WHO classification of ovarian tumours

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WORLD HEALTH ORGANISATION CLASSIFICATION OF OVARIAN TUMORS : 

WORLD HEALTH ORGANISATION CLASSIFICATION OF OVARIAN TUMORS -Shamsuz Zaman Dept of Pathology JNMCH Aligarh Muslim University, Aligarh-India Email; movingantibody@gmail.com

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SURFACE EPITHELIAL TUMOURS SEX CORD STROMAL TUMOURS GERM CELL TUMOURS GERM CELL SEX CORD STROMAL TUMOURS TUMOUR OF THE RETE OVARII MISCELLANEOUS TUMOURS TUMOUR LIKE CONDITION LYMPHOID AND HEMATOPOETIC TUMOURS SECONDARY TUMOURS.

SURFACE EPITHELIAL TUMOURS : 

Serous tumours Mucinous tumours Endometroid tumours including variants of squamous differentiation Clear cell tumours Transitional tumours Squamous cell tumours Mixed epithelial tumours Undifferentiated and unclassified tumours SURFACE EPITHELIAL TUMOURS

SURFACE EPITHELIAL TUMOURS : 

Serous tumours Mucinous tumours Endometroid tumours including variants of squamous differentiation Clear cell tumours Transitional tumours Squamous cell tumours Mixed epithelial tumours Undifferentiated and unclassified tumours SURFACE EPITHELIAL TUMOURS

SURFACE EPITHELIAL TUMOURS (SEROUS TUMORS) : 

BENIGN cystadenoma papillary cystadenoma surface papilloma adenofibroma and cystadenofibroma BORDERLINE papillary cystic tumour surface papillary tumour. cystadenofibroma MALIGNANT adenocarcinnoma surface papillary carcinoma adenocarcinofibroma SURFACE EPITHELIAL TUMOURS (SEROUS TUMORS)

SURFACE EPITHELIAL TUMOURS : 

Serous tumours Mucinous tumours Endometroid tumours including variants of squamous differentiation Clear cell tumours Transitional tumours Squamous cell tumours Mixed epithelial tumours Undifferentiated and unclassified tumours SURFACE EPITHELIAL TUMOURS

SURFACE EPITHELIAL TUMOURS (MUCINOUS TUMORS) : 

BENIGN cystadenoma adenofibroma and cystadenofibroma BORDERLINE intestinal type endocervical type MALIGNANT adenocarcinoma adenocarcinofibroma MUCINOUS CYSTIC TUMOUR WITH MURAL NODULES MUCINOUS CYSTIC TUMOUR WITH PSEUDOMYXOMA PERITONEI SURFACE EPITHELIAL TUMOURS (MUCINOUS TUMORS)

SURFACE EPITHELIAL TUMOURS : 

Serous tumours Mucinous tumours Endometroid tumours including variants of squamous differentiation Clear cell tumours Transitional tumours Squamous cell tumours Mixed epithelial tumours Undifferentiated and unclassified tumours SURFACE EPITHELIAL TUMOURS

Endometroid tumours including variants of squamous differentiation (SURFACE EPITHELIAL TUMOURS) : 

Endometroid tumours including variants of squamous differentiation (SURFACE EPITHELIAL TUMOURS) Benign cystadenoma adenofibroma and cystadenofibroma Borderline Cystic tumour adenofibroma and cystadenofibroma Malignant adenocarcinoma (NOS) adenocarcinofibroma malignant mullerian mixed tumour (carcinosarcoma) adenosarcoma endometroid stromal sarcoma (low grade) undifferentiated ovarian sarcoma

SURFACE EPITHELIAL TUMOURS : 

Serous tumours Mucinous tumours Endometroid tumours including variants of squamous differentiation Clear cell tumours Transitional tumours Squamous cell tumours Mixed epithelial tumours Undifferentiated and unclassified tumours SURFACE EPITHELIAL TUMOURS

Clear cell tumours SURFACE EPITHELIAL TUMOURS) : 

Benign cystadenoma adenofibromma and cystadenofibroma Borderline cystic tumour adenofibroma and cystadenofibroma Malignant adenocarcinoma adenocarcinofibroma Clear cell tumours SURFACE EPITHELIAL TUMOURS)

SURFACE EPITHELIAL TUMOURS : 

Serous tumours Mucinous tumours Endometroid tumours including variants of squamous differentiation Clear cell tumours Transitional tumours Squamous cell tumours Mixed epithelial tumours Undifferentiated and unclassified tumours SURFACE EPITHELIAL TUMOURS

Transitional tumours (SURFACE EPITHELIAL TUMOURS ) : 

Benign brenner metaplastic variant Borderline brenner (proliferating variant) Malignant Transitional cell carcinoma (non-brenner type) Malignant Brenner tumour Transitional tumours (SURFACE EPITHELIAL TUMOURS )

SURFACE EPITHELIAL TUMOURS : 

Serous tumours Mucinous tumours Endometroid tumours including variants of squamous differentiation Clear cell tumours Transitional tumours Squamous cell tumours Mixed epithelial tumours Undifferentiated and unclassified tumours SURFACE EPITHELIAL TUMOURS

SURFACE EPITHELIAL TUMOURS : 

Squamous cell tumours Squamous cell carcinoma Epidermoid cyst Mixed epithelial tumours Benign. Borderline Malignant . Undifferentiated and unclassified tumours SURFACE EPITHELIAL TUMOURS

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SURFACE EPITHELIAL TUMOURS SEX CORD STROMAL TUMOURS GERM CELL TUMOURS GERM CELL SEX CORD STROMAL TUMOURS TUMOUR OF THE RETE OVARII MISCELLANEOUS TUMOURS TUMOUR LIKE CONDITION LYMPHOID AND HEMATOPOETIC TUMOURS SECONDARY TUMOURS. SEX CORD STROMAL TUMOURS

