ovary slide share 3
TRANSCRIPT
OVARIAN TUMORS-III
Dr Aksharaditya ShuklaResident, Department Of Pathology
MGM Medical College & M.Y. Hospital, Indore
Dr Aksharaditya Shukla
Ovarian tumours
Tumour of the ovary are common form of neoplasia in women
Accounts for 3% of all cancers in females80% are benignMore common in older white women of
northern European ancestry90% of malignancies are carcinoma, 80%
have spread beyond the ovary at diagnosis.
Dr Aksharaditya Shukla
Risk factors for carcinoma
NulliparityFamily historyChildhood gonadal dysgenesisClomipheneHereditary non polyposis colon cancerBRCA1 and BRCA2 mutationsCA-125 present in 80% of serous and
endometrioid tumoursCytogenetics-gain of 12 & 8loss of chr X,22 18,17,14,13,12 & 8 ,benign/borderline tumor exhibit trisomy12
Dr Aksharaditya Shukla
Dr Aksharaditya Shukla
Classification of ovarian tumours
Novak's classification (1967) has advantage of being simple but has certain obvious drawbacks, since it depends primarily on two fundamental factors; benign or malignant and solid or cystic.
Thus the borderline tumors, solid tumors with cystic degeneration and predominantly cystic tumors with solid areas fall into grey zone.
Dr Aksharaditya Shukla
In 1971, the cancer committee of International Federation of Gynecology and Obstetrics (FIGO) proposed a histological classification of common primary epithelial ovarian tumors. Although this classification covered only epithelial tumors, it was a step in the direction of uniformity in classification and it also included the group of tumors of "low potential malignancy".
A significant stride in the direction of a histogenesis-based classification system was made in 1973 with the publication of the World Health Organization (WHO) Classification of Ovarian Tumors. This classification system was updated in 1999 and recently in 2003.
Dr Aksharaditya Shukla
WHO classification of ovarian tumours
1. SURFACE EPITHELIAL TUMOURS2. GERM CELL TUMOURS3. SEX CORD STROMAL TUMOURS 4. GERM CELL SEX CORD STROMAL TUMOURS 5. TUMOUR OF THE RETE OVARII 6. MISCELLANEOUS TUMOURS 7. TUMOUR LIKE CONDITIONS8. LYMPHOID AND HEMATOPOETIC TUMOURS9. SECONDARY TUMOURS
Dr Aksharaditya Shukla
Granulosa stromal cell tumours
Sertoli stromal cell tumoursSex cord stromal tumours of mixed or
unclassified cell types Steroid cell tumours
SEX CORD STROMAL TUMOURS
Dr Aksharaditya Shukla
Sertoli stromal cell tumors
Sertoli leydig cell tumour group (androblastoma).
a) well differentiated b) intermediate differentiation
c) poorly differentiated (sarcomatoid)
d) retiform
2. Sertoli cell tumour.3. Stromal leydig cell
tumour
Dr Aksharaditya Shukla
Sertoli leydig cell tumor
Young patients (average 25 years)
50% shows signs of androgen excess i.e defeminisation
(breast atrophy, loss of subcutaneous Fat)
Later masculinisation appears
Dr Aksharaditya Shukla
Sertoli leydig cell tumor
Mixture of variable proportions of cells morphologically resembling male sertoli and leydig cells.
0.1% of ovarian neoplasms.
Grossly predominantly solid.
Variegated appearance of cut surface of ovarian Sertoli–Leydig cell tumor.
Dr Aksharaditya Shukla
Microscopic pattern
Well differentiated
(meyer’s type I)
Tubules lined by sertoli like cells seperated by variable number of leydig like cells
Well-differentiated (Meyer’s type I) Sertoli–Leydig cell tumor.
Dr Aksharaditya Shukla
Microscopic patterns of SLCT
Intermediate(meyer’s type II)
Formation of cords, sheets sertoli like cells seperated by spindle stromal cells
Dr Aksharaditya Shukla
Microscopic patterns of SLCT
Poorly differentiared
(meyer’s type III)
Composed of masses of spindle shaped cells arranged in “sacomatoid” pattern
Dr Aksharaditya Shukla
Special Stains and Immunohistochemistry of SLCT
Testosterone and estradiol both in sertoli and leydig cells
Areas of sertoli cell differentiation are Keratin+
Gonadal stromal components- inhibin+
Dr Aksharaditya Shukla
Sex Cord Tumor with Annular Tubules (Sex cord stromal tumours of mixed or unclassified cell types )
A distinctive variant of sex cord stromal-tumor with features of Sertoli and granulosa cell differentiation, divided in two subsets including those associated with Peutz-Jeghers syndrome and those without such association
33% associated with Peutz–Jeghers syndrome
Symptoms suggestive of hyperestrinism in ≈50%
Gross Pathology
If associated with Peutz–Jeghers syndrome typically:
- multifocal - bilateral - small (or even
microscopic) - calcified - benign * If unassociated with
Peutz–Jeghers syndrome: - unilateral - often large - ≈22% of cases
clinically malignant
Dr Aksharaditya Shukla
Sex cord tumor with annular
tubules
Combines: - features
suggestive of granulosa
cell tumor - pattern of
growth reminiscent sertoli cells Simple and
complex annular tubules containing eosinophilic hyaline bodies, often calcified.
- morphologic hallmark
Sex cord tumor with annular tubules. The patient had Peutz–Jeghers syndrome
Dr Aksharaditya Shukla
Steroid cell tumor (Sertoli stromal cell tumors)
Syn. Lipid, lipoid cell tumor
Heterogeneous group of tumors composed entirely of cells with morphologic features indicative of steroid hormone secretion.
