Ovarian cancer

Question 1

Define

Answer 1

• Benign ovarian neoplasm: excessive growth of normal ovarian tissue types without dysplasia
• Malignant ovarian tumour: malignant transformation of ovarian tissue types

Question 2

Risk factors / Protective Factors

Answer 2

Protective factors:

• Pregnancy
• COCP

Risk factors

• (more ovulations; i.e. nulliparity, early menarche, late menopause)
• Increasing age
• FHx (BRCA1/2, MLH1, MSH2)
• Endometriosis
• HRT Obesity
• Smoking
• Talcum powder
• Ovulations
• o Associations: Lynch syndrome (Autosomal Dominant HNPCC; MLH-1, MSH-2), breast cancer (BRCA1/2)
• o Many genetic associations exist (p53 (serous), BRAF, K-ras, etc.) à see Hi6s lecture

Question 3

Aetiology - Benign

Answer 3

BENIGN

Evolves from pluripotent stem cells that lack normal growth regulation BUT do NOT possess the ability to invade other issues.

Originating from surface Ovarian Epithelium:

Serous cystadenomas- COMMONEST

• Filled with watery fluid
• Develop papillary growths
• 30% bilateral and 30% are malignant
• Commonest in women aged 30-40 years
• Psamoma bodies

Mucinous cystadenomas

• Multilocular
• Can become very large, lined by mucinous epithelium
• Filled with mucinous material and rupture à can cause pseudomyxoma peritonei
• About 5% will be malignant

Endometriomas

• Endometrial tissue from the uterus grows on the ovary
• This responds to hormones like the uterus so endometriomas tend to bleed within the cyst cavity during menstruation
• Fill up with old, dark blood and shed tissue –also called chocolate cysts
• Also release pro-inflammatory factors which cause inflammation and results in cyst growth.
• When get too large, can rupture and contents spill into the peritoneal cavity
• Have a ground-glass appearance on USS
• Endometrioid tumours can also be derived from surface epithelium

Brenner’s tumours

• Transitional cell tumour
• Arise from metaplasia of celomic epithelium into uroepithelium

Mixed types

NOTE: each of these can give rise to low-malignant and frank malignant tumours

Originating from Ovarian Germ cells:

Mature cystic teratomas- also known as dermoid cysts

• Most common ovarian tumours in women < 30 years
• Arise from primitive germ cells
• Benign mature teratoma (dermoid cyst) may contain well differentiated tissues e.g. hair, teeth- can contain Rokitansky’s protuberance

Sex cord Stromal Tumour –> incr production of hormones

Fibromas

• Small, soft, benign fibrous tissue tumours (fibroblasts)
• Associated with Meig’s syndrome
• TRIAD: Pleural effusion (often right sided), and benign ovarian fibroma and ascites
• Occur around menopause, classically causing a pulling sensation in the pelvis

Thecoma

• May secrete oestrogens or rarely androgens
• Benign

Sertoli-Leydig cell Tumours

• Hormone producing (androgen) cells in the ovary (often unilateral)
• Can lead to masculinising effects
• Associated with Peutz-Jegher syndrome

Question 4

Aetiology - malignant

Answer 4

MALIGNANT

Recent evidence suggests a role for the fallopian tubes in development of ovarian cancers.

Epithelial MOST COMMON (95% malignant)

• Cystadenocarincoma (most common)

Serous

• Often bilateral
• Psammoma bodies seen (collection of calcium)

Mucinous

• May be associated with pseudomyxoma peritonei if ruptured

Clear cell carcinoma- very strong association with endometriosis

• postmenopausal women (56yo)
• Present LATE with a BAD prognosis

Germ cell (rare)

Dysgerminoma

• Most common malignant germ cell tumour
• Similar to that of testicular seminoma histologically
• Associated with Turner’s syndrome
• Typically secretes hCG + LDH

Yolk Sac Tumour

• Typically secretes aFP
• Schiller-Duval bodies on histology- PATHOGNOMONIC

Choriocarcinoma

Immature teratomas

• Young women (20yo) and old women (70yo)

Sex-cord stromal tumours

• These are rare and usually low-grade malignancies
• All ages (but more common in post-menopausal)
• Arise from the cortical mesenchyme

Granulosa cell tumours

• Granulosa cells support the ovum in the follicle
• May produce oestrogen and inhibin
• Can lead to precocious puberty if in children, endometrial hyperplasia in adults
• Contains Call-Exner bodies (small eosinophilic fluid-filled spaces between granulosa cells)
• Variable behaviour

Theca-cell tumours produce oestrogen and may present with precocious puberty, menstrual problems or postmenopausal bleeding

Arrhenoblastomas secrete androgens

 

Secondary Ovarian Tumours

Krukenberg Tumours

• Metastases from GI tumour whereby BOTH ovaries are infiltrated with mucin secreting cells àsignet ring cell adenocarcinoma

Metastatic colorectal carcinoma