Diseases of the ovary

Diseases of the ovary

1. DISEASES OF THE OVARY By Dr.Varughese George

2. Learning Objectives At the end of this session, you should know about Non- neoplastic lesions of the ovaries. Neoplastic lesions of the ovaries.

3. Normal Structure of the Ovary

4. Manifestations of ovarian diseases: Pelvic pain Menstrual irregularities ( abnormal pattern of ovarian hormone secretion). Infertility; failure of ovulation (Stein- Leventhal ). Ovarian mass : either non- neoplastic (cysts) or neoplastic (cystic or solid). OVARIAN DISEASES

5. INFLAMMATORY - OOPHORITIS: - Inflammation of the ovaries is always secondary to salpingitis or peritonitis. - If chronic & bilateral leading to extensive fibrosis & infertility.

6. NON-NEOPLASTIC OVARIAN CYSTS Follicular and Luteal cysts: Common, 1-8 cm in diameter. They are lined by follicular ( granulosa ) cells or luteinized cells. Asymptomatic, but may rupture, causing peritoneal reaction & pain. Chocolate cysts: Blood-filled cysts, due to endometriosis of the ovaries.

7. Polycystic Ovarian Disease(Stein- Leventhal Syndrome) ( PCOD) It is important cause of infertility. There is excessive production of androgens, increase conversion of androgens to estrogen, insulin resistance, and inappropriate gonadotrophin production by the pituitary . Morphology: Ovaries are large, white, many subcortical follicular cysts(0.5-1 cm.) in diameter, and covered by thickened fibrosed outer tunica. No corpora lutea (= no ovulation ). Manifestations: Young females with Oligomenorrhea , infertility, obesity & hirsuitism .

8. Ovarian Endometriotic Cyst Microscopy Foci of endometrial glands and stroma seen. Old/New haemorrhages and haemosiderin -laden macrophages Surrounding zone of inflammation and fibrosis

9. POLYCYSTIC OVARY

10. OVARIAN TUMORS Common forms of neoplasia in women. 80-90% of ovarian tumors are benign. Most ovarian tumors occur between 20-45 years. Ovarian cancer is second MC malignancy of the female genital tract (after endometrial cancer). Most ovarian tumors are derived from surface epithelium, and “ CA-125” is the tumor marker for surface epithelial tumors of the ovary. Malignant ovarian tumors present at a late stage, thus are associated with high mortality rate. Known risk factors are nulliparity , family history, and specific inherited mutations (BRCAI & BRCAII) genes.

11. Tumour types-- a basic classification Site of origin Types Frequency Age group Surface epithelial tumours 1.Serous 2.Mucinous 3.Endometroid 4.Clear cell 5.Brenner 60%-70% 20 years and greater Germ cell 1.Teratoma 2.Dysgerminoma 3.Endodermal Sinus(Yolk Sac Tumour ) 4.Choriocarcinoma 15%-20% 0 to 25 years and greater Sex cord stromal tumours 1.Granulosa Theca cell tumours 2.Sertoli-Leydig cell tumours 3.Gynandroblastoma 5%-10% All ages Miscellaneous 1.Lipid cell tumour 2.Gonadoblastoma Variable variable Metastasis Krukenberg tumours 5% variable

12. Serous Ovarian Tumours GROSS APPEARANCE Serous tumours of benign, borderline and malignant type are large and spherical masses. Cut section of benign tumours is unilocular while larger cysts are multilocular with daughter loculi in their walls containing clear watery fluid. Malignant serous tumours have solid areas in the cystic mass and may contain exophytic as well as intracystic papillary projections Papillary serous cystadenoma of the ovary. Cut surface shows a large unilocular cyst containing numerous papillary structures projecting into it (arrow).

13. SEROUS CYSTADENOMA OVARY MICROSCOPIC APPEARANCE The cyst is lined by properly-oriented low columnar epithelium. The lining cells may be ciliated and resemble tubal epithelium Papillary serous cystadenoma of the ovary. Microscopic features include single layer of low columnar, at places ciliated, epithelium lining with pronounced papillary pattern .

14. PAPILLARY SEROUS CYSTADENOCARCINOMA OVARY MICROSCOPIC APPEARANCE Lining of the cyst is by multilayered malignant cells having features such as loss of polarity, presence of solid sheets of anaplastic epithelial cells . There is definite evidence of stromal invasion by malignant cells . Papillae formations are more frequent in malignant variety and may be associated with psammoma bodies

15. Mucinous Ovarian Tumours GROSS APPEARANCE Mucinous tumours are larger than serous type. They are smooth-surfaced cysts with characteristic multiloculations containing thick and viscid gelatinous fluid. Benign tumours have thin wall and septa which are translucent while malignant variety has thickened areas. Mucinous cystadenoma of the ovary. Cut surface shows a large, multiloculated cyst without papillae. The loculi contain gelatinous material.

16. MUCINOUS CYSTADENOMA OVARY MICROSCOPIC APPEARANCE The cyst is lined by a single layer of cells having basal nuclei and apical mucinous vacuoles, resembling intestinal mucosa . There is no invasion or papillae formation. The cyst wall and the septa are lined by a single layer of tall columnar mucin secreting epithelium with basally-placed nuclei and large apical mucinous vacuoles.

