L36- Ovarian Pathology I Flashcards
list the types of ovarian lesions
Cysts: cystic follicle, follicular cyst, luteal cyst, chocolate cyst, PCOD
Tumors:
- metastasis (colon, GI, breast), 5%
- primary ovarian tumors: surface epithelium (90%), germ cell (3-5%), sex cord stromal (2-3%)
list the types of ovarian cysts
Non-Neoplastic:
-follicular, corpus luteum, chocolate, PCOD
Neoplastic:
- serous cystadenoma / carcinoma
- mucinous cystadenoma / carcinoma
- dermoid cyst
Follicular Cysts:
- stem from (1)
- (2) size
- (3) clinical features
- (4) Dx
1- unruptured follicle OR ruptured follicle that is immediately sealed off
2- 2cm, up to 4-5 cm
3- silent, pain, endometrial hyperplasia
4- US
Chocolate Cysts:
- stem from (1)
- chocolate color results from (2), which also induces (3) processes
- (4) appearance
1- endometriosis (endometrial tissue in ovary)
2- repeated cyclical hemorrhage
3- fibrosis, adhesions, pain
4- normal endometrial glands + stroma + RBC + hemosiderin
Chocolate Cysts:
- mainly needs to be distinguished from (1)
- may grow / extend with (2)
- associated with (3) as a symptom or complication
1- corpus luteum cysts
2- pelvic ligaments
3- infertility
PCOD, aka (1):
- (2) most commonly affected women
- (3) main Sxs
1- Stein Leventhal Syndrome
2- young, post-menarche, those with persistent anovulation
3- oligomenorrhea, secondary amenorrhea, hirsutism, obesity (40%), infertility
PCOD: describe hormonal changes and why
- inc androgen => 50% hirsutism, rarely virulization (poorly regulated enzymes)
- inc LH // dec FSH
- insulin resistance
PCOD causes increase in circulating androgens:
- (1) is the main fate of androgens
- (2) and (3) are the hormonal effects of (1)
- (4) is the connection to repeat this cycle
1- androgens –> (adipose) –> estrogens
2- inhibits FSH release
3- stimulates GnRH release –> inc LH release (but not FSH)
4- LH stimulates theca cell androgen production
PCOD, describe the direct or symptomatic effects of:
- (1) excess estrogen
- (2) excess androgen
1- endometrial hyperplasia, stimulates adipose cells in body –> obesity
2- hirsutism, virilization + processed thru adipose / liver –> excess estrogens
PCOD ovarian changes
- 2x larger
- subcortical cysts, 0.5-1.5 cm
- large, thick capsule, multiple unruptured follicles as cysts lined by granulosa cells and hypertrophied theca interna cells
- thick hypertrophied stroma
PCOD Dx
- hormonal assay
- transvaginal US
PCOD Tx
-depends on age and Sxs
Hormonal: break cycle; clomiphene induces ovulation if fertility is desired
Previously: wedge resection of ovary to help ovulation to reduce mass
Sxs:
- hirsutism - spironolacone
- DM - metformin
- obesity - weight loss
list the many clinical features of ovarian disease
-clinically silent for long time –> lots of space to grow
Mass Effects (mostly): pressure, swelling, ascites –> abdominal pain / enlargement, pelvic discomfort, frequent micturation, GI issues
Hormonal Effects (rare): endometrium (menstrual irregularities), breast enlargment, hirsutism
- infertility (no ovulation)
- Advanced CA: cachexia, weight loss, weakness
list the ovarian tumor investigations
- abdominal palpation
- US, CT scan
- FNAC via pouch of douglas
- ascitic fluid tap
- mass biopsy (uncommon)
- CA125 levels in serum
- hormone estimation
CA125 is described as (1) and is mainly used for (2). (3) is a main caveat to its use. (4) is its main value clinically.
1- high MW glycoprotein
2- tumor marker –> endometrial CA
3- inc in a variety of non-specific conditions that irritate peritoneum + tumors limited to ovary are 50% negative
4- possible use as screening in asymptomatic post-menopausal women, BUT mainly for monitoring response to therapy / disease progression
(1) is the most common gynecological malignancy. (2) and (3) generally reduce risk of (1). (4) is the main issue with diagnosing (1).
