This document summarizes ovarian tumors. It notes that ovarian tumors are common in women and most are benign. Malignant tumors often spread beyond the ovaries at diagnosis. Risk factors for carcinoma include nulliparity and family history. Ovarian tumors are classified into surface epithelial tumors, germ cell tumors, sex cord stromal tumors, and other categories. Within sex cord stromal tumors are Sertoli-Leydig cell tumors and steroid cell tumors. Metastatic tumors from other organs like the stomach or colon can also involve the ovaries.
2. 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.
Dr Aksharaditya Shukla
3. 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
Dr Aksharaditya Shukla
5. 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.
Dr Aksharaditya Shukla
6. 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.
Dr Aksharaditya Shukla
7. 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
Dr Aksharaditya Shukla
8. 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
Dr Aksharaditya Shukla
9. Sertoli stromal cell tumors
Sertoli leydig cell
tumour group
(androblastoma).
a) well differentiated
b) intermediate
differentiation
c) poorly differentiated
(sarcomatoid)
d) retiform
2. Sertoli cell tumour.
3. Stromal leydig cell
tumour
Dr Aksharaditya Shukla
10. Sertoli leydig cell tumor
Young patients (average 25 years)
50% shows signs of androgen excess i.e
defeminisation
(breast atrophy, loss of subcutaneous Fat)
Later masculinisation appears
Dr Aksharaditya Shukla
11. Sertoli leydig cell tumor
Mixture of variable
proportions of cells
morphologically
resembling male sertoli
and leydig cells.
0.1% of ovarian neoplasms.
Grossly predominantly
solid.
Variegated appearance of
cut surface of ovarian
Sertoli–Leydig cell tumor.
Dr Aksharaditya Shukla
12. Microscopic pattern
Well differentiated
(meyer’s type I)
Tubules lined by
sertoli like cells
seperated by
variable number of
leydig like cells
Well-differentiated
(Meyer’s type I) Sertoli–Leydig cell
tumor.
Dr Aksharaditya Shukla
13. Microscopic patterns of SLCT
Intermediate
(meyer’s type II)
Formation of cords,
sheets sertoli like
cells seperated by
spindle stromal cells
Dr Aksharaditya Shukla
14. Microscopic patterns of SLCT
Poorly
differentiared
(meyer’s type III)
Composed of
masses of spindle
shaped cells
arranged in
“sacomatoid”
pattern
Dr Aksharaditya Shukla
15. Special Stains and Immunohistochemistry of
SLCT
Testosterone and estradiol both in sertoli and
leydig cells
Areas of sertoli cell differentiation are Keratin+
Gonadal stromal components- inhibin+
Dr Aksharaditya Shukla
16. Sex Cord Tumor with Annular Tubules
(Sex cord stromal tumours of mixed or unclassified cell types )
A distinctive variant of sex
cord stromal-tumor with
features of Sertoli and
granulosa cell
differentiation, divided in
two subsets including those
associated with Peutz-
Jeghers syndrome and those
without such association
33% associated with Peutz–
Jeghers syndrome
Symptoms suggestive of
hyperestrinism in ≈50%
Gross Pathology
If associated with Peutz–
Jeghers syndrome typically:
- multifocal
- bilateral
- small (or even
microscopic)
- calcified
- benign
* If unassociated with Peutz–
Jeghers syndrome:
- unilateral
- often large
- ≈22% of cases clinically
malignantDr Aksharaditya Shukla
17. Sex cord tumor with
annular tubules
Combines:
- features suggestive
of granulosa cell
tumor
- pattern of growth
reminiscent
sertoli cells
Simple and complex
annular tubules
containing eosinophilic
hyaline bodies, often
calcified.
- morphologic
hallmark
Sex cord tumor with annular tubules. The
patient had Peutz–Jeghers syndrome
Dr Aksharaditya Shukla
18. Steroid cell tumor
(Sertoli stromal cell tumors)
Syn. Lipid, lipoid cell tumor
Heterogeneous group of
tumors composed entirely of
cells with morphologic
features indicative of steroid
hormone secretion.
Any age
Most associated with a
virilizing syndrome
(defeminization and
amenorrhea)
Sometimes:
- Cushing's syndrome
-associated with
endometrioid carcinoma
Dr Aksharaditya Shukla
19. Gross Pathology
Usually unilateral
Composed of yellow or
yellowish brown nodules
separated by fibrous
trabeculae
Malignant tumors tend to:
- be larger (≥06cm in
diameter)
- have foci of necrosis and
hemorrhage
Cut surface of ovarian lipid cell
tumor.
