Ovary slide share 2

OVARIAN TUMORS-II
Dr Aksharaditya Shukla
Resident, Department Of Pathology
MGM Medical College & M.Y. Hospital, Indore

Ovarian tumours
 Tumour of the ovary are common form of
neoplasia in women
 Accounts for 3% of all cancers in females
 80% are benign
 More common in older white women of
northern European ancestry
 90% of malignancies are carcinoma, 80% have
spread beyond the ovary at diagnosis.

Risk factors for carcinoma
 Nulliparity
 Family history
 Childhood gonadal dysgenesis
 Clomiphene
 Hereditary non polyposis colon cancer
 BRCA1 and BRCA2 mutations
 CA-125 present in 80% of serous and endometrioid
tumours
 Cytogenetics-gain of 12 & 8
 loss of chr X,22 18,17,14,13,12 & 8 ,
 benign/borderline tumor exhibit trisomy12

Classification of ovarian tumours
 Novak's classification (1967) has advantage of
being simple but has certain obvious drawbacks,
since it depends primarily on two
fundamental factors; benign or malignant
and solid or cystic.
 Thus the borderline tumors, solid tumors with cystic
degeneration and predominantly cystic tumors with
solid areas fall into grey zone.

 In 1971, the cancer committee of International
Federation of Gynecology and Obstetrics (FIGO)
proposed a histological classification of common primary
epithelial ovarian tumors. Although this classification
covered only epithelial tumors, it was a step in the
direction of uniformity in classification and it also
included the group of tumors of "low potential
malignancy".
 A significant stride in the direction of a
histogenesis-based classification system was made in
1973 with the publication of the World Health
Organization (WHO) Classification of Ovarian Tumors.
This classification system was updated in 1999 and
recently in 2003.

WHO classification of ovarian
tumours
1. SURFACE EPITHELIAL TUMOURS
2. GERM CELL TUMOURS
3. SEX CORD STROMAL TUMOURS
4. GERM CELL SEX CORD STROMAL TUMOURS
5. TUMOUR OF THE RETE OVARII
6. MISCELLANEOUS TUMOURS
7. TUMOUR LIKE CONDITIONS
8. LYMPHOID AND HEMATOPOETIC TUMOURS
9. SECONDARY TUMOURS

GERM CELL TUMOURS
 Origin- germ cells (totipotent) which migrate to ovary
from yolk sac .
 Frequency-15-20%
 Age group- children & young adults
 ~95% are benign.
The younger the patient, more chances of malignancy

Dysgerminoma
 Dysgerminoma is the most
common malignant germ cell
neoplasia of the ovary, and is
similar to seminoma which
is the testicular counterpart
 <1% of all ovarian tumors
 ≈5% of malignant ovarian
tumors
 Usually young <30 years of
age.
 ≈5% arise in abnormal gonads:
a) pure or mixed gonadal
dysgenesis (from a
gonadoblastoma),
b) testicular feminization
(androgen insensitivity)
syndrome
 More common on right.
 Bilateral in 15% of cases.
 Metastases commonly in:
* contralateral ovary
* retroperitoneal nodes
* peritoneal cavity:
(associated with
decreased survival rate).
Exceptionally associated
with hypercalcemia
Extremely radiosenstive.

DYSGERMINOMA
 Often: large:
may be >1000g
encapsulated
Smooth, often convoluted surface
 Cut surface
 solid
 gray
Cut surface of ovarian dysgerminoma.
The multinodular solid quality and the
tan color are characteristic features.
Foci of hemorrhage and
necrosis: not as common or
prominent as in other malignant
germ cell tumors.
 Typical lobulated outer
aspect of ovarian
dysgerminoma

Dysgerminoma
 Diffuse insular or trabecular pattern.
 Tumor cells: uniform
* nuclei: Central large
 nucleoli:
- one or more
- prominent
* cytoplasm:
-abundant
- clear to finely
- contains:
+ glycogen
+ sometimes fine droplets of fat
* cell membrane prominent
 fibrous strands infiltrated by lymphocytes
(most T-cell type5)
 May be:
* focal necrosis
* hyaline changes in vessels
* germinal centers
* granulomatous fociDr Aksharaditya Shukla

Special Stains and Immunohistochemistry
of dysgerminoma
 Tumor cells reactive for:
-PLAP
-CD117 (c-KIT)
 Often keratin (erratically and focally)
 Sometimes
-GFAP
-Desmin

