1. Ovarian neoplasms.
Ovarian neoplasms. Anita Chudecka - Głaz

2. Human ovarian neoplasms (especially epithelial ovarian cancer) presents a major challenge to oncological research , because they are frequently diagnosed late and show poor prognosis and low survival despite the apparent success of chemotherapy in achieving remission with no evidence of disease.
Ovarian neoplasms. Anita Chudecka - Głaz

3. Epithelial ovarian cancer is the fourth most common cause of death from cancer in women and the most lethal of gynaecologic neoplasms.
Epithelial ovarian cancer is the fourth
most common cause of death from cancer in women
and the most lethal of gynaecologic neoplasms.
It is fourth most frequent cause of cancer death among women after lung cancer, breast cancer and colorectal cancers .
Ovarian neoplasms. Anita Chudecka - Głaz

4. BUT EARLY STAGE OVARIAN CANCERS DON’T PRODUCE SYMPTOMS !!!
The most important positive prognostic feature continues to be diagnosis at an early stage.
BUT EARLY STAGE OVARIAN CANCERS DON’T PRODUCE SYMPTOMS !!!
Ovarian neoplasms. Anita Chudecka - Głaz

5. The incidence of ovarian cancer is relatively high in Scandinavian (15/100000) countries , lower in western Europe and North America ( 10/ ) and low in Japan (3/100000).
Ovarian neoplasms. Anita Chudecka - Głaz

6. ETIOLOGY
Two hypotheses have been proposed to explain the biological mechanisms that increase the risk of ovarian cancer :
genetics
gonadotropin hypothesis
Ovarian neoplasms. Anita Chudecka - Głaz

7. ETIOLOGY
The involvement of gonadotropins in human ovarian carcinoma is backed by a number of epidemiological and experimental studies showing:
increase occurrence of disease with exposure to high levels of LH , FSH during menopause , after ovariectomy or during fertility treatment
Ovarian neoplasms. Anita Chudecka - Głaz

8. ETIOLOGY
reduced risk of cancer associated with multiple pregnancies, oral contraceptives , breast - feeding
LH and hCG receptors are expressed in 40% of epithelial ovarian cancer
LHRH receptors are expressed in almost 80% of EOC
* INCOMPLETE PREGNANACIES also reduce risk although not as much as fulltherm pregnancies.
* WHAT IS INTERESTING THAT PROSPECTIVE INVESTIGATIONS INDICATE THAT A LARGE AGE AT FIRST BIRTH REDUCE EPITHELIAL OVARIAN CANCER RISK.
*LACTATION PROTECTS AGANIST EPITHELIAL OVARIAN CANCER ESPECIALLY LACTATION CLOSE AFTER DELIVERY
* EVER USERS OF OC HAVE 30 % LOWER RISK COMPARED WITH NEVER USERS . tHE PROTECTION INCREASED WITH DURATION OF oc USE , BEING ABOUT 50% AFTER 5 YEARS. tHE REDUCE RISK AMONG PAST OC USERS PERSIST FOR AT LEAST 10 YEARS AFTER CESSATION OF USE.
Ovarian neoplasms. Anita Chudecka - Głaz

9. ETIOLOGY
deficit of cases of ovarian cancer among women with diagnosis of alcoholism in
animals ovarian cancer may be induced by gonadal radiation or chemical toxins that cause premature oocyte death , but hypophysectomized animals do not develop ovarian tumours after oocyte depletion which suggests a specific role of gonadotropins
Ovarian neoplasms. Anita Chudecka - Głaz

10. ETIOLOGY other risk factors: diet talc pelvic irradiation viruses age
AGE- younger women under 30 had better prognosis than women with an older age at diagnosis bacouse of higher rate of early stage and low grade tumours
TALC-which contents asbestos
DIET- Cramer found that lactose consumption may be a dietary risk factor and significant consumption of animal fat may also be a risk factor
VIRUSES- especially mumps virus , but only in women who didn't have clinical symptoms of mumps but they have antibodies
Ovarian neoplasms. Anita Chudecka - Głaz

