Ovarian neoplasm I

AP DR. MIE MIE SEIN

MBBS BLOCK 4
Learning Outcomes
Ovarian neoplasms
Classify ovarian neoplasms. (C4)
Epithelial neoplasms
1. Explain the aetiopathogenesis of epithelial ovarian neoplasms. (C2)
2. Classify ovarian epithelial neoplasms. (C4)
3. Describe the morphology, complications and prognosis of ovarian epithelial neoplasms. (C2)
Teratomas
Describe the types, morphology and prognosis of teratomas. (C2)
Krukenberg tumour
1. List the possible sites of origin. (C1)
2. Describe the morphology of Krukenberg tumour. (C2)
Tumour markers of ovary
Explain the role of tumour markers in the diagnosis and prognosis of ovarian tumours. (C2)

Manipal University College Malaysia 2

 Normal anatomy

• Paired pelvic organs located on the sides of the uterus close to the lateral
pelvic wall, behind the broad ligament and anterior to the rectum.
• During the reproductive period, their average size is 4 × 2 × 1 cm and their
average weight is 5–8 g.
• After menopause, they shrink to one half or less of this size.

Manipal University College Malaysia 3

 Classification
Origin Tumour

Types Subtypes

Epithelium Serous Benign, borderline or malignant

Mucinous

Endometrioid

Transitional cells

Germ cell Dysgerminoma

Teratoma Mature cystic, immature solid or monodermal

Extraembryonic Yolk sac, choriocarcinoma

Malignant mixed germ cells tumours

Sex cord stroma Thecoma

Granulosa cell tumour

Sertoli-Leydig cell tumour

Mixed germ cell stromal tumour

Steroid cell tumour

Metastatic Various sites of body

Miscellaneous Haemangioma, lipoma, etc

Manipal University College Malaysia 4

 Clinical features
Age – infancy to old age
Nulliparous female
Family history of gonadal dysgenesis
-asymptomatic
-Pressure symptoms (large size): GI- indigestion, nausea, vomiting, constipation
Urinary- compression on bladder and ureter, obstructive uropathy; edema of the lower
extremities & varicose veins
-Abdominal mass/pelvic mass; Benign-mobile, single, cystic tumour; Malignant- fixed,
bilaterality, irregular, nodular & solid, rapid increase in size
-Abdominal pain: painless/dull aching pain
-Abdominal swelling: due to tumour mass/ascites/pseudomyxoma peritonei
-Functional effects- hormonal effects (endocrinopathies)
-Malignant cachexia
-features of complications: Torsion, haemorrhage, infection, necrosis, rupture, infertility
Manipal University College Malaysia 5
 Epithelial neoplasm

Aetiopathogenesis
• The majority of ovarian tumors arise from the fallopian tube or epithelial cysts in the cortex of
the ovary
• Nulliparity, family history, and heritable mutations play a role in tumor development.
• There is a higher incidence of carcinoma in unmarried women and married women with low
parity. prolonged use of oral contraceptives reduces the risk.
• Around 5% to 10% of ovarian cancers are familial, and most of these are associated with
mutations in the BRCA1 or BRCA2 tumor suppressor genes.
• Mutations in BRCA1 and BRCA2 are found in only 8% to 10% of sporadic ovarian cancers
• Low grade tumors show KRAS, BRAF mutations
• High-grade tumors have a high frequency of TP53 mutations and lack mutations in either KRAS
or BRAF
• KRAS is expressed in 30% of tumors (Mucinous cystadenocarcinoma)

Manipal University College Malaysia 6

 Serous Tumors

Morphology
Gross:
Most serous tumors are large, spherical to ovoid, cystic structures up to 30 to 40 cm in diameter.
About 25% of the benign tumors are bilateral.
In the benign tumors, the serosal covering is smooth and glistening.
By contrast, the surface of adenocarcinomas often has nodular irregularities representing areas in
which the tumor has invaded the serosa.
On cut section, small cystic tumors may have a single cavity, but larger ones frequently are divided by
multiple septa into multiloculated masses. The cystic spaces usually are filled with a clear serous
fluid.
Protruding into the cystic cavities are papillary projections, which are more prominent in malignant
tumours.
Microscopy:
On histologic examination, benign tumors contain a single layer of columnar epithelial cells that line
the cyst or cysts. The cells often are ciliated.

