7. Ovary Flashcards
Disorders of the ovary
- Non-neoplastic ovarian cysts
- Follicular cysts
- Corpus luteal cysts
- Theca lutein cysts
- Endometriotic cysts
- Multiple follicular cysts (polycystic ovary syndrome) - Ovarian neoplasms
a. Epithelial ovarian tumours
i. Benign
- Ovarian serous cystadenoma
- Ovarian mucinous cystadenoma
- Brenner tumour
ii. Malignant
- Serous cystadenocarcinoma
- Mucinous cystadenocarcinoma
- Endometrioid carcinoma
- Clear cell tumours
b. Ovarian germ cell tumours
i. Benign
- Mature cystic teratoma
- Mature teratoma
ii. Malignant
- Immature teratoma
- Yolk sac tumour of the ovary
- Dysgerminoma
- Nongestational choriocarcinoma
c. Sex cord-stromal tumours of the ovary
i. Benign
- Ovarian fibroma
- Theca cell tumour
- Sertoli-leydig cell tumour
ii. Malignant
- Granulosa cell tumour
d. Krukenberg tumour
Follicular cysts
- Most common ovarian mass in young women
- Develops when a Graafian follicle does not rupture and release the egg (ovulation) but continues to grow
- Eventually develops into a large cyst (∼ 7 cm) lined with granulosa cells
- Associated with hyperestrogenism and endometrial hyperplasia
Corpus luteum cyst
Enlargement and buildup of fluid in the corpus luteum after failed regression following the release of an ovum
Theca lutein cysts
- Often multiple cysts that typically develop bilaterally
- Result from exaggerated stimulation of the theca interna cells of the ovarian follicles due to excessive amounts of circulating gonadotropins such as β-hCG
- Strongly associated with gestational trophoblastic disease and multiple gestations
- Usually resolve once β-hCG levels have normalized
Epidemiology of polycystic ovary syndrome
6–12% of women in their reproductive years in the US
Pathophysiology of polycystic ovary syndrome
- Strong association with obesity → ↑ in peripheral estrogen synthesis from adipose tissue and ↓ in peripheral sensitivity to insulin
- Reduced insulin sensitivity (peripheral insulin resistance) and the consequent hyperinsulinemia result in:
- Epidermal hyperplasia and hyperpigmentation (acanthosis nigricans)
- ↑ Androgen production in ovarian theca interna cells → imbalance between androgen precursors and the resulting estrogen produced in granulosa cells
i. ↑ LH secretion disrupts the LH/FSH balance → impaired follicle maturation with cyst formation due to lack of follicle rupture and anovulation/oligoovulation → infertility
ii. ↑ Androgen precursor release and ↑ estrogen production in adipose tissue
- Inhibition of sex hormone-binding globulin (SHBG) in the liver → ↑ free androgens and estrogens
i. ↑ Unopposed estrogen (lack of progesterone) during anovulatory cycles → endometrial hyperplasia → ↑ risk of endometrial carcinoma
Clinical features of polycystic ovary syndrome
- Menstrual irregularities
- Primary or secondary amenorrhea
- Oligomenorrhea
- Menorrhagia
- Infertility or difficulties conceiving - Insulin resistance and associated conditions
- Metabolic syndrome (especially obesity) - Skin conditions
- Hirsutism
- Acne vulgaris
Complications of polycystic ovary syndrome
- Cardiovascular disease
- Type 2 diabetes mellitus
- Increased cancer risk (before menopause)
- Endometrial cancer
- Increased miscarriage rate
Epidemiology of cystadenoma
Most (serous) and second most common (mucinous) benign ovarian tumor
Pathology of Ovarian serous cystadenoma
- Cysts with watery fluid
- May contain small papillary projections
- Psammoma bodies
- Cyst is lined by serous epithelial cells (similar to the epithelium of fallopian tubes)
Pathology of Ovarian mucinous cystadenoma
- Smooth or bosselated appearance
- Cyst is loculated; loculi contain gelatinous material
- Cyst is lined by columnar epithelium that secretes thick mucus (similar to the epithelium of cervix)
Epidemiology of Brenner tumour
- Rare
2. Peak age: 40–60 years
Pathology of Brenner tumour
- Encapsulated, pale yellow solid tumor
- Similar to transitional cells of the bladder (urothelium)
- Circular patches of cells with coffee bean nuclei
Epidemiology of serous cystadenocarcinoma
Most common malignant ovarian tumor
Pathology of serous cystadenocarcinoma
- Cysts with watery fluid
- Tumor cells with papillary structures and small cytoplasm
- Psammoma bodies are a typical feature.
