderline ovarian mass
  3. Malignant ovarian mass
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6
Q

What are the “other” type of ovarian masses?

A

Endometrima

Enlarged PCO

Parovarian cyst

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7
Q

Epidemiology of Ovarian Tumors

A
  • 80% are benign
  • cmost 20-45 yrs.
  • High mortality in malignancies
  • accounts for 27% of gynecologic cancer
    • and accounts for 53% of deaths
  • 75% are diagnosed with advanced stage
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8
Q

What are the risk factors for ovarian carcinoma?

A
  1. Nulliparity
  2. Family history
  3. Childhood gonadal dysgenesis
  4. Clomiphene
  5. Inheredited
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9
Q

What genes are responsible for Familial Ovarian Cancers?

A

BRCA1 [39%]

BRCA 2 [11%]

HNPCC- Mutations in mismatch repair genes

  • MLH1
  • MSH2
  • MSH6
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10
Q

What cancers are associated with BRCA1 mutations?

A
  1. Breast
  2. Ovary
  3. Fallopian tube
  4. Colorectal
  5. Prostate
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11
Q

What cancers are associated with BRCA2 mutations?

A
  1. Breast
  2. Ovary
  3. Fallopian tube
  4. Pancreatic
  5. Gallbladder
  6. Bile Duct
  7. Gastric
  8. Melanoma
  9. Male Breast
  10. Prostate
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12
Q

What is the risk of Hereditary ovarian cancer in women? [General population, BRCA1, BRCA2, HNPCC]

A
  • General Population: 1/70
  • BRCA1: 20-40% [65%]
  • BRCA2: 20-25%
  • HNPCC: 9%
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13
Q

What are the different classification of Primary ovarian tumors?

A
  1. Surface/Mullerian Epithelial tumors
  2. Germ cell tumors
  3. Sex cord-stromall tumors
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14
Q

What is the frequency of each type of ovarian tumors?

A
  1. Surface/Mullerian Epithelial tumors
    • 65-70%
  2. Germ cell tumors
    • 15-20%
  3. Sex cord-stromall tumors
    • 5-10%
  4. Metastasis
    • 5%
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15
Q

What are the different types of Surface epithelial cell tumor?

A
  1. Serous [75-80%]
  2. Mucinous [8-10%]
  3. Endometrioid [10%]
  4. Clear cell [<1%]
  5. Brenner [<1%]
  6. Cystadenofibrma
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16
Q

What are the different types of Germ cell tumor?

A
  1. Teratoma
  2. Dysgerminoma
  3. Endodermal sinus
  4. Choriocarcinoma
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17
Q

What are the different types of Sex-cord stroma tumor?

A
  1. Fibroma
  2. Granulosa-theca cell tumor
  3. Sertoli-Leydig cell tumor
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18
Q

Describe the gross and microscopic features of borderline surface epithelial tumors?

A

Gross: cystic /solid foci

Microscopic:

  1. Papillary complexity
  2. Stratification
  3. Nuclear atypia
  4. No stromal invastion
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19
Q

Describe the gross and microscopic features of benign surface epithelial tumors?

A

Gross: mostly cystic

Microscopic:

  1. Cuboidal-Columnar epithelium
  2. Fine Papillae
  3. No stratification
  4. No nuclear atypia
  5. No stromal invastion
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20
Q

Describe the gross and microscopic features of malignant surface epithelial tumors?

A

Gross: mostly solid, and hemorrhage/necrosis

Microscopic:

  1. Papillary complexity
  2. Stratification
  3. Nuclear atypia/ Malignany cells in glandular pattern
  4. High mitotic activity
  5. Psammoma bodies
  6. Stromal invastion
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21
Q

What does the lining epithelium of serous tumors resemble?

A

Fallopian tube

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22
Q

What does the lining epithelium of mucinous tumors resemble?

A
  • Intestinal → gastrointestinal mucosa
  • Müllerian → endocervix
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23
Q

What does the lining epithelium of endometrioid tumors resemble?

