Ovary Diseases PDF

Diseases of Female Reproductive System (OVARY) Dr. Fatin Al. Mosawi  Ovarian Causes ◦ Gonadal dysgenesis - Turner’s Syndrome 45XO or mosaics 46 XX/45 XO ◦ Testicular feminization ◦ Premature ovarian failure Oophoritis: secondary to fallopian tube infl...

Diseases of Female Reproductive System (OVARY) Dr. Fatin Al. Mosawi  Ovarian Causes ◦ Gonadal dysgenesis - Turner’s Syndrome 45XO or mosaics 46 XX/45 XO ◦ Testicular feminization ◦ Premature ovarian failure Oophoritis: secondary to fallopian tube inflammation, or peritonitis Tubo-ovarian inflammation is called salpingo- oophoritis, commonly associated with intrauterine contraceptive device. Complication of oophoritis is tuboovarian abscess, adhesion, peritonitis, infertility due to extensive adhesion. Follicular cyst & Luteal Cysts:  Are so common as almost to constitute a physiologic variants.  Originate in un ruptured Graffian follicles or in follicles that ruptured and immediately sealed.  Usually they are small 2 cm diameter and filled with clear serous fluid.  Histologically they lined by granulosa or lutein cells.  They might rupture produce acute abdominal pain. Polycystic ovary ( Stein- Leventhal Syndrome ):  Oligomenorrhea, hirsutism, infertility, sometimes obesity.  Biochemical: Increase estrogen & androgen, Increase Leutinizing hormone, Decreased follicular stimulating hormone (FSH). Gross: The ovaries are twice normal size , gray white , with subcortical cysts. Histology: Thickened fibrosed outer tunica (Cortical Stromal Fibrosis), beneath which multiple cysts lined by granulosa cells , with hyperplastic leutinized theca interna cells , and absence of corpus luteum. Ovarian Tumors: Risk factors: 1. Nulliparous women. 2. Persistent high concentrations of pituitary gonadotropins after menopause 3.Irritants, such as talc or asbestos. 4.Family history of ovarian carcinoma. BRCA-1 BRCA-2 HNPCC Surface Epithelial Tumors : Derived from coelomic epithelium, could be benign, borderline (low malignant potential), or malignant. Serous Tumors: * Most common epithelial tumors. * Age 30- 40 years. * Usually cystic, known as serous cystadenoma & serous cystadenocarcinoma. * Serous cystadenocarcinoma is the most common malignant tumor of the ovary forming about 60% of all ovarian cancer. * 25% of benign tumors are bilateral Gross:  size variable 5-40 cm,  usually cystic, filled with clear serous fluid  grossly visible papillary projections are more marked in malignant type. Histology Benign cyst Borderline tumors Malignant tumors * Malignant tumors spread to regional lymph nodes , but distant hematogenous and lymphatic metastases are infrequent. * Prognosis of malignant tumors depends on stage of the disease at time of diagnosis. Mucinous tumors Differ from serous tumor in:  epithelium consisting of mucous secreting cells.  They less likely to be malignant than serous tumors,  more multilocular than serous tumors  Rupture of the cyst may results in mucinous deposits in the peritoneum (pseudomyxoma peritonei)  The prognosis of mucinous cystadenocarcinoma is somewhat better than serous counterpart. Endometrioid Tumor: Solid or cystic , they develop sometime as a mass projecting from the wall of endometriotic cyst. Microscopically there is tubular glands similar to those of endometrium. They are usually malignant. Brenner Tumor; Un common, solid, encapsulated, white- gray cut section. Microscopically : abundant stroma containing nests of transitional like epithelium, resembling that of urinary tract. Although most are benign, both malignant and borderline categories are present. Germ Cell Tumors: Teratomas : Mature cystic teratoma (dermoid cyst ) *Is one of the commonest ovarian tumors *Is a smooth – walled unilocular cyst, filled with hair, sebaceous materials and teeth. *It is bilateral in 10 – 15 % of cases. Histologically : The cyst is lined by stratified squamous epithelium, and showing a wide range of tissue haphazardly arranged, including sebaceous glands, nervous tissue, respiratory epithelium, intestinal epithelium, cartilage, bone, muscle, fibrous tissue and thyroid tissue. These tumors are usually benign, however malignant transformation may develop in elderly patients in rare instances ( 1% ), usually squamous cell carcinoma. Immature teratomas: Are usually solid, presents in an early life and are malignant. They contain immature tissue, similar to those seen in the developing embryo, typically of primitive neural tissue and immature mesenchyme. They are rapidly growing and may metastasized to the peritoneum. Monodermal ( specialized ) teratoma : Is a germ cell tumor, almost entirely composed of tissue derived from one germ cell layer, as the Stroma ovarii, which is composed of thyroid tissue, which can be benign, or malignant, and rarely cause thyrotoxicosis. Dysgerminoma : Is malignant GCT , found in young patients. Gross; solid, yellow- white Microscopically: Nests of large clear, round cells with large nuclei separated by fine connective tissue septi infiltrated by lymphocytes. This histologic appearance is identical to seminoma of the testis. It has relatively good prognosis. Endodermal sinus tumor (yolk Sac Tumor):  tumors are solid and cystic and often hemorrhagic.  