Ovarian tumors Lecture notes for MBBS.pptx

Introduction to ovarian tumors, Epidemiology, Classification of ovarian tumor, Pathogenesis of epithelial ovarian tumors, Serous tumors of the ovaries, definition, pathogenesis, gross and microscopic pathology, Mucinous tumors of ovaries, definition, pathogenesis, gross and microscopic pathology, Teratoma of the ovaries,definition, pathogenesis, gross and microscopic pathology, Dysgerminma,definition, pathogenesis, gross and microscopic pathology

1. Dr. Sizan Thapa MBBS,MD OVARIAN TUMORS

2. Introduction To Ovarian Tumors Mostly benign and occur in young females (20-45 y) Borderline tumors (tumors of intermediate malignancies) - seen in slightly older women Malignant tumors - 45-65 yrs Ovarian cancers : 3% of all the female tumors and eighth most common diagnosis and cause of cancer death in women world wide High grade serous carcinoma - most common histological type

3. Classification of Ovarian Tumors Surface epithelial- stroma tumors Serous tumors Benign (Cystadenoma, Cystadenofibroma Borderline (Serous borderline tumor) Malignant (Low and high grade serous Adenocarcinoma) Mucinous tumors, endocervical like and intestinal type Benign (Cystadenoma, cystadenofibroma) Borderline (Mucinous borderline tumor) Malignant (Mucinous adenocarcinoma)

4. Endometroid tumor Benign (Cystadenoma, cystadenofibroma) Borderline (Endometroid borderline tumor) Malignant (Endometroid adenocarcinoma) Clear cell tumor Benign Borderline Malignant (Clear cell adenocarcinoma)

5. Transitional cell tumor Benign Brenner tumor Brenner tumor of borderline malignancy Malignant Brenner tumor Epithelial- stromal tumor Adenosarcoma Malignant mixed Mullerian tumor

6. Sex cord-stromal Tumor Granulosa tumor Fibroma Fibrothecoma Thecoma Sertoli-leydig cell tumor Steroid (lipid) cell tumor

7. Germ cell tumors Teratoma Mature Immature Solid Cystic (Dermoid Cyst) Monodermal (eg. Struma ovarii, carcinoid) Dygerminoma Yolk sac tumor Mixed germ cell tumor

8. Metastatic tumor from non-ovarian primary Colonic, appediceal Gastric Pancreaticobilliary Breast

9. EPITHELIAL TUMORS Three most common types : serous, mucinous and endometroid Subclassification: benign, borderline and malignant Based on clinicopathological and molecular studies: 2 types Type I : Low grade; Associated with borderline tumor or endometriosis Type II : High grade serous carcinoma arising from STIC

10. Serous Tumor Definition Group of cystic ovarian epithelial neoplasms with neoplastic cells resembling the tubal epithelium Most common ovarian tumor (30%) 50% of ovarian epithelial tumors 30 % of serous tumors : malignant Benign/ borderline : age 20-45 Malignant later in life; young adults in familial cases

11. Pathogenesis Risk factors for benign and borderline : Unclear Risk factors (malignant serous tumor) Nulliparity Family history Heritable mutations (BRCA1 and BRCA2) Higher frequency in low parity Reduced risk in women 40-59 y; oral contraceptives and tubal ligation

12. Low grade - Serous borderline tumor High grade - Insitu lesions in fallopian tube (STIC) or serous inclusion cysts in ovary

13. Mutational profiles : distinct regardless of origin Low grade : Mutation of KRAS, BRAF or ERBB2 oncogenes, and wild type TP53 genes High grade : High frequency of TP53 muation absent KRAS and BRAF mutation Genomic imbalance : amplification of oncogenes(PIK3CA) and deletion of tumor supressor genes (RB)