11. ETIOLOGY other risk factors: PID endometriosis blood group
legal status
education
BLOOD GROUP- especially women with group A
LEGAL STATUS- unmerried women
EDUCATION- high education
Ovarian neoplasms. Anita Chudecka - Głaz

12. SYMPTOMS
EOC oftenest are asymptomatic until advanced stage , when the prognosis is poor and 5 year survival less then 40%.
EOC
oftenest are asymptomatic until advanced stage ,
when the prognosis is poor
and 5 year survival less then 40%.
Unfortunately 70% of cases are not detected until the advanced stage , when the extensive surgery and chemotherapy offer a dismal prognosis in the best cases.
Ovarian neoplasms. Anita Chudecka - Głaz

13. SYMPTOMS
Irrespective of histology , most ovarian neoplasms when they have large size in advanced stage cause symptoms by exerting pressure on contiguous structures (urinary frequency, pelvic discomfort and constipation).
Ovarian neoplasms. Anita Chudecka - Głaz

14. SYMPTOMS The most common : abdominal swelling fatigue abdominal pain
Ovarian neoplasms. Anita Chudecka - Głaz

15. SYMPTOMS
Upper abdominal metastases or ascites cause nausea, heart burn , bloating , weight loss and anorexia.
Acute abdominal pain secondary to haemorrhage , rupture or torsion can all result from tumour growth.
Ovarian neoplasms. Anita Chudecka - Głaz

16. SYMPTOMS
Biologically active hormones , including estrogen, progesterone, testosterone , corticosteroids and hCG can be produce by a variety of ovarian neoplasms and cause the predicted symptoms associated with each compound.
Ovarian neoplasms may produce not only steroid hormones.
Teratomas can contain also thyroid tissue which can produce hyperthyroid state. Also teratomas can cause autoimmune hemolytic anaemia but by unnown mechanism of action.
Ovarian neoplasms. Anita Chudecka - Głaz

17. DIAGNOSIS
1. Physical examination-bimanual rectovaginal pelvic examination
2. Ultrasound investigation
3. Tumour markers
4. Ascites puncture
5. Biopsy the tumour
6. Laparoscopy
7. CT
8. NMR
9. Chest X ray
PHYSICAL EXAMINATION- a complete physical examination is imperative when evaluating a patient with known or suspected pelvic mass always keeping in mind differential diagnosis
- abdominal examination including palpation of all four quadrants can diagnose ascites or upper abdominal mass
- a lypmh node-bearing(zachowanie) including axillary nodes should be palpated carefully
- auscultation of both lungs becouse of pleural effusion suspected
- pelvic examination is the most important part of physical
diagnosis of pelvic mass . Always inspect the vulva, vagina and cervix first look for presence of any other disease
process and displacement (przemieszczenie) secondary to a mass. Palpation of both adnexa should be carefully undertaken. In premenopausal the ovaries are: 3x2x2 cm In postmenopausal women they should be approximately ( około) the size of an almond 2x1x1,5 cm.
- rectal examination to evaluation the posterior uterine surface , uterosacral ligaments , punch of Douglas, parametria and also to screen colorectal cancer
CT- can be useful in evaluating the extent of metastatic disease in patients with known or strongly suspected ovarian carcinoma
NMR-magnetic resonans -I can say that in our clinic it isn't useful to asses adnexal pathology.It can be useful in pregnant women with ovarian mass becouse like usg there is no radiation exposure
ASCITES PUNCTURE- we made this kind of procedure to obtain cells to cytological examination and to decompression
BIOPSY THE TUMOUR- we made when it is III C or IV FIGO stage and radical operative menagemant is impossible and in this way we can obtain material to histopathological examination
LAPAROSCOPY- it is also diagnostic method , we can always made laparoscopy before laparotomy when we suspected ovarian neoplasm and when we are not sure , always when the patient is young also when we suspected unoperative process
Ovarian neoplasms. Anita Chudecka - Głaz

