ovariantumors-201130105621 pathology robbins

Ovarian tumors

1. OVARIAN TUMORS

2. CONTENT Non neoplastic cyst & benign neoplastic tumours Clinical features Diagnosis Differential diagnosis Management Complications

3. 2 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

4. O V A R Y THE HUMAN OVARY HAS A STRICKING PROPENSITY TO DEVELOP A WIDE VARITY OF TUMORS MOST OF WHICH ARE BENIGN. 80% OF ALL OVARIAN TUMORS ARE BENIGN,ALTHOUGH THIS VARIES WITH AGE.

5. BENIGN LESIONS OF OVARY NON NEOPLASTIC NEOPLASTIC(BENIGN ) FUNCTIONAL PATHOLOGY 1.Follicular cyst 1.PCOS A. SURFACE EPITHELIUM 2.Corpus luteal cyst 2. E ndometri al cyst 1. Serous 3.Theca lutein & (Chocolate cyst) 2. Mucinous granulosa lutein cyst 3. Endometroid 4. Brenner B.GERM CELL TUMOUR (BENIGN) C. SEX CORD STROMAL TUMORS Granulosa cell tumours T hecoma /fibroma A ndroblastoma gynandro blastoma unclassified tumours D. Lipid cell tumors E. Gonadoblastoma

6. FOLLICULAR CYST (commonest) CORPUS LUTEUM CYST THECA LUTEIN CYST AGE GROUP Adolescent, reproductive age groups ,can occur in perimenopause Reproductive age Reproductive age CAUSE Hyper estronism Over activity of corpus luteum Excess chorionic gonadotropin secret ion , following to ovulation induction drugs Size Laterality Grow ≥3 & ≤8 cm B/L or U/L 3 – 10 cm U/L Large upto 30 cm B/L

7. FOLLICULAR CYST CORPUS LUTEUM CYST THECA LUTEIN CYST GROSS Thin walled , unilocular , filled with straw coloured fluid Pink or haemorrhagic cyst, cut section yellowish orange, filled with blood clots Multicystic , greyish blue colour, filled with straw colour fluid or blood Histology Lining epithelium Granulosa cells Luteinised granulosa cell Theca lutein c el l s,g r an u losa lutein cells C/F Usually asymptomatic , diagnosis incidental - Dull pelvic pain with U/L - Rupture with h emop e r it on e um more common Small are asymptomatic, large - discomfort , pain Rupture/torsion (more common)

8. Hemorrhagic cyst with unusual appearance simulating a neoplasm

9. P C OS: - 0. 5-4%, infertile women, young reproductive age - due to excess androgen , chronic anovulation - Pathology : ovaries enlarged, stroma increased, capsule thickened, pearly white appearance - Gross appearance : multiple follicles in cortex - Histo logy : thickened tunica albuginea, stromal hyperthecosis -CF : amenorrhoea, hirsutism, obesity, enlarged PCO. - Investigations : Hormonal investigations- Blood tests  can be used to measure the levels of  FSH , LH and circulating  male hormones. Ultrasound - TVS Laparoscopy Hysteroscopy. - Management – Wt. reduction COCP (Combined oral contraceptive pills) T reatment Of hirsutism T reatmen t Of infertility

10. Definition Ovarian tumors may arise at any age, but are commonest between 30 and 60. 1.Ovarian tumors are particularly liable to be nign or to become malignant. 2.In their early stages they are asymptomatic and painless. 3.They may grow to a large size and tend to undergo mechanical complications such as torsion and perforation. OVARIAN TUMOURS

11. B E NIGN O V A R IAN T U MO R S These are the benign Ovarian neoplasm s, may be divided generally by cell type of origin into three types: 1. Epithelial 2.Stromal 3.Germ cell Incidence: It varies from 1-3 percent. About 75% of these are benign.

12. ETIOLOGY Etiology not well known May be considered as, Repeated trauma to epithelium Hereditary or familial ovarian cancer Gene mutations Oncogenes

13. RISK Modifiers Nulliparity Infertility Early menarche Late menopause Endometriosis Family history Prolonged use of ovulation inducing drugs HRT Oral contraceptive usage Multi parity Breast feeding Tubal –ligation Hysterectomy Prophylactic salpingo-oophorectomy . Risk factors Protective factors

14. Ovarian Tumors Epithelial tumors : These tumors arise from a layer of cells that surrounds the outside of the ovary called the germinal epithelium. About 70-80% of all ovarian cancers are epithelial. These are most common in women who have been through menopause (aged 45-70 years).