Yolk Sac Tumor
 Malignant germ cell tumor of the ovary developed as a result of
differentiation of primitive malignant germ cell
elements in the direction of yolk sac or vitelline
structures.
 Usually children and young adults:
* Median age 19 years
* ≈25% prepubertal at diagnosis
 Vaginal bleeding in 1%
 Serum AFP level invariably elevated
 Chorionic gonadotropin levels normal.
 Highly aggressive, and associated with other germ cell tumour

Yolk Sac Tumor
 Average diameter
15cm
 External surface:
* smooth
* glistening
 Cut surface:
* variegated
* partially cystic
* often large foci of
hemorrhage and
necrosis
 Component of benign
cystic teratoma in
≈15% of cases
 Gross appearance of yolk sac tumor. The cut surface is
remarkably heterogeneous due to extensive hemorrhage,
necrosis, and cystic degeneration

YOLK SAC TUMOR
 Many histologic variants occur,
including the reticular,
endodermal sinus (papillary),
polyvesicular–vitelline,
hepatoid, and glandular
patterns.
 The endodermal sinus pattern
is the second most common
pattern(after reticular).
 This pattern features
characteristic Schiller–
Duvall bodies (rounded
papillae containing a single
central vessel and lined by
columnar tumor cells) .

YOLK SAC TUMOR
 PAS-positive hyaline droplets
* intracytoplasmic and
extracellular
* nearly always present
 High-power view of ovarian yolk
sac tumor. Numerous hyaline
globules are seen in the cytoplasm
of the tumor cells lining the
papillae

Yolk Sac Tumor
 Some show
differentiation
toward hepatic,
intestinal, and
parietal yolk sac
structures
 Yolk sac tumor with
endometrioid features

Special Stains and
Immunohistochemistry
 Yolk sac tumor:
stains positive for : pankeratin
negative for : keratin 7:
(in contrast with endometrioid and clear cell ovarian ca)
stains positive for -WT-1:
( in contrast with serous ovarian carcinoma)
 Hyaline droplets:
- usually stain for α-fetoprotein
- may also contain:
- α1-antitrypsin
- basement membrane components:
#type IV collagen
# laminin

Embryonal carcinoma
 Rare and the least differentiated of the ovarian germ cell
tumors.
 Considered to be homologous to the embryonal carcinoma of
adult testis.
 Young age group (median age 15 years):
 47% prepubertal at diagnosis, 43% of whom present with
precocious puberty
 Vaginal bleeding in 33%
 Amenorrhea in 7%
 Hirsutism in 7%
 Serum α-fetoprotein levels often elevated
 Chorionic gonadotropin levels invariably high:
 results in consistently positive pregnancy tests

Embryonal carcinoma
 Median diameter
17cm.
 smooth and
glistening.
 Cut surface:
 predominantly
solid and
variegated.
 extensive areas of
necrosis and
hemorrhage.
 Gross appearance of embryonal
carcinoma of ovary.

Embryonal carcinoma
 Similar appearance to
embryonal carcinoma of
adult testis.
 Solid sheets and nests of
large primitive cells:
 occasionally forming
papillae and abortive
glandular structures.
 Frequently
syncytiotrophoblast-like
tumor cells scattered
among smaller cells
 Microscopic appearance of embryonal
carcinoma of ovary

Special Stains and Immunohistochemistry of embryonal
carcinoma
 Syncytiotrophoblast-like tumor cells
immunoreactive for hCG.
 CD30 and cytokeratin

Choriocarcinoma
 Malignant tumor of the ovary with trophoblastic
differentiation composed of syncytiotrophoblast,
cytotrophoblast and intermediate trophoblast.
 Exceedingly rare.
 May be associated with mature cystic teratoma of
contralateral ovary.

Choricarcinoma
 Typical admixture of
syncytial and
cytotrophoblastic
elements in a
necrotic and
hemorrhagic
background
 Choriocarcinoma arising in a
dermoid cyst

 Usually immunohistochemical reactivity
for hCG.
 Keratin 7 said to represent a marker for
subset of trophoblastic cells.
 LK26 (a folate-binding protein):
- consistently expressed

References
 ROSAI AND ACKERMAN`S SURGICAL PATHOLOGY
 DIAGNOSTIC SURGICAL PATHOLOGY- STERNBERG
 PATHOLOGIC BASIS OF DISEASE– ROBBINS AND
COTRAN
 ANDERSON`S PATHOLOGY
 CURRAN`S ATLAS OF PATHOLOGY
 WWW.WEBPATH.COM