18. ULTRASONOGRAPHY abdominal transvaginal TVS colour Doppler CDI
ABDOMINAL- it is very useful method when the pelvic mass has large size , futhermore we can see the liver and eventually metastases to the liver
TVS- has greates acuracy (dokładność) then abdominal usg , we can see pelvic mass when they have'nt large size , we can see septum , papilla form inside or outside the tumour , thickness of capsule and all the factors can evidence about malignancy of tumour
CDI-this method quantifies blood flow in the ovarian vessels . impendance in ovarian cancer is less then in benign tumour.
It is serviceable ( przydatny) especially in early stage to forecasting (prognozowanie) about malignancy
Ovarian neoplasms. Anita Chudecka - Głaz

19. epithelial ovarian cancer
TUMOR MARKERS
CA 125 CA CEA
epithelial ovarian cancer
CA 125 all epithelial ovarian cancer but first of all serous rarely in immature teratoma
CA 19-9 first of all in endometriois and mucinous
CEA- especially in mucinous
INHIBIN- mucinous epithelial ovarian cancer
Ovarian neoplasms. Anita Chudecka - Głaz

20. AFP TUMOR MARKERS endodermal sinus tumors embryonal carcinomas
mixed germ cell tumors
rarely immature teratoma and polyembryoma
Ovarian neoplasms. Anita Chudecka - Głaz

21. hCG TUMOR MARKERS chorioncarcinoma embryonal carcinoma
mixed germ cell tumors
polyembryoma
Ovarian neoplasms. Anita Chudecka - Głaz

22. adult granulosa cell tumors
TUMOR MARKERS
ESTRADIOL
adult granulosa cell tumors
thecomas
Ovarian neoplasms. Anita Chudecka - Głaz

23. adult granulosa cell tumors
TUMOR MARKERS
INHIBIN
adult granulosa cell tumors
Ovarian neoplasms. Anita Chudecka - Głaz

24. PREMENOPAUSAL OVARIAN MASS EXCLUDE NON-GYNAECOLOGICAL PROBLEM
Solid or complex
on US OR
> 6 cm
Elevated
AFP/hCG/LDH
Elevated CA 125
Simple on US
AND
< 6 cm
Normal CA 125
Observation for 6-8 weeks
and
Gonadotrpopin suppression
Surgical evaluation
Peristent on US

25. POSTMENOPAUSAL OVARIAN MASS EXCLUDE NON-GYNAECOLOGICAL PROBLEM
Asymptomatic
AND
Simple on US
< 3 cm
Normal CA 125
Symptomatic OR
Complex on US
> 3 cm
Elevated CA 125
Observe with
Follow up US
Surgical
Evaluation

26. DIFFERENTIAL DIAGNOSIS
gynaecologic
tuboovarian abscess
ectopic pregnancy
leiomyoma
fallopian tube neoplasia
luteal or follicular cysts
Ovarian neoplasms. Anita Chudecka - Głaz

27. DIFFERENTIAL DIAGNOSIS
gynaecologic
ovarian hyperthecosis
pregnancy luteoma
theca-lutein cysts
endometrioma
simple cysts
OVARIAN HYPERTHECOSIS- it is non neoplastic proliferation of ovarian stromal cells , virilization is commonly seen secondary to increased production of ovarian derived testosteron and androstendion. also estrogen manifestation can be present but much less frequently. Normal gonadotropin differrentila this lesions from PCOS
PREGNANCY LUTEOMA- this non neoplastic condition must be kept in mind when a solid tumour develops during pregnancy this tumours are bilateral in 30% cases ans often have more than 6 cm.
THECA FOLLICULAR CYSTS- both are common in reproductive years , these . patients usually present with palpable mass but less then 8 cm On ocassion they can present with cysts rupture and intraabdominal haemorrhagiae.
ENDOMETRIOMA- endometriosis often occurs in the ovary and chocolate cysts is formed. On bimanual examination: andxal mass, nodularity of uterosacral ligaments , culdesac tendress. serum CA 125 are often elevated.
SIMPLE CYSTS which probably derived from follicular cysts , germinal inclusion cysts and cause of absence of epithelium is intyracystic fluid pressure
Ovarian neoplasms. Anita Chudecka - Głaz