A

Endometrial glands

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24
Q

What does the lining epithelium of brenner tumors resemble?

A

Bladder [transitional epithelium]

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25
Q

What does the lining epithelium of clear cell tumors resemble?

A

Mesonephric [renal cell]

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26
Q

General epidemiology of Serous tumors

A
  1. Most common in 4th/5th decades of life
  2. Most common cystic neoaplasm of ovary
  3. accounts for 75% of epithelial ovarian tumors
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27
Q

What are the different types of serous tumors and the incidence of each?

A
  1. Benign / Cystadenomas[60%]
  2. Borderline [15%]
  3. Malignant / Cystadenocarcinoma [25%]
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28
Q

How likely would both ovaries be affected in the different types of serous tumors

A
  1. Benign → 20%
  2. Borderline → 30%
  3. Malignanct → 65%
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29
Q

What factors would determine the prognosis of serous tumors?

A
  1. Stage of disease
  2. presence of peritoneal implants
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30
Q

Prognosis of Borderline Serous Cystadenoma

A
  • Age: 20-50 yrs
  • Bilaterally: 30%
  • Prognosis: 100% 5yrs survival
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31
Q

Describe the histological appearance of ovarian cystadenofibroma

A

Well differentiated glands are embedded within a dense fibrous stroma

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32
Q

What type of ovarian tumors is the largest?

A

Mucinous tumors [mall fill entire abdominal cavity]

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33
Q

What is the condition may be associated with Endometrioid tumors?

A

Endometrial cancers [15-20%]

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34
Q

Describe the Gross and Morphological appearance of Endometrioid tumors

A
  • May be cystic or solid
  • Content tends to be hemorrhagic rather than serous or mucinous
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35
Q

T/F: Endometrioid tumors are benign.

A

False, almost all cases of Endometrioid tumors are malignant

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36
Q

What two other condition may be found in a patient with Endometrioid tumor?

A
  • Concurrent endometrioisis [10-20%]
  • Endometrial cancer [15-20%]
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37
Q

Describe clear cell tumors , in terms of its grade, malignancy and incidence

A
  • Uncommon
  • Agressive tumor
  • Invariable high grade
  • Mostly malignant
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38
Q

Describe the appearance of Clear cell tumors

A

clear, peg-like or hobnail-like cells

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39
Q

What is the precurosr of clear cell tumors?

A

in 1/4 of cases they arise from lining of benign endometrioid cyst

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40
Q

What other condition may a patient with clear cell tumor also complain of?

A

50-70% have endometriosis

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41
Q

What is the average age of incidence of Brenner tumor?

A

50 years

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42
Q

What signs maybe found in patients with Brenner Tumors?

A
  • Sign of Hyperestronsim
    • Post-menopausal bleeding from endometrial hyperplasia
  • Ascites [rarely]
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43
Q

Describe the gross appearance of Brenner Tumor

A
  • white to tan-yellow whorled cut surface
  • Cystic spcaes and calcification [possible]
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44
Q

Describe the microscopic appearance of Brenner Tumors

A
  • Epithelial cells: solid and cystic nests
  • Resemble transitional epithelium
  • Surrounded by abundant stroma.
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45
Q

T/F: Brenner tumor is described as a large and fast growing malignant tumor

A

False, its mostly benign and its slow growing with a variable size of 1-30 cm

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46
Q

What is the treatment of Borderline Brenner tumors?

A

Surgical removal

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47
Q

Define Malignant Brenner tumor

A

benign or borderline when coexisting with invasive transitional cell carcinoma

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48
Q

What are the prognostic factors in ovarian cancer?

A
  1. Stage of disease
  2. Volume of Residual disease post surgery
  3. Histological type and Grade of Tumor
  4. Age at presentation
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49
Q

What are the different complications of Ovarian tumors?

A
  1. Torsion
  2. Rupture
  3. Haemorrhage
  4. Infection
  5. Pseudomyxoma peritonei
  6. Malignancy
50
Q

Describe the hematogenous spread of ovarian tumors?