Thanks
 Presented By: Dr Aksharaditya Shukla
Resident, Department Of Patholgy

OVARIAN TUMOURS II
 Moderator: Dr Poonam Nanwani
Asst. Prof. Department Of Pathology

Immature Malignant Teratoma
 Malignant ovarian
germinal tumor composed
of mixture of immature
embryonal and mature
adult tissue derived from
all three germ layers.
 Usually children and
adolescents.
 May be:
* solid throughout
* solid with multiple
minute cysts
* predominantly cystic
 Gross appearance of
ovarian immature
teratoma

Immature teratoma
 Mixture of embryonal and adult
tissues derived from all three
germ layers:
* any type of tissue
* main component usually
neuroepithelial
* mesodermal elements also
common
* sometimes predominantly
composed of endodermal
derivatives, including
-esophagus
- liver
-intestinal structures
This is immature teratoma containing
immature neuroepithelium forming
rosettes
 immature teratoma
containing immature
neuroepithelium forming
rosettes.

Grading system for immature teratoma
(Norris et al)
 Grade I
a. Abundance of mature tissues
b. Loose mesenchymal tissue with
occasional mitoses
c. Immature cartilage
d. Tooth anlage
 Grade II
a) Fewer mature tissues
b) Rare foci of neuroepithelium
with common mitoses not
exceeding three low-
magnification (×10) fields in any
one slide
 Grade III
a) Few or no mature tissues
b) Numerous neuroepithelial
elements merging with a cellular
stroma occupying four or more
low-magnification fields

 Glial fibrillary acidic protein (GFAP):
- helpful in identification of mature and
immature glial tissue
- also detectable in chondrocytes
 * Long-chain polysialic acid moiety of neural cell
adhesion molecule:
- another marker of immature and mature neural tissue

Mature Cystic Teratoma
 Cystic germ cell tumors
composed of multiple mature
elements derived from
ectoderm, mesoderm and
endoderm.
 Almost 20% of all ovarian
neoplasms:
 Most common ovarian tumor
in childhood
 88% unilateral
 usually benign
 Symptoms:
* relate to mass
* occasionally:
- hemolytic anemia
- virilization
* May coexist with:
- mucinous
cystadenoma
- Brenner tumor
- * Usually benign

 Usually multiloculated
 Cystic content:
 greasy
 largely composed of:
 keratin
 sebum
 hairs
 commonly teeth
(tend to be in well-defined
nipple-like structure covered
with hair (Rokitansky's
protuberance)
 Admixture of sebum and hair within
the cavity of an ovarian mature cystic
teratoma

Mature cystic teratoma
 #Cystic cavities lined by
mature epidermis
 Extremely common:
* skin appendages
* neural (particularly glial)
tissue
 Also:
* cartilage
* respiratory tissue
* gastrointestinal tract tissue
(- may be peptic ulcer
formation)
Mature cystic teratoma of ovary:
gastric mucosa of pyloric type

Germ cell tumors (continued)
 Monodermal
teratoma
a) Thyroid tumour group
Struma ovarii –benign or
malignant
b) Carcinoid group
-insular
-trabecular
-mucinous
-strumal carcinoid
c) Neuroectodermal tumour group
-ependymoma
-primitive neuroectodermal
tumour
-glioblastoma multiforme
-medulloblastoma
d) Carcinoma
e) Melanocytic group
f) Sarcoma group
g) Sebaceous tumour group

Struma Ovarii
 Ovarian teratoma composed exclusively or predominantly of
thyroid tissue
 May show any of the pathologic changes seen in a normally
placed gland, including:
diffuse or nodular hyperplasia:
- may lead to
hyperthyroidism
- thyroiditis
-carcinoma:
( sometimes resulting in metastases)
 Thyroid nature fully documented with biologic and
immunohistochemical studies for thyroid hormones

Struma Ovarii
 Color and
consistency of
thyroid tissue, but
often cystic

Struma Ovarii
 Dominant growth
of thyroid tissue in
a teratoma,
sometimes to
exclusion of other
components
 Struma ovarii. The thyroid tissue,
which has a microscopically
unremarkable appearance, is sharply
delimited from the ovarian stroma

Carcinoid Tumor (monodedrmal teratoma)
 Primary well differentiated neuroendocrine tumor of the
ovary.
 Carcinoid syndrome:
* more likely the larger tumor ( > 7 cm)
 Sometimes severe constipation:
* presumably due to secretion of peptide YY

carcinoid
 Usually unilateral
 Mean diameter 10 cm
* smooth or bosselated
* predominantly solid
* firm
* tan to yellow
Cut surface of carcinoid
tumor of ovary showing
typical solid
appearance and white
to yellowish color
 Cut surface of carcinoid tumor of ovary
showing typical solid appearance and white
to yellowish color

