Ovarian disorders Flashcards
what is the most common ovarian mass?
follicular cyst
what is a follicular cyst?
- what happens if it ruptures?
- does it regress?
- best screening test?
- what if it’s symptomatic?
non-neoplastic cyst (accumulation of fluid in a follicle, or previously ruptured follicle)
- rupture produces sterile peritonitis with pain
- most regress spontaneously
- US is best screening test
- surgical removal if symptomatic
what is the most common ovarian mass in pregnancy?
corpus luteum cyst
what is a corpus luteum cyst?
- does it regress?
- what if it’s symptomatic?
non-neoplastic cyst (accumulation of fluid in CL during pregnancy; may be confused with amniotic sact)
- most regress spontaneously
- surgical removal if symptomatic
what is oophoritis?
may be a complication of mumps or PID
epidemiology of stromal hyperthecosis?
occurs primarily in obese postmenopausal women, causing bilateral ovarian enlargement
- hypercellular ovarian stroma (vacuolated/luteinized stromal hilar cells are present to make excess androgens)
- may cause hirutism or virilization
clinical findings of stromal hyperthecosis?
- hirutism or virilization
- association with acanthosis nigricans and insulin resistance (metabolic syndrome)
- HTN
treatment of stromal hyperthecosis
oophorectomy
epidemiology and pathogenesis of ovarian tumors
more likely benign in women <45 yo
- risk increases with age
- median age of presentation is 61 yo, and approx. 60% present with advanced disease
- peaks in late 70s
risk factors for ovarian tumors
- nulliparity (increased number of ovulatory cycles increases risk for surface-derived ovarian tumors)
- genetic factors (mutations of BRCA1/2 suppressor genes, Lynch syndrome, Turner’s syndrome (increased risk for dysgerminoma), Peutz-Jeghers syndrome (increased incidence of sex cord tumors with annular tubules))
- history of breast cancer
- postmenopausal estrogen therapy, obesity (increased estrogen)
what decreases risk of surface-derived ovarian cancers?
OCPs/pregnancy (decreased number of ovulatory cycles)
surface-derived ovarian tumors
- percentage
- derivation
most common group (65-70% of ovarian tumors)
- derive from coelomic epithelium
- account for greatest number of malignant ovarian tumors, which commonly seed omentum
germ cell ovarian tumors
- how many are malignant?
- common benign and malignant types
account for 15-20% of ovarian tumors
- cancers similar to testicular cancer
- small number of tumors are malignant
- teratoma and dysgerminoma are most common benign and malignant, respectively
serous cystadenocarcinoma
most common ovarian cancer (surface-derived, serous tumor)
- benign, with psammoma bodies (dystrophically calcified tumor cells)
- most common malignant tumor that is bilateral
what do malignant surface-derived cancers commonly seed?
abdominal cavity
sex cord stromal tumors
- percentage
- derivation
- benign or malignatn?
3-5% of ovarian tumors
- derive from stromal cells
- may be hormone producing
- majority of tumors are benign
metastisized ovarian tumors?
5% of ovarian tumors
-common primary cancers metastasize to ovaries (breast, stomach)
clinical findings of ovarian tumors (6)
- abdominal enlargement due to fluid (most common sign)
- malignant ascites most often due to seeding (induration of rectal pouch on digital rectal exam, and intestinal obstruction with colicky pain) - palpable ovarian mass in postmenopausal women (should NOT be palpable; cancer until proven otherwise)
- malignant pleural effusion (common site for ovarian cancer metastasis)
- cystic teratomas undergo torsion leading to infarction (radiographs show calcification from bone/teeth)
- signs of hyperestrinism from estrogen-secreting tumors (bleeding from endometrial hyperplasia/cancer, 100% superficial squamous cells in cervical Pap smear)
- Hirsutism or virilization from androgen-secreting tumors
ovarian tumor markers
increased serum cancer antigen 125
-only increased in surface-derived malignant tumors
treatment for ovarian cancer
surgery, chemotherapy, sometimes radiation
ovarian tumor prognosis
better if <65 yo
-overall 1 and 5 year relative survival rates are 75% and 45%
4 types of surface derived (serosal epithelium) tumors and if benign/malignant
- serous tumors (benign cystaderoma to malignant adenocarcinoma)
- mucinous tumors (benign cystaderoma to malignant adenocarcinoma)
- endometrioid (malignant)
- Brenner tumor (benign)
3 types of germ cell tumors and if benign/malignant
- cystic teratoma (benign)
- dysgerminoma (malignant)
- yolk sac tumor (malignant)
4 types of sex-cord stromal tumors and if benign/malignant
- thecoma-fibroma (benign)
- granulosa-theca cell tumor (malignant)
- Sertoli-Leydig cell (malignant)
- gonadoblastoma
what is a Krukenberg tumor?
a tumor metastatic to ovary
- may affect both ovaries
- contains signet-ring cells from hematogenous spread of a gastric cancer
serous tumors characteristics
-most common type?