SEX CORD STROMAL TUMOURS : 

Granulosa stromal cell tumours Sertoli stromal cell tumours Sex cord stromal tumours of mixed or unclassified cell types Steroid cell tumours SEX CORD STROMAL TUMOURS

SEX CORD STROMAL TUMOURS : 

Granulosa stromal cell tumours Sertoli stromal cell tumours Sex cord stromal tumours of mixed or unclassified cell types Steroid cell tumours SEX CORD STROMAL TUMOURS

Granulosa stromal cell tumours (SEX CORD STROMAL TUMOURS) : 

Granulosa stromal cell tumours (SEX CORD STROMAL TUMOURS) Granulosa cell tumour group a) adult granulosa cell tumour. b) juvenile granulose cell tumour Thecoma fibroma group thecoma (typical or lutenised) fibroma cellular fibroma fibrosarcoma sclerosing stromal tumours signet ring stromal tumour stromal tumour with minor sex cord elements unclassified

SEX CORD STROMAL TUMOURS : 

Granulosa stromal cell tumours Sertoli stromal cell tumours Sex cord stromal tumours of mixed or unclassified cell types Steroid cell tumours SEX CORD STROMAL TUMOURS

Sertoli stromal cell tumours (SEX CORD STROMAL TUMOURS ) : 

Sertoli stromal cell tumours (SEX CORD STROMAL TUMOURS ) Sertoli leydig cell tumour group androblastoma). well differentiated intermediate differentiation poorly differentiated (sarcomatoid) retiform Sertoli cell tumour. Stromal leydig cell tumour

SEX CORD STROMAL TUMOURS : 

Granulosa stromal cell tumours Sertoli stromal cell tumours Sex cord stromal tumours of mixed or unclassified cell types Steroid cell tumours SEX CORD STROMAL TUMOURS

Sex cord stromal tumours of mixed or unclassified cell types (SEX CORD STROMAL TUMOURS ) : 

Sex cord stromal tumours of mixed or unclassified cell types (SEX CORD STROMAL TUMOURS ) Sex cord tumour with annular tubules Gynandroblastoma Sex cord stromal tumours (unclassified)

SEX CORD STROMAL TUMOURS : 

Granulosa stromal cell tumours Sertoli stromal cell tumours Sex cord stromal tumours of mixed or unclassified cell types Steroid cell tumours SEX CORD STROMAL TUMOURS

Steroid cell tumours (SEX CORD STROMAL TUMOURS ) : 

Steroid cell tumours (SEX CORD STROMAL TUMOURS ) Stromal luteoma Leydig cell tumour group hilus cell tumour leydig cell tumour, non hilar type leydig cell tumour, unclassified Steroid cell tumour, not otherwise specified

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SURFACE EPITHELIAL TUMOURS SEX CORD STROMAL TUMOURS GERM CELL TUMOURS GERM CELL SEX CORD STROMAL TUMOURS TUMOUR OF THE RETE OVARII MISCELLANEOUS TUMOURS TUMOUR LIKE CONDITION LYMPHOID AND HEMATOPOETIC TUMOURS SECONDARY TUMOURS. GERM CELL TUMOURS

Germ cell tumors : 

Germ cell tumors Primitive germ cell tumor Dysgerminoma Yolk cell tumour Variants: polyvesicular vitelline tumour,glandular,hepatoid Embryonal carcinoma Polyembryoma Non gestational choriocarcinoma Biphasic or triphasic teratoma Immature cystic teratoma Mature teratoma solid cystic (dermoid cyst) retiform teratoma

Germ cell tumors : 

Germ cell tumors Monodermal teratoma Thyroid tumour group Struma ovarii –benign or malignant Carcinoid group -insular -trabecular -mucinous -strumal carcinoid Neuroectodermal tumour group -ependymoma -primitive neuroectodermal tumour -glioblastoma multiforme -medulloblastoma Carcinoma Melanocytic group Sarcoma group Sebaceous tumour group

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SURFACE EPITHELIAL TUMOURS SEX CORD STROMAL TUMOURS GERM CELL TUMOURS GERM CELL SEX CORD STROMAL TUMOURS TUMOUR OF THE RETE OVARII MISCELLANEOUS TUMOURS TUMOUR LIKE CONDITION LYMPHOID AND HEMATOPOETIC TUMOURS SECONDARY TUMOURS. GERM CELL SEX CORD STROMAL TUMOURS

GERM CELL SEX CORD STROMAL TUMOURS : 

GERM CELL SEX CORD STROMAL TUMOURS Gonadoblastoma Mixed germ cell sex cord stromal tumour

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SURFACE EPITHELIAL TUMOURS SEX CORD STROMAL TUMOURS GERM CELL TUMOURS GERM CELL SEX CORD STROMAL TUMOURS TUMOUR OF THE RETE OVARII MISCELLANEOUS TUMOURS TUMOUR LIKE CONDITION LYMPHOID AND HEMATOPOETIC TUMOURS SECONDARY TUMOURS. TUMOUR OF THE RETE OVARII

TUMOUR OF THE RETE OVARII : 

TUMOUR OF THE RETE OVARII Adenoma Cystadenoma Cystadenofibroma Adenocarcinoma

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SURFACE EPITHELIAL TUMOURS SEX CORD STROMAL TUMOURS GERM CELL TUMOURS GERM CELL SEX CORD STROMAL TUMOURS TUMOUR OF THE RETE OVARII MISCELLANEOUS TUMOURS TUMOUR LIKE CONDITION LYMPHOID AND HEMATOPOETIC TUMOURS SECONDARY TUMOURS. MISCELLANEOUS TUMOURS

MISCELLANEOUS TUMOURS : 

MISCELLANEOUS TUMOURS Small cell carcinoma, hypercalcemic type Small cell carcinoma, pulmonary type Large cell neuroendocrine carcinoma Hepatoid carcinoma Primary ovarian mesothelioma Gestational choriocarcinoma Adenoid cystic carcinoma Basal cell carcinoma Ovarian wollfian tumour Paraganglioma Myxoma

