Ovarian cancer - pathology

Question 1

What are the main pathological groups which affect the ovaries ?

Answer 1

• Cysts
• Endometriosis
• Tumours

Question 2

In general what are symptoms of ovarian cysts and ovarian cancer someone can have ?

Answer 2

1. Pain - on intercourse, if a cyst breaks, or abdo pain/pressure
2. Abodminal swelling/bloating - this may be due to ascites or presence of a mass + early satiety
3. Endocrine effects – e.g. some ovarian tumours or in polycystic ovarian syndrome (thecoma, granulosa cell tumours) may secrete oestrogens or androgens which present relatively early with endometrial abnormalities or virilisation
4. Frequent or urgent urinatation

Question 3

What are ovarian cysts ?

Answer 3

A cyst is a fluid-filled sac.

Ovarian cysts can vary in size - from less than the size of a pea upto or larger than the size of a large melon

Are pretty much a tumour (growth) but are mainly benign although some occasions where they are malignant

Question 4

In general terms what are the different types of ovarian cysts which can develop ?

Answer 4

• Functional cysts - follicular or corpus luteum cysts
• Dermoid cysts also called cystic teratomas (made up of a variety of different cell types) they are usually benign but sometimes malignant
• Cystadenomas - develop from cells on surface of ovary, most are benign but some can be malignant
• Endometriomas - can develop if you have endometriosis
• Epithelial
• Mesothelial
• Other rare types

Question 5

Ovarian cysts how are they diagnosed ?

Answer 5

Usually incidental as often no symptoms but you would do abdo and vaginal exam

Then diagnosed with Ultrasound

Question 6

How do follicular cysts arise ?

Answer 6

They arise where ovulation doesnt occur and the follicle doesnt rupture but grows into a cyst

Question 7

What are follicular cysts lined by ?

Answer 7

Granulosa cells

Question 8

What are follicular cysts often associated with ?

Answer 8

Polycystic ovarian syndrome

Perimenopause

Question 9

What is the normal progression of follicular cysts ?

Answer 9

usually resolve over a number of months

Question 10

What is endometriosis and what are the common areas it can be found ?

Answer 10

This is the presence of endometrial glands and stroma outside of the uterus:

• Ovary
• Pouch of Douglas
• Peritoneal surfaces, including uterus
• Cervix, vulva, vagina
• Bladder, bowel etc

Question 11

What are the macroscopic and micoscopic features of ovarian endometriosis ?

Answer 11

Macroscopic:

• Multiple Peritoneal spots or nodules
• Inflammation associated with endometriosis leads to formation of fibrous adhesions - these can then affect fallopian tubes (infertility and predisposes to ectopic pregnancy)
• Chocolate cysts

Microscopic:

• Endometrial glands and stroma
• Haemorrhage, inflammation, fibrosis

Question 12

What are some of the complications of ovarian endometriosis/in general?

Answer 12

• Pain
• Cyst formation
• Adhesions
• Infertility
• Ectopic pregnancy
• Malignancy (endometrioid carcinoma)

Question 13

What condition and classic feature of this condition is shown ?

Answer 13

Ovarian endometriosis and the classic chocolate cyst

Question 14

What are the 3 key features of polycystic ovarian syndrome ?

Answer 14

Is a condition where at least two of the following occur and often all three:

1. At least 12 tiny cysts (follicles) develop in your ovaries.
2. Clinical or biochemical signs of hyperandrogenism (such as hirsutism, acne, or male pattern alopecia), or elevated levels of total or free testosterone.
3. You do not ovulate each month. Some women do not ovulate at all. In PCOS, although the ovaries usually have many follicles, they do not develop fully and so ovulation often does not occur. If you do not ovulate then you may not have a period.

Question 15

What are the features of PCOS ?

Answer 15

• Excess hair growth (hirtiuism) mainly on the face, tummy and chest
• Acne
• Thinning of hair on scalp (male pattern baldness)
• Weight gain
• Depression
• Irregular or light periods, or no periods at all.
• Infertility

Question 16

What diagnostic investigations can you do to clarify a diagnosis of PCOS ?

Answer 16

US to look for polycystic ovaries

Blood tests:

1. To measure LH and FSH levels - LH levels rasied but FSH levels normal (distinguishes from premature ovarian failure)
2. Also measure total testosterone - this may be raised >5

Question 17

Treatment of PCOS

Answer 17

Question 18

What are the 3 distinct cell types ovarian the different types of ovarian tumours arise from ?

Answer 18

1. Epithelial
2. Germ cell
3. Sex‐cord/stromal

Metastases to ovary always need to be considered when delaing with malignant tumour in the ovary

Question 19

What are the different sub-types of epithelial origin ovarian tumours ?

Answer 19

• Serous
• Mucinous
• Endometrioid
• Clear cell
• Brenner
• Undifferentiated carcinoma

Question 20

What is the cell of origin of epithelial type ovarian tumours ?

Answer 20

Unknown

Question 21

How are epithelial ovarian tumours categorised ?

Answer 21

Into benign, boderline or malignant based on histopathological exammination:

Benign:

• No Cytological abnormalities, proliferative activity absent or scant
• No stromal invasion

Borderline:

• Cytological abnormalities, proliferative
• No stromal invasion

Malignant:

• Cytological abnormalities present but always malignant if stromal invasion occurs
• Stromal invasion

Question 22

Macroscopically how may the appearance of epithlial tumours vary ?

Answer 22

They may be smooth walled, cytic lesions or contain a mixture of solid and cystic areas, or just solid areas

Question 23

After being classified into sub-categories previously mentioned, a serous tumour is now classified as a malignant serous carcinoma - how are malignant serous carcinomas further classified ?

Answer 23

into high or low grade

High grade:

• Serous tubal intraepithelial carcinoma (STIC)
• Most cases are essentially tubal in origin

Low grade:

• Serous borderline tumour

Pic shows high grade serous carcinoma