Carcinoid (monodermal teratoma)
 insular pattern of
growth similar to in
appendix and small
bowel
 -trabecular appearance
similar to in rectum
- mucinous (goblet cell)
appearance similar to
those seen primarily in
appendix
 Primary ovarian carcinoid tumor with a
trabecular pattern of growth

1. SURFACE EPITHELIAL TUMOURS
2. GERM CELL TUMOURS
3. SEX CORD STROMAL TUMOURS
4. GERM CELL SEX CORD STROMAL
TUMOURS
5. TUMOUR OF THE RETE OVARII
6. MISCELLANEOUS TUMOURS
7. TUMOUR LIKE CONDITION
8. LYMPHOID AND HEMATOPOETIC
TUMOURS
9. SECONDARY TUMOURS.
SEX CORD STROMAL TUMOURS

Granulosa stromal cell tumours
 Sertoli stromal cell tumours
 Sex cord stromal tumours of mixed or
unclassified cell types.
 Steroid cell tumours
SEX CORD STROMAL TUMOURS

Granulosa stromal cell tumours
(SEX CORD STROMAL TUMOURS)
 Granulosa cell
tumour group
a) Adult granulosa cell tumour.
b) Juvenile granulosa cell
tumour.
 Thecoma fibroma
group
a) Thecoma (typical or
lutenised)
b) Fibroma
c) Cellular fibroma
d) Fibrosarcoma
e) Sclerosing stromal
tumours
f) Signet ring stromal tumour
g) Stromal tumour with minor
sex cord elements
h) Unclassified

Granulosa Cell Tumor group
(sex cord stromal tumor)
 Differentiation towards follicular granulosa cells that can
occur in adults (adult granulosa cell tumor) and in younger
patients (juvenile granulosa cell tumor).
 Two distinct types:
* adult
* juvenile

 Adult Granulosa Cell Tumor
 Usually childbearing age.
 - 75% have hyperestrinism, which may result in:
+isosexual precocious puberty
+metrorrhagia in adults, including
postmenopausal women
 Elevated serum inhibin and follicle regulatory proteins.

AGCT
 The tumors are usually large
(>10 cm) and unilateral.
 The cut surface is soft and
yellow-tan with cysts and
hemorrhage.
 encapsulated
 smooth, lobulated outline
 Cut surface:
-predominantly solid
 May be:
cystic:
 -filled with straw-colored
or mucoid fluid
-sometimes so prominent
as to simulat appearance
of a cystadenoma
 Granulosa cell tumor with solid cut
surface.

AGCT
 Different histologic patterns
occur, including microfollicular,
macrofollicular, “watered-silk,”
gyriform, and diffuse.
 However, all are composed of
round to oval granulosa cells
that have little cytoplasm and
round to angular nuclei with
longitudinal nuclear grooves
(coffee bean appearance)
 There is minimal cytologic
atypia
 Mitotic rate is low.

Coffee-bean( longitudnally grooved) nuclei in adult type
of ovarian granulosa cell tumor

 The microfollicular
and diffuse
variants often
contain
characteristic
Call–Exner
bodies consisting
of a very small
collection of
eosinophilic
material lined by
well-differentiated
granulosa cells.

Juvenile Granulosa Cell Tumor
More aggressive than adult
 More likely to produce distant metastases
 ≈80% during first two decades
of life
* Usually presents with isosexual precocity
* Occasionally associated with:
- enchondromatosis (Ollier's disease)
- Maffucci's syndrome

Juvenile Granulosa Cell
Tumor
 Typical morphologic features
include:
diffuse or macrofollicular patterns
of growth (former
predominating)
- eosinophilic mucin-positive
intrafollicular secretion.
- larger tumor cells with
extensive luteinization
- paucity of nuclear grooves
- nuclear atypia
- variable but often high mitotic
activity.
On high power the tumor cells lack
the coffee-bean nuclei seen in the
adult type
 The follicle-like spaces seen on low-power
examination are a common feature of this
neoplasm.