Any age
Most associated with a virilizing syndrome (defeminization and amenorrhea)
Sometimes: - Cushing's syndrome -associated with
endometrioid carcinoma
Dr Aksharaditya Shukla
Gross Pathology
Usually unilateral Composed of yellow
or yellowish brown nodules separated by fibrous trabeculae
Malignant tumors tend to:
- be larger (≥06cm in
diameter) - have foci of
necrosis and hemorrhage
Cut surface of ovarian lipid cell tumor.
Dr Aksharaditya Shukla
Steroid cell tumor
Masses of large rounded or polyhedral cells
Composed entirely of cells with features indicative of steroid hormone secretion:
cytoplasm: + abundant + eosinophilic + may be vacuolated + often positive for
fat stains
Malignant tumors tend to exhibit:
- nuclear atypia - mitotic activity
Dr Aksharaditya Shukla
Special Stains and Immunohistochemistry
* Immunohistochemically: - reactivity for: + vimentin in 75% + keratin in 50% + actin in ≈33%8
consistent reactivity for: - inhibin - A103 - Mart-1
Dr Aksharaditya Shukla
GERM CELL SEX CORD STROMAL TUMOURS
a) Gonadoblastoma
b) Mixed germ cell sex cord stromal tumour
Dr Aksharaditya Shukla
Gonadoblastoma
Tumor composed of a combination of germ cells and sex-cord cells that arises almost exclusively in dysgenetic gonads.
Usually sexually abnormal:
commonly gonadal dysgenesis and carrying Y chromosome, i.e.:
- XY gonadal dysgenesis - XO–XY mosaicism - but not XX gonadal dysgenesis1 estimated 25% risk of neoplasia in these dysgenetic
gonads
Also documented in: * phenotypically and chromosomally normal females, even
during pregnancy * ataxia–telangiectasia
Dr Aksharaditya Shukla
Gross Pathology
Usually small
Often impossible to determine nature of gonad bearing tumor:
- sometimes identified as: + a streak(many become
apparent only on microscopic examination)
+ cryptorchid testis
Never a normal ovary
* ≈36% bilateral Streak gonad microscopically
shown to contain gonadoblastoma. The tumor was barely apparent grossly.
Dr Aksharaditya Shukla
Gonadoblastoma
Admixture of: primitive germ cells:
resembling those of dysgerminoma
sex cord–stromal cells: resembling
morphologically and immunohistochemically immature Sertoli and granulosa cells
Commonly: hyalinization:
when abundant may be obvious on plain abdominal radiograph
calcification
Ovarian gonadoblastoma. Note the sharply outlined tumor nests and the heavy calcification
Dr Aksharaditya Shukla
Special Stains and Immunohistochemistry
Hyaline material reacts strongly with anti-laminin antibodies,
Dr Aksharaditya Shukla
Metastatic tumors
Malignant secondary tumors involving ovaries originated in other organs.
* ≈7% of lesions presenting as primary ovarian tumors are metastatic
* >50% bilateral * Most common sources: - stomach - large bowel - appendix - breast - uterus (corpus and
cervix) - lung - skin (melanoma)
Metastases From Breast Carcinoma * Immunoreactive for GCDFP-15: - important in differential
diagnosis with primary ovarian carcinoma, which is generally negative
Dr Aksharaditya Shukla
Metastases From Adenocarcinoma of Large Bowel
Large bowel adenocarcinoma metastatic to ovary
Dr Aksharaditya Shukla
Krukenberg Tumors Usually: * >40 years of age * bilateral * metastatic origin
Usual primary sources: * stomach: - diffuse gastric carcinoma (linitis plastica) used to be
most common* large bowel, Appendix, Breast
May be: * retroperitoneal lymph node metastases * peritoneal implants
Dr Aksharaditya Shukla
Gross Pathology
Krukenberg Tumor
Moderate solid multinodular enlargement of the ovaries.
Typical gross appearance of Krukenberg tumors of ovary. The involvement is bilateral and the tumors are characterized by a multinodular outer appearance
Dr Aksharaditya Shukla
Krukenberg Tumor
* Diffuse infiltration by signet ring cells
- signet ring cells.
* Tumor emboli >50% of cases
Krukenberg tumor of ovary. Presence of intracellular
mucin
Krukenberg tumor of ovary. Microscopic appearance. Numerous signet ring cells are present in a highly fibrous stroma, either individually or in small nests
Dr Aksharaditya Shukla
Features favoring primary ovarian tumor:
* expansile (pushing) pattern of invasion
* complex papillary architecture
* size over 10cm
* smooth external surface
* benign- and borderline-appearing foci
Ovarian metastases tend to be:
* cystic
* well differentiated
* mucin-producing
* associated with necrosis and hemorrhage
Dr Aksharaditya Shukla
References
ROSAI AND ACKERMAN`S SURGICAL PATHOLOGY
DIAGNOSTIC SURGICAL PATHOLOGY- STERNBERG
PATHOLOGIC BASIS OF DISEASE– ROBBINS AND COTRAN
ANDERSON`S PATHOLOGY
CURRAN`S ATLAS OF PATHOLOGY
WWW.WEBPATH.COM
Dr Aksharaditya Shukla
Thanks Presented By: Dr Aksharaditya Shukla
Resident, Department Of PatholgyMGM Medical College & M.Y. Hospital, Indore