Ovary pathology Flashcards
1
Q
General facts about ovarian tumors
A
- Ovarian cancers less common than those of uterus and breast but produce more deaths because of late detection
- 4th most common cancer after lung, breast and colon
- In general, pregnancy and oral contraceptives reduce the risk of ovarian cancer
2
Q
Pathologic lesions of ovary
A
Cysts
- Follicular
- Corpus Luteaum (C.L)
- Chocolate
- PCOD
Tumors
- Metastasis
- Epithelial
- Stromal
- Germ cell Cystic
- Solid
3
Q
A
Cysts of the ovary aka Simple cysts:
- solid cysts
- Usually < 1.5cms, sometimes large (4 to 5 cm)
- Lining may atrophy due to pressure
- follicular cyst: failure of follicle to rupture during ovulation-> dilation; lined by layers of cuboidal granulosa rimmed by ovarian tissue
- corpus luteal cyst: hemorrhagic from corpus luteum (yellow; image below; Pathoma)
- chocolate cysts: RBC w hemosiderin due to endometriosis;
- Induce fibrosis, adhesions, pain
- Consist of normal looking endometrial glands + stroma + RBC + hemosiderin
- May extend along pelvic ligaments
- Need to be distinguished from corpus luteum cysts
- Usually associated with infertility
- assoc w infertility
Etiopath:
- functional cyst: hormonal secreting
- non-functional: no secretion; chocolate cyst
Sx:
- asx & benign (usually)
- endometrial hyperplasia
- pain
Investigations
- US & CT
4
Q
A
PCOD
- cysts more towards outside
- Ovaries are 2x larger
- Ovaries - large, thick capsule, multiple unruptured follicles as cysts- lined by granulosa cells and hypertrophied theca interna cells
- Thick, hypertrophied stroma
- Persistent anovulation, no CL
- enlarged ovaries w thick capsule and hypertrophied stroma
- Multiple unruptured follicles as cysts (lined by granulosa cells and hypertrophied theca interna cells)
Etiopath:
- Young women, post menarche, persistant anovulation
- Oligomenorrhea, secondary amenorrhea, hirsutism, obesity (40%), infertility
- ↑ androgen (hirsuitism 50%, rarely virulization)
- High levels of LH
- Low levels of FSH
- Hyperinsulinemia due to peripheral resistance to insulin
- Excess androgens secreted by ovary and adrenals (?under the influence of abnormal pituitary axis)
- Androgens converted in to estrogen by adipose tissue
- Excess estrogens inhibit release of FSH by pituitary and stimulate the release of GnRH by hypothalamus
- GnRH acts on pituitary to release LH
- LH elevated, FSH levels fall, LH:FSH ratio
- elevated (greater than 3)
- Persistently elevated LH stimulates theca cells in ovary to produce excess androgens
- Cycle continues unabated
Hormonal effects & sx
Excess estrogen–
– endometrial hyperplasia
– stimulates adipose cells in body-obesity
Excess androgens–
– hirsutism, virilization, obesity
– androgens processed through adipose tissue and liver excess leading to estrogens
Dx
- hormonal assay, transvaginal ultrasound
Rx: chlomiphene - induce ovulation
- *C&C**
- endometrial carcinoma due to incr estrogen levels
- diabetes, hypertension, dyslipidemia, cardiovascular diseases, non-alcoholic fatty liver disease
5
Q
Tumors of the Ovary
A
- 4th commonest cause of cancer in women, 6% of all cancer in women
- 80% benign (20-45 years), 20% malign (40-65 years)), often bilateral more in nulliparous, family history, oral contraceptives reduce risk
- Problem is late detection,
- Rarely functional
- Marker: CA 125 useful for:
- useful in screening asymptomatic postmenopausal women for ovarian malignancy
- Greater value in monitoring response to therapy
6
Q
Ovarian tumour gross features
A
- Cystic - generally benign
- Benign: Solid - homogenous, cystic, unilocular, no papillae, smooth
- Malignant: Solid variegated - , solid, multilocular, nodular,papillae
- Spread:
- Peritoneum - ascites, omental pancakes
- LN - iliac, paraaortic
- Blood - lungs
7
Q
Surface epithelial tumors
A
Classification based on differentiation
- Serous: Towards fallopian tube - columnar cells with cilia -
- Mucinous: Towards endocervix - tall mucin secreting cell -
- Endometrioid: Towards endometrium - nonciliated - columnar cell
- Brenner’s tumor: Towards transitional epithileum - transitional cells