28. DIFFERENTIAL DIAGNOSIS
nongynaecologic
diverticular disease
appendiceal abscess
Crohn’s disease
primary nongynaecological malignancy
pelvic kidney
DIVERTICULOSIS- complicated by a sigmoid colon phlegmon or pericolonic abscess may present as a pelvic mass esp. in postmenopausal women. The most common symptoms are left quadrant pain and obstipation . The diagnosis in this case is best confirmed by CT.
APPENDICEAL ABSCESS - may present as a right sided pelvic mass , commonly found in women of reproductive age
We have right lower quadrant pain, anorexia, localization peritonitis, fluctuant mass , leucocytosis.
CROHN'S DISEASE- most commonly in women in the second or third decades of life. Patients often present with a history of diarrhoea, weight loss and abdominal pain
NONGYNAECOLOGIC MALIGNANCY- lymphoma, retroperitoneal tumours, mesothelial tumours, colorectal cancer ,
PELVIV KIDNEY- the incidence of PK in general population is 1:20 000, it increase to 7 or 15% in women with vaginal agenesis.
Ovarian neoplasms. Anita Chudecka - Głaz

29. CLASSIFICATION
1. Epithelial ovarian tumours - 70% of all ovarian neoplasms
2. Sex cord stromal tumours 5-10%
3. Germ cell tumours 15-20%
4. Metastatic 5 %
5. Other
METASTATIC - 5% of ovarian tumours are metastatic most commonly from alimentary tract (bowel, stomach), breast, uterus rarely lymphoma, melanoma malignum
Ovarian neoplasms. Anita Chudecka - Głaz

30. BORDERLINE TUMORS- were first describe in 1929 but in 70 s they were officially included in the WHO and FIGO classification system. Histologicaly BL are defined as epithelial ovarian tumors where there is stratification and increased athypia but the basement membrane is intact. The prognosis for patient with LMP tumors is much better than for patient with ovarian carcinoma . This is partly bacouse of fact that only 20-25% patient have extraovarian disease in the time of diagnosis. Importent to prognosis is presence of invasive or non invasive extra ovarian implants. BL tumors may recurrence up 20 years after initial diagnosis.
Ovarian neoplasms. Anita Chudecka - Głaz

31. Ovarian neoplasms. Anita Chudecka - Głaz

32. SEX CORD STROMAL TUMOURS
1. Granulosa stromal cell
granulosa cell
thecoma-fibroma
2. Sertoli stromal cell
3. Lipid cell tumours
4. Gynanandroblastoma
Ovarian neoplasms. Anita Chudecka - Głaz

33. GERM CELL TUMOURS 1. Dysgerminoma 2. Endodermal sinus tumour
3. Embryonal carcinoma
4. Polyembryoma
5. Chorioncarcinoma
6. Teratomas
7. Mixed forms
8. Gonadoblastoma
Ovarian neoplasms. Anita Chudecka - Głaz

34. Growth limited to the ovaries
STAGE I
Growth limited to the ovaries
Ovarian neoplasms. Anita Chudecka - Głaz

35. Growth involving one or both ovaries with pelvic extension
STAGE II
Growth involving one or both ovaries with pelvic extension
Ovarian neoplasms. Anita Chudecka - Głaz

36. STAGE III
Tumour involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperotoneal or inguinal nodes; superficial liver metastasis ; tumour is limited to the true pelvis but with histologically proven malignant extension to small bowel or omentum
Ovarian neoplasms. Anita Chudecka - Głaz

37. STAGE IV
Tumour involving one or both ovaries with distant metastases; if pleural effusion is present , there must be positive cytology to allot a case to stage IV
Ovarian neoplasms. Anita Chudecka - Głaz

38. Five - year survival rates for epithelial ovarian cancer
Stage
IA 82,3%
IB 74,9%
IC 67,7%
IIA 60,6%
IIB&IIC 53,8%
III 22,7%
IV %
Ovarian neoplasms. Anita Chudecka - Głaz