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SURFACE EPITHELIAL TUMOURS SEX CORD STROMAL TUMOURS GERM CELL TUMOURS GERM CELL SEX CORD STROMAL TUMOURS TUMOUR OF THE RETE OVARII MISCELLANEOUS TUMOURS TUMOUR LIKE CONDITION LYMPHOID AND HEMATOPOETIC TUMOURS SECONDARY TUMOURS. TUMOUR LIKE CONDITION

TUMOUR LIKE CONDITION : 

TUMOUR LIKE CONDITION Luteoma of pregnancy Stromal hyperthecosis Stromal hyperplasia Fibromatosis Massive ovarian oedema

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SURFACE EPITHELIAL TUMOURS SEX CORD STROMAL TUMOURS GERM CELL TUMOURS GERM CELL SEX CORD STROMAL TUMOURS TUMOUR OF THE RETE OVARII MISCELLANEOUS TUMOURS TUMOUR LIKE CONDITION LYMPHOID AND HEMATOPOETIC TUMOURS SECONDARY TUMOURS. LYMPHOID AND HEMATOPOETIC TUMOURS

LYMPHOID AND HEMATOPOETIC TUMOURS : 

LYMPHOID AND HEMATOPOETIC TUMOURS Malignant lymphoma Leukemia Plasmacytoma

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SURFACE EPITHELIAL TUMOURS SEX CORD STROMAL TUMOURS GERM CELL TUMOURS GERM CELL SEX CORD STROMAL TUMOURS TUMOUR OF THE RETE OVARII MISCELLANEOUS TUMOURS TUMOUR LIKE CONDITION LYMPHOID AND HEMATOPOETIC TUMOURS SECONDARY TUMOURS SECONDARY TUMOURS

SECONDARY TUMOURS : 

SECONDARY TUMOURS Peritoneal tumors Mesothelial tumors Smooth muscle tumor Tumors of uncertain origin

Discussion of individual tumors : 

Discussion of individual tumors

SURFACE EPITHELIAL TUMOURS : 

Serous tumours Mucinous tumours Endometroid tumours including variants of squamous differentiation Clear cell tumours Transitional tumours Squamous cell tumours Mixed epithelial tumours Undifferentiated and unclassified tumours SURFACE EPITHELIAL TUMOURS

Serous tumors : 

¼ of all ovarian tumors Adults 30-50% bilateral Clonal origin Papillary formation present M/E: cuboidal to columnar cells lining walll of cysts and papillae Psammoma bodies 30% Serous tumors

Serous tumors- gross : 

cystic masses usually unilocular, containg clear but sometimes viscid fluid Serous tumors- gross

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Papillary formations are often present, most of them protruding into the cavity

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More malignant tumors tend to be sold and invasive, with areas of necrosis and hemorrhage Serous cystedenocarcinoma

Serous cystadenoma : 

Serous cystadenoma Cuboidal to columnar cells are seen lining wall of the cysts and papillae in better differentiated tumors

Borderline category: some or all of the freatures assosiated with carcinoma but lacking lacking stromal invasion : 

Benign cystadenoma lined by single layer of cells, without atypia, No architectural complexity or No invasion serous adenocarcinoma serous papillary adeno-CA serous papillary cystadenocarcinoma Nuclear atypia High mitotic activity Stratification Papillary fronds Stromal invasion Borderline category: some or all of the freatures assosiated with carcinoma but lacking lacking stromal invasion

Serous cystadenocarcinoma : 

Complex papillary architecture Nuclear atypia High mitotic activity Stratification Serous cystadenocarcinoma

Borderline serous neoplasm : 

Numerous papillary projections facing the lumen Borderline serous neoplasm

Borderline serous tumor. : 

Borderline serous tumor. Entirely increased complexity of stromal papilla with stratification and nuclear atypia but there is no infiltrative growth into the stroma

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In some serous neoplasm fIbroblastic stromal component is unduly prominent Grossly as white , nodular foci in an otherwise cystic neoplasm Benign (common) adenofibroma & cystadenofibroma Borderline Malignant adenifibrocarcinoma and cystadenofibrocarcinoma

Ovarian cystadenofibroma : 

Ovarian cystadenofibroma Well differentiated glands are embedded within a dense fibrous stroma

Some serous neoplasms grow exophytically on the surface of ovary , with little involvement of underlying organ : 

Benign surface papillomas Intermediate borderline surface papillary tumors Malignant serous surface papillary tumors Some serous neoplasms grow exophytically on the surface of ovary , with little involvement of underlying organ

Serous surface papillary carcinoma : 

Papillomatous outer surface of the ovary Marginal enlargement Serous surface papillary carcinoma

Serous surface papillary carcinoma : 

Serous surface papillary carcinoma There is hardly any infiltration of the stroma.

Serous psammocarcinoma : 

Serous psammocarcinoma A rare form of serous adenocarcinoma Involve ovarian surface Massive psammoma body formation Low grade cytologic features invasive stromal growth, abundant psammoma bodies in at least 75% of the papillae,

Immunohistochemistry of serous tumors : 

Immunohistochemistry of serous tumors keratin profile CK 7+/ CK20- Also CK8, CK18, CK19, EMA, S100 WT-1 stains diffusely most serous carcinomas

SURFACE EPITHELIAL TUMOURS : 

Serous tumours Mucinous tumours Endometroid tumours including variants of squamous differentiation Clear cell tumours Transitional tumours Squamous cell tumours Mixed epithelial tumours Undifferentiated and unclassified tumours SURFACE EPITHELIAL TUMOURS

MUCINOUS TUMORS : 

Less common Bilateral 10%-20% (clonal) Benign -Mucinous cystadenoma Borderline Malignant -Mucinous cystadenocarcinoma -cystadenocarcinoma MUCINOUS TUMORS