Dr Aksharaditya Shukla
20. Steroid cell tumor
Masses of large rounded or
polyhedral cells
Composed entirely of cells with
features indicative of steroid
hormone secretion:
cytoplasm:
+ abundant
+ eosinophilic
+ may be vacuolated
+ often positive for fat
stains
Malignant tumors tend to
exhibit:
- nuclear atypia
- mitotic activity
Dr Aksharaditya Shukla
21. Special Stains and Immunohistochemistry
* Immunohistochemically:
- reactivity for:
+ vimentin in 75%
+ keratin in 50%
+ actin in ≈33%8
consistent reactivity for:
- inhibin
- A103
- Mart-1
Dr Aksharaditya Shukla
22. GERM CELL SEX CORD STROMAL
TUMOURS
a) Gonadoblastoma
b) Mixed germ cell sex cord stromal tumour
Dr Aksharaditya Shukla
23. Gonadoblastoma
Tumor composed of a combination of germ cells and sex-cord cells that
arises almost exclusively in dysgenetic gonads.
Usually sexually abnormal:
commonly gonadal dysgenesis and carrying Y chromosome, i.e.:
- XY gonadal dysgenesis
- XO–XY mosaicism
- but not XX gonadal dysgenesis1
estimated 25% risk of neoplasia in these dysgenetic gonads
Also documented in:
* phenotypically and chromosomally normal females, even during
pregnancy
* ataxia–telangiectasia
Dr Aksharaditya Shukla
24. Gross Pathology
Usually small
Often impossible to
determine nature of gonad
bearing tumor:
- sometimes identified as:
+ a streak(many become
apparent only on
microscopic examination)
+ cryptorchid testis
Never a normal ovary
* ≈36% bilateral
Streak gonad microscopically shown to
contain gonadoblastoma. The tumor
was barely apparent grossly.
Dr Aksharaditya Shukla
25. Gonadoblastoma
Admixture of:
primitive germ cells:
resembling those of
dysgerminoma
sex cord–stromal cells:
resembling
morphologically and
immunohistochemical
ly immature Sertoli
and granulosa cells
Commonly:
hyalinization:
when abundant may
be obvious on plain
abdominal radiograph
calcification
Ovarian gonadoblastoma. Note the sharply outlined
tumor nests and the heavy calcification
Dr Aksharaditya Shukla
26. Special Stains and Immunohistochemistry
Hyaline material reacts strongly with anti-laminin
antibodies,
Dr Aksharaditya Shukla
27. Metastatic tumors
Malignant secondary tumors
involving ovaries originated in
other organs.
* ≈7% of lesions presenting as
primary ovarian tumors are
metastatic
* >50% bilateral
* Most common sources:
- stomach
- large bowel
- appendix
- breast
- uterus (corpus and cervix)
- lung
- skin (melanoma)
Metastases From Breast Carcinoma
* Immunoreactive for GCDFP-15:
- important in differential diagnosis
with primary ovarian carcinoma, which
is generally negativeDr Aksharaditya Shukla
29. Krukenberg Tumors
Usually:
* >40 years of age
* bilateral
* metastatic origin
Usual primary sources:
* stomach:
- diffuse gastric carcinoma (linitis plastica) used to be most
common
* large bowel, Appendix, Breast
May be:
* retroperitoneal lymph node metastases
* peritoneal implants
Dr Aksharaditya Shukla
30. Gross Pathology
Krukenberg Tumor
Moderate solid
multinodular
enlargement of the
ovaries.
Typical gross appearance of
Krukenberg tumors of ovary. The
involvement is bilateral and the
tumors are characterized by a
multinodular outer appearance
Dr Aksharaditya Shukla
31. Krukenberg Tumor
* Diffuse infiltration by signet
ring cells
- signet ring cells.
* Tumor emboli >50% of cases
Krukenberg tumor of ovary.
Presence of intracellular
mucin
Dr Aksharaditya Shukla
32. Features favoring primary
ovarian tumor:
* expansile (pushing)
pattern of invasion
* complex papillary
architecture
* size over 10cm
* smooth external surface
* benign- and borderline-
appearing foci
Ovarian metastases tend to
be:
* cystic
* well differentiated
* mucin-producing
* associated with necrosis
and hemorrhage
Dr Aksharaditya Shukla
33. 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
Dr Aksharaditya Shukla
34. Thanks
Presented By: Dr Aksharaditya Shukla
Resident, Department Of Patholgy
MGM Medical College & M.Y. Hospital, Indore
Dr Aksharaditya Shukla
Editor's Notes
Ocps, salphingooprectomy pregnancy before 25 yrs are associated with decreased risk. abdominal enlargement, pressure on adjacent organs.