surface derived tumors
- most common group of primary benign and malignant tumors
- most common group of tumors that can be bilateral
- cysts are lined by ciliated cells (similar to fallopian tube)
- serous cystadenoma(carcinoma) is most common benign
mucinous tumors characteristics
surface derived tumors
- cysts lined by mucus-secreting cells (similar to endocervix)
- large, multiloculated tumors
- seeding produces pseudomyxoma peritonei
- mucinous cystadenoma (benign) may be associated with Brenner tumors
- -mucinous cystadenocarcinoma
Brenner tumor characteristics
surface derived tumors
- usually benign
- contain Walthard rests (transitional-like epithelium)
endometrioid tumor
surface derived tumors
- malignant tumors associated with endometrial carcinoma (15-30% of cases)
- tumor resembles endometrial carcinoma
- commonly bilateral
cystic teratoma characteristic
most common benign germ cell tumor; less than 1% become malignant (usually squamous cancer)
- ectodermal differentiation (hair, sebaceous glands, teeth) most prominent
- most found in nipple-like structure in cyst wall (Rokitansky tubercle)
- immature malignant types contain mature and immature components (muscle, neuroepithelium)
- struma ovarii type has functioning thyroid tissue
dysgerminoma characteristics
most common malignant germ cell tumor; characteristic increase in serum LDH
- same histologic picture as seminoma of testis
- associated with streak gonads of Turner syndrome
yolk sac tumor characteristics
germ cell tumor
- malignant
- most common ovarian cancer in girls < 4 yo
- contains Schiller-Duval bodies (resemble yolk sac)
- increased a-FP
thecoma-fibroma characteristics
sex-cord stromal tumor
- benign and associated with Meigs’ syndrome (ascites, right-sided pleural effusion)
- -regression of effusions follows removal of tumor
- commonly calcify
granulosa-theca cell tumor characteristics
sex-cord stromal tumor
- low-grade malignant tumor
- feminizing (estrogen-secreting) tumor that contains Call-Exner bodies
Sertoli-Leydig cell tumor characteristics
sex-cord stromal tumor
- benign masculinizing (androgen-producing) tumor
- pure Leydig cell tumors contain cells with crystals of Reinke
gonadoblastoma characteristics
sex-cord stromal tumor
- malignant tumor with mixture of germ cell tumor (dysgerminoma) and sex-cord stromal tumor
- associated with abnormal sexual development in 80% of cases
- commonly calcify
causes of vaginal bleeding in adolescent (common to rare)
- anovulation
- pregnancy
- exogenous hormone use
- coagulopathy
causes of vaginal bleeding in reproductive age (common to rare)
- pregnancy
- anovulation
- exogenous hormone use
- uterine leiomyomas
- cervical and endometrial polyps
- thyroid dysfunction
causes of vaginal bleeding in perimenopausal (common to rare)
- anovulation
- uterine leiomyomas
- cervical and endometrial polyps
- thyroid dysfunction
causes of vaginal bleeding in postmenopausal (common to rare)
- endometrial lesions (including cancer)
- exogenous hormone use
- atrophic vaginitis
- other tumor (vulvar, vaginal, cervical)
what are the markers CA-125, alpha-FP, beta-hCG, and inhibin usually associated with?
CA-125: serous cystadenoma (usually benign)
aFP: yolk sac tumor (malignant)
BhCG: choriocarcinoma (malignant)
inhibin: granulosa cell tumor
what mutations are usually seen in low-grade serous carcinomas?
mutually exclusive genetic abnormalities affecting MAPK pathway in 80% of cases
- HER2 amplification
- KRAS mutations
- BRAF mutations
differences between type I and II serous ovarian cancers
- progression
- grade
- Ras, BRCA, and TP53 status
- Xm
- platinum effect
I
- progress from LMP
- usually low grade
- Ras pathway frequently mutated
- BRCA wild type
- generally TP53 wild type
- Xmally stable
- frequently platinum insensitive
II
- de novo invasive tumors
- high grade
- Ras wild type
- BRCA dysfunction
- TP53 mutant
- widespread DNA copy number change
- usually platinum sensitive
what is the T/N/M staging method for tumors?
T: size or direct extent of the primary tumor
-Tx: tumor cannot be evaluated
-Tis: carcinoma in situ
-T0: no signs of tumor
-T1, T2, T3, T4: size and/or extension of the primary tumor
N: degree of spread to regional lymph nodes
-Nx: lymph nodes cannot be evaluated
-N0: tumor cells absent from regional lymph nodes
-N1: regional lymph node metastasis present; (at some sites: tumor spread to closest or small number of regional lymph nodes)
-N2: tumor spread to an extent between N1 and N3 (N2 is not used at all sites)
-N3: tumor spread to more distant or numerous regional lymph nodes (N3 is not used at all sites)
M: presence of distant metastasis
-M0: no distant metastasis
-M1: metastasis to distant organs (beyond regional lymph nodes)[3]
between the grades and the stages (if only 1 ovary affected), what’s the risk for ovarian cancer?
low risk: grade 1, stage 1A
intermediate: grade 1,, stage 1BC; grade 2, stage 1A
high: grade 2, stage 1BC; grade 3, stage 1ABC
when is adjuvant chemotherapy most effective?
improves survival in high risk early stage ovarian cancer