Mucinous cystadenoma : 

Mucinous cystadenoma Larger then serous Cystic Multiloculated Fluid to viscous material of mucoid nature present

Mucinous cystadenoma : 

Mucinous cystadenoma These benign cysts are lined by a single layer of mucinous epithelium without cilia

Borderline mucinous tumors : 

Intestinal type (80%) Endocervical type (20%) Borderline mucinous tumors

Borderline mucinous tumor (intestinal type) : 

Borderline mucinous tumor (intestinal type) Epithelial lining with a “picket fence appearance” intestinal-type lining which may be several layers thick mild to moderate nuclear atypia is present but destructive stromal invasion with an associated desmoplastic stromal response ABSENT Goblet cells Intestinal enzymes lipase , trypsin) But No evidence of hormone excess Lining of mucinous cystadenoma

Borderline mucinous tumor(endocervical type) : 

Borderline mucinous tumor(endocervical type) Associated with endometriosis Lining of tall nonciliated cells Basally located nuclei Abundant intracellular mucin Endocervical lined tumors are more likely to be bilateral and have associated peritoneal implants Lining of mucinous cystadenoma resembling endocervical epithelium

Malignant Mucinous tumors : 

Malignant Mucinous tumors Gross appearance of mucinous cystadenocarcinoma. The neoplasm is predominantly solid, but some mucin-containing cystic spaces can still be appreciated.

Malignant Mucinous tumors : 

Malignant Mucinous tumors Cell atypia Increase layering Gland complexity Papillae Areas of stromal invasion Complex architecture and obvious nuclear atypia in mucinous cystadenoma

STROMAL INVASION in MUCINOUS TUMORS : 

STROMAL INVASION in MUCINOUS TUMORS Unquestionable stromal invasion carcinoma Uncertain invasion i.e. (atypical epithelium less then 4 cells thick) borderline

Immunohistochemistry of Mucinous tumors : 

Immunohistochemistry of Mucinous tumors CEA EMA (particularly if malignant) MUC5AC Dpc4 CK7+ (always) CK20+ (50 %) Intestinal Type Immunohistochemically endocrine cells contain: 5-hydroxytryptamine (serotonin) ACTH gastrin somatostatin

SURFACE EPITHELIAL TUMOURS : 

Serous tumours Mucinous tumours Endometroid tumours including variants of squamous differentiation Clear cell tumours Transitional tumours Squamous cell tumours Mixed epithelial tumours Undifferentiated and unclassified tumours SURFACE EPITHELIAL TUMOURS

ENDOMETROID TUMORS : 

ENDOMETROID TUMORS 10-25% of all primary ovarian carcinomas Coexistent endometriosis in 10-20% Grossly, endometroid carcinoma may present as cystic or sold mass Contents are hemorrhagic Visibally papllary formations absent

ENDOMETROID TUMORS : 

ENDOMETROID TUMORS resembles appearance of endometrial carcinoma Psammoma bodies exceptional villous papillary structures and/or tubular glands composed of a stratified layer of epithelial cells with smooth luminal borders. By definition, destructive stromal invasion is present with an associated desmoplastic response

ENDOMETROID TUMOR : 

ENDOMETROID TUMOR Foci of squamous metaplasia in 50% May be peritoneal keratin granulomas Well-differentiated endometrioid ovarian carcinoma with extensive squamous metaplasia

International Federation of Gynecology and Obstetrics (FIGO) scheme grading for endometrioid adenocarcinomas : 

International Federation of Gynecology and Obstetrics (FIGO) scheme grading for endometrioid adenocarcinomas

Immunohistochemistry of endometroid carcinoma : 

Immunohistochemistry of endometroid carcinoma Keratin EMA Vimentin CEA usually negative or weak

SURFACE EPITHELIAL TUMOURS : 

Serous tumours Mucinous tumours Endometroid tumours including variants of squamous differentiation Clear cell tumours Transitional tumours Squamous cell tumours Mixed epithelial tumours Undifferentiated and unclassified tumours SURFACE EPITHELIAL TUMOURS

Clear cell tumors : 

Clear cell tumors Epithelial tumors of the ovary in which most or all of the cells have clear cytoplasm; most are malignant with rare benign and borderline variants. often associated with endometriosis Grossly spongy, white-tan to yellow. mixed solid and cystic masses Clear cell carcinomas are always high grade The tumor is predominantly cystic, but it contains several mural nodules

Clear cell tumors : 

Clear cell tumors Tumor cells: large Clear Nuclei: some protrude into lumina, resulting in hobnail configuration cytoplasm: clear often contains: glycogen mucin fat may be PAS-positive diastase-resistant hyaline globules Clear cell carcinoma of ovary. Note the high nuclear grade and the hobnail configuration

Growth patterns: tubular–cystic papillary solid sheet Clear cell adenocarcinomas have abundant clear cytoplasm and significant nuclear atypia. Clear cell tumor

Clear cell carcinoma : 

Clear cell carcinoma Cores of papillae often show prominent hyalinization Clear cell carcinoma of ovary showing short papillae with hyalinized cores lined by highly atypical cells

Special Stains and Immunohistochemistry of Clear cell tumors : 

Special Stains and Immunohistochemistry of Clear cell tumors Hyaline globules negative for α-fetoprotein Tumor cells: always reactive for: keratin (CK7, CK5/6, CAM 5.2 EMA CEA CD15 (Leu-M1) vimentin bcl-2 p53 CA-125 variably reactive for: estrogen and progesterone receptors: much greater expression of ER than PR ER exclusively of β rather than αtype HER2/neu α-fetoprotein negative for: CK20 also reactive for: hepatocyte nuclear factor-1β: transcription factor involved with liver differentiation

SURFACE EPITHELIAL TUMOURS : 