14. Morphology Gross features Cystadenoma: Smooth outer and inner surfaces, may be septate; filled with serous fluid; Cystadenofibroma - cyst with variable amout of solid areas Serous borderline tumor: large (>5cm); may be intracystic; Increased papillary projections (30% bilateral) Malignant serous tumor: Bilateral; large solid or papillary growth; tumor irregularity; nodularity of the capsule

15. Microscopic Features Benign : cysts lined by simple columnar with retained cilia and microscopic papillae

16. Borderline : Increased complexity of stromal papillae; stratification of epithelium; mild atypia; no invasion

17. Low grade serous carcinoma : Small nests, Glands, papillae or complex micropapillae and inverted papillae; Invasion seen; Moderate degree of nuclear atypia

18. High grade serous carcinoma : - More complex growth pattern than borderline tumors; - Wide spread stromal infiltration or stromal effacement; - Marked nuclear atypia (pleomorphism, multinucleation, atypical mitotic figures); - Necrosis; - Psammoma bodies

19. Mucinous Tumors Definition Group of ovarian epithelial tumors with neoplastic cells resembling gastrointestinal or Mullerial type mucinous epithelium 20 - 25 % of all ovarian neoplams Malignant mucinous carcinoma is rare (3%); majority are benign or borderline

20. Pathogenesis KRAS proto-oncogene mutation in benign, borderline and malignant mucinous tumors Borderline mucinous tumors arise from mucinous cystadenomas Malignant mucinous carcinoma arise from borderline mucinous tumors; CDK2NA and TP53 mutation present

21. Morphology Gross Features Usually unilateral Surface of ovary rarely involved Benign : - up to 30 cm or more - Filled with sticky gelatinous fluid

22. Borderline - Larger than benign mucinous tumors (up to 50 cm) - Multiloculated - Solid areas may be seen - Filled with mucinous content

23. Malignant - Solid and cystic - Mucinous content - Necrosis and hemorrhage may be present

24. Microscopic Features Benign - Lined by tall columnar cells with apical mucin; lack cilia - Gastric or intestinal type; rarely endocervical type

25. Borderline - Epithelial stratification - Tufting - Papillary intraglandular growth - Low grade nuclear atypia - Mucin in glandular lumen

26. Malignant Mucinous carcinoma - 2 patterns of invasion: confluent glandular (expansile) or infiltrative/desturctive ; may coexist - Cofluent pattern - glandular crowding with little or no intervening stroma - Infiltrative pattern: Irregular glands, nests and single cells - Marked atypia

27. DYSGERMINOMA Primitive germ cell tumor composed of cells showing no specific differentiation Ovarian counterpart of testicular seminoma 2% of ovarian cancers 50% of malignant ovarian germ cell tumors Age: 2nd and 3rd decade; may occur in childhood

28. Pathogenesis may occur in gonadal dysgenesis Chromosome 12 abnormalities typically iso12p KIT mutation

29. Gross Features Size : variable; very small to large ones filling the abdomen Fleshy yellow or cream colored, lobulated

30. Microscopic features

31. TERATOMA Three types mature immature monodermal

32. Mature (benign) teratoma also known as Dermoid cyst Gross features unilateral or bilateral Unilocular cyst containing hair and sebaceous material Teeth and bones may be visible Microscopic Features Tissues from at least 2 of the 3 germ layers eg skin with nerves, bones or cartilage etc

33. Immature Teratoma Component resemble embryonal and immature fetal tissue Adolescent and young girls Gross features Bulky with smooth exterior; cut sections --> solid may contain hair, sebaceous material, teeth bones and calcification Necrosis and hemorrhage

34. Microscopic Features Varying amount of immature neuroepithelium, cartilage bone muscles and other elements Extraovarian spread is dependent on grade Grading is based on the portion of the tumor that is based on immature component

35. Monodermal or specialized teratoma Rare Struma ovarii and carcinoid Sturma ovarii entirely composed of mature thyroid tissue may be functional and cause hyperthyroidism Carcinoid arise from intestinal tissue found in teratoma May be functional; large ones produce 5-HT to produce carcinoid synd

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