17. ENDOMETROID TUMOURS 20% of all ovarian tumours . Majority are carcinomas, if benign forms are present they are cyst adenofibromas . Distinguished from serous and mucinous tumours by presence of tubular glands bearing close resemblance to benign or malignant endometrial glands. 30% associated with carcinoma endometrium and 15% with endometriosis whereas 40% involve both ovaries.

18. ENDOMETRIOD CARCINOMA Gross: presence of both solid and cystic areas Microscopic : Tubular glands resemble those of typical endometrial adenocarcinoma.

19. CLEAR CELL TUMOUR These are uncommon and aggressive tumours . Grossly can present in solid and or cystic pattern (figure solid tumour with cysts and necrosis) Microscopically: large epithelial cells with abundant clear cytoplasm.

20. BRENNER TUMOUR Uncommon adenofibromas Epithelial components– nests of transitional cells resembling urinary bladder. Most are benign,variable size(1cm to 30 cm). Gross—solid or cystic Microscopic – fibrous stroma resembling normal ovarian stroma seperated by sharply demarcated nests of urinary tract, with mucinous glands.

21. BRENNER TUMOUR Gross : A sharply demarcated, yellow-white fibromatous tumor occupies a portion of the sectioned surface of the ovary. Microscopically : Nests of transitional cells, some containing cysts, lie in a fibromatous stroma .

22. GERM CELL TUMORS 15-20% of all ovarian tumors. It arises from totipotent germ cells capable of differentiation into the three germ layers. - Mostly benign cystic teratomas while Other tumours are found principally in children and young adults. - Homologous to germ cell tumours in male testis.

23. II. GERM CELL TUMORS: 1- Teratoma 2- Dysgerminoma ( seminoma ovarii ) 3- Yolk sac tumor= Endodermal sinus tumor 4- Embryonal carcinoma (MC mixed with other types) 5- Choriocarcinoma (MC mixed with other types)

24. TERATOMAS Mature Benign teratomas Immature Malignant Monodermal or highly specialized

25. TERATOMAS 1-Mature (Benign) Teratoma : MC germ cell tumors of the ovary, cystic ( dermoid cysts) , lined by skin & hairs, and filled with sebaceous secretion . There may be mature cartilage, bone (teeth) & other structures . 10-15% are bilateral. < 1% undergo malignant transformation (MC sq.c.c .). 2-Immature (Malignant) Teratoma : Rare , solid, bulky, with areas of hemorrhage and necrosis. It contains embryonic elements of the three germ layers. Age: adolescent & young women. Grading is based on the amount of immature neuroepithelium . It causes wide spread extraovarian metatases depending on the degree of the immaturity of the including tissues . 3- Monodermal (Specialized ) Teratomas : differentiate along the line of single tissue. Examples :- Strauma ovarii is MC (mature thyroid tissue) – Carcinoid tumor.

26. Benign Cystic Teratoma Ovary GROSS APPEARANCE Benign cystic teratoma is characteristically a unilocular cyst , 10-15 cm in diameter. On sectioning, the cyst is filled with paste-like sebaceous secretions and desquamated keratin admixed with masses of hair. The cyst wall is thin and opaque grey-white . The cyst wall also shows a solid prominence where tissue elements such as tooth, bone, cartilage and other odd tissues are present Benign cystic teratoma ( dermoid cyst) of the ovary . Cut surface shows a large unilocular cyst containing hair, pultaceous material and bony tissue.

27. Benign Cystic Teratoma Ovary MICROSCOPIC APPEARANCE Viewing a benign cystic teratoma in different microscopic fields reveals a variety of mature differentiated tissues, producing kaleidoscopic appearance . Ectodermal derivatives are most prominent. The lining of the cyst wall is by stratified squamous epithelium and its adnexal structures such as sebaceous glands, sweat glands and hair follicles . Tissues of mesodermal and endodermal origin are commonly present and include bronchus, intestinal epithelium , cartilage, bone, smooth muscle, neural tissue, salivary gland, retina, pancreas and thyroid tissue

28. DYSGERMINOMA GROSS : Small nodules to very large size.Cut surface: yellow white to gray pink appearance and are soft and fleshy. Microscopic :large vesicular cells, clear cytoplasm and well defined boundaries and centrally placed regular nuclei.cells in sheets or cords seperated by scant fibrous stroma , which has mature lymphocytes.

29. III. SEX CORD-STROMAL TUMORS: 1- Granulosa -Theca cell tumor: secrete estrogen 2- Sertoli-Leydig cell tumor: secrete androgens 3- Fibroma : associated with Meig’s syndrome 4- Sex cord stromal tumor with annual tubules 5- Gynandroblastoma 6- Steroid (Lipid)cell tumors

30. METASTATIC TUMOR Very common, The primary tumors is from abdominal and breast tumors. A bilateral metastatic ovarian carcinoma, composed of mucin-producing signet ring cells, metastasizing from GIT, mostly from the stomach , it may produce pseudomyxoma peritonei like well differentiated appendicial tumors. Krukenberg tumor

31. HISTOPATHOLOGY OF KRUKENBERG TUMOR Numerous signet ring cells are present in a highly fibrous stroma , either individually or in small nests.