15. Stromal tumors: Stromal tumors develop from connective- tissue cells that form the structure of the ovary and produce hormones. These account for 5-10% of ovarian cancers and also these tumors typically occur in women aged 40-60 years. Germ cell tumors: Tumors that arise from germ cells (cells that produce the egg) account for about 15% of all ovarian cancers. These tumors develop most often in young women (including teenaged girls). Although 90% of women with this type of cancer are successfully treated, many become permanently infertile.

16. 27 1. Epithelial Ovarian TUMORS 70 – 8 0 % of overall tumors Age 4 0+ Traditionally divided into Benign , Malignant , and Borderline in malignancy Can be strictly epithelial (serous, Mucinous) Only 25% diagnosed in Stage I

17. EPIDEMOLOGY: -Incidence: 1-3% among outpatient , 75% -benign -R acial factors: higher in white population, lowest in japan -Economic status: higher in industrialised countries PATHOLOGY: - Origin : mesoepithelial cells on ovarian surface - Incidence : epithelial tumours—80% of all ovarian tumours serous cystadenoma– 50% of all epithelial tumours mucinous cysts—12-15% endometroid—10% unspecifi e d —25- 2 7 %

18. 26 Classification of Surface Epithelial Tumors - Serous Tumors : Benign ,Borderline and malignant - Mucinous T. : Benign ,Borderline , and malignant - Endometrioid T . : Benign, Borderline, and malignant Clear cell carcinoma - Transitional cell T. : Brenner tumors, Benign ,Borderline ,and malignant - Undifferentiated Carcinoma

19. SEROUS CYSTADENOMA Generally benign Bilateral – 10 -25 % Risk of malignancy : 5 – 10 % borderline malignant 20 -25% malignant GROSS : multilocular with papillary components. MICRO : low columnar epithelium with cilia. Associated fibrosis may lead to “ cystadenofibroma ”

20. 29 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

21. SEROUS CYSTADENOMA

22. 31

23. MUCINOUS CYSTADENOMA Have tendency to become huge masses Round to ovoid masses with smooth capsules that are usually translucent or bluish to whitish gray. Interior divided by discrete septa into loculi containing clear , viscid fluid. Epithelium – tall, pale staining, secretary with basal nuclei and goblet cells 5 – 10% are malignant

24. 43 Mu c i no u s Tu m o r s Epithelium consists of mucin-producing cells Less likely to be malignant 10% of ovarian cancers 80% of them benign 10% L ow malignant potential 10% malignant

25. MUCINOUS CYSTADENOMA

26. SEROUS /MUCINOUS CYS T ADENOMA Gross appearance of a mucinous ( A ) and serous ( B ) cystadenoma of the ovary. The mucinous type is generally multiloculated and can be quite large.

27. U sually benign. occur in reproductive life They can be malignant. May be associated with endometrial hyperplasia May coexist with mucinous cystadenoma BRENNER TUMORS

28. BENIGN BRENNER TUMOR

29. Gross appearance of a cut-open Brenner tumor

30. BRENNER TUMOR Uncommon tumor grossly identical to fibroma Arise from Walthard cell n ests ,also from surface epithelium, and ovarian stroma On microscopy – markedly hyperplastic fibromatous matrix with nests of epitheloid cells showing coffee bean pattern Considered uniformly benign. But scattered reports of malignant Brenner ' s available . Endocrinologically inert, but could spread with virilization and endometrial hyperplasia

31. Clear cell ovarian tumors are part of the surface epithelial tumor group of ovarian cancers, Accounting for 6% of these cancers. Polypoid masses that protrude into the cyst. On microscopic examination, composed of cells with clear cytoplasm (that contains glycogen) The pattern may be glandular, papillary or solid. Clear cell carcinoma

32. ENDOMETROID TUMOUR : -2% of all ovarian tumours -Lined by glandular epithelium -Moderate size, solid, with cystic areas with haemorrhagic fluid.

