7. Ovarian Neoplasms Flashcards
Review ovary anatomy.
- Follicle is functional unit of ovary
- Follicle is surrounded by oocyte which contains theca cells and granulosa cells
- LH —> theca cells —> androgen
- FSH —-> granulosa cells producing androgen —> estradiol (active in proliferative phase) - When estradiol surges, so does LH = ovulation (secretory phase)
- After ovulation, follicle turns into corpus luteum and secretes progesterone (can lead to pregnancy)
What is ovarian torsion?
- Can occur with any ovarian mass
1. Functioning cysts
2. Benign neoplasms
3. Malignant tumours (cystic or solid)
What is polycystic ovary disease?
How is it characterized ?
What are the clinical presentations?
(3)
Multiple ovarian follicular cysts due to hormonal imbalance = excess androgen
- Characterized by: increase LH, decrease FSH
- Increased LH = increase in androgen (causing hirutism) and increase in estrone (in adipose tissue) —> this decreases FSH, causing cystic follicular degeneration
CP:
- Olignomennrohea: infrequent periods
- Infertility
- Insulin resistance and may develop T2DM
What are the categories of cysts and give examples?
4
Ovaries are cysts, not all cysts are neoplastic
- Physiological / Variants: follicular cysts (during degeneration of follicles)
- Simple
- Inclusion: cystadenoma
- Epithelial: based on lining epithelium (mucinous, serous, simple)
- Histology used to predict behaviour (benign, malignant, borderline)
What are risks for ovarian cancer?
4
- Nulliparous
- Family hx
- Oncogenes / TSG (BRCA1, BRCA2, Her2, P53)
- OCP is protective
What are the benign ovarian neoplasms?
(3)
What age group gets them?
- Cystadenoma
- Cystadenofibroma
- Adenofibroma
- 80%
- young women (20-45)
Describe malignant ovarian neoplasms (growth - 2 , microscopic findings - 4, clinical suspect - 3).
GROWTH
- Papillary projections
- Necrosis
MICRO FINDINGS
- Papillae or micropapillae
- Psammoma bodies
- Features of neoplasia
- Invasion
CLINICAL SUSPICION
- Both ovaries enlarged
- Surface involvement
- Mucinous tumours
Describe borderline neoplasms.
6
- No stromal invasion
- Architectural complexity
- Cytologic features of malignancy
- Most common: serous / mucinous (95%)
- Recurrence in 5-12%, especially where implants are seen
- 5 year survival rate > 95%
What are the 9 ovarian tumours?
- Surface epithelial-stromal tumours
- Sex cord - stromal tumours
- Germ cell tumours
- Gonadoblastoma
- Germ cell-sex cord-stromal tumours, non GB type
- Tumours of rete ovarii
- Mesothelial tumours
- Uncertain origin / miscellaneous
- Metastatic tumours
How are ovarian tumours sub-classified?
(4)
How are ovarian tumours staged?
Sub-classified based on tissue of origin
- Epithelium
- Germ cells
- Stroma (sex cord stromal)
- Metastatic
- Grade
- Stage: involvement of peritoneum (invasive and non invasive implants)
What are the types of surface epithelial-stromal tumours (Mullerian origin)? Describe each type.
(6)
What is the prognosis?
How does it present clinically?
(3)
What is the serum marker used for diagnosis?
Which ovarian tumour types have endometriosis?
(4)
- 70% of primary tumours, 90% malignant tumours
- Age 20+
- Prognosis: poor
- Serum marker: CA-125
CLINICALLY
- Late
- Abdominal symptoms (pain, fullness)
- Compression (urinary frequency)
TYPES
1. Serous: watery fluid, usually cystic, 1/3 of ovarian tumours, 25% malignant
- Mucinous: mucous fluid, usually cystic, 80% benign / borderline
- Metastatic (uncommon)
- Primary sites: appendix / colon, pancreas
- Gross features: unilaterality, nodular surface, pseudomyxoma peritoneii (lots of mucus in peritoneum) or ovarii (associated with appendix tumours)
- If tumours in both ovaries, usually metastatic from elsewhere
- Cytokeratins help localize primary tumour to GI (Cytokeratin 7- and 20+) - Intestinal: GI mucosa
- Mullerian: endocervix
- A) Endometriod: tubular glands resembling endometriosis (arises from endometriosis) up to 1/3 have simultaneous tumours in endometrium MALIGNANT
- B) Endometriod Adenocarcinoma: identical to endometriod tumours of uterus (squamous morule) - Clear cell: clear and hobnail cells and can be a/w endometriosis (poor prognosis), pattern of tubular, solid, and cystic
- Brenner: transitional cells (like the bladder), microcyst often with mucinous element, BENIGN, can be hormone producing (endometrial pathology)
OVARIAN TUMOUR TYPES WITH ENDOMETRIOSIS
- Endometriod: 28%
- Clear cell: 49%
- Mucinous: 4%
- Serous: 3%
Describe the metastatic tumours:
From Mullerian primaries?