Serous tumours Mucinous tumours Endometroid tumours including variants of squamous differentiation Clear cell tumours Transitional tumours Squamous cell tumours Mixed epithelial tumours Undifferentiated and unclassified tumours SURFACE EPITHELIAL TUMOURS

Transitional tumours (SURFACE EPITHELIAL TUMOURS ) : 

Benign brenner metaplastic variant Borderline brenner (proliferating variant) Malignant Transitional cell carcinoma (non-brenner type) Malignant Brenner tumour Transitional tumours (SURFACE EPITHELIAL TUMOURS )

Brenner Tumor and Transitional Cell Carcinoma : 

Brenner Tumor and Transitional Cell Carcinoma resemble those of transitional cell neoplasms of the urinary tract 1–2% of all ovarian neoplasms Average age at presentation ≈50 years: Sometimes signs of hyperestrinism, such as postmenopausal uterine bleeding from endometrial hyperplasia2 * Slow rate of growth * Rarely ascites

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Grossly, these tumors have a white to tan-yellow whorled cut surface, but may show cystic spaces and calcification unilateral firm May be associated with: mucinous cystadenoma exceptionally struma ovarii also transitional cell tumors of urinary bladder

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Epithelial cells: solid and cystic nests resemble transitional epithelium (urothelium) surrounded by abundant stromal cysts with eosinophilic fluid in a fibrotic stroma Brenner tumor of ovary showing solid and cystic epithelial cells embedded within fibrous tissue.

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Nuclei: oval small but distinct nucleolus longitudinal grooves clear cytoplasm: The epithelial nests of Brenner tumor are composed of cells with oval nuclei, many of which exhibit longitudinal grooves

Metaplastic Brenner tumor : 

Metaplastic Brenner tumor * unduly prominent cystic formations * florid mucinous changes * papillary fronds and nuclear atypia absent

Proliferating Brenner tumor : 

Proliferating Brenner tumor papillary fronds nuclear atypia resemble pattern of low-grade (I or II) transitional carcinoma of urinary bladder Highly proliferating (borderline) Brenner tumor

Borderline or low malignant potential Brenner tumor : 

Borderline or low malignant potential Brenner tumor pattern of proliferating Brenner tumor with greater atypia (equivalent to grade III transitional cell carcinoma) stromal invasion cannot be demonstrated Borderline Brenner tumor showing solid area with papillary formations, associated with a large cystic space

Malignant Brenner tumor : 

Malignant Brenner tumor stromal invasion some bilateral recognized mainly because of association with a typical benign, metaplastic, proliferating, or borderline component The nuclear atypia is evident. Other areas of the tumor had the typical appearance of Brenner tumor

Transitional cell carcinomas of ovary (non-brenner type) : 

Transitional cell carcinomas of ovary (non-brenner type) (TCCs) of the ovary resemble other epithelial carcinomas with solid and cystic areas. closely resemble TCC of the bladder By definition, no Brenner tumor component is present. Ovarian TCC is graded using the criteria for TCC of the urothelial tract.

TCC ovarypapillary cores lined by stratified, cytologically atypical epithelium : 

TCC ovarypapillary cores lined by stratified, cytologically atypical epithelium

Special Stains and Immunohistochemistry of Brenner tumors and TCC : 

Special Stains and Immunohistochemistry of Brenner tumors and TCC Cytoplasm of tumor cells: immunoreactive for: o keratin o EMA o CEA: + also in lumen of cysts * may contain: o glycogen o mucin o lipid + in larger amounts in stromal cells if hyperestrinism Steroidogenic enzymes usually absent

Malignant Mixed Müllerian Tumor (carcinosarcoma ) : 

Malignant Mixed Müllerian Tumor (carcinosarcoma ) Also known occurs in postmenopausal women As with their endometrial counterparts, carcinosarcomas contain both malignant epithelial and malignant mesenchymal elements. both elements are derived from the same precursor, proving that the neoplasm does not represent a collision tumor; the tumor is now considered to represent a poorly differentiated carcinoma with metaplastic sarcomatous elements. The epithelial component is often serous carcinoma, but may be endometrioid, mucinous, clear cell, or even squamous. The mesenchymal elements may be homologous to the female genital tract (e.g., smooth muscle, endometrial stroma) or may be heterologous elements not normally found in the female genital tract (e.g., bone, cartilage, skeletal muscle) poor prognosis

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Resembles grossly in every respect its more common uterine counterpart Gross appearance of malignant mixed müllerian tumor of ovary. The neoplasm is large, variegated, solid and cystic, with hemorrhagic and necrotic areas

MMMT : 

MMMT Carcinomatous component may appear: serous endometrioid squamous clear cell (mesonephroid) Sarcoma-like elements may have appearance of: chondrosarcoma (mostcommon) osteosarcoma rhabdomyosarcoma angiosarcoma Malignant mixed müllerian tumor of ovary exhibiting heterologous foci in the form of bone and cartilage

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Malignant mixed müllerian tumor of ovary exhibiting heterologous foci in the form of skeletal muscle

Special Stains and Immunohistochemistryof MMMT : 

Special Stains and Immunohistochemistryof MMMT Often hyaline droplets containing α1-antitrypsin in cytoplasm of tumor cells Prognosis Extremely poor Most reliable prognostic criterion is initial tumor stage most tumors have already extended outside ovary at surgery

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SURFACE EPITHELIAL TUMOURS SEX CORD STROMAL TUMOURS GERM CELL TUMOURS GERM CELL SEX CORD STROMAL TUMOURS TUMOUR OF THE RETE OVARII MISCELLANEOUS TUMOURS TUMOUR LIKE CONDITION LYMPHOID AND HEMATOPOETIC TUMOURS SECONDARY TUMOURS. SEX CORD STROMAL TUMOURS

SEX CORD STROMAL TUMOURS : 

