Ovarian Tumors
Ovarian Tumors
1)
Categories: Epithelial, Sex cord stromal tumors,
Germ cell tumors
a.
Epithelial (surface-derived)
i. Features
1.
Most common, 65-70% of ovarian tumors
2.
Most likely to seed the omentum
ii. Types
1.
Serous
a.
Types
i. Serous
cystadenoma
1.
Benign
2.
Most common benign ovarian tumor
ii. Serous
cystadenocarcinoma
1.
Malignant
2.
Bilateral
3.
Most common malignant bilateral ovarian tumor
4.
CA-125 tumor marker
b.
Appearance
i. Cysts
lined by ciliated cells (similar to fallopian tube)
ii. Psammoma
bodies
1.
Round collections of calcium
c.
Features
i. Most
common primary benign and malignant tumors
d.
Low-Grade Serous Ovarian Cancer (LGSOC)
i. Younger
than HGSOC
ii. Longer
overall survival vs HGSOC, however slower growing cells are less responsive to
chemotherapy
iii. Treatment
is often surgical (aggressively)
e.
Borderline Ovarian Tumors
i. Rare
ii. Atypical
epithelial proliferation without stromal invasion
1.
25% will have invasive disease on final
pathology
2.
Excellent survival
2.
Mucinous
a.
Types
i. Mucinous
cystadenoma
1.
Benign
2.
Grow very rapidly
ii. Mucinous
cystadenocarcinoma
1.
Malignant
b.
Appearance
i. Similar
to endocervical cells
ii. Cysts
lined by mucus-secreting cells
iii. Large,
multiloculated tumors
c.
Features
i. Seeding
produces pseudomyxoma peritonei
1.
Gelatinous ascites
2.
Compresses other organs causing obstruction or
cachexia
ii. Staging
surgery includes removal of the appendix
1.
Is believed to differentiate appendiceal cancer
metastasizing to the ovary
3.
Endometrioid
a.
Resembles Endometrial cells
b.
Malignant
c.
Commonly bilateral
4.
Transitional-Cell
a.
Resembles transitional-like epithelium or
urothelium
b.
Usually malignant
c.
Often has a stromal component, in which case it
is a Brenner tumor (which itself can be benign or malignant)
5.
Clear Cell
a.
Resemble renal cells
b.
Most often malignant
c.
Poor prognosis
b.
Germ cell tumors
i. Features
1.
15-20% of ovarian tumors
2.
Small number are malignant
ii. Types
1.
Teratoma
a.
>99% benign
b.
Most common benign germ cell tumor
c.
Congenital neoplasms that differentiate into
different cell populations
i. Ectoderm,
endoderm, mesoderm
d.
Types
i. Immature
(malignant)
1.
<1% of teratomas
2.
All 3 germ cell layers in haphazard manner
3.
Often with neuroepithelium
ii. Mature
(benign)
1.
Dermoid Cyst
a.
Contain all 3 cell populations
b.
May contain Rokitansky nodule, a thickened
portion of the cyst wall
c.
Compared to immature teratomas, have greater
cystic component
iii. Monodermal/Highly
Specialized
1.
Struma Ovarii
a.
Mature thyroid tissue
b.
Secretes thyroid hormone (tumor marker)
2.
Carcinoid Neoplasm
a.
Secrete bioactive polypeptides and amines, may
develop carcinoid syndrome
i. Flushing/Diarrhea
b.
Differs from appendiceal carcinoid tumors which
undergo first-pass by liver
2.
Dysgerminoma
a.
Most common malignant germ cell tumor
b.
Tumor Marker - Increased LDH
i. ‘Lysol
Kills Germs’
c.
Similar to seminoma of testis
d.
A/w streak gonads of Turner Syndrome (XO)
3.
Yolk Sac (endodermal sinus tumor)
a.
Malignant
b.
Most common in toddlers <4yo
c.
Schiller-Duval bodies
i. Central
vessel surrounded by tumor cells contained in a cystic space lined by flattened
tumor cells.
ii. Represents
an attempt to form yolk sacs
d.
Increased a-FP
i. ‘Grade
A Eggs’
e.
Hyaline bodies
4.
Embryonal carcinoma
a.
Teenagers
b.