39. PREDICTORS OF SURVIVAL
stage
grade
age
residual disease
max. cytoreductive surgery
histopathology
others ( protein p53, CA 125, EGF-R)
STAGE it is a very strong predictor of survival . Approximately 70-75% will have greater then I stage disease. Invasive epithelial carcinoma can spread by local extension, lymphatic invasion , intraperitoneal implantation , hematogenous dissemination and transdiaphragmatic passage all of which have implications for staging.
GRADE- EOC are graded as well differentiated , moderately and poorly differentiated and grade I,II and III respectively.Grading system is mostly based on architectural pattern and is most importent prognostic factor followed by stage and histologic subtype.
HISTOPATHOLOGY- patient with mucinous and endometrioid cancer lives longer then with other hitologic type, the worst prognosis is in anaplastic cancers
AGE- better prognosis have patients younger , under 50
RESIDUAL DISEASE-The median survival time is longer when residual mass after cytoreductive surgery is less then 1,5 ew 2 cm.
CA 125- eleveted serum levels in I stage is worse prognostic factors , also in patients with stage III when is elevated after 20 days froma cytoreductive surgery
p53-presence of p53 protein is bad prognostic factor
EGF-R- presence of receptor for EGF is also bad prognostic factor
Ovarian neoplasms. Anita Chudecka - Głaz

40. TREATMENT surgical chemotherapy radiotherapy hormonal treatment
postoperative
procedures
Ovarian neoplasms. Anita Chudecka - Głaz

41. SURGICAL TREATMENT cytoreductive operation: hysterectomy
bilateral oophorectomy
omentectomy
appendectomy
lypmphadenectomy ??
Nowotwory jajnika. Anita Chudecka - Głaz

42. CHEMOTHERAPY CT PC PAC Vepesid or Ifosfamid with CDDP as II LINE CHT.
Hycamptin or Gemzar as III LINE CHT.
I LINE CHEMOTHERAPY
Ovarian neoplasms. Anita Chudecka - Głaz

43. SURGICAL TREATMENT - EOC
benign
In young women conservative surgery usually including cystectomy or oophorectomy. In postmenopausal women TAH/BSO should be considered to avoid the risk of cancer in the future.
borderline
In young women conservative surgery oophorectomy or USO can be performed. In women who have completed their child bearing a TAH/BSO/Omentectomy is appropriate always with very precise surgical staging.
Ovarian neoplasms. Anita Chudecka - Głaz

44. SURGICAL TREATMENT - EOC
malignant
In all cases we have to carry out cytoreductive surgery. It includes TAH/BSO complete omentectomy with resection of any metastatic lesions. In some cases bowel resection and retroperitoneal lymphadenectomy are necessary in order to obtain optimum cytoreduction. Optimum cytoreduction is achieved when the largest residual tumour mass measures less then 1,5 cm.
Ovarian neoplasms. Anita Chudecka - Głaz

45. POSTOPERATIVE TREATMENT - EOC
chemotherapy
Platinum-based combination with paclitaxel chemotherapy is now the standard postoperative treatment for patient with ovarian cancer
radiation therapy
It is useful method especially in patient who have positive second-look laparoscopy or laparotomy after chemotherapy treatment but the residual mass are less than 2 cm.
hormonal treatment
Ovarian neoplasms. Anita Chudecka - Głaz

46. FOLLOW - UP
second-look laparoscopy every year during first 5 year to detect early microscopic relapse
CA 125 every 3 to 4 month
complete medical history
physical examination
rectovaginal pelvic examination
CA a rising CA 125 is predictor for relapse however a negative CA 125 does not exclude the presence of disease. A combination of CA 125 and general and pelvic exam has been shown to detect progression of disease in 90% of patients with recurrent EOC
LAPAROSCOPY- during second-look laparoscopy we always take cytological smears , make washing, and take biopsy from peritoneum , adhesions and suspected about relapse places
Ovarian neoplasms. Anita Chudecka - Głaz