1- ovarian cancer 2- pregnancy 3- OCTs (+ FHx is important) 4- late detection --> majority are clinically silent
Ovarian Tumors:
- mostly (benign/malignant)
- (normally/rarely) functional
- (3) describe malignant spread
1- 80% benign, mostly 20-45 y/o //// malignant more in 40-65 y/o
2- rarely functional
3-
i) peritoneum (ascites, omental caking)
ii) LNs- illiac, para-aortic
iii) blood- lungs, liver, GIT
describe the classifications of ovarian tumors
(based on origin)
-Surface epithelium: serous, mucinous (intestinal, endocervical), endometroid, clear cell, Brenner, mixed, undifferentiated
- Germ Cell: teratoma, dysgerminoma, endodermal sinus tumor, chorioarcinoma
- Sex Cord stromal: fibroma/fibrothecoma, granulosa tumor, sertoli leydig tumor
Metastasis
describe (simplistic) classification of Surface Epithelial tumors (ovarian)
Serous- columnar cells w/ cilia (towards fallopian tube)
Mucinous- tall mucin secreting cells (towards endocervix)
Endometroid- non-ciliated columnar cells (towards endometrium)
Brenner tumor- transitional cells (toward transitional epithelium)
Ovarian Epithelial Tumor:
- benign = (1)
- borderline / intermediate has (high/low) malignant potential
- malignant = (3)
1- cystadenomas
2- low
3- cystadenocarcinomas (usually aggressive)
describe gross appearances of surface epithelial ovarian tumors
Cystic, no solid areas / papillary excrescences – generally benign
Solid- homogenous, benign
Solid- variegated (nodular, fleshy, papillae), generally malignant
Serous Tumors:
- (1) prevalence
- mostly (benign/malignant)
- mostly (uni/bi)-lateral
1- 30% of all ovarian tumors
2- benign (60%) more in younger people, 20-50 y/o // malignant (25%) mostly >50 y/o
3- unilateral if benign, bilateral if malgnant
list the risk factors of Serous Ovarian Tumors
- Nulliparity (no pregnancies)
- FHx
- BRCA1/2
- KRAS, BRAF mutations (low-grade)
- p53 mutation (high-grade)
describe general structure of Benign Serous Cystadenoma (ovarian)
- cysts filled with serous fluid
- 10-15 cm
- smooth and glistening lining, single layer of tall ciliated columnar cells
Variant- cystadenofibrma had fibrous tissue under epithelium (benign)
Borderline / Malignant Serous Ovarian Tumors:
- (1) changes are more numerous structurally
- (2) nodules are most worrisome / dangerous
- (3) borderline specific (+ 10yr survival rate)
- (4) malignant specific (+ 10yr survival rate)
1- papillae, polyploid changes
2- solid nodules
3- (75%) multi-layering, moderate mitosis, nuclear atypia (NO stromal invasion)
4- multi-layering, nuclear atypia, Stromal invasion
Mucinous Ovarian Tumors:
- (1) prevalence
- mostly (benign/malignant)
- mostly (uni/bi)-lateral
- (4) are main risk factors (hint- 1 genetic, 1 environmental)
1- 30% of all ovarian tumors
2- benign (80%)
3- unilateral, 95%
4- KRAS, smoking??
malignancy of mucinous tumors (ovarian) are based on….
- mucus composition
- general size
- # locules (cavities) in cysts- more present => more likely to be malignant
- solid composition
Extra:
- sticky gelantinous material, rich in glycoproteins
- very large mass, one of the largest in ovary
Mucinous Ovarian Tumors:
- (1) cell description
- importantly lacking (2)
- (better/worse) prognosis in comparison to serous carcinoma
1- tall columnar cells w/ apical mucinous vacuole, no cilia
2- no papillae, psammoma bodies
3- better
Pseudomyxoma Peritonei:
- (1) definition
- (2) most cases location
- (3) most end-results
1- extensive mucinous ascites = ‘jellybelly’ / mucoid material in peritoneal cavity implanted over abdominal and ovarian surfaces
2- extraovarian (appendiceal usually) w/ secondary ovarian and peritoneal spread
3- fatal