Special Stains and Immunohistochemistry granulosa cell
tumors
 Adult Granulosa Cell Tumor
* Immunohistochemically:
- steroid production:
+ by both theca and granulosa cells
with predominance of:
# estradiol in granulosa cell
# progesterone in luteinized theca
cells
- vimentin
- desmoplakin (desmosomal plaque
protein)
 - inhibin (also JGCT)
 follicle regulatory proteins
- CD99
 keratin:
+ 33–50% of cases
+ typical dot-like distribution
+ mainly CK8 and CK18 types25,26
 smooth muscle actin:
+ nearly all cases
 S-100 protein: + ≈50% of cases
Strong immunoreactivity for inhibin in
granulosa cell tumor.

Thecoma
 Postmenopausal women.
 Symptoms of hyperestrogenism.
 Most are unilateral and can measure up to 10 cm in
diameter.
 Immunohistochemically, the tumor is positive for
inhibin expression. Oil Red O fat stains (which
require fresh tissue) highlight the intracellular lipid.

Thecoma
Cut surface of thecoma showing a predominance of
yellow areas alternating with whitish foci
 Variable size
 Well-defined capsule
 Firm consistency
 Cut surface:
* largely or entirely solid
* may be cysts
 Yellow color

THECOMA
 Fascicles of spindle cells with:
centrally placed nuclei
moderate amount of pale
cytoplasm.
 Only mild atypia and rare mitoses
 Intervening tissue may show:
-considerable collagen
deposition.
- focal hyaline plaque
formation.
 Degree of cellularity varies
considerably
 Some in young women are
heavily calcified
 Bland microscopic appearance of
thecoma, with some variability in
cellularity.

 Oil red O: (require fresh tissue)
- abundant intracytoplasmic neutral fat
 Positive for inhibin expression
 Silver stains:
 Estradiol usually limited to a small number of tumor cell

FIBROMA
 The most common type of sex-cord stromal tumor developing
from specialized ovarian stroma.
 Common
 Almost invariably after puberty
 Fibromas are not hormonally functional
 average of 5 cm in diameter
 Sometimes in young women with basal cell nevus (Gorlin's)
syndrome.
 Benign
 May be ascites:
 especially if large
 sometimes with right-sided pleural effusion (Meigs' syndrome)
(disappears on removal of tumor).

Gross Pathology
 Solid
 Lobulated
 Firm
 Uniformly white
 Usually no adhesions
 Average diameter 6cm
 May be myxoid changes,
sometimes resulting in cystic
degeneration
Cut surface of ovarian
fibroma.
 Outer aspect of ovarian
fibroma

FIBROMA
 Spindle stromal cells:
- closely packed
- arranged in 'feather-stitched'
or storiform pattern
- no atypia and few mitoses
 May be:
- hyaline bands
- edema
 If in basal cell nevus (Gorlin's)
syndrome:
- calcified
- usually bilateral
- often multinodular

Cellular fibroma. The tumor is
hypercellular, but
pleomorphism and mitotic
activity are minimal

Immunohistochemistry of Fibromas
 diffusely positive for vimentin

Small Cell Carcinoma
 Poorly differentiated tumors,
composed mostly of small
cells, and subclassified into
hypercalcemic and pulmonary
type
 Two types:
* hypercalcemic:
-most common
* pulmonary
 Hypercalcemic-type Small
Cell Carcinoma
 Young females
(average age 23 years)
 Nearly always bilateral
 Occasionally familial
 Hypercalcemia:
- 67% of cases
- disappears following
removal
 * High-grade malignancy

Gross Pathology
 Hypercalcemic-type
Small Cell Carcinoma
 Large and solid
 Areas of necrosis and
hemorrhage

Hypercalcemic-type Small Cell Carcinoma
 Diffuse proliferation of small, closely
packed cells of carcinomatous
appearance with:
- scant cytoplasm
- small nuclei
 May be:
- clusters of larger and more
pleomorphic cells,
some resembling luteinized cells:
+ if a large number referred to as
large variant
of small cell carcinoma
- cytoplasmic hyaline globules
- islands
- cords
- mucinous glands
- follicle-like structures
+ important clue to diagnosis
 Small cell carcinoma, hypercalcemic type.
The presence of follicle-like formations is an
important diagnostic feature

Pulmonary-type Small Cell Carcinoma
 Resembles homonymous
lung tumor.
 May be pure or associated
with endometrioid
carcinoma or other
patterns.
 Ultrastructurally:
- neurosecretory-type
granule

Ovary slide share 2

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Ovary slide share 2

Similar to Ovary slide share 2 (20)

Recently uploaded

Recently uploaded (20)

Ovary slide share 2

Editor's Notes