A
  1. This spread at the time of diagnosis is uncommon
  2. Spead to lungs and liver in 2-3%
51
Q

Describe the Lymphatic spread of ovarian tumors

A
  • Pelvic LN: via broad ligament
  • Inguinal LN: Retrograde dissemination via lymphatics → round ligament to → Inguinal LN
    • Advanced stage disease
  • Precaval/Paraaortic LN: follows ovarian vein
52
Q

Describe the Transcoelomic pattern of spread of Ovarian tumors

A
  1. Most common & earliest mode by exfoliation of cells which implant along surfaces of peritoneal cavity
  2. Metastasis typically seen on POD, paracolic gutters, right hemidiaphragm, liver capsule, peritoneal surface of intestine & mesenteries, omentum
  3. It seldom invades intestinal lumen, but progressively agglutinates loops of bowel - functional intestinal obstruction and carcinomatous ileus
53
Q

What is the tumor markers for Serous tumors?

A
  • CEA
  • CA-125
54
Q

What are the tumor markers for Mucinous tumors?

A
  1. CA19-9
55
Q

What are the tumor marker for Dysgerminoma?

A
  • LDH
  • ß-hCG
56
Q

What are the tumor marker for Sertoli-Leydig tumors?

A

Testosterone

57
Q

What are the tumor markers for Endodermal sinus tumors?

A

AFP

58
Q

What are the tumor markers for Choriocarcinoma?

A

ß-hCG

59
Q

What are the tumor markers for Teratomas?

A

AFP

60
Q

What tumor markers are important for screenign gynecological malignancies?

A
  1. CA19-9
  2. CA-125
  3. CEA
61
Q

When is CA-125 useful to use as a tumor marker?

A

Whn non-mucinous epithelial cancers are present

  • found in 85% of patients with epithelialc ovarian cancers
62
Q

Relevance of Ca-125 to cancer treatment

A

used to monitor response to therapy

63
Q

What conditions are associated with a rise in CEA?

A
  • Colonic carcinoma
  • Ovarian carcinoma
64
Q

What imaging modality is most useful to investigate ovarian tumors?

A

US is the most useful non invasive test for suspected malignancy

65
Q

What is the indication for FNA as an investigative option for ovarian tumor?

A

For patients with advanced ovarian cancer who are medically unfit to undergo surgery permitting initiation of neoadjuvant chemotherapy (NACT)

66
Q

What is the common origin of metastatic tumors of the ovary?

A
  • Stomach [70%]
  • Large bowel [15%]
  • Breast [6%]
67
Q

Describe the appearance of Krukenberg tumors

A

Bilateral tumors

Grossly:

  • Smooth surface, slightly bossed, freely movable in pelvis
  • No infiltration through the capsule
  • No tendency to form adhesions
  • Tumour retains the shape of normal ovary, with solid waxy consistency

Microscopic:

  • cellular or myxomatous stroma, scattered “signet ring” mucin- secreting cells
68
Q

What are the signs and symptoms of Sertoli-Leydig cell tumors?

A

Clinical virilisation in 70-85%

Signs of virilisation/defeminizing:

  • oligomenorhoea
  • amenorrhoea
  • breast atrophy
  • acne
  • hirsuitism
  • clitoromegaly
  • deepening of voice
  • receding hair line
69
Q

What causes the virulizing effects seen in sertoli-leydig cell tumor?

A

The androgen produced by tumor cells

70
Q

Epidemiology of Sertoli-Leydig cell tumor

A
  • Rare (0.2% of ovarian cancers)
  • Occur most frequently in 3rd or 4th decade [75% in women < 40 yrs]
  • Unilateral
71
Q

What is another name for Sertoli-Leydig cell tumors?

A

ARRHENOBLASTOMA

72
Q

Describe the morphology of Sertoli-Leydig cell tumor

A
  • Unilateral
  • Recapitulates development of testis with tubules or cords and plump pink Leydig cells
73
Q

What is Meig’s Syndrome?