Resemble early embryos
i. Contain
amniotic cavity, thick germ discs that may include primitive gut, and
voluminous yolk sac cavity
c.
Tumor marker – Increased b-HCG
i. “Teenagers
have sex and make embryos”
5.
Polyembryoma
a.
Rare, very aggressive
b.
Is a combination of multiple germ cell tumors
i. For
instance, may possess embryoid bodies and yolk sac features
c.
A/w Klinefelter’s Syndrome (XXY)
c.
Sex cord stromal tumors
i. Features
1.
Least common, 3-5% of ovarian tumors
2.
May have hormonal activity
3.
Majority are benign
ii. Types
1.
Thecoma-Fibroma
a.
Benign
b.
A/w Meig’s Syndrome
i. Triad
of Pleural Effusion, Ascites and Ovarian Tumor
1.
Ascites and effusion resolve after removal of
tumor
c.
Commonly calcified
2.
Granulosa Cell
a.
Low-grade malignant tumor
b.
Tumor Marker – Inhibin B
i. ‘Insulin
If Fails GCT’
c.
Call-Exner bodies
i. Eosinophilic
fluid-filled spaces between granulosa cells
3.
Sertoli-Leydig
a.
Very rare
b.
Benign
c.
Produces androgens and can virilize female genitalia
d.
May have crystals of Reinke
i. Rod-shaped
crystals
4.
Gonadoblastoma
a.
Malignant
b.
Mixture of germ cell tumor and sex-cord stromal
tumor
c.
A/w abnormal chromosomal karyotype, gonadal
dysgenesis, or presence of Y chromosome
d.
Commonly have microcalcifications
2)
Metastases to Ovary
a.
Features
i. Traditionally,
5% of ovarian tumors viewed as metastatic from other location (however recent
evidence suggests serous ovarian cancer represents metastases from the
fallopian tube, which would change this number)
1.
Reason we do prophylactic salpingectomies or
fimbriectomies.
ii. Of
non-gynecologic mets, Breast is most common, followed by Stomach
b.
Types
i. Krukenberg
Tumor
1.
Stomach primary; may affect both ovaries
2.
Hematogenous spread
3.
Signet-ring cells
3)
Ovarian Cancer Staging (and Fallopian Tube and
Peritoneal)
0: No evidence of
primary tumor
I: Confined to
ovaries or tubes
IA: One ovary or tube, capsule intact, no tumor on ovarian surface, no
cells in ascites or peritoneal washings
IB: Both ovaries or tubes, capsules intact, no tumor on ovarian surfaces,
no cells in ascites or peritoneal washings
IC: One or both ovaries
IC1:
Surgical spill
IC2: Capsule rupture pre-op or tumor on ovarian surface
IC3:
Malginant cells in ascites or peritoneal washings
II: Pelvic
extension
IIA:
Extension to uterus/tubes
IIB:
Extension to other pelvic organ
III: Peritoneal
Metastasis or Nodes
IIIA: Microscopic peritoneal metastasis beyond pelvis or retroperitoneal
IIIA1:
Positive retroperitoneal nodes only
IIIA1(i): Mets <10mm
IIIA1(ii):
Mets >10mm
IIIA2:
Microscopic extrapelvic peritoneal involvement
IIIB: Macroscopic peritoneal metastasis beyond pelvis <2cm in greatest
dimension
IIIC: Peritoneal metastasis beyond pelvis >2cm in greatest dimension
or lymph node metastasis
IV: Spread beyond
peritoneal cavity or metastases
IVA:
Pleural effusion with positive ascites
IVB: Hepatic/splenic parenchyma mets, metastasis beyond abdomen
4)
Ovarian Cancer Presentation and Clinical Course
a.
Ovarian cancer is often diagnosed at advanced
stages.
i. Most
common presentation is bloating, abdominal pain, nausea/emesis
1.
Imaging may find ascites, carcinomatosis, pelvic
mass
ii. The
ascites compresses their GI tract, making it difficult to take in nutrition.
Increasing tumor burden also compresses the gut, and can result in adhesions
and obstructions.
1.
Patients typically die from obstruction and
malnutrition, and may receive a palliative PEG tube placement
Image from ObGynKey.com
Image from ObGynKey.com
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