4/28 Ovarian Neoplasm

Question 1

what is a functional cyst?

Answer 1

cysts that form as a normal part of the menstrual cycle; usually transient in nature and does not progress to cancer

Question 2

examples of functional cysts?

Answer 2

Follicle cyst
Corpus luteum cyst
Hemorrhagic cyst

Question 3

What is a follicle cyst?

Answer 3

functional cyst

distension of an unruptured graafian follicle; may be associated with hyperestrogenism and endometrial hyperplasia

Question 4

What is a Corpus luteum cyst?

Answer 4

functional cyst

Appear after ovulation; hemorrhage into the persistent corpus luteum, commonly regresses spontaneously within 5–9 days

Question 5

What is a Hemorrhagic cyst?

Answer 5

functional cyst

Ovulates -> bleeds into itself; Blood vessel rupture in the cyst wall; cyst grows with increased blood retention; usually self-resolves

Question 6

What is a non-functional cyst?

Answer 6

aka non-functional neoplasms; does NOT occur as a normal part of the menstrual cycle

Question 7

examples of non-functional cyst?

Answer 7

Theca-lutein cyst 
Dermoid cyst (teratomas)
Endometrioid cyst

Question 8

What is a theca-lutein cyst?

Answer 8

Often bilateral/multiple
Due to gonadotropin stimulation
Associated with choriocarcinoma and moles

Question 9

what is a dermoid cyst?

Answer 9

Dermoid cyst (teratomas) filled with various types of tissue, such as fat, hair, teeth, bits of bone, and cartilage

Question 10

what is an Endometrioid cyst?

Answer 10

cyst formation secondary to endometriosis within the ovary; varies with menstrual cycle. When filled with dark, reddish-brown blood, AKA “chocolate cyst”

Question 11

RA: chocolate cyst

Answer 11

Endometrioid cyst

Question 12

What are various types of tumors of the ovary? (general)

Answer 12

Surface epithelial cells
Germ cell tumors
Sex-cord stromal cell tumor
Metastasis to ovaries (krukenberg)

Question 13

How does BRCA1/BRCA2 affect risk of ovarian cancer?

which one is associated with a greater risk of ovarian cancer?

Answer 13

• recognize and repair dsDNA breaks
• mutation in BRCA genes results in ø DNA repair, leading to p53 activation, leading to cell cycle arrest, apoptosis, or both. If p53 is also inactivated, cells with DNA damage continue to proliferate and accumulate; increased malignancy potential

• greater risk of ovarian cancer with BRCA1

Question 14

What is the “Inclusion-related Carcinogenesis model” for development of surface epithelial ovarian tumors?

Answer 14

surface epithelium invaginates and loses connection to the ovarian surface; lined by mesothelial or tubal-type epithelium (though studies suggest that tubal origin, specifically in high grade serous carcinomas).

the mesothelium is of an uncommitted phenotype and has the potential to differentiate in response to signals associated with ovulation or those associated with the stromal microenvironment (commonly undergoes Müllerian metaplasia usually to a serous phenotype)

Question 15

What is the “tubal carcinogenesis model” for development of surface epithelial ovarian tumors?

Answer 15

epithelial cells experience genotoxic damage, including p53 and BRCA tumor suppressor genes, leading to the clonal expansion of ciliated cells/ “dysplastic” epithelium; progresses from STIL -> STIC in the fallopian tube, and then releases mutated cells or ROS into the ovaries

Question 16

wtf are STIL and STICs? WHY DO WE HAVE TO KNOW THIS USELESS STUFF

Answer 16

STIL – serous tubal intraepithelial lesions – contain “p53 signatures” (mutations) have some cytologic abnormalities but fall short of STICs

STIC – serous tubal intraepithelial carcinomas – precursor of ovarian high-grade serous carcinoma; contains p53 mutations and high levels of chromosomal instability in both lesions; frequently detected in fallopian tubes of women with hereditary BRCA mutations.

Dx based on nuclear enlargement, hyperchromasia, irregularly distributed chromatin, nucleolar prominence, mitotic activity, apotosis, loss of polarity, and epithelial tufting

Question 17

risk factors for surface epithelial ovarian tumors?

Answer 17

• age
• early menarche/late menopause
• nulliparity, infertility
• endometriosis
• PCOS
• post-menopausal hormone therapy
• BRCA1/BRCA2
• HPNCC

Question 18

when do ovarian tumors commonly present?

Answer 18

Teens:  	Germ cell tumors
20's:		Functional and benign adenomas
30's:		Endometriomas
40's:		Benign and Borderline tumors
50-60's:   	Epithelial carcinomas
70+:		Granulosa cell tumors

Question 19

Serous Cystadenoma
when does it occur?
bilateral? unilateral?
features?
subtypes?

Answer 19

surface epithelial ovarian tumors

Most common ovarian neoplasm; 20s
Often bilateral
Thin walled
Serous benign or serous borderline

Question 20

difference btwn serous cystadenoma - benign or serous borderline?