Pathoma Note: surface epithelium of ovary aka coelomic epithelium
Sx
- Similar clinical features in most
- Abdominal pain, swelling, tumor mass or compression
- Gastro intestinal symptoms, dysuria, increased frequency urine, pelvic pressure
- Resection of benign tumors leads to cure
C&C
- Malignant: progressive weakness, weight loss, cachexia
- Seedling into peritoneum - massive ascites
- Tumor implants grow on the surface of other structures (not invade)
- Regional lymph nodes can be involved
- Metastasis to liver, lung, GIT, 50% to opposite ovary
8
Q
Serous cystadenomas, borderline, cystadenocarcinoma
A
Gross
- Lined by single layer of tall columnar ciliated cells
- Cysts filled with serous fluid
- uniloculated typically
- unilateral typically
- Benign - 20-50 years, over 50 years - malignant
- 20% of benign are bilateral, 2/3 of malignant are bilateral
- 10-15 cm diameter, lining smooth and glistening
Microscopic
- Papillae and polyps are seen in benign but are more numerous in malignant
- Psammoma bodies are seen in both benign and malignant
- Solid nodules indicate serosal penetration and hence are evidence of malignancy
- Serous tumors can reach very large sizes and may fill the abdomen
- recognize malignancy by solid nodules, more papillae and more polyps
- Borderline: multi layering, moderate mitosis, nuclear atypia BUT no stromal invasion
- Malignant: multi layering, nuclear atypia and Stromal invasion
- 10 year survival - borderline - 75% malignant - 10-20%
- Variant - cystadenofibroma - abundant fibrous tissue under epithelium, usually benign
Etiopath:
- Nulliparity, family history, and heritable mutations may play a role
- BRCA1 and p53
9
Q
A
Mucinous tumors
- Multiloculated cyst w septa in bw, sticky gelatinous material rich in glycoproteins
- Papillae, polyps and psammoma bodies are not a feature of mucinous tumors
- Benign tumors tend to have few locules
- Look for multiloculation and solid nodules to suspect malignancy
- commonly unilateral
Microscopic
- tall columnar & non-ciliated
- Malignant: atypia, BM invasion, invasion into stroma (all stroma on figure), stroma producing mucin
Etiopath:
- K-RAS & smoking
C&C
- small percentage complicated by pseudomyxoma pertionei (next card)
- Occasionally mixed with dermoid cyst or Brenner’s tumor
- 10 year survival - 70% for Borderline and 35% for carcinoma-so it is better than that of serous carcinomas
10
Q
Pseudomyxoma peritonei
A
- 2 - 5% of borderline and malignant mucinous tumors complicated by Pseudomyxoma peritonei
- Peritoneal cavity filled with mucoid material, matted tumor implants all over the abdomen on serosal surfaces -> “Jelly Belly”
- (It is also a complication of mucocele of the appendix due to carcinoma of appendix).
- Can also be a complication of mucocele of the appendix
- Mucocele of appendix can be caused by either carcinoma or a fecolith blocking the lumen
- Only the mucocele due to carcinoma can lead to pseudomyxoma peritonei
11
Q
Endometroid tumours
A
- Mostly behave as carcinomas
- 20%ofallovariancarcinomas,15-30% associated with concomitant endometrial carcinoma (not metastasis)
- Gross: solid and cystic, small, papillae, velvety surface
- Micro: resemble endometrial carcinoma - not normal endometrium (as seen in endometriosis)
- 40% bilateral, 5 year survival 4-50%
- Variant - clear cell carcinoma
12
Q
A
Brenner’s tumour
Gross
- solid mass, unilateral, pale yellow
- dense fibrous tissue
Microscopic
- nodules of epithelium not resembling that ovary called “nest cells”
- coffee bean shaped nuclei indicating transitional epithelial cells
- dense stroma w cells inside
- Transitional epithelial cells - like urinary bladder(may come from urogenital remnants)
- Plus - dense fibrous tissue • Small multiple nodules (not
- cysts)
- Clinically silent
- Usually benign - Occasionally malignant
C&C
- infertility
13
Q
Germ cell tumours
A
- 95% are benign cystic teratomas
- 5% - in children and young adults - malignant
- Teratoma,dysgerminoma,endodermal sinus tumor and choriocarcinoma (nongestational)
14
Q
A
Mature teratoma aka dermoid cyst
- Young women in active reproductive years
- Skin, adnexa, sebaceous - cheesy material
- hair, teeth, bone cartilage, thyroid, etc
- predominant ectodermal differentiation
- 90% unilateral,10% bilateral mostly right sided
- Usually associated with sterility reason not clear
- Unilocular, wrinkled opaque epidermal lining
- 1% malignant - squamous cell carcinoma
C&C
- infertility
- torsion
- 1% malignant transformation -> squamous cell carcinoma
- presence of neuroepithelial cells indicates malignancy
- Rapid growth
- May be mixed with chorio carcinoma, endodermal sinus tumor, embryonal carcinoma
15
Q
Immature teratoma (Malignant teratoma)
A
Wide variety of embryonic immature tissue
Usually seen in young women (18 years)
Bulky, solid, hemorrhage, necrosis
Micro:
- immature cartilage, glands, bone, muscle, nerves, etc
- Presence of neuroepithelium/neuroectoderm generally suggests malignancy
- Rapid growth
- May be mixed with chorio carcinoma, endodermal sinus tumor, embryonal carcinoma
16
Q
A
Monodermal or specialised teratomas
- Struma ovarii: hyperthyroidism
- Carcinoid tumor: carcinoid syndrome
- Strumal carcinoid: combined
Etiopath: unknown
C&C: malignancy (rare)
17
Q
Endodermal sinus tumor (Yolk sac tumor)
A
- Children and young women
- Malignant behavior
- serum AFP elevated and alpha I antitrypsin
- Cystic spaces, papillary projections
-
Schiller Duval bodies:
- layers of epithelial cells around blood vessels
- resemble glomeruli
- Cytoplasmic pink inclusion:
18
Q
A
Dysgerminoma
Gross
- no necrosis or hemorrhage; characteristic of dysgerminoma, seminoma, medullary carcinoma
Microscopic
- large cell
- clear cytoplasm
- large nucleus w prominent nucleolous
- Unilateral solid tumor
- Homogenous gray-pink, soft fleshy tumor
- Large uniform round cells, clear cytoplasm, central regular nuclei, no stroma
- Infiltration by lymphocytes
- 2% of all ovarian cancers, 75% in II and III decades
- Similar in appearance to seminoma testis and medullary carcinoma breast
Dx: elevated LDH (Pathoma)
19
Q
A
Ovarian choriocarcinoma
- multinucleated giant cells
- synctial trophoblasts -> surrounding and takes over villi (no villi) -> produce HCG
- cytotrophoblasts
- high mitotic activity
- presence of hemorrhage
- resembles normal placental tissue
- *Etiology**
- not monoclonal
- nongestational refers to without pregnancy
- gestational related to pregnancies and moles
- quick metastasis
- *Investigations:**
- high HCG in blood and urine (higher than pregnancy) -> nausea, vomiting, vaginal bleed
- alpha-HCG similar to TSH
- *Clinical presentation:**
- nausea, vomiting, vaginal bleed
Dx
- Raised chorionic gonadotrophin (CGT syn to HCG) in blood and urine
C&C
- Highly fatal; More malignant than uterine choriocarcinoma
- Similar to placental choriocarcinoma
- Early and widespread metastasis
- Hemorrhage, necrosis, pleomorphism, giant cells, multi nucleation
- resistant to therapy
- primary may regress leaving only secondaries
21
Q
A
Granulosa theca cell tumors (GTCT)
- sex cord tumour
- proliferation of G & T cells
- Rosette around Call-Exner bodies (eosinophilic filled w fluid from Granulosa cells) but may not be present in all GTCT
- variegated cells
- GRANULOSA + THECA with or without leutinisation, Call-Exner bodies
- Estrogen - precocious puberty, endometrial hyperplasia, carcinoma
- 5-25% of granulosa cell tumors can be malignant NOT theca cell tumors
- 2/3rd are postmenopausal
Etiology:
- 2/3 postmenopausal
Sx (Pathoma): varies w age
- heavy menstrual bleeding
- post-menopausal bleeding
Investigations:
- inhibin secreted by Granulosa cells
22
Q
A
Fibrothecoma
- Large polygonal cells and spindle cells resembling fibrocytes (bottom layer right image) and thecal cells (top layer right image)
- Lipid droplets
- Similar in appearance to thecomas
- Curious association with ascites (40%) and pleural effusion/hydrothorax on right side (Meig’s syndrome)
- Occasionally associated with basal cell nevus syndrome
25
Q
A
KRUKENBERG TUMOURS
Gross: solid, shiny tumours
Microscopic
- signet ring cells
- mucin stained w PAS
Etiopath:
- most common in young women
- most likely seeding from ab cavity; can be hematogenous
