Lecture 3 Ovarian Pathologies

Lecture 3 Ovarian Pathologies
Ovarian cysts
➢ Functional : follicular, corpus luteal, thecal, hemorrhagic
➢ Non – functional : dermoid, endometriotic, cystadenoma, parovarian etc.
Most ovarian cysts are functional in nature and benign
1- Follicular Cyst: 2- Corpus Leuteum Cyst: 3- Theca Lutein Cyst:
▪ Unruptured non-ovulatory ▪ From degenerated corpus ▪ Multiple.
Graafian follicles. Luteus. ▪ Are due to high levels of hCG
▪ Usually multiple, bilateral & ▪ Yellow, filled with serous fluid above normal single-fetus
filled with serous fluid. or blood. pregnancy levels
▪ Lined by cubical cells & secrete ▪ Associated with vesicular mole &
estrogen. choriocarcinoma.
4- Endometriotic Cyst (Chocolate cyst): Endometriosis Cyst filled with blood
5- Polycystic Ovary (Stein Leventhal Syndrome):
▪ High LH-> high androgens→ low FSH (negative feedback)→missed/irregular periods
▪ Multiple, bilateral, anovulation (no corpus luteum).
▪ Oligomenorrhea, infertility, obesity.
▪ Cyst lined by granulosa cells & luteinized theca interna.
▪ Complicated by endometrial hyperplasia & adenocarcinoma.
Ovarian Tumors
▪ Common neoplasms. ▪ 6% of all cancers in women.
▪ 80% are benign – young (20-45) ▪ 50% deaths due to late detection.
▪ 20% are Malignant - older (>40)
Manifestations & Complications of ovarian tumors:
➢ Abdominal pain. ➢ Acute abdomen (if ruptured or torsion).
➢ GIT symptoms. ➢ Cachexia (if malignant).
➢ Urinary → dysuria. ➢ Spread (if malignant).
➢ Ascites. ➢ Infertility.
Ovarian cancer
❑ Symptoms include bloating, pelvic pain, difficulty eating and frequent urination, and are easily confused
with other illnesses.
❑ Ovarian cancer is the second most common gynecologic cancer.
Classification according to origin
▪ Surface epithelial ➔ 65-70%
1. Serous Tumors: From original ovarian epithelium
- Cystadenoma. - Boderline. -Cystadenocarcinoma.
2. Mucinous Tumors: Exact origin for mucinous cells still unclear (may be tubal-related)
- Cystadenoma. - Boderline. - Cystadenocarcinoma.
3. Endometrioid Carcinoma. Usually, endometriotic origin
4. Clear Cell Carcinoma. Usually, endometriotic origin
5. Brenner Tumor.
Arises directly from the ovarian surface epithelium that has undergone transitional metaplasia
6. Undifferentiated Carcinoma.
▪ Stromal ➔ 15-20%
Relatively chemo-insensitive
1. Granulosa-Theca Cell Tumors.
2. Sertoli-Leydig Cell Tumors (Androblastoma).
3. Gonadoblastoma.
▪ Germ cell tumors ➔ 5-10%, Start from the cells that produce the eggs (ova)
Chemo-insensitive
1. Teratoma:
- Benign. - Malignant. - Specialized.
2. Dysgerminoma.
3. Endodermal Sinus Tumor.
4. Choriocarcinoma.
5. Mixed Germ Cell Tumors.
▪ Metastatic tumors ➔ 5%
Mostly rules in surface epithelial tumors
Borderline surface epithelial tumors=
atypical: Architectural complexity
high recurrence rate
may progress to frank carcinoma
Serous Tumors: Commonest, Bilateral

Serous cystadenoma Borderline Serous Cystadenocarcinoma
Spread: Local, Lymph, Blood
▪ Rounded or oval, may be As benign but larger. ▪ Unilateral, large with nodular
pedunculated. surface.
▪ Gray, glistening. ▪ Cut surface: partially solid, gray
▪ Cut surface: unilocular cyst white with hemorrhage &
filled with serous fluid. necrosis.
▪ If papillary projection → ▪ Cyst with papillary projection →
papillary serous cystadenoma. papillary serous
Gross
cystadenocarcinoma, with
psammoma bodies
Usually, bilateral: Single layer of ▪ Cyst lined by more than one ▪ Cyst lined by more than three
columnar or cuboidal ciliated layer of cells with layers with malignant features:
epith. malignancy. invasion, microscopic features of
▪ Low cytologic atypia No or malignancy.
little invasion. Peritoneal ▪ Can be low grade or high grade
implants (not invasive)
Mic
Mucinous tumors: Less common, Unilateral, Mostly benign