Answer 20

Serous benign - Lined with fallopian-like epithelium (single layer of tall, columnar ciliated cells); no atypia, no architectural complexity, no invasion of the stroma

Serous borderline – more complex papillary structures, absence of stromal invasion

Question 21

Mucinous cysatdenoma 
when does it occur?
bilateral? unilateral?
features?
subtypes?

Answer 21

surface epithelial ovarian tumors

20s
Often unilateral
Multi-loculated, large
Mucinous benign or mucinous borderline

Question 22

difference btwn mucinous benign or mucinous borderline?

Answer 22

Mucinous benign - lined by mucus-secreting epithelium; lining is a single layer (indicates benign)

Mucinous borderline – lining w/ proliferative nuclei

Question 23

Endometrioma
features?
common presentation?

Answer 23

surface epithelial ovarian tumors

Endometrioid cyst “chocolate cyst”; mass arises from ectopic endometrial tissue; when it bleeds, the blood accumulates and turns brown

Presents with pelvic pain, dysmenorrhea, dyspareunia

Question 24

Clear cell histology?

Answer 24

surface epithelial ovarian tumors

Neoplastic cells with cleared cytoplasm (contains glycogen)

Question 25

Brenner tumor
Gross appearance?
Histologic feature?

Answer 25

surface epithelial ovarian tumors

Looks like bladder; solid tumor that is pale yellow-tan in color; circumscribed

encapsulated “coffee bean” nuclei lying in abundant fibrous stroma

Question 26

when does Mature teratoma (dermoid cyst) occur?

What is unique about this tumor?

sx?

Answer 26

20s

can contain elements from all 3 germ layers (teeth, bone, cartilage, hair, sebum; thyroid tissue is less common)

Presents

• pain secondary to ovarian enlargement or torsion
• hyperthyroidism (struma ovarii) if it contains functional thyroid tissue!!!

Question 27

What is a Fibroma?
clinical presentation?

characteristic hx features?

Answer 27

Sex-cord; stromal cell tumor

Meigs syndrome – triad of ovarian fibroma, ascites, and hydrothorax
Pulling sensation in groin

Bundles of spindle-shaped fibroblasts

Question 28

Thecoma - what is it and common presentation?

Answer 28

Like granulosa cell tumors; may produce estrogen

Usually presents as abnormal uterine bleeding in a post-menopausal woman

Question 29

What are some malignant ovarian neoplasms?

Answer 29

Serous cystadenocarcinoma
Mucinous cystadenocarcinoma
Immature teratoma
Sertoli-Leydig Cell tumor 
Granulosa-theca cell tumor 
Dysgerminoma
Choriocarcinoma
Yolk sac (endodermal sinus) tumor
Krukenberg tumor

Question 30

Serous cystadenocarcinoma?
unilateral? bilatera?
hx features?

Answer 30

Surface epithelial tumor
Most common ovarian neoplasm
frequently bilateral

Psammoma bodies, solid, cystic, papillary, necrotic, hemorrhagic

Question 31

Immature teratoma
what is it?
features?
likelihood of containing thyroid tissue?

Answer 31

Germ cell tumor Aggressive, contains fetal tissue, neuroectoderm

Most typically represented by immature/embryonic-like neural tissue

Less likely to contain thyroid tissue

Question 32

Sertoli-Leydig Cell tumor
typical onset?
presentation?
markers? 3

Answer 32

Sex-cord stromal tumor that produces excess testosterone

onset: young adults

F = present with history of progressive masculinization preceded by anovulation, oligomenorrhea, amenorrhea, defeminization (acne, hirsutism, voice deepening, clitormeagly, temporal hair recession)

Marker: CA-125, AFP, incr testosterone

Question 33

Granulosa-theca cell tumor
typical onset?
presentation?
markers? 2

Answer 33

Sex-cord stromal tumor that produce estrogen and/or progesterone

Predominately F, 50s

Presents with abnormal uterine bleeding, precocious puberty, breast tenderness

Marker: inhibin, CA-125

Question 34

Dysgerminoma
typical onset?markers? 2
histological features?

Answer 34

Germ cell tumor

adolescents

Tumor markers: hCG, LDH

Sheets of uniform “fried-egg” cells with lymphocytes

Question 35

Choriocarcinoma
typical onset?
presentation? 
marker? 
treatment?

Answer 35

Trophoblast malignancy (cytotrophoblasts, syncytiotrophoblast)

Rare, can develop during or after pregnancy in mother or baby

presentation: shortness of breath, hemoptysis due to hematogenous spread to LUNGS
marker: ß-hCG
presentation: shortness of breath, hemoptysis due to hematogenous spread to lungs

very responsive to chemotherapy

Question 36

Yolk sac (endodermal sinus) tumor
typical onset?
prognosis?
marker? 
gross-apperance?
Hx features?

Answer 36

Male infants

bad = aggressive tumor!

tumor marker: AFP

Gross appearance: Yellow, friable (hemorrhagic) solid mass

Hx presentation: Schiller-Duval bodies (resembles glomeruli)

Question 37

what is a Krukenberg tumor?

Answer 37

Metastasis tumor: GI malignancy that metz to the ovaries, causing a mucin-secreting signet cell adenocarcinoma