33. 2 . GERM CELL TUMORS Ovarian germ cell tumor is a disease in which malignant ( cancer ) cells form in the germ (egg) cells of the ovary. CAN OCCUR AT ANY AGE 12-15% OF OVARIAN NEOPLASM 60% OF GCTS OCCURS IN CHILDREN MOST COMMON BENIGN TYPE IS ‘BENIGN CYSTIC TERATOMA’

34. Germ cell tumors Dermoid cyst (benign cystic teratoma ) 25% of all ovarian neoplasm Contain tissue derived from two or more germ cell layers Unilocular cyst. May contain teeth, bone , cartilage, nerves, hair, Tissues Almost always benign. Malignant changes may occur in any component Occur at any age. peak is 20-30 years. Bilateral in 20%

35. DERMOID CYST GROSS: thick, opaque , whitish wall. CONTENTS: hair, bone, cartilage, and a large amount of greasy sebaceous material. MICROSCOPICALLY : all the three germ layers (ectoderm, mesoderm and endoderm) Malignant change occurs in 1-3%. Usually of a squamous type. Risk of torsion is 15% An ovarian cystectomy is almost always possible, even if it appears that only a small amount of ovarian tissue remains

36. Benign o v a r i a n tumors MU C INOUS CYST ADENOMA SEROUS CYST AD E NOMA BRENNER BENIGN CYSTIC TER A T OMA INCIDENC E 12-15 % of Epithelial tumors 50 % of all Epithelial tumors 2 – 3 % of all Epithelial tumors 95 % of Germ cell tumors 20-25% of all OV.tumors 40% of all ovarian tumors 1 -2% of all ovarian tumors 15 – 2 5 % of all ovarian tumors Bilateral 10% 40% 8 -10% 15 -20% Mal i g n a n t chance 5 –10% 40% rare 1 -2% 20- 40 % of all ov. Tumors in pregnancy

37. TUMOR MUCINOUS SEROUS DERMOID ORIGIN Totipotent surface epithelium of ovary Totipotent surface epithelium of ovary germ cells arrested after 1 st meoitic division PATHOLOGY naked eye : huge size & wt 5-10 kg pedunculated, largest. smooth, lobulated with whitish or bluish white , translucent tumor. naked eye : smooth, shiny, greyish white exuberant papillary projections . naked eye : moderate size, capsule tense & smooth c/s : thick, visid mucin (glycoprotein) colourless multiloculated with papillary. honey combed appearance c / s : mult i lobul a t ed clear fluid (serum) proteins (albumin & globulin) c/s : trabeculated appearance , sebaceous material with hair , clear protruberance

38. - microscopy: lined by 1 layer of tall coloumnar epithelium with dark staining basal nuclei without any cilia. Epithelium resemble to those of endocervix. - complication: rupture pseudomyxoma peritonei & shows adhesions with visera . microscopy: - lined by cubical epithelium - papillary structures – dense fibrous stroma covered by single or multiple layers of columnar epithelium. ciliated secretory & peg cells. Epithelium resemble to those of endosalpingeal epithelium micro: stratified squamous epith e l ium , g r a nu l a t ion tissue, may be transitional/ columnar .

39. 3 . SEX CORD STROMAL OVARIAN NEOPLASMS Hormone secreting tumors of the ovary. Thes e t u m o r s i n clu d e f ib r om a s, S e r tol i -L e y dig c e ll tumors (Arrheno–blastomas or androblastomas ).

40. FIBROMA Most common benign, solid neoplasms of the ovary. Compose approx 5% of benign ovarian neoplasms and 20% of all solid tumors of the ovary. Frequently seen in middle-aged women. Characterized by their firmness and resemblance to myomas Misdiagnosed as exophytic fibroids or primary ovarian malignancy Not hormonally active Fibromas may be associated with ascites or hydrothorax as a result of increased capillary permeability .

41. Gross appearance of an ovarian fibroma .

42. FIBROMA: -origin: stromal cells of ovarian cortex -small nodule with long pedicle ,solid, smooth surfaced tumour -microscopy: interlacing bundles of spindle shaped cells -complication: torsion ,meig syndrome ANDROBLASTOMA/SERTOLI-LEYDIG CELL TUMOR -testicular adenoma -androgen secreting tumour -seen in women less than 30 year s -gynandroblastoma (granulosa + androblastoma cells) -cf: amennorhoea, atrophy of breasts, enlargement of clitoris, body hair growth, deepening of voice.

