1. Ovarian Cysts and Tumors

4. 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

5. Ovarian Cysts and Tumors
Non neoplastic cysts are common but they are not serious problems
Primary inflammation of ovaries is rare
Salpingitis of fallopian tubes frequently causes periovarian reaction (salpingo-Oophoritis)
Frequently ,the ovaries affected by endometriosis.

6. Non-Neoplastic and Functional Cysts of ovary
Non Neoplastic Cyst are more common than the neoplastic ones
Follicular and Luteal cysts are most probably physiologic
Follicular cyst is due to distension of unruptured graafian follicle
Corpus luteum cyst results from hemorrhage into a persistent mature corpus luteum.

7. Theca lutein cyst is lined by luteinized theca cells and results from gonadotrophin stimulation.
Chocolate cyst is a blood containing cyst resulting from endometriosis with hemorrhage. The ovary is the most frequent site of endometriosis

11. Polycystic Ovaries Stein-Leventhal Syndrome
Young women ,and usually in girls after menarche.
-Oligomenorrhea
-hirsutism
-infertility
-Obesity

12. Polycystic Ovaries Stein-Leventhal Syndrome
Secondary to excessive production of estrogens and androgens, mainly androgens
The ovaries are usually twice normal in size ,gray-white with smooth outer surface
Studded with sub cortical cysts 0.5 to 1.5 cm in diameter.

13. Polycystic Ovaries Stein-Leventhal Syndrome
Histologically ,thickened fibrosed outer tunica
Multiple cysts lined by granulosa cells
Absence of corpora lutea
Cortical stromal fibrosis
High level of LH and low FSH

15. Figure Polycystic ovarian disease and cortical stromal hyperplasia. A, The ovarian cortex reveals numerous clear cysts. B, Sectioning of the cortex reveals several subcortical cystic follicles. C, Cystic follicles seen in a low-power microphotograph. D, Cortical stromal hyperplasia manifests as diffuse stromal proliferation with symmetrical enlargement of the ovary.
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© 2007 Elsevier

16. Figure Polycystic ovarian disease and cortical stromal hyperplasia. A, The ovarian cortex reveals numerous clear cysts. B, Sectioning of the cortex reveals several subcortical cystic follicles. C, Cystic follicles seen in a low-power microphotograph. D, Cortical stromal hyperplasia manifests as diffuse stromal proliferation with symmetrical enlargement of the ovary.
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© 2007 Elsevier

18. Ovarian Tumors Fifth most common cancer in the USA
Fifth leading cause of cancer death in women
Diversity of pathologic entities because of the three cell types make up the normal ovary

19. Ovarian Tumors classification
Primary tumor, three cell types :
1- the surface epithelium tumors
2- Germ cells tumors
3- Stromal /sex cord cells tumors
Secondary or metastatic tumors

20. Figure Derivation of various ovarian neoplasms and some data on their frequency and age distribution.
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© 2007 Elsevier

21. Classification of Ovarian Tumors, Surface Epithelial Tumors:
-Serous Tumors : Benign ,Borderline,And malignant
-Mucinous T. : Benign ,Borderline , and malignant
-Endometrioid T. : Benign, Borderline, and malignant
-Transitional cell T. :
Brenner tumors, Benign ,Borderline ,and malignant
-Undifferentiated Carcinoma

22. Classification of Ovarian Tumors, Sex Cord-Stromal tumors
-Granulosa Cell tuomr
-Thecoma –Fibroma
-Sertoli-Leydig cell tumor
-Gynandroblastoma
-Unclassified

23. Classification of Ovarian Tumors, Germ Cell Tumors
- -Dysgerminoma
-Yolk Sac Tumor
-Embryonal Carcinoma
-Choriocarcinoma
-Teratoma : Mature, Immature
-Polyembryoma

25. Ovarian Tumors Surface Epithelium Origin
Neoplasms of surface epithelium account for the great majority of all primary ovarian tumors.

26. Ovarian Tumors , Surface Epithelium Origin
65 – 70 % of overall tumors
90 % of malignant tumors
Age 20+
Traditionally divided into Benign ,Malignant ,and Borderline in malignancy
Can be strictly epithelial (serous ,Mucinous)

27. Ovarian Tumors , Surface Epithelium Origin
Can have stromal component (Cystadenofibroma ,
Brenner tumor )

28. Ovarian Tumors , Surface Epithelium Origin
The intermediate ,or the borderline tumors are referred as tumors of low malignant potential
These appear to be low grade cancers with limited invasive potential
They have better prognosis

29. Serous Tumors The most frequent ovarian tumor Age is 30 -40
May be solid ,usually cystic
Cystadenoma or Cystadenofibroma
65% benign ,15% low malignant potential , and 25% malignant
65 % of all ovarian cancers

30. Serous Tumors Most are large ,spherical to ovoid ,cystic structures
5 – 10 cm and might be 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

31. Serous Tumors Cystic spaces are filled by serous fluide
Papillary formation is very important and need to be sampled well
Histologically the benign tumors are lined by a single layer of tall columnar epithelium
Papillary formation can be seen in both the benign and the malignant ones

32. Serous Tumors Psammoma bodies could be seen
Between the clearly benign and the solid malignant tumors we can see the tumors of low malignant potential
LMP tumors may seed the peritoneum, the implants of tumors are non invasive. Sometimes may behave as invasive peritoneal implants

33. Serous Tumors
The prognosis of LMP tumors is determined mainly by the nature of the peritoneal implants
Prognosis of invasive Serous cystadenocarcinoma after surgery ,chemotherapy ,and radiation is poor and depend on stage
70% 5 –year survival for the tumors confined to the ovary

34. Serous Tumors 5 year survival f0r LMP is 100% ,
Malignant Tumors with capsular invasion ,survival for 10 years is 13%
LMP with capsular invasion the 10 year survival is 80%.