Epidemiology of mucinous cystadenocarcinoma
- Rare
2. Can also be metastatic from GI malignancies (e.g., of the appendix)
Pathology of mucinous cystadenocarcinoma
- Cysts filled with mucoid material, cellular debris, and/or blood
- Cystic or colloid type, depending on intracellular or extracellular mucin deposition
Epidemiology of endometrioid carcinoma
- 10% of epithelial tumors
2. Concomitant endometrial carcinoma in 10–15% of cases
Pathology of endometrioid carcinoma
- Possible appearances are:
- Smooth surface with cystic spaces filled with blood-stained fluid
- Completely solid with necrosis/hemorrhage - Characteristic confluent glandular/expansile pattern
- Tightly packed, back-to-back glands lined with tumor cells
- Absent intervening stroma
Epidemiology of clear cell tumour
- 5–10% of epithelial tumors
2. Most commonly occur in perimenopausal women
Pathology of clear cell tumour
- Endometriosis-associated tumors are filled with chocolate-colored fluid
- Variable appearance: tubulocystic, papillary, and solid
Tumour marker for epithelial ovarian tumours
CA-125
Epidemiology of mature cystic teratoma
- Most common of all germ cell tumors (90% of all cases)
2. Most common ovarian tumor in women < 30 years
Pathology of mature cystic teratoma
Contains somatic tissue (e.g., hair, teeth, sebaceous glands) from any of the three embryonic germ layers:
- Endoderm
- Mesoderm
- Ectoderm
Epidemiology of mature teratoma
∼ 5% of all ovarian teratomas
Pathology of mature teratoma
Endodermal differentiation into thyroid tissue
Epidemiology of immature teratoma
- Rare
2. Peak age: women < 20 years of age
Pathology of immature teratoma
Composed of immature neuroectodermal tissue
Epidemiology of Yolk sac tumor of the ovary
Occurs mainly in children and adolescents
Pathology of Yolk sac tumour of the ovary
- Macroscopic appearance: yellow, friable mass (due to hemorrhage)
- Schiller-Duval bodies (resemble glomeruli on microscopy)
Tumour marker for immature teratoma
- LDH
- AFP
- CA-125
Tumour marker for yolk sac tumour of the ovary
- LDH
2. AFP
Epidemiology of ovarian fibroma
Peak age: postmenopause
Pathology of ovarian fibroma
- Smooth, lobulated
- Cut surface: chalky, firm, yellow-to-white color
- Clusters of spindle-shaped cells (fibroblasts)
Epidemiology of theca cell tumour
Peak age: postmenopause
Pathology of theca cell tumour
- Solid yellow-orange tumor
2. Ovarian stromal cells filled with lipids on microscopy
Epidemiology of sertoli-leydig cell tumour
- Rare
2. Peak age: 30–40 years
Pathology of sertoli-leydig cell tumour
- Small, yellow-brown tumor
2. Seminiferous-like tubules lined by Sertoli cells and Reinke crystals
Epidemiology of granulosa cell tumour
- Most common type of sex cord-stromal malignancy (∼ 90%)
2. Peak age: 50–55 years
Pathology of granulosa cell tumour
- Tan/yellow color
Encapsulated; smooth lobulated surface, possibly with areas of necrosis/hemorrhage - Call-Exner bodies: granulosa cells arranged in clusters surrounding a central cavity with eosinophilic secretions, resembling primordial follicles
Tumour marker for granulosa cell tumour
Inhibin
Krukenberg tumour
Secondary ovarian tumor that most commonly arises from metastatic spread of gastric carcinoma
- Often bilateral
- Characteristic mucin-secreting signet ring cells on histology
Clinical feature of ovarian fibroma
May be associated with Meigs syndrome: ascites and pleural effusion in association with a benign ovarian tumor
Clinical feature of sertoli-leydig cell tumour
Symptoms of excessive androgens and/or estrogen production
- ↑ Testosterone
- Virilization, hirsutism, acne, temporal balding
- Amenorrhea, clitoral enlargement, ↓ fertility - ↑ Estrogen
- Menstrual bleeding abnormalities
- Endometrial polyps and hyperplasia
Clinical feature of granulosa cell tumour
- Symptoms caused by estrogen and/or progesterone secretion
- Adult subtype: menstrual irregularities (e.g., postmenopausal bleeding, endometrial hyperplasia with metrorrhagia)
- Juvenile subtype: precocious puberty - Breast tenderness
- Associated with increased risk of endometrial cancer
Spread of malignant ovarian neoplasms
- Local infiltration into broad ligament
- Urethral obstruction
- Bladder involvement - Peritoneal spread
- Ascites with malignant cells in fluid
- Peritoneal nodules - Lymphatic spread
- Hematogenous spread
- Lung nodules
Epidemiology of dysgerminoma
Most common malignant ovarian germ cell tumor in adolescents and young women
Pathology of dysgerminoma
Equivalent to seminoma (e.g., presence of fried egg cells)
Tumour markers of dysgerminoma
- LDH
2. hCG (rare: ∼ 5%)