43. THECOMA Solid fibromatous lesions that show varying degrees of yellow or orange discoloration . Almost always confined to one ovary . Usually >40 years, 65% after menopause May be hormonally active and hence associated with estrogenic or occasionally androgenic effects. Luetinised thecoma – younger, sclerosing peritonitis and ascites Leydeig cell thecoma – ass ociated with Reinke crystals Rarely malignant

44. 4. GONADOBLASTOMAS Gonadoblastoma is a rare benign tumor that has the potential for malignant transformation and affects a subset of patients with an intersex disorder or disorder of sex development (DSD). Contain both germ cells and sex cord stromal cells. Arise in patients with dysgenetic gonads - 4 4 X XY / 45XO Presents usually as phenotypic female <30 years with primary amenorrhea and virilization. Treatment – laparoscopy or laparotomy with removal of b/l dysgenetic gonads. Further treatment depends on malignant germ cell component

45. On clinical examination (Differences b/w benign & malignant) Character Age L a t e r ality Mobility Feel Surface Ascites Growth nodules M a lig n a n t older Bilateral Fixed Solid Irregular Present Rapid Present Be n ign younger unilateral Mobile Cystic Smooth Absent Slow Absent

46. DIAGNOSTIC Criteria on USG BENIGN U/L ,uni/multi locular Cystic areas with regular thin wall , thin septa and nonechogenic cavity TVS(doppler) shows regular vascular branching MALIGNANT B/L, thick wall, thick septa, echogenic areas in cavity . Irregular heterogenous parts TVS neovascularisation

47. US G : Benign Malignant

48. CLINICAL FEATURES AGE :- late child bearing age -dermoid, mucinous adenoma common in reproductive period. -dermoid common in pregnancy symptoms: -asymptomatic detected accidently -heaviness in lower abdomen, a gradually increasing mass in lower abdomen dull aching pain, - c a r dio r espi r at o r y & g a s t r oi n t e s tinal u p s e t (nausea, indigestion) -menstrual pattern unaffected except in hormone producing tumours signs : cachetic due to protein loss , pitting edema of legs

49. ABD OMINAL EXAMINATION Inspection -- bulging of lower abdomen mass – central/ one side/ whole abdomen visible veins , flanks – flat Palpation -- cystic / tense cystic freely mobile from side to side but restricted from above down, smooth surface , nontender Percussion -- dull in center and resonant in flanks fluid thrill + Auscultation -- friction rub + Bimanual pelvic examination -- uterus separated from mass G roove is felt between uterus & mass movement of mass p/a fails to move cx lower pole of cyst felt through fornix absence of pulsation of ut vessels thro ugh the forni ces

50. INVESTIGATION S To confirm diagnosis USG Straight x-ray abdomen CT Laproscopy Laparotomy Cytology

51. D ifferential D iagnosis Full bladder Pregnancy Pregnancy with fibroid Ascites Fibroid uterus Encysted peritonitis Functional ovarian cyst

52. COMPLICATIONS Torsion of the pedicle Intracystic h aemorrha ge Infection Rupture Malignancy Pseudomyxoma peritonei Torsion: (axial rotation) 10 – 15% cases moderate size & moderate wt free mobility & long pedicle common in dermoid or serous cystadenoma Causes: -Trauma, violent physical movement, contraction of preg nant uterus, intestinal peristalsis.

53. Symptoms- acute pain + lump, vomiting, fever, shock , tachycardia. P/A : tense, tender, cystic mass with restricted mobility P/v : mass abd omen separate from uterus DD: Disturbed ectopic preg nancy Acute hydramnios Perforating h ydatidiform mole Torsion of subserous pedunculated fibroid Rx: Pain– morphine Laparotomy ( cystectomy/ salpingoophorectomy )

54. INTRACYSTIC H aemorrha GE: -serous cystadenoma, malignancy. -venous congestion. INFECTION: -following torsion -organisms – from intestine, uterine tubes. RUPTURE : -big & tense cyst -trauma, malignancy, papillary type. PSEUDOMYXOMA PER I TONEI : -mucinous ascites - asso ciated with mucinous cyst adenoma ovary, mucocele appendix & gall bladder, intestinal malignancy. -spontaneous perforation -recurrence high, prognosis poor ( infection, intestinal obstr uction ) - Rx : hystrectomy, BSO (Bilateral salphingo-OOphorectomy ) with removal of mucin, peritoneal implants with appendix.