Histologically: Show ch. structures called Shiller- Duvol bodies,  Extracellular and intracellular hyaline droplets are characteristics, some of which can be positive for alpha-fetoprotein shown immunohistochemically, and is used as serum tumor marker.  Intra-abdominal metastasis occur, untreated cases carry poor prognosis. Choriocarcinoma: Is highly malignant, with early metastasis, most exist in combination with other germ cell tumors, they produce human chorionic gonadotrophin. Sex- Cord Stromal Tumors: 1. Granulosa cell Tumor: potentially malignant, associated with estrogenic manifestation, precocious puberty, endometrial hyperplasia, leading to menorrhgia. Usually solid but may be multicystic. Histologically: composed of granulosa cells arranged in follicles, trabeculae, or sheets, with grooved nuclei, cells surrounding central space contain eosinophilic materials , called Call- Exner body. 2. Thecoma: Commonest sex –cord stromal tumor , present during reproductive years as abdominal mass. It is usually unilateral, well circumscribed, with pale fleshy cut surface. Histologically: cellular spindle cell tumor containing abundant lipid. It may produce estrogen causing abnormal uterine bleeding, endometrial hyperplasia, and endometrial carcinoma. 3. Fibroma  They occur at all ages, with a peak in the perimenopausal period, and are virtually always benign.  Tumors are solid, firm and white.  Microscopically, the cells resemble the stroma of the normal ovarian cortex.  Half of the larger tumors are associated with ascites and, rarely, with  ascites and pleural effusions (Meigs syndrome). 4. Sertoli- Leydig cell tumors:  Rare tumors composed of mixture of cell types normally seen in the testis.  Present with androgenic sign and symptoms , virilisation.  Histologically: many tubules lined by seroli , with leydig cell in the stroma. Metastatic Tumors: The ovaries are common site for metastasis from extragenital primaries, as from stomach, colon, breast. The term Krukenburg tumor refer to bilateral ovarian neoplasms composed of malignant, mucin secreting cells, usually of gastric origin. Gestational Trophoblastic Disease: The term gestational trophoblastic disease is a spectrum of disorders with abnormal trophoblast proliferation and maturation, as well as neoplasms derived from trophoblast. Complete Hydatidiform Mole  This does not Contain an embryo.  Complete mole results from fertilization of an empty ovum that lacks functional maternal DNA (23X). Risk Factors: 1. Maternal age : The risk of hydatidiform mole relates to maternal age and has two peaks. Girls under 15 years have a 20-fold higher risk than women 20 to 35 years old. Risk increases progressively for women over 40. 2.The incidence is many fold higher in Asian women than white women. 3.Women with a prior hydatidiform mole have a 20-fold greater risk of a subsequent molar pregnancy than the general population. PATHOLOGY: Gross: Molar tissue is voluminous and consists of macroscopically visible villi that are obviously swollen like brancges of grapes. Microscopically: Many individual villi have cisternae, which are central, acellular, fluid-filled spaces devoid of mesenchymal cells. Trophoblast is hyperplastic and composed of syncytiotrophoblast, cytotrophoblast and intermediate trophoblast. Partial Hydatidiform Mole :  Partial hydatidiform moles have 69 chromosomes (triploidy), of which one haploid set is maternal and two are paternal. This abnormal chromosomal complement results from fertilization of a normal ovum (23,X) by two normal spermatozoa, each with 23 chromosomes Gestational Choriocarcinoma  Is a Malignant Tumor Derived From Fetal Trophoblast Risk Factors: 1. complete hydatidiform mole will transform into choriocarcinoma in 2% of cases 2. Highest risk in women of blood group A married to men of the same blood group PATHOLOGY: The uterine lesions of choriocarcinoma range from microscopic foci to huge necrotic and hemorrhagic tumors. Viable tumor is usually confined to the rim of the neoplasm because, unlike most other cancers, choriocarcinomas lack intrinsic tumor vasculature. These tumors contain a dimorphic population of cytotrophoblast and syncytiotrophoblast, with varying degrees of intermediate trophoblast. The tumor resembles the trophoblast of an early implanting blastocyst. Rims of syncytiotrophoblast surround central cytotrophoblastic cores, in addition to being arranged around maternal blood spaces, which resemble the intervillous space of normal placentation. hCG is localized to the syncytiotrophoblastic element. By definition, tumors containing any villous structures, even if metastatic, are considered hydatidiform mole and not choriocarcinoma. Choriocarcinoma invades mainly through venous sinuses in the myometrium. It metastasizes widely via the bloodstream, especially to lungs (over 90%), brain, gastrointestinal tract, liver and vagina