A

Triad of:

  • Solid ovarian mass
  • Ascite
  • Pleural effusion
74
Q

Investigation of Thecomas

A
  1. Inhibin
  2. Oil Red O fat stains
75
Q

T/F: Fibromas and Thecomas are both hormonally active tumors that secrete androgens.

A

False:

  1. Fibromas are hormonally inactive
  2. Thecomas secrete estrogen
76
Q

Malignancies of Thecoma-Fibroma group

A
  1. Thecoma: pure thecomas are always benign
  2. Fibroma: generally benign
    1. malignant transformation in 1% of cases
77
Q

What group of woman would thecomas be found in?

A

Post-menopausal women in their 60s

78
Q

What group of woman would fibromas be found in?

A

In perimenopausal and menopausal women

79
Q

Describe the clinical picture of patients with Fibromas

A
  • Ascites [40%]
  • Meig’s syndrome [1%]
80
Q

Describe the clinical picture of Thecomas

A
  • Abnormal bleeding
  • Pelvic mass
  • Cystic disease of breast
81
Q

What is the origin of fibromas?

A

Arises from spindle stromal cells that form collagen

82
Q

Describe the appearance of thecomas

A

Cells resemle thecal cells

83
Q

Adult GC

A
  • common in postmenopausal
  • Avg age is 50years
  • Associated with ESTROGEN production.
  • Endometrial hyperplasia ( 25-50%)
  • endometrial Carcinoma (5-10%)
84
Q

Juvenile GC

A
  • 90% before puberty
  • Mean age at diagnosis is 13 years.
  • Menstrual irregularities
  • amenorrhea
  • precocious puberty.
  • True GC tumors are low grade; confined to one ovary with EXCELLENT PROGNOSIS
  • long term survival 75-90 %
85
Q

T/F: Granulosa cell tumors are bilateral in 98% of cases

A

False only bilateral in 2% of cases

86
Q

Describe the morphology fo Granulosa Cell tumors

A

Grossly:

  • solid can be cystic
  • cut surface is soft and yellow-tan

Microscopically:

  • Mixture of cuboidal granulosa cells
  • Scant cytoplasm
  • “COFFEE BEAN” grooved nuclei
  • spindled or plump lipid- laden theca cells
  • Call-Exner bodies
87
Q

What is the most common complication of Mature cystic Teratomas?

A

Torsion

88
Q

What is Rokitansky’s protuberance?

A

A solid protuberance projecting from an ovarian cyst in the context of mature cystic teratoma. It often contains calcific, dental, adipose, hair, and/or sebaceous components

89
Q

Malignancy and Mature Teratomas

A

< 1% undergo malignant transformation (commonly squamous cell ca)

90
Q

Epidemiology of Mature Teratomas

A
  • Almost 20% of all ovarian neoplasms:
  • App 95% of all ovarian teratomas
  • Age < 20 years
91
Q

What are immature teratomas?

A

Malignant ovarian germinal tumor composed of mixture of immature embryonal and mature adult tissue derived from all three germ layers.

92
Q

Epidemiology of Immature Teratomas

A

Usually children and adolescents

93
Q

What determines the grade of immature teratomas?

A

Quantity of immature neural tissue alone determines grade

94
Q

Describe Grade I and III of Immature teratomas

A
  • Grade I: mature teratoma with only rare immature foci
  • Grade III: large portion embryonal tissue with atypia and mitotic activity
95
Q

Describe the appearance of immature teratomas

A
  • immature neuroepithelium forming rosettes
  • Maybe solid with a few cysts
  • Rarely bilateral
96
Q

What is struma ovarii?

A

Thyroid tumor group that can be either benign or malignant

  • Dominant growth of thyroid tissue in a teratoma, sometimes to exclusion of other components
97
Q

Epidemiology of Dysgerminoma

A
  • Commonest malignant germ cell tumor (30 to 40% )
  • 75% seen at 10 to 30 years of age
    • Rare after 50yrs.
  • Occur with gonadal dysgenesis
  • Unilateral in 80%–90%
98
Q

What pathology in the testis is similar to Ovarian Dysgerminoma?