47. Screening is recommended in women with HOCS and HBOCS and include:
rectovaginal pelvic examination
CA 125 determination
TVS
prophylactic TAH/BSO
In these women when childbearing is ended or at least by age 35 prophylactic bilateral oophorectomy is recommended to reduce this significant risk, but it is not preclude a small risk of developing peritoneal carcinomatosis which clinically similar to advanced ovarian carcinoma.
Ovarian neoplasms. Anita Chudecka - Głaz

48. MALIGNANT GERM CELL TUMOURS
Dysgerminoma most common germ cell malignancy , in 10-15% is bilateral , survival rate for early stage is 95% and even in advanced stage grater then 80% when appropriate adjuvant therapy is given. LDH is useful tumour marker. hCG levels is elevated in small number of patients. In young women and stage I unilateral oophorectomy is recommended with inspection and biopsy of opposite ovary and staging with retroperitoneal lymphadenectomy. In other women TAH/BSO. Adjuvant therapy should be given in all patients radiotherapy and/or chemotherpy.
Germ cell tumours are principally disease of early reproductive women. They are second in frequency to epithelial tumours. Mean age of ocurance is 19 years. The most common of malignant GCT is dysgerminoma followed by mixed, endodermal sinus tumour , immature teratoma, emryonal carcinoma and chorioncarcinoma. Polyembryoma is very rare. In general prognosis for patients with malignant GCT is much more favorable then those with EOC . This is result of early diagnosis and the development of effective chemotherapy agents.
Ovarian neoplasms. Anita Chudecka - Głaz

49. MALIGNANT GERM CELL TUMOUR
Embryonal carcinoma is quite rare , rarely bilateral and trends to spread intraperitoneally , survival is slightly better then with EST using the same platinum based chemotherapy regiments . Both AFP and hCG can serve as tumour markers. Surgical treatment depend on age and stage . Adjuvant therapy ( chemotherapy) is recommended in all cases.
Ovarian neoplasms. Anita Chudecka - Głaz

50. MALIGNANT GERM CELL TUMOURS
Immature teratoma represents approximately 20% of all malignant germ cell tumours and 25 % in girls under 10. After grade surgicopathologic stage is the most prognostic factors. Fortunately most patient are diagnosed with early stage. Occasionally immature carcinoma produce AFP as tumour marker but hCG is never produced. Surgical treatment depend on age and stage. Chemotherapy is kind of adjuvant therapy but only in immature teratoma of all malignant germ cell tumours chemotherapy in stage IA grade I does not benefit.
Ovarian neoplasms. Anita Chudecka - Głaz

51. MALIGNANT GERM CELL TUMOURS
Endodermal sinus tumour also known as “yolk sac tumour” is an extremely aggressive malignancy. Almost never is bilateral. Intraperitoneal and hematogenous spread is common. Commonly patients present with acute abdomen secondary to spontaneous rupture and haemorrhagiae. Platinum based chemotherapy significantly improves the survival. AFP is useful tumour marker.
Ovarian neoplasms. Anita Chudecka - Głaz

52. MALIGNANT GERM CELL TUMOURS
Chorioncarcinoma nongestational is extremely rare , 50% is diagnosed in prepuberatal females , produced hCG as tumour marker . Although gestsational chorioncarcinoma is treated successfully in most patients with platinum based chemotherapy , remission is less common in patients with nongestational type.
Polyembryoma
Mixed
MEXED- 8% of all malignant ovarian tumours and 10-15% of germ cell tumours The most frequent combination is dysgerminoma and EST.
Ovarian neoplasms. Anita Chudecka - Głaz