Granulosa stromal cell tumours Sertoli stromal cell tumours Sex cord stromal tumours of mixed or unclassified cell types Steroid cell tumours SEX CORD STROMAL TUMOURS

Granulosa stromal cell tumours (SEX CORD STROMAL TUMOURS) : 

Granulosa stromal cell tumours (SEX CORD STROMAL TUMOURS) Granulosa cell tumour group a) adult granulosa cell tumour. b) juvenile granulose cell tumour Thecoma fibroma group thecoma (typical or lutenised) fibroma cellular fibroma fibrosarcoma sclerosing stromal tumours signet ring stromal tumour stromal tumour with minor sex cord elements unclassified

Granulosa Cell Tumor group(sex cord stromal tm) : 

Granulosa Cell Tumor group(sex cord stromal tm) differentiation towards follicular granulosa cells that can occur in adults (adult granulosa cell tumor) and in younger patients (juvenile granulosa cell tumor) Two distinct types: * adult * juvenile:

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Adult Granulosa Cell Tumor Usually childbearing age - 75% have hyperestrinism, which may result in: +isosexual precocious puberty +metrorrhagia in adults, including postmenopausal women Elevated serum inhibin and follicle regulatory proteins

AGCT : 

AGCT The tumors are usually large (>10 cm) and unilateral. The cut surface is soft and yellow-tan with cysts and hemorrhage. encapsulated smooth, lobulated outline Cut surface: -predominantly solid May be: cystic: -filled with straw-colored or mucoid fluid -sometimes so prominent as to simulate appearance of a cystadenoma Granulosa cell tumor with solid cut surface.

AGCT : 

AGCT different histologic patterns occur, including microfollicular, macrofollicular, “watered-silk,” gyriform, and diffuse. However, all are composed of round to oval granulosa cells that have little cytoplasm and round to angular nuclei with longitudinal nuclear grooves (coffee bean appearance) There is minimal cytologic atypia mitotic rate is low.

Coffee-bean( longitudnally grooved) nuclei in adult type of ovarian granulosa cell tumor : 

Coffee-bean( longitudnally grooved) nuclei in adult type of ovarian granulosa cell tumor

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The microfollicular and diffuse variants often contain characteristic Call–Exner bodies consisting of a very small collection of eosinophilic material lined by well-differentiated granulosa cells

Juvenile Granulosa Cell Tumor : 

Juvenile Granulosa Cell Tumor more aggressive than adult more likely to produce distant metastases ≈80% during first two decades of life * Usually presents with isosexual precocity * Occasionally associated with: - enchondromatosis (Ollier's disease) - Maffucci's syndrome

Juvenile Granulosa Cell Tumor : 

Juvenile Granulosa Cell Tumor Typical morphologic features include: o diffuse or macrofollicular patterns of growth (former predominating) - eosinophilic mucin-positive intrafollicular secretion - larger tumor cells with extensive luteinization - paucity of nuclear grooves - nuclear atypia - variable but often high mitotic activity . . On high power the tumor cells lack the coffee-bean nuclei seen in the adult type The follicle-like spaces seen on low-power examination are a common feature of this neoplasm.

Special Stains and Immunohistochemistry granulosa cell tumors : 

Special Stains and Immunohistochemistry granulosa cell tumors Adult Granulosa Cell Tumor * Immunohistochemically: - steroid production: + by both theca and granulosa cells with predominance of: # estradiol in granulosa cells # progesterone in luteinized theca cells o vimentin o desmoplakin (desmosomal plaque protein) o inhibin (also JGCT) follicle regulatory proteins o CD99 keratin: + 33–50% of cases + typical dot-like distribution + mainly CK8 and CK18 types25,26 smooth muscle actin: + nearly all cases S-100 protein: + ≈50% of cases Strong immunoreactivity for inhibin in granulosa cell tumor.

Granulosa stromal cell tumours (SEX CORD STROMAL TUMOURS) : 

Granulosa stromal cell tumours (SEX CORD STROMAL TUMOURS) Granulosa cell tumour group a) adult granulosa cell tumour. b) juvenile granulose cell tumour Thecoma fibroma group thecoma (typical or lutenised) fibroma cellular fibroma fibrosarcoma sclerosing stromal tumours signet ring stromal tumour stromal tumour with minor sex cord elements unclassified

thecoma : 

thecoma postmenopausal women,. symptoms of hyperestrogenism. Most are unilateral and can measure up to 10 cm in diameter. Histologically, typical thecomas show. Immunohistochemically, the tumor is positive for inhibin expression. Oil Red O fat stains (which require fresh tissue) highlight the intracellular lipid.

Thecoma : 

Thecoma Cut surface of thecoma showing a predominance of yellow areas alternating with whitish foci Usually unilateral Variable size Well-defined capsule Firm consistency Cut surface: * largely or entirely solid * may be cysts Yellow color

THECOMA : 

THECOMA Fascicles of spindle cells with: o centrally placed nuclei o moderate amount of pale cytoplasm only mild atypia and rare mitoses Intervening tissue may show: -considerable collagen deposition - focal hyaline plaque formation Degree of cellularity varies considerably Some in young women are heavily calcified Bland microscopic appearance of thecoma, with some variability in cellularity.