A

Testicular seminoma

99
Q

Malignancy and Dysgerminomas

A

All malignant- 1/3 metastasize

100
Q

Treatment of Dysgerminomas

A

80% cure rate

  • All radiosensitive and chemosensitve
101
Q

What is Dysgerminoma?

A

Consists of germ cells that have not differentiated to embryonic or extraembryonic structures

102
Q

Describe the morphology of Dysgerminomas

A
  • Sheets or cords of large clear cells
  • stroma may contain lymphocytes and occasional granulomas
103
Q

What is the significance of AFP in endodermal sinus tumors?

A

correlates extent of disease & monitoring treatment

104
Q

Epidemiology of Endodermal Sinus tumor

A
  • 3rd most frequent malignant GCT
  • Median age 16 – 18 yrs
  • Unilateral in 100 %
105
Q

Clinical picture of Yolk sac tumor

A
  • Abdomen or pelvic pain (75 %)
  • Asymptomatic pelvic mass (10%)
106
Q

Malignancies of Endodermal sinus tumors

A

Highly aggressive, and associated with other GCT

107
Q

Describe the morphology of Yolk Sac tumors

A

Gross:

  • Soft-Grayish brown mass with cystic areas

Microscopic:

  • Schillar Duval bodies with central capillary and mantle of endoderm
  • Extracellular hyaline droplet
108
Q

Choriocarcinomas

A
  • Malignant tumor of the ovary with trophoblastic differentiation composed of syncytiotrophoblast and cytotrophoblast
  • Resistant to chemotherapy
  • High HCG
109
Q

Embryonal carcinomas

A
  • Most malignant but rare (4%)
  • Homologous to the embryonal carcinoma of adult testis.
  • 47% prepubertal at diagnosis
  • 43% may present with hormonal abnormalities
    • precocious puberty, vaginal bleeding etc
110
Q

What is pseudomyxoma peritonei?

A

Mucinous tumors may involve the peritoneal surface with collection of extensive mucinous material resembling cystic contents within the peritoneal cavity.

  • A rare condition
  • Seen with primarily borderline or malignant neoplasms.
111
Q

Describe the gross and microscopic morphology of Malignant Mucinous tumors

A

Gross:

  • Solid with some mucin-containing cystic spaces
  • Thickened cyst wall
  • Hemorrhage + necrosis

Microscopic:

  • Cell atypia
  • Increased layering
  • Gland complexity
  • Papillae
  • Areas of stromal invasion
112
Q

Epidemiology of Malignancy Mucinous tumors

A

Age:c40-70 yrs

Bilateral: 5-15%

113
Q

Describe the gross and microscopic appearance of benign mucinous tumor

A

Gross:

  • Multiloculated
  • Mucoid fluid

Microscopic:

  • Lined by a single layer of tall columnar mucinous epithelium without cilia.
114
Q

What complications arise from rupture of mucinous ovarian tumors?

A
  • pseudomyxoma peritonei
  • adhesion formation
115
Q

What type of epitheliums line mucinous tumors?

A
  1. intestinal epithelium (intestinal type) - more frequently
  2. columnar epithelium (mullerian mucinous tumors)
116
Q

Describe the gross appearance of mucinous tumors

A
  • Honey cob appearance [cut surface]
  • Cystic tumor
117
Q

What genes are mutated in Lynch Syndrome?

A

HNPCC- Mutations in mismatch repair genes

  • MLH1
  • MSH2
  • MSH6
118
Q

Lynch Syndrome

A
  • ~7% of hereditary ovarian cancer cases
  • Predominance of early onset proximal colon cancer, ca ovary and endometrium.
119
Q

Inherited vs. Sporadic Ovarian cancers

A

Inherited familial ovarian cancers occur 10 years younger than sporadic

120
Q

What is the pattern of inheritance of familial ovarian cancers?

A

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Reproductive module (41 decks)

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