Ovarian Pathology Flashcards
peak age of ovarian cancer?
75
are there precursor lesions in ovarian cancer?
no
most common type of primary ovarian tumour?
epithelial (arise from surface epithelium)
what is the main risk factor for ovarian cancer?
the number of times the woman ovulates
therefore COCP, several pregnancies and breastfeeding reduces risk
genetic predisposition to ovarian cancer?
1 first degree relative under 50 = 5% risk
2 first degree relatives under 50 = 25% risk
HNPCC (lynch syndrome)
BRCA1 and BRCA2 = 10-50% risk
how is BRCA risk managed?
women with these genes should attend regular screening and may be offered bilateral oophrectomy once their family is complete
what are the 4 categories of ovarian tumour?
epithelial
sex-cord/stromal tumours
germ cell tumours
metastatic tumours
5 types of epithelial ovarian tumour?
endometrioid mucinous serous (most common ovarian cancer) clear cell brenner
two types of serous tumour with precursor lesions?
high grade serous carcinoma (precursor = serous tubal intra-epithelial carcinoma (STIC))
low grade serous carcinoma (precursor = serous borderline tumour)
can serous tumour be benign?
yes
serous cystadenomas
make up 20% of benign ovarian tumours
which epithelial ovarian tumours are associated with lynch syndrome?
endometrioid
clear cell
which epithelial ovarian tumour is associated with endometrial cancere?
endometrioid
histologically similar to endometrioid cancer
30% of women will also have a co-existent primary endometrial cancer
which epithelial ovarian cancer is associated with ovarian endometriosis?
clear cell
what is brenner tumour?
type of epithelial ovarian tumour
AKA urothelial like
tumour of transitional type epithelium
3 types of sex cord/stromal tumour?
granulosa cell
thecoma/fibroma
sertoli/leydig cell
describe granulosa cell tumours?
low grade but all are potentially malignant
75% secrete hormones (oestrogen)
contain cells with coffee bean nuclei and gland like spaces called call-exner bodies
symptoms of granulosa cell tumours?
precocious pseudopuberty
abnormal menstrual bleeding
post-menopausal bleeding
(all due to oestrogen secretion)
describe thecoma/fibroma?
usually benign
contain variety of cells such as theca cells or fibroblastic-type cells
symptoms of thecoma/fibroma?
may produce oestrogen causing uterine bleeding
can cause meigs syndrome (ascites and pleural effusion)
how is meigs syndrome managed?
removal of tumour
describe sertoli/leydig tumour?
rarest type
occur in young women (20s)
usually unilateral
usually non-functional but can be androgenic
stroma-derived fibroblasts may be seen if tumour contains leydig cells
4 types of germ cell tumour?
teratoma
dysgerminoma
endodermal sinus/yolk sac tumour
choriocarcinoma
who usually gets germ cell tumours?
20-25% of all ovarian neoplasms
usually affects children/young women
describe teratoma?
common
usually benign
contain elements from all 3 germ layers
what is a mature teratoma?
type of teratoma which may contain hair, teeth, epithelium, sebum etc
AKA dermoid cyst
95% of all germ cell tumours
(immature teratomas are rare)
most common malignant germ cell tumour?
dysgerminoma
what is dysgerminoma associated with?
gonadoblastoma in gonadal dysgenesis
increased HCG level
how does yolk sac tumour usually present?
sudden pelvic mass
20% of woman also have a teratoma
tumour markers in yolk sac tumour?
raised AFP
HCG usually normal
what does choriocarcinoma secrete?
HCG
therefore may present with precocious pseudopuberty
prognosis of choriocarcinoma?
poor prognosis
doesnt respond to chemo
what cancers often metastasise to ovary?
endometrium
breast
pancreas
GI
how do ovarian cancers spread?
trans-coelomically
can seed into peritoneal cavity
para-aortic lymph nodes
death results from intestinal blockage and cachexia
how might ovarian cancer present?
usually present late with non-specific symptoms
only have GI symptoms in late stage
often have abdominal distension (due to ascites or mass itself)
what is RMI?
risk of malignancy index
tool used to separate benign and malignant lesions
how is RMI calculated?
RMI = US X menopausal score X CA125
what is done if RMI is high?
CT/MRI is performed
US better for imaging cysts, CT/MRI done for malignant masses
suspicious US findings on ovarian mass?
complex mass with solid + cystic area multi-loculated thick septations associated ascites bilateral disease
how is CA125 used in ovarian cancer?
sensitive but not that specific
raised in 80% of ovarian cancers
but also raised in other things to its a better indicator of disease progression at follow up than for diagnosis
what else can cause raised CA125?
endometriosis peritonitis pregnancy pancreatitis ascites other malignancies
what other tumour markers are used in ovarian cancers?
CEA may be raised in ovarian cancer (esp in mucinous), mainly used to exclude mets from a GI primary cancer
65% of germ cell tumours produce HCG and AFP so these can be used to indicate response to treatment
how is ovarian cancer staged?
FIGO system
1A = tumour limited to one ovary
1B = tumour limited to both ovaries
1C = cancer involving ovarian surface/rupture/surgical spill/tumour in washings
2A = extension or implants on uterus/fallopian tubes
2B = extension to other pelvic intraperitoneal
3A = retroperitoneal lymph node metastasis or microscopic extrapelvic peritoneal involvement
3B = macroscopic peritoneal metastasis beyond pelvis up to 2cm in dimension
3C = macroscopic peritoneal metastasis >2cm in dimension
4 = distant metastasis
how are benign ovarian tumours managed?
excision or drainage
often cant distinguish between benign and malignant so diagnosis occurs after surgery
how are epithelial ovarian tumours managed?
usually surgery + chemo - surgery = debulking - chemo = usually adjuvant to surgery chemotherapy can be used as first line therapy if unfit for surgery chemo treatment of choice in relapse
how are non-epithelial ovarian tumours managed?
fertility preservation important as these often occur in younger women
many are sensitive to chemo
limited surgery and chemotherapy can produce good results in many cases
mean survival in ovarian cancer?
5 year survival is 40%
germ cell survival is better at 75%