Manipal University College Malaysia 7

 Benign serous cystadenoma ovary

-Thin-walled cystic ovarian tumour

-The sectioned surface reveals single cavity
-Serosal covering is smooth and glistening

Manipal University College Malaysia Source: diagnostic surgical pathology 8

 Ovarian serous tumours

Borderline serous cystadenoma opened to Cystadenocarcinoma The cyst is opened to show

display a cyst cavity lined by delicate papillary a large, bulky tumor mass
tumor growths
Manipal University College Malaysia Source: Courtesy of Dr. Christopher Crum, Brigham and Women’s Hospital, Boston, Massachusetts
9
 Microscopic appearances of serous tumours of the ovary

Serous cystadenoma revealing stromal papillae with a Borderline serous tumor showing
columnar epithelium increased architectural complexity and epithelial cell stratification

low-grade “micropapillary” serous carcinoma High-grade serous carcinoma of the ovary with invasion of underlying stroma

Manipal University College Malaysia Source: Robbins Cotran Pathologic basic of disease 10
 Serous cystadenocarcinoma Ovary

Gross
• Bulky tumour
• Predominantly solid with variable cystic area
Microscopic features
• Psammoma bodies (concentrically laminated calcified
concretions) are common in the tips of papillae.
• In high-grade carcinoma, the cells are markedly
atypical, the papillary formations are usually complex
and multilayered, and nests or sheets of malignant
cells invade the ovarian stroma.

Manipal University College Malaysia 11

 Mucinous tumours

Morphology
Gross:
-cystic masses that may be indistinguishable from serous tumors except by the mucinous nature of the
cyst contents.
-more likely to be larger and multicystic
-Serosal penetration and solid areas of growth are suggestive of malignancy

Microscopy:
-Mucin-producing epithelial cells line the cysts.
-Malignant tumors are characterized by solid areas of growth, piling up (stratification) of lining cells,
cytologic atypia, and stromal invasion
-bilateral

Manipal University College Malaysia 12

 Ovarian mucinous cystadenoma

-multicystic appearance and delicate septa Columnar cell lining of mucinous cystadenoma
-presence of glistening mucin within the cysts

Manipal University College Malaysia Source: Robbins basic pathology 13

 Ovarian mucinous cystadenocarcinoma

• Unilocular/multilocular cystic masses filled with viscous mucinous fluid

• Solid areas
• Haemorrhagic and necrotic foci

Manipal University College Malaysia Source: pathorama.ch and https://medicine.nus.edu.sg/pathweb/ 14

 Complications

• Ruptured ovarian mucinous tumours

may seed the peritoneum- typically
regress spontaneously
• Stable implantation of mucinous
tumour cells in the peritoneum with
production of copious amounts of
mucin is called “pseudomyxoma
peritonei”

Massive gelatinous accumulation arranged

in loculated pattern in the peritoneal cavity

Source: pathorama.ch
Manipal University College Malaysia 15
 Prognosis

• The prognosis for patients with high-grade serous carcinoma is poor,

even after surgery and chemotherapy, and depends heavily on the
stage of the disease at diagnosis.
• The 5-year survival for women with carcinoma confined to one ovary
is about 90% but falls precipitously with higher stage tumors to less
than 40% depending on the exact stage.
• Borderline tumors are associated with nearly 100% survival.
• Women with tumors containing BRCA1/2 mutations tend to have a
better prognosis than women whose tumors lack these genetic
abnormalities.

Manipal University College Malaysia 16

References:

Robbins and Cotran Pathologic Basis of Disease 10th Edition

Robbins basic pathology 10th Edition
Underwood’s pathology: A clinical approach 7th edition

Manipal University College Malaysia 17

 Thank you!

Manipal University College Malaysia 18