42. Figure A, Borderline serous cystadenoma opened to display a cyst cavity lined by delicate papillary tumor growths. B, Cystadenocarcinoma. The cyst is opened to reveal a large, bulky tumor mass. C, Another borderline tumor growing on the ovarian surface (lower).
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© 2007 Elsevier

43. Figure A, Borderline serous cystadenoma opened to display a cyst cavity lined by delicate papillary tumor growths. B, Cystadenocarcinoma. The cyst is opened to reveal a large, bulky tumor mass. C, Another borderline tumor growing on the ovarian surface (lower).
Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 28 April :14 PM)
© 2007 Elsevier

44. Figure 22-40 Papillary serous cystadenoma revealing stromal papillae with a columnar epithelium.
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© 2007 Elsevier

45. Figure Borderline serous cystadenoma exhibiting increased architectural complexity and epithelial cell stratification.
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© 2007 Elsevier

47. Figure 22-42 Papillary serous cystadenocarcinoma of the ovary with invasion of underlying stroma.
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© 2007 Elsevier

52. Mucinous Tumors Epithelium is consists of mucin-producing cells
Less likely to be malignant
10% of ovarian cancers
80% of them benign
10% LMP
10% malignant

53. Figure A, A mucinous cystadenoma with its multicystic appearance and delicate septa. Note the presence of glistening mucin within the cysts. B, Columnar cell lining of mucinous cystadenoma.
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© 2007 Elsevier

55. Brenner Tumor
Transitional cell epithelium
Most are benign

58. Figure A, Brenner tumor (right) associated with a benign cystic teratoma (left). B, Histologic detail of characteristic epithelial nests within the ovarian stroma. (Courtesy of Dr. M. Nucci, Brigham and Women's Hospital, Boston, MA.)
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60. Sex Cord Tumors, Granulosa Cell Tumor
Most postmenopausal ,could be any age
Unilateral
Solid and cystic
Tiny to large in size
Produce estrogen
Malignant behaviour in 5-25%

62. Sex Cord Tumors, Thecoma-Fibroma
Any age
Unilateral
Solid gray to yellow
Rarely malignant

64. Sex Cord Tumors Sertoli - Leydig
All ages
Unilateral Gray to yellow
Produce androgens
Uncommonly malignant

66. Germ Cell Tumors Dysgerminoma
2nd and 3rd decades
Unilateral
Counterpart to Seminoma
Solid ,gray to yellow
All malignant
PLAP positive

68. Embryonal carcinoma 2nd and 3rd decade Solid Aggressive
CD 30 positive.

69. Germ Cell Tumors Teratoma
15-20 % of Ovarian tumors
Majority in the first 2 decades
The younger the patient ,the greater the likelihood of malignancy
Over 90% are benign cystic ,mature teratomas
Immature teratomas are malignant and are rare.

71. Figure 22-48 Opened mature cystic teratoma (dermoid cyst) of the ovary
Figure Opened mature cystic teratoma (dermoid cyst) of the ovary. Hair (bottom) and a mixture of tissues are evident.
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75. Figure 22-49 Benign cystic teratoma
Figure Benign cystic teratoma. Low-power view of skin (top), beneath which there is brain tissue (bottom).
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© 2007 Elsevier

76. Endodermal Sinus (Yolk Sac) Tumor
the tumor is rich in α-fetoprotein and α1-antitrypsin.
Its characteristic histologic feature is a glomerulus-like structure composed of a central blood vessel enveloped by germ cells within a space lined by germ cells (Schiller-Duval body)
stained for α-fetoprotein by immunoperoxidase techniques
Most patients are children or young women presenting with abdominal pain and a rapidly developing pelvic mass. The tumors usually appear to involve a single ovary but grow rapidly and aggressively.

77. Figure 22-52 A Schiller-Duval body in yolk sac carcinoma.
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78. Choriocarcinoma
More commonly of placental origin, the choriocarcinoma, similar to the
Most ovarian choriocarcinomas exist in combination with other germ cell tumors, and pure choriocarcinomas are extremely rare.
are aggressive tumors that generally have metastasized widely through the bloodstream to the lungs, liver, bone, and other viscera by the time of diagnosis.
high levels of chorionic gonadotropins that are sometimes helpful in establishing the diagnosis or detecting recurrences.

79. Ovarian Tumors Metastatic Carcinoma
Accounts for approximately 5% of ovarian tumors
Older ages
Mostly Bilateral
Primaries are Breast ,lung, and G.I.T. (Krukenberg Tumors)