Benign cystadenoma Borderline Cystadenocarcinoma
Gross Larger than serous. As benign + presence of causing Pseudo-myxoma
Cut section → multilocular with papillary projection peritonei: Peritoneum filled
fibrous septa. with mucinous material due to
rupture cyst
Mic Cyst lined with single epith. layer More than one layer lining Prominent papillae with
of columnar non ciliated epith., cytological atypia & no marked atypia.
invasion to capsule Metastasis is present.
Poor prognosis
Endometrioid Carcinoma Clear Cell Carcinoma Brenner Tumor

Gross Solid and cystic masses Solid & cystic masses 2 % of ovarian tumors. Can be benign
(commonest), borderline or malignant
Firm, white with small cyst contain
mucin.
Mic Adenocarcinoma associated Large cells with clear Islets of transitional epith. in fibrous
with endometriosis cytoplasm arranged in solid stroma.
sheets.
Germ cell tumors
Teratoma:
Mature benign: common, Most benign teratomas: Dermoid Cyst
▪ Lined by stratified sq with hair & sebaceous glands
▪ Grossly a cyst filled with oily material & hair. It has a dermoid ridge in its wall
Immature malignant:
▪ Predominantly solid and occurs in pre-pubertal adolescents and young
women.
▪ Immature neural elements
▪ Invasion, spread
Monodermal or specialized: Rare, composed of one tissue type.

a) Carcinoid tumor: Similar to that arising in gut.
b) Struma ovarii: tumor is composed of mature thyroid tissue →
hyperthyroidism.
Dysgerminoma: Commonest malignant germ cell tumors.
Gross: Solid, rare: soft, cut section → yellow white.
Mic: Large cells, clear cytoplasm and central nuclei arranged in sheets or cords separated by fibrous stroma.
Stromal (sex cord) cell tumor
Granulosa Cell Tumors
Gross: Yellow in color with hge & cystic degeneration.
Mic: Rosettes of cuboidal cells around small spaces (Call-Exner Body).
Nuclear grooving (coffee bean nuclei) in adult type tumor
Effects:
1. Secretion of estrogen → precocious puberty.
2. In adult → endometrial hyperplasia → abnormal uterine bleeding.
Theca Cell Tumors
Gross: Firm, capsulated, yellow with cystic areas.
Mic: Sheets of spindle shaped cells like fibroma.
Metastatic: kurkenberg
▪ Metastatic carcinomas in ovaries are more common than primary carcinoma.
▪ Originate from carcinomas of endometrium, stomach, large intestine, gall bladder, pancreas and breast.
▪ Reach both ovaries by transperitoneal implantation, blood stream, retrograde lymphatic spread or
direct infiltration.
▪ Transperitoneal spread leads to the finding: the larger bulk of the tumor is more superficial in the
ovaries + bilaterality
Inflammatory lesions of ovary & tubes
A tubo-ovarian abscess (TOA): is an inflammatory mass involving the fallopian tube, ovary and, occasionally,
other adjacent pelvic organs (eg, bowel, bladder).
This may manifest as a tubo-ovarian complex (an agglutination of those structures) or a collection of pus.
 a complete breakdown of ovarian and tubal architecture such that separate structures are no longer
identified.
Clinical
▪ Unilateral adnexal tenderness ▪ Fever (not always)
▪ Unilateral mass ▪ Chills
Risk factors Same as PID
Multiple sexual partners Age between 15 to 25 Prior history of PID
Microbiology Polymicrobial
Salpingitis: Pyosalpinx
 Edema and endosalpingeal folds' thickening allow visualization with ultrasound.
Tubo-ovarian complex: As the disease progresses, the ovary can become involved. When the ovary adheres to
the tube, but is still visualized

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Lecture 3 Ovarian Pathologies

Serous Tumors: Commonest, Bilateral

Mucinous tumors: Less common, Unilateral, Mostly benign

Endometrioid Carcinoma Clear Cell Carcinoma Brenner Tumor

Monodermal or specialized: Rare, composed of one tissue type.

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