Ovarian Pathology Flashcards
Luteal Cyst
- > 3cm
- reproductive age
- thick hemorrhagic fluid
- hormone producing
- interspersed peripheral theca cells
Follicular cyst
- Prepubescent and reproductive age
- Contain serosanguinous fluid
- Thin smooth lining of inner granular and outer theca cells
Presence of “ectopic” endometrial tissue at a site
outside of the uterus
• Repeated cyclical hemorrhage during menstrual cycle- “chocolate” color
• Consist of normal looking endometrial glands + stroma + RBC + hemosiderin
• Induce fibrosis, adhesions, pain
• May extend along pelvic ligaments
• Usually associated with infertility
Chocolate cyst
Polycystic Ovarian Syndrome Pathogenesis
Caused by genetics, sedentary lifestyle, obesity
Insulin resistance—> hyperinsulinemia—> increased androgens (prolonged high estrogen levels)—> no LH surge; no ovulation—> no corpus luteum; low progesterone—> unopposed excess estrogen —> inhibits FSH—> increased LH:FSH ratio
Symptoms of PCOS
Hirsutism, acne, infertility and endometrial hyperplasia
Menstrual irregularities
Polycystic ovaries (string of pearls)
Cysts lined by granulosa cells and hypertrophied theca interna cells
PCOS
Type I epithelial ovarian tumors
progress from benign tumors through borderline tumors that may give rise to a low-grade carcinoma.
• These include low-grade serous, endometrioid, and mucinous carcinomas
• Genes involved: KRAS, BRAF
Type II epithelial ovarian tumors
- They demonstrate high-grade features and are most commonly of serous histology.
- STIC: Serous tubal intraepithelial carcinoma—> areas of marked epithelial atypia in fallopian tube epithelium: observed in fallopian tubes of women with germline BRCA1/2 mutations undergoing prophylactic salpingo-opherectomy
- Genes involved: p53, Rb
Serous ovarian tumors
• Benign and borderline tumors
• Serous carcinomas occur later in life
• Papillae: dystrophic calcification at tips —> Psammoma bodies
What are the risk factors
- Women aged 40-59 years on oral contraceptives or tubal ligation: decreased risk
- Germline mutations in BRCA1 and BRCA2
SEROUS CYSTADENOMA
Borderline serous tumor
Serous cyst adenocarcinoma
- KRAS gene mutation
- Very large bulky masses
- Multiloculated (M: Mucinous, M: multiloculated) tumors filled with sticky, gelatinous fluid rich in glycoproteins
- Tall columnar cells with apical mucus vacuole, no cilia
- Pseudomyxoma peritonei can be seen
Mucinous Ovarian Tumors
• Mucinous ascites (jelly belly)
• Cystic epithelial implants on the peritoneal surfaces, adhesions, and frequent involvement of the ovaries
• If extensive, may result in intestinal obstruction and death
• Most cases extraovarian (usually appendiceal) with secondary ovarian and
peritoneal spread
PSEUDOMYXOMA PERITONEI
- Coexists with endometriosis & endometrial carcinoma
- Genes involved: PTEN, microsatellite instability (MSI due to mismatch repair genes), KRAS
- malignant
- cystic and solid areas
- Microscopy: presence of tubular glands resembling benign or malignant endometrium
ENDOMETRIOID TUMORS
occur in association with endometriosis or endometrioid carcinoma of the ovary + resemble clear cell carcinoma of the endometrium
Genes involved: KRAS, PTEN, p53
Microscopy: sheets of large epithelial cells with abundant clear cytoplasm
CLEAR CELL TUMORS
Brenner tumors
Neoplastic epithelial cells resembling urothelium
• Gross: firm, solid and yellowish
• Microscopy: fibrous stroma (resembling that of the normal ovary) with sharply demarcated nests of epithelial cells (resembling the epithelium of the urinary tract)
TRANSITIONAL CELL TUMORS
Dermoid cysts
Lined by skin
Young women
Gross: Unilocular cyst containing hair and sebaceous materials
Mature Teratoma (benign)
Prepubertal and young adults (~18 yrs.)
Contain tissues that resemble embryonal and primitive fetal tissue
Gross: more solid
Micro: immature neuroepithelium, cartilage, bone, muscle, and other elements
Immature (malignant) teratoma
- Single dominant differentiation like thyroid, neuroendocrine cells etc
- Thyroid tissue- “Struma ovarii”- hyperthyroidism
- Neuroendocrine- “Carcinoids”- carcinoid syndrome
Monodermal teratoma
Presence of Alpha-fetoprotein and alpha 1 antitrypsin
Glomerulus-like structure composed of a central blood vessel enveloped by tumor cells within a space that is also lined by tumor cells—> Schiller-Duval body (*)
In young women and children
Presenting with abdominal pain and a rapidly growing pelvic mass
Yolk Sac Tumor
Malignant
• Genes involved: c-kit
• Serum tumor marker: Lactate dehydrogenase (LDH), human chorionic gonadotropin (hCG) (if syncytiotrophoblasts also present)
• Gross: unilateral, solid, fleshy, yellow-white to grey-pink, homogenous
• Microscopy: large vesicular cells in sheets with clear cytoplasm, well defined cell boundaries, and centrally placed regular nuclei; scant fibrous stroma rich in
infiltrating lymphocytes
• Very responsive to chemotherapy
Dysgerminoma
Can be gestational (arising in placenta) or non gestational (arising in ovary)
Aggressive —> usually metastasized hematogenously to the lungs, liver, bone, and other sites by the time of diagnosis
High levels of chorionic gonadotropins
Generally unresponsive to chemotherapy and are often fatal
Choriocarcinoma
Composed of cells that resemble granulosa cells of a developing ovarian follicle
Large amounts of estrogen
• In prepubertal patients: precocious sexual development
• In adult women: proliferative breast disease, endometrial hyperplasia, and endometrial carcinoma
• Gross: usually unilateral, hormonally active have a yellow coloration to their cut surfaces
• Microscopically: small, distinctive, glandlike structures filled with an acidophilic material recall immature follicles (Call-Exner bodies)
• Serum tumor marker: inhibin**
Granulosa Cell Tumors
Arising in the ovarian stroma that are composed of either fibroblasts (fibromas) or plump spindle cells with lipid droplets (thecomas)
• Gross: usually solid, spherical, encapsulated, hard, grey-white masses covered by glistening, intact ovarian serosa
• Microscopy: composed of well-differentiated fibroblasts and scant interspersed collagenous stroma
Hormonally inactive
Fibroma
Two curious associations:
- Ovarian tumor + hydrothorax + ascites =Meigs syndrome
- With basal cell nevus syndrome
masculinization or defeminization
atrophy of the breasts, amenorrhea, sterility, and loss of hair
May progress to striking virilization (hirsutism) —> male hair distribution, hypertrophy of the clitoris, and voice changes.
Sertoli-Leydig Cell Tumors
Metastatic/ Secondaries
• Most common metastatic tumors of the ovary are derived from tumors of müllerian origin: the uterus, fallopian tube, contralateral ovary, or pelvic peritoneum
• Most common extra-müllerian tumors metastatic to the ovary: carcinomas of the breast and gastrointestinal tract, including colon, stomach, biliary tract, and pancreas.
• Also included in this group are rare cases of pseudomyxoma peritonei, derived from appendiceal tumors
• Classic metastatic gastrointestinal carcinoma involving the ovaries is termed
**Krukenberg tumor—> characterized by bilateral metastases composed of mucin producing cancer cells with a “signet-ring” appearance, most often of gastric origin