53. BENIGN GERM CELL TUMOURS
Gonadoblastoma is almost always found in patients with gonadal dysgenesis associated with chromosome Y. In 50% coexist with malignant germ cell tumours
Teratomas 25-40% of all ovarian neoplasms. The most common is cystic teratoma - “dermoid cysts”. Most cases diagnosed in premenopausal women . Most patients are asymptomatic and often dermoids are diagnosed by usg. This tumours can be bilateral in 15%. The risk of malignancy is 1-2% and most commonly occurs in postmenopausal women.
Struma ovarii it is dermoid where thyroid tissue comprises greater than 50% of teratomas. This is unusual and accounts for only 2,7% of ovarian teratomas.
MANAGEMENT OF BENIGN TUMOURS- if gonadoblastoma coexist with chromosome Y bilateral gonadectomy is indicated except patients with testicular feminization ( androgen sensitivity syndrom)
In teratomas laprotomy ( in same hospitals laparoscopy) can be used to remove a dermoid and perform a cystectomy in most cases or oophorectomy when necessary.
Ovarian neoplasms. Anita Chudecka - Głaz

54. SEX CORD STROMAL TUMOURS
Adult granulosa cell tumours (GCTs) excess estrogen production is often found causing precocious puberty and menometrorrhagia in menstruating or postmenopausal. Endometrial hyperplasia or carcinoma is at 60% in patients with this tumour.50% occur in postmenopausal women and only 5% in prepubertal girls. It is interestin that this king of tumour may relapse after many years ( even above 20 ) after primary diagnosis. Estardiol and in nowadays inhibin are useful tumour marker.
Ovarian neoplasms. Anita Chudecka - Głaz

55. SEX CORD STROMAL TUMOURS
Juvenile granulosa cell tumours in 50% occur in prebubertal girls , rare relapse after many years from diagnosis , typically is early recurrence. Rarely lethal as GCTs.
Fibroma unilateral , diagnosed in 5 decade of life. Hormone production is unusual , eventually estrogen. It is benign tumour, when 1 to 3 mitoses are present is called cellular fibroma, if greater then 3 it is considered as fibrosarcoma.
Thecoma very similar to fibroma but more commonly produce etsrogen which causes postmenopausal bleeding , menorrhagia, endometrial hyperplasia or cancer.
Ovarian neoplasms. Anita Chudecka - Głaz

56. SEX CORD STROMAL TUMOURS
Sertoli stromal cell tumours 1 % of all ovarian neoplasms , many of these tumours androgen producing , many are hormonally inert and some occasionally may produce estrogen. Diagnosed of pure Sertoli tumours is unlikely in the presence of virilization. Rarely is malignant.
Sertoli-Leydig cell tumours are the most common in these group , 40% have evidence of estrogen or androgen production, unilateral and occur in 3 decade of life. Rather frequently is malignant.
Sex cord tumour with annular tubules (SCTAT) in 30% associated with Peutz-Jegers syndrome.
Very important exception in management with ovarian sex cord stromal tumours.
I - if there is evidence of estrogen production an currete the uterus cavity should be obtain prior to laparotomy . in the event that endometrial cancer is found consideration must be given to performing TAH/BSO.
II- if androgen excess is evident the differential diagnosis includes an adrenal tumour and ovarian tumour. This is particulary important when there is no ovarian enlargement. Generally elevated serum dehydroepiandrosterone level points to ab adrenal source while elevated serum testosterone to ovarian process. The operative management in patients with sex cord stromal tumors is age dependent. For women beyond the reproductive age TAH/BSO is aproppiate. In younger interesting in preserving child bearing a unilateral oophorectomy should be performed. If the pathologist is confident the diagnosis peritoneal washings, selective biopsies, subtotal omentectomy and careful inspection of the opposite ovary are indicated. Adjuvant therapy in advanced cases in androblastoma in another type prospective studies are needed.
Ovarian neoplasms. Anita Chudecka - Głaz

57. SEX CORD STROMAL TUMOURS
Lipid cell tumour are typically virilizing with increased serum levels of testosteron and androstendione. Occasionally produce estrogen, estron and cortisol and in 10% cases Cushing Syndrom in found. In 20 % develop metastases.
Gynanroblastoma is rare ovarian tumours which contain granulosa stromal cell and Sertoli stromal cell tumours.
Leydig cell tumours mean age is 50 and almost always behaves in benign fashion. Testosterone is commonly produced resulting in mild virilization.
Ovarian neoplasms. Anita Chudecka - Głaz