Special Stains and Immunohistochemistry : 

Special Stains and Immunohistochemistry Oil red O: (require fresh tissue) - abundant intracytoplasmic neutral fat positive for inhibin expression Silver stains: - usually reticulin fibers surrounding individual cells -may be islands devoid of reticulin, especially in areas of luteinization Estradiol usually limited to a small number of tumor cell

FIBROMA : 

FIBROMA The most common type of sex-cord stromal tumor developing from specialized ovarian stroma Common Usually unilateral Almost invariably after puberty Fibromas are not hormonally functional average of 5 cm in diameter Sometimes in young women with basal cell nevus (Gorlin's) syndrome Benign May be ascites: especially if large sometimes with right-sided pleural effusion (Meigs' syndrome) (disappears on removal of tumor)

Gross Pathology : 

Gross Pathology Solid Lobulated Firm Uniformly white Usually no adhesions Average diameter 6cm May be myxoid changes, sometimes resulting in cystic degeneration Cut surface of ovarian fibroma. Outer aspect of ovarian fibroma

FIBROMA : 

FIBROMA Spindle stromal cells: - closely packed - arranged in 'feather-stitched' or storiform pattern - no atypia and few mitoses May be: - hyaline bands - edema If in basal cell nevus (Gorlin's) syndrome: - calcified - usually bilateral - often multinodular Cellular fibroma. The tumor is hypercellular, but pleomorphism and mitotic activity are minimal Ovarian fibroma showing hypocellular appearance, bland nuclear features, and a suggestion of a storiform pattern of growth

Immunohistochemistry of Fibromas : 

Immunohistochemistry of Fibromas diffusely positive for vimentin

SEX CORD STROMAL TUMOURS : 

Granulosa stromal cell tumours Sertoli stromal cell tumours Sex cord stromal tumours of mixed or unclassified cell types Steroid cell tumours SEX CORD STROMAL TUMOURS

Sertoli stromal cell tumors : 

Sertoli stromal cell tumors Sertoli leydig cell tumour group ( androblastoma). a) well differentiated b) intermediate differentiation c) poorly differentiated (sarcomatoid) d) retiform 2. Sertoli cell tumour. 3. Stromal leydig cell tumour

Sertoli leydig cell tumor : 

Sertoli leydig cell tumor Young patients (average 25 years) 50% shows signs of androgen excess i.e defeminisation (breast atrophy, loss of subcut. Fat) Later masculinisation appears

Sertoli leydig cell tumor : 

Sertoli leydig cell tumor Mixture of variable proportions of cells morphologically resembling male sertoli and leydig cells 0.1% of ovarian neoplasms Grossly predominantly solid Variegated appearance of cut surface of ovarian Sertoli–Leydig cell tumor.

Microscopic pattern : 

Microscopic pattern Well differentiated (meyer’s type I) Tubules lined by sertoli like cells seperated by variable number of leydig like cells Well-differentiated (Meyer’s type I) Sertoli–Leydig cell tumor.

Microscopic patterns of SLCT : 

Microscopic patterns of SLCT Intermediate (meyer’s type II) Formation of cords, sheets and aggregates of sertoli like cells seperated by spindle stromal cells

Microscopic patterns of SLCT : 

Microscopic patterns of SLCT Poorly differentiared (meyer’s type III) Composed of masses of spindle shaped cells arranged in “sacomatoid” pattern

Microscopic patterns of SLCT : 

Microscopic patterns of SLCT With heterologous elements (teratoid androblastoma) a/w mucinous epithelium of gastrointestinal type, liver, cartilage

Special Stains and Immunohistochemistry of SLCT : 

Special Stains and Immunohistochemistry of SLCT Testosterone and estradiol both in sertoli and leydig cells Areas of sertoli cell differentiation are Keratin+ Gonadal stromal components- inhibin+

Sex Cord Tumor with Annular Tubules (Sex cord stromal tumours of mixed or unclassified cell types ) : 

Sex Cord Tumor with Annular Tubules (Sex cord stromal tumours of mixed or unclassified cell types ) A distinctive variant of sex cord stromal-tumor with features of Sertoli and granulosa cell differentiation, divided in two subsets including those associated with Peutz-Jeghers syndrome and those without such association 33% associated with Peutz–Jeghers syndrome Symptoms suggestive of hyperestrinism in ≈50% Gross Pathology If associated with Peutz–Jeghers syndrome typically: - multifocal - bilateral - small (or even microscopic) - calcified - benign4 * If unassociated with Peutz–Jeghers syndrome: - unilateral - often large - ≈22% of cases clinically malignant

Sex cord tumor with annular tubules : 

Sex cord tumor with annular tubules Combines: - features suggestive of granulosa cell tumor - pattern of growth reminiscent sertoli cells Simple and complex annular tubules containing eosinophilic hyaline bodies, often calcified. - morphologic hallmark Sex cord tumor with annular tubules. The patient had Peutz–Jeghers syndrome

Steroid cell tumor (Sertoli stromal cell tumors) : 

Steroid cell tumor (Sertoli stromal cell tumors) Syn. Lipid, lipoid cell tumor Heterogeneous group of tumors composed entirely of cells with morphologic features indicative of steroid hormone secretion. Any age Most associated with a virilizing syndrome (defeminization and amenorrhea) Sometimes: - Cushing's syndrome -estrogenic or progestogenic manifestations -associated with endometrioid carcinoma

Gross Pathology : 

Gross Pathology Usually unilateral Composed of yellow or yellowish brown nodules separated by fibrous trabeculae Malignant tumors tend to: - be larger (≥cm in diameter) - have foci of necrosis and hemorrhage Cut surface of ovarian lipid cell tumor.

Steroid cell tumor : 

Steroid cell tumor Masses of large rounded or polyhedral cells Composed entirely of cells with features indicative of steroid hormone secretion: cytoplasm: + abundant + eosinophilic + may be vacuolated + often positive for fat stains Malignant tumors tend to exhibit: - nuclear atypia - mitotic activity Lipid cell tumor showing clear appearance of the cytoplasm of the tumor cells. Lipid cell tumor showing acidophilic appearance of the cytoplasm of the tumor cells

Special Stains and Immunohistochemistry : 

Special Stains and Immunohistochemistry * Immunohistochemically: - reactivity for: + vimentin in 75% + keratin in 50% + actin in ≈33%8 consistent reactivity for: - inhibin - A103 - Mart-1

Slide 136: 

