Disorders of the Ovaries Quiz

Disorders of the Ovaries

• Inflammation of the ovary (oophoritis): Oophoritis is inflammation of one or both ovaries, often preceded by infection of the fallopian tubes or peritoneum. It's part of chronic pelvic inflammatory disease (PID), an inflammation and infection in the upper genital tract (uterus, fallopian tubes, and ovaries). Females under 35 are most at risk for PID and oophoritis. It's rare before menstruation, during pregnancy, or after menopause. Extensive inflammation with fibrosis can lead to infertility.

Non-neoplastic Cysts of the Ovary

• Follicular ovarian cysts: A very common type of cyst arising from unruptured ovarian follicles. Often multiple, these cysts can grow large (over 10 cm), but are more typically small (around 1.5 cm). The lining resembles a normal follicle (granulosa and theca cell layer) and rarely secretes estrogen.

• Luteal cysts: Cystically dilated corpus luteum, about 2 cm in diameter (can reach up to 3 cm) Often multiple, lined by luteal cells and usually secrete progesterone.

• Chocolate cyst (endometriotic cyst):

• Germinal inclusion cyst: Caused by germinal epithelium dipping into the ovarian stroma.

Polycystic Ovary Syndrome (PCOS)

• PCOS is a common condition affecting 12-21% of women of reproductive age. Up to 70% remain undiagnosed. Obesity is a risk factor. PCOS can cause infertility.
• Diagnosis requires two of three criteria:
  • Oligomenorrhea/anovulation
  • Hyperandrogenism (clinically reflected by hirsutism or biochemically by raised free androgen index (FAI) or free testosterone)
  • Polycystic ovaries on ultrasound

Classification of Ovarian Tumors

• Surface epithelial tumors:

  • Serous tumors
  • Mucinous tumors
  • Brenner tumor
  • Endometrioid
  • Clear cell tumors

• Germ cell tumors:

  • Teratoma
  • Dysgerminoma
  • Choriocarcinoma
  • Embryonal carcinoma
  • Yolk sac tumor (endodermal sinus)

• Sex-cord stromal tumors:

  • Granulosa-theca cell tumor
  • Sertoli-stromal cell tumor
  • Gynandroblastoma

• Soft tissue tumors:

  • Fibroma
  • Angioma

• Metastatic secondary tumors:

Clinicopathological Features of Surface Epithelial Tumors

• Serous tumors:
  • Benign (60%)
  • Malignant (25%)
  • Borderline (15%)

Serous Cystadenomas

• Grossly: Small or large (up to 40 cm in diameter), rounded, mostly unilateral, unilocular, filled with clear yellowish fluid, and can show papillary projections inside or outside the surface.
• Microscopically: The lining is a single layer of tall columnar ciliated cells and has small microscopic papillae.

Papillary Serous Cystadenocarcinoma

• Grossly: Papillary projections penetrate the cyst capsule (papillary processes on both sides of the cyst wall); solid loculi may be present.
• Microscopically: The lining epithelium is more than one layer, showing malignancy criteria, and psammoma bodies may be present.

Borderline Serous Tumors

• Grossly: Resemble benign serous tumors.
• Microscopically: Resemble malignant serous tumors but without stromal invasion.

Mucinous Tumors

• Benign (mucinous cystadenoma): 80%
• Malignant (mucinous cystadenocarcinoma): 5-10%
• Borderline (mucinous cystadenomas):

Mucinous Cystadenoma

• Grossly: Can be large, ovoid, or lobulated; usually unilateral; multilocular, filled with gelatinous material; thick and fibrous wall.
• Microscopically: Tumors are lined by tall columnar cells with apical mucinous vacuolation.

Mucinous Cystadenocarcinoma

• Grossly: Presence of atypia in the cells and invasion of the capsule.
• Microscopically: Solid masses of tumor.

Borderline Forms

• Same changes as malignant forms but without invasion of the capsule.

Complications of Benign Serous & Mucinous Cystadenomas

• Torsion of pedicle leading to hemorrhage
• Rupture leading to acute abdomen
• Pressure effects
• Malignant change in serous cystadenoma

Endometrioid Tumors

• 20% of all ovarian cancers
• 50% associated with ovarian endometriosis
• Grossly show solid & cystic areas; 40% are bilateral.
• Microscopically, the glandular structures resemble endometrial adenocarcinoma.

Brenner Tumors

• Mostly benign, unilateral, occasionally cystic.
• Vary from small lesions to large masses.
• Composed of dense fibrous stroma and nests of transitional cells.

Teratomas

• Arise from totipotent cells, capable of differentiation into all layers of germ cells

• Mature teratomas: Mostly cystic, small, "dermoid cysts"

  • Lined by skin with adnexal structures; filled with hair and sebaceous secretion.
  • Microscopically, composed of epidermis, hair follicles, sebaceous glands, teeth, cartilage, bone, thyroid tissue, and other organ tissues.

• Malignant change (squamous cell carcinoma) in 1% of cases

• Monodermal teratomas: struma ovarii (thyroid tissue) is most common, also may be carcinoid or combined.

• Immature (malignant) teratoma:

  • Most common in adolescents and young women (mean age is 18 years)
  • Gross: bulky, solid with areas of necrosis and hemorrhage
  • Microscopic: mixture of immature tissues, differentiating towards cartilage, glands, bone, muscle, or nerve

Dysgerminoma

• Ovarian counterpart of seminoma
• Age incidence: childhood, teens, to twenties.
• Gross: solid tumor; 90% unilateral; fleshy, yellowish-white to gray-pink
• Microscopic: sheets and cords of large cells with clear cytoplasm, separated by scant fibrous stroma containing lymphocytes.

Gross and microscopic appearances of dysgerminoma: (Image provided)

Clinicopathological features of Sex cord stromal tumors

• Arise from sex cords of the embryonic gonads or ovary stroma.
• Frequently functioning(secreting estrogen (granulosa and theca tumors) or androgen (Sertoli-Leydig cell tumor).

Granulosa-theca cell tumor

• Common in postmenopausal women
• Gross: unilateral, solid and cystic areas, varies in size, encapsulated.
• Potentially malignant (5%-25%).
• Microscopically: mixture of granulosa and theca cells.
• Granulosa component; small cuboidal cells in cords, sheets or strands, forming rosettes.
• Theca cell component; spindle cells with lipid droplets in their cytoplasm.

Fibroma-thecomas

• Common tumors.
• Usually unilateral, solid, hard masses.
• Composed of well differentiated fibroblasts.
• 40% associated with hydrothorax and ascites ("Meigs syndrome")

Sertoli-Leydig cell (androblastoma) tumor

• Produce androgens
• Usually unilateral
• Composed of Sertoli or Leydig cells and stroma.

Metastatic Tumors

• Primarily from GIT and breast.
• Krukenberg tumor is metastatic ovarian cancer (bilateral), often from the stomach, spreading through the peritoneal cavity.