Ovarian Cysts and Tumors

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

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.

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

Polycystic Ovaries Stein-Leventhal Syndrome Young women ,and usually in girls after menarche. -Oligomenorrhea -hirsutism -infertility -Obesity

Polycystic Ovaries Stein-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.

Polycystic Ovaries Stein-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

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. Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 28 April 2008 01:14 PM) © 2007 Elsevier

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. Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 28 April 2008 01:14 PM) © 2007 Elsevier

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

Ovarian Tumors classification Primary tumor, three cell types : 1- the surface epithelium tumors 2- Germ cells tumors 3- Stromal /sex cord cells tumors Secondary or metastatic tumors

Figure 22-37 Derivation of various ovarian neoplasms and some data on their frequency and age distribution. Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 28 April 2008 01:14 PM) © 2007 Elsevier

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

Classification of Ovarian Tumors, Sex Cord-Stromal tumors -Granulosa Cell tuomr -Thecoma –Fibroma -Sertoli-Leydig cell tumor -Gynandroblastoma -Unclassified

Classification of Ovarian Tumors, Germ Cell Tumors - -Dysgerminoma -Yolk Sac Tumor -Embryonal Carcinoma -Choriocarcinoma -Teratoma : Mature, Immature -Polyembryoma

Ovarian Tumors Surface Epithelium Origin Neoplasms of surface epithelium account for the great majority of all primary ovarian tumors.

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)

Ovarian Tumors , Surface Epithelium Origin Can have stromal component (Cystadenofibroma , Brenner tumor )

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

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

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

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

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

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

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%.

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). Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 28 April 2008 01:14 PM) © 2007 Elsevier

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). Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 28 April 2008 01:14 PM) © 2007 Elsevier

Figure 22-40 Papillary serous cystadenoma revealing stromal papillae with a columnar epithelium. Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 28 April 2008 01:14 PM) © 2007 Elsevier

Figure 22-41 Borderline serous cystadenoma exhibiting increased architectural complexity and epithelial cell stratification. Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 28 April 2008 01:14 PM) © 2007 Elsevier

Figure 22-42 Papillary serous cystadenocarcinoma of the ovary with invasion of underlying stroma. Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 28 April 2008 01:14 PM) © 2007 Elsevier

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

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. Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 28 April 2008 01:14 PM) © 2007 Elsevier

Brenner Tumor Transitional cell epithelium Most are benign

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.) Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 28 April 2008 01:14 PM) © 2007 Elsevier

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%

Sex Cord Tumors, Thecoma-Fibroma Any age Unilateral Solid gray to yellow Rarely malignant

Sex Cord Tumors Sertoli - Leydig All ages Unilateral Gray to yellow Produce androgens Uncommonly malignant

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

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

Germ Cell Tumors Teratoma 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.

Figure 22-48 Opened mature cystic teratoma (dermoid cyst) of the ovary Figure 22-48 Opened mature cystic teratoma (dermoid cyst) of the ovary. Hair (bottom) and a mixture of tissues are evident. Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 28 April 2008 01:14 PM) © 2007 Elsevier

Figure 22-49 Benign cystic teratoma Figure 22-49 Benign cystic teratoma. Low-power view of skin (top), beneath which there is brain tissue (bottom). Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 28 April 2008 01:14 PM) © 2007 Elsevier

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.

Figure 22-52 A Schiller-Duval body in yolk sac carcinoma. Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 28 April 2008 01:14 PM) © 2007 Elsevier

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.

Ovarian Tumors Metastatic Carcinoma Accounts for approximately 5% of ovarian tumors Older ages Mostly Bilateral Primaries are Breast ,lung, and G.I.T. (Krukenberg Tumors)