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Ovarian Cysts and Tumors

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Ovaries

The most important medical problems in ovaries are the neoplasms

Death from ovarian cancers is more than that of cervix and uterus together

Silent growth of ovarian tumors is the rule ,which make them so dangerous

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Ovarian Cysts and Tumors Non neoplastic cysts are common

but they are not serious problems Primary inflammation of ovaries is

rare Salpingitis of fallopian tubes

frequently causes periovarian reaction (salpingo-Oophoritis)

Frequently ,the ovaries affected by endometriosis.

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Non-Neoplastic and Functional Cysts of ovary Non Neoplastic Cyst are more common

than the neoplastic ones Follicular and Luteal cysts are most

probably physiologic Follicular cyst is due to distension of

unruptured graafian follicle Corpus luteum cyst results from

hemorrhage into a persistent mature corpus luteum.

Theca lutein cyst is lined by luteinized theca cells and results from gonadotrophin stimulation.

Chocolate cyst is a blood containing cyst resulting from endometriosis with hemorrhage. The ovary is the most frequent site of endometriosis

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Polycystic OvariesStein-Leventhal Syndrome

Young women ,and usually in girls after menarche.

-Oligomenorrhea-hirsutism-infertility-Obesity

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Polycystic OvariesStein-Leventhal Syndrome

Secondary to excessive production of estrogens and androgens, mainly androgens

The ovaries are usually twice normal in size ,gray-white with smooth outer surface

Studded with sub cortical cysts 0.5 to 1.5 cm in diameter.

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Polycystic OvariesStein-Leventhal Syndrome

Histologically ,thickened fibrosed outer tunica

Multiple cysts lined by granulosa cells

Absence of corpora lutea Cortical stromal fibrosis High level of LH and low FSH

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Figure 22-36 Polycystic ovarian disease and cortical stromal hyperplasia. A, The ovarian cortex reveals numerous clear cysts. B, Sectioning of the cortex reveals several subcortical cystic follicles. C, Cystic follicles seen in a low-power microphotograph. D, Cortical stromal hyperplasia manifests as diffuse stromal proliferation with

symmetrical enlargement of the ovary.

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Figure 22-36 Polycystic ovarian disease and cortical stromal hyperplasia. A, The ovarian cortex reveals numerous clear cysts. B, Sectioning of the cortex reveals several subcortical cystic follicles. C, Cystic follicles seen in a low-power microphotograph. D, Cortical stromal hyperplasia manifests as diffuse stromal proliferation with

symmetrical enlargement of the ovary.

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Ovarian Tumors

Fifth most common cancer in the USA

Fifth leading cause of cancer death in women

Diversity of pathologic entities because of the three cell types make up the normal ovary

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Ovarian Tumors classification

Primary tumor, three cell types : 1- the surface epithelium tumors2- Germ cells tumors3- Stromal /sex cord cells tumors Secondary or metastatic tumors

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Figure 22-37 Derivation of various ovarian neoplasms and some data on their frequency and age distribution.

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Classification of Ovarian Tumors, Surface Epithelial Tumors :-Serous Tumors : Benign ,Borderline,And

malignant-Mucinous T. : Benign ,Borderline , and

malignant-Endometrioid T. : Benign, Borderline, and

malignant-Transitional cell T. :Brenner tumors, Benign ,Borderline ,and

malignant-Undifferentiated Carcinoma

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Classification of Ovarian Tumors, Sex Cord-Stromal tumors

- -Granulosa Cell tuomr- -Thecoma –Fibroma- -Sertoli-Leydig cell tumor- -Gynandroblastoma- -Unclassified

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Classification of Ovarian Tumors, Germ Cell Tumors

- -Dysgerminoma- -Yolk Sac Tumor- -Embryonal Carcinoma- -Choriocarcinoma- -Teratoma : Mature, Immature- -Polyembryoma

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Ovarian TumorsSurface Epithelium Origin

Neoplasms of surface epithelium account for the great majority of all primary ovarian tumors.

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Ovarian Tumors ,Surface Epithelium Origin

65 – 70 % of overall tumors 90 % of malignant tumors Age 20+ Traditionally divided into

Benign ,Malignant ,and Borderline in malignancy

Can be strictly epithelial (serous ,Mucinous)

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Ovarian Tumors ,Surface Epithelium Origin

Can have stromal component (Cystadenofibroma ,

Brenner tumor )

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Ovarian Tumors ,Surface Epithelium Origin

The intermediate ,or the borderline tumors are referred as tumors of low malignant potential

These appear to be low grade cancers with limited invasive potential

They have better prognosis

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Serous Tumors

The most frequent ovarian tumor Age is 30 -40 May be solid ,usually cystic Cystadenoma or Cystadenofibroma 65% benign ,15% low malignant

potential , and 25% malignant 65 % of all ovarian cancers

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Serous Tumors

Most are large ,spherical to ovoid ,cystic structures

5 – 10 cm and might be 30-40 cm 25% of benign tumors are bilateral The surface of the benign is smooth

and glistening .In contrast to the malignant forms ,the surface is nodular and irregular