55. Metastatic tumors (SECONDARY METASTASIS) Always bilateral. From mucin secreting tumors, stomach and colon (krukenberg tumors) May be secondary to breast

56. Metastatic ovarian cancer Ku r ke nb e r g tumor

57. Second most common gynaecological malignancy Major cause of death from gyn. Cancer 2% lifetime risk (1.4% in gen eral pop ulation .) Mean age – 64y Rare in young (3% <35y)

58. Present with late stage (66% - stage 3 or more) Most common, Persistent pelvic/abdominal pain Abdominal distention/bloating Early satiety Constitutional ( fatigue,weight loss) Abnormal uterine bleeding Ascites , effusions Urinary symptoms (frequency, urgency)

59. Benign ovarian tumour or cyst. Uterine or tubal mass. Endometriosis. Bowel mass or primary peritoneal carcinoma. Secondary carcinoma: breast, gastrointestinal tract, lymphomas and pelvic-organ tumours.

60. Fixed, Hard mass arising from pelvis Ascites Adenexal mass In premenopausal <20% malignant In postmenopausal 50% malignant Pleural effusions Lymphadenopathy (cervical, inguinal)

61. To confirm the diagnosis To identify the extent of lesion To detect the primary site

62. US G abdomen and pelvis CXR AY – pleural effusions, lung met astasis Colonoscopy – bowel involvement MRI – nature of neoplasm, retroperitoneal tumors

63. US G f or suggestive of malignancy Solid + cystic areas Ascites Multilocular/complex cyst Papillary projections Neovascularization Bilateral tumor Liver deposits

64. MANAGEMENT Once an ovarian tumor is diagnosed, the patient should be admitted for operation, sooner the better. The complication can occur at any time and the nature of the tumor cannot be assessed clinically. Differentiation between benign and malignant ovarian tumours could be made by clinical examination, ultrasonography, laparotomy and finally biopsy.

65. M ANAGE M E NT Surgery Chemotherapy

66. Primarily surgical Diagnosis Staging Treatment Ideally done by Gynaecological oncologist Objective is, Accurate staging Removing all visible tumor No residual disease after laparotomy

67. INDICATIONS FOR SURGERY Any solid ovarian lesion Any ovarian lesion with papillary vegetation on the cyst wall Any adnexal mass >10cm in diameter Palpable adnexal mass in a premenarch e al or p ostmenopausal women Torsion or rupture suspected

68. Ovarian mass in reproductive age group <5 cms. >/= 5 cms U S G U S G c y stic observation Complex, solid, suspici o u s Persistence or progression surgery

69. Guidelines for surgery in benign tumor Incision should be vertical paramedian & sufficiently big enough to deliver the cyst intact. Inspect the nature of the peritoneal fluid – clear, straw colour, hemorrhagic or infective Deliver the tumor intact and note it carefully about its nature. Inspect and palpate the other ovary, pelvic organs, omentum and liver. Proceed for the definitive surgery Cut the tumor and inspect the inner side for any evidence of malignancy.

70. DEFINITIVE SURGERY: In young women- ovarian cystectomy leaving behind the healthy ovarian tissue Ovariotomy ( salpingo - o o phorectomy ) – For a big tumor . In parous women Around 40 years - TAH+BSO O thers (any age other than above) - individualisation .

71. OPERATIVE MODALITIES Laparoscopic cystectomy / ovariotomy laparoscopy/ USG guided aspiration of cyst/Laparotomy. Laparoscopy vs laparotomy – decision based on suspicion of malignancy and technical expertise No recurrence rates following laparoscopy or laparotomy. The objective is to try cystectomy if possible. Laparoscopic surgery for benign ovarian tumours is associated with less pain, shorter hospital stay, and fewer adverse events than with laparotomy.

72. The standards for laparoscopy in benign tumours careful examination of the external surface of the tumour and sampling of the peritoneal cavity avoidance of any tumoral rupture protection of the ovarian tumour with an endoscopic bag before removal

73. Borderline malignant epithelial tumours have got some features of malignancy but not all. Young females U/L : salpingo -oophorectomy Older females TAH + BSO If unfit for surgery Primary chemotherapy If responds, interval surgery after 3-6 cycles

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