SURFACE EPITHELIAL TUMOURS SEX CORD STROMAL TUMOURS GERM CELL TUMOURS GERM CELL SEX CORD STROMAL TUMOURS TUMOUR OF THE RETE OVARII MISCELLANEOUS TUMOURS TUMOUR LIKE CONDITION LYMPHOID AND HEMATOPOETIC TUMOURS SECONDARY TUMOURS. GERM CELL TUMOURS

Germ cell tumors : 

Germ cell tumors Primitive germ cell tumor Dysgerminoma Yolk cell tumour Variants: polyvesicular vitelline tumour,glandular,hepatoid Embryonal carcinoma Polyembryoma Non gestational choriocarcinoma Biphasic or triphasic teratoma Immature cystic teratoma Mature teratoma solid cystic (dermoid cyst) retiform teratoma

Germ Cell tumors : 

Germ Cell tumors 20% of all ovarian neoplasm Children and young adults 95% benign cystic teratomas Younger the patient, more likely the germ cell tumor will be malignant

Dysgerminoma : 

Dysgerminoma Dysgerminoma is the most common malignant germ cell neoplasia of the ovary, and is similar to seminoma which is the testicular counterpart <1% of all ovarian tumors ≈5% of malignant ovarian tumors1 Usually young <30 years of age2 ≈5% arise in abnormal gonads: a) pure or mixed gonadal dysgenesis (from a gonadoblastoma), b) testicular feminization (androgen insensitivity) syndrome Exceptionally associated with hypercalcemia More common on right Bilateral in 15% of cases Metastases commonly in: * contralateral ovary * retroperitoneal nodes * peritoneal cavity: (associated with decreased survival rate)

DYSGERMINOMA : 

DYSGERMINOMA Often: large: may be >1000g encapsulated #Smooth, often convoluted surface Cut surface solid gray may be foci of hemorrhage and necrosis: not as common or prominent as in other malignant germ cell tumors Cut surface of ovarian dysgerminoma. The multinodular solid quality and the tan color are characteristic features. Typical lobulated outer aspect of ovarian dysgerminoma

Dysgerminoma : 

Dysgerminoma Tumor cells: * uniform * nuclei: large nucleoli: - one or more - prominent - elongated * cytoplasm: -abundant - clear to finely - contains: + glycogen + sometimes fine droplets of fat * cell membrane prominent fibrous strands infiltrated by lymphocytes (most T-cell type5) May be: * focal necrosis * hyaline changes in vessels * germinal centers * granulomatous foci

Special Stains and Immunohistochemistryof dysgerminoma : 

Special Stains and Immunohistochemistryof dysgerminoma Tumor cells reactive for: -PLAP -CD117 (c-KIT) often keratin (erratically and focally) sometimes -GFAP -Desmin

Yolk Sac Tumor (Germ cell tumors) : 

Yolk Sac Tumor (Germ cell tumors) Malignant germ cell tumor of the ovary developed as a result of differentiation of primitive malignant germ cell elements in the direction of yolk sac or vitelline structures #Usually children and young adults: * median age 19 years * ≈25% prepubertal at diagnosis Vaginal bleeding in 1% Serum AFP level invariably elevated Chorionic gonadotropin levels normal:

Slide 144: 

Average diameter 15cm External surface: * smooth * glistening Cut surface: * variegated * partially cystic * often large foci of hemorrhage and necrosis Component of benign cystic teratoma in ≈15% of cases Gross appearance of yolk sac tumor. The cut surface is remarkably heterogeneous due to extensive hemorrhage, necrosis, and cystic degeneration

YOLK SAC TUMOR : 

YOLK SAC TUMOR Many histologic variants occur, including the reticular, endodermal sinus (papillary), polyvesicular–vitelline, hepatoid, and glandular patterns. The endodermal sinus pattern is the second most common pattern(after reticular); this pattern features characteristic Schiller–Duvall bodies (rounded papillae containing a single central vessel and lined by columnar tumor cells) .

YOLK SAC TUMOR : 

YOLK SAC TUMOR PAS-positive hyaline droplets * intracytoplasmic and extracellular * nearly always present High-power view of ovarian yolk sac tumor. Numerous hyaline globules are seen in the cytoplasm of the tumor cells lining the papillae

YOLK SAC TUMOR : 

YOLK SAC TUMOR Some show differentiation toward hepatic, intestinal, and parietal yolk sac structures Yolk sac tumor with endometrioid features

Special Stains and Immunohistochemistry : 

Special Stains and Immunohistochemistry Yolk sac tumor: stains for: - pancreatin negative for: - keratin 7: (in contrast with endometrioid and clear cell ovarian carcinoma) -WT-1: ( in contrast with serous ovarian carcinoma) Hyaline droplets: -heterogeneous chemical composition - usually stain for α-fetoprotein - may also contain: - α1-antitrypsin - basement membrane components: #type IV collagen # laminin

Embryonal carcinoma : 

Embryonal carcinoma Rare and the least differentiated of the ovarian germ cell tumors considered to be homologous to the embryonal carcinoma of adult testis. Young age group (median age 15 years): 47% prepubertal at diagnosis, 43% of whom present with precocious puberty Vaginal bleeding in 33% Amenorrhea in 7% Hirsutism in 7% Serum α-fetoprotein levels often elevated Chorionic gonadotropin levels invariably high: results in consistently positive pregnancy tests

Embryonal carcinoma : 

Embryonal carcinoma Median diameter 17cm External surface: smooth and glistening Cut surface: predominantly solid and variegated extensive areas of necrosis and hemorrhage Gross appearance of embryonal carcinoma of ovary.

Embryonal carcinoma : 

Embryonal carcinoma Similar appearance to embryonal carcinoma of adult testis Solid sheets and nests of large primitive cells: occasionally forming papillae and abortive glandular structures Frequently syncytiotrophoblast-like tumor cells scattered among smaller cells Microscopic appearance of embryonal carcinoma of ovary

Special Stains and Immunohistochemistry of embryonal carcinoma : 

Special Stains and