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Serous Tumors Cystic spaces are filled by serous fluide Papillary formation is very important

and need to be sampled well Histologically the benign tumors are

lined by a single layer of tall columnar epithelium

Papillary formation can be seen in both the benign and the malignant ones

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Serous Tumors Psammoma bodies could be seen Between the clearly benign and the

solid malignant tumors we can see the tumors of low malignant potential

LMP tumors may seed the peritoneum, the implants of tumors are non invasive. Sometimes may behave as invasive peritoneal implants

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Serous Tumors The prognosis of LMP tumors is

determined mainly by the nature of the peritoneal implants

Prognosis of invasive Serous cystadenocarcinoma after surgery ,chemotherapy ,and radiation is poor and depend on stage

70% 5 –year survival for the tumors confined to the ovary

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Serous Tumors

5 year survival f0r LMP is 100% , Malignant Tumors with capsular

invasion ,survival for 10 years is 13%

LMP with capsular invasion the 10 year survival is 80%.

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Figure 22-39 A, Borderline serous cystadenoma opened to display a cyst cavity lined by delicate papillary tumor growths. B, Cystadenocarcinoma. The cyst is opened to reveal a large, bulky tumor mass. C, Another borderline tumor growing on the ovarian surface (lower).

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Figure 22-39 A, Borderline serous cystadenoma opened to display a cyst cavity lined by delicate papillary tumor growths. B, Cystadenocarcinoma. The cyst is opened to reveal a large, bulky tumor mass. C, Another borderline tumor growing on the ovarian surface (lower).

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Figure 22-40 Papillary serous cystadenoma revealing stromal papillae with a columnar epithelium.

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Figure 22-41 Borderline serous cystadenoma exhibiting increased architectural complexity and epithelial cell stratification.

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Figure 22-42 Papillary serous cystadenocarcinoma of the ovary with invasion of underlying stroma.

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Mucinous Tumors

Epithelium is consists of mucin-producing cells

Less likely to be malignant 10% of ovarian cancers 80% of them benign 10% LMP 10% malignant

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Figure 22-44 A, A mucinous cystadenoma with its multicystic appearance and delicate septa. Note the presence of glistening mucin within the cysts. B, Columnar cell lining of mucinous cystadenoma.

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Brenner Tumor

Transitional cell epithelium Most are benign

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Figure 22-46 A, Brenner tumor (right) associated with a benign cystic teratoma (left). B, Histologic detail of characteristic epithelial nests within the ovarian stroma. (Courtesy of Dr. M. Nucci, Brigham and Women's Hospital, Boston, MA.)

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Sex Cord Tumors,Granulosa Cell Tumor

Most postmenopausal ,could be any age

Unilateral Solid and cystic Tiny to large in size Produce estrogen Malignant behaviour in 5-25%

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Sex Cord Tumors,Thecoma-Fibroma

Any age Unilateral Solid gray to yellow Rarely malignant

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Sex Cord TumorsSertoli - Leydig

All ages Unilateral Gray to yellow Produce androgens Uncommonly malignant

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Germ Cell TumorsDysgerminoma

2nd and 3rd decades Unilateral Counterpart to Seminoma Solid ,gray to yellow All malignant PLAP positive

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Embryonal carcinoma

2nd and 3rd decade Solid Aggressive CD 30 positive.

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Germ Cell TumorsTeratoma 15-20 % of Ovarian tumors Majority in the first 2 decades The younger the patient ,the

greater the likelihood of malignancy Over 90% are benign cystic ,mature

teratomas Immature teratomas are malignant

and are rare.

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Figure 22-48 Opened mature cystic teratoma (dermoid cyst) of the ovary. Hair (bottom) and a mixture of tissues are evident.

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Figure 22-49 Benign cystic teratoma. Low-power view of skin (top), beneath which there is brain tissue (bottom).

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Endodermal Sinus (Yolk Sac) Tumor the tumor is rich in α-fetoprotein and α1-

antitrypsin. Its characteristic histologic feature is a

glomerulus-like structure composed of a central blood vessel enveloped by germ cells within a space lined by germ cells (Schiller-Duval body)

stained for α-fetoprotein by immunoperoxidase techniques

Most patients are children or young women presenting with abdominal pain and a rapidly developing pelvic mass. The tumors usually appear to involve a single ovary but grow rapidly and aggressively.

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Figure 22-52 A Schiller-Duval body in yolk sac carcinoma.

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Choriocarcinoma More commonly of placental origin, the

choriocarcinoma, similar to the Most ovarian choriocarcinomas exist in

combination with other germ cell tumors, and pure choriocarcinomas are extremely rare.

are aggressive tumors that generally have metastasized widely through the bloodstream to the lungs, liver, bone, and other viscera by the time of diagnosis.

high levels of chorionic gonadotropins that are sometimes helpful in establishing the diagnosis or detecting recurrences.

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Ovarian TumorsMetastatic Carcinoma

Accounts for approximately 5% of ovarian tumors

Older ages Mostly Bilateral Primaries are Breast ,lung, and

G.I.T. (Krukenberg Tumors)

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