(4)
Other (GIT)?
(5)
MULLERIAN PRIMARIES
- Uterus
- Fallopian tubes
- Contralateral ovary
- Pelvic peritoneum
OTHERS (GIT)
- Colon
- Stomach
- Biliary tract
- Pancreas
- Krukenberg tumour (GI and breast primary): bilaterality, involves both ovaries b/c of metastasis of gastric carcinoma
What are the types of germ cell tumours? Describe each type.
5
20%, 3-5% malignant ovarian tumours, age 0-25+
2nd most common ovarian tumours (benign cystic teratoma)
Derived from germ cells
Very similar to testicular tumours
TYPES
1. Teratoma: fetal tissue
- A) Immature (young): malignant, greater amount of immature tissue = greater risk of spread
- B) Mature (adult): benign, obtain elements of 3 embryonic germ layers: bilateral (10%) and cystic (teeth, hair, tissue) // 1% undergo malignant transformation
- C) Solid:
- D) Cystic (dermoid cyst): benign, fetal tissue from embroyogenic layers
- E) Monodermal (struma ovarii, carcinoid): specialized tissue
— > struma ovarii: ectopic thyroid tissue, can produce hyperthyroidism
- Dysgerminoma: oocytes
- PROGNOSIS: good (radiotherapy)
- SERUM: increase LDH
- A) Ovarian “seminoma” :clear cells, fibrous tissue, lymphocytes, central nuclei
- B) Uncommon: childhood and young adults
- C) All (malignant): no endocrine function - Yolk Sac Tumour: endodermal sinus tumour
- Rapid and aggressive, malignant
- SERUM: increase AFP
- Schiller Duvall body: glomerulus-like structures
- Hyaline droplets - Mixed Germ Cell Tumours: Choriocarcinoma (placental tissue)
- Composed of cytotrophoblasts and syncytiotrophoblasts (high B-HCG characteristic, thecal cysts in ovary)
- Can only be an ovarian primary if prepuberty vs. Origin from ovarian ectopic pregnancy
- Identical to placental lesions —> aggressive and malignant, metastasis via blood all over body (hematogenous) - Embryonal / Polyembryonal: large, primitive cells (malignant, aggressive with early metastasis)
What are the types of sex cord / stromal tumours? Describe them.
(6)
5-10%, 2-3% malignant ovarian tumours, all ages
Ovarian mesenchyme —> same mesenchyme may give rise to male (Sertoli and Leydig) and female (granulosa and theca) structures
TYPES
- Granulosa Cell Tumours (adult and juvenile)
- Composed of granulosa cells or mix granulosa and theca cells
- 5% of all tumours —> 2/3 postmeno
- Usually unilateral, any size —> yellow if produce hormones (estrogens and signs = precocious puberty, menorrhagia, endometrial hyperplasia w/ postmeno uterine bleeding
- Granluosa component: small, cuboidal cells, cords, sheets, strands, Card-Exner bodies
- Theca component: clusters or sheets of cuboidal to polygonal cells, produce estrogen (a/w endo hyperplasia, breast disease and 10% endo carcinoma)
- Malignant potential - Tumours of Thecoma-Fibroma Group: benign
- Sclerosing stromal tumour
- Stromal tumour with minor sex cord elements
- 4%, unilateral
- Fibroblasts and thecal cells
- A/w: ascites (Meigs syndrome), hydrothorax - Sertoli-stromal cell tumours (androblastomas): produces androgen (a/w hirtuism)
- Sex cord tumour with annular tubules
- Gynandroblastomas
- Steroid (lipid) cell tumours
What are diseases of the fallopian tubes? Describe them.
3
- Inflammation: PID (suppurative, TB) + endometriosis
- Ectopic pregnancy: implantation of fetus outside of uterus
- 90% of tubes: PID, peritubal adhesions
- 10% others: ovary, abdominal - Neoplasms
- 1% of genital tract malignancies
- 70% of patients with Fallopian tube car income have BRCA 1/2 mutations
- A) Benign: paratubular cysts (cysts of Morgagni), Salpingitis Isthmica Nodosa, Endosalpingiosis, Adenomatoid tumour (most common, derived from mesothelioma)
- Primary adenocarcinoma of fallopian = RARE
- B) Malignant: adenocarcinoma, same as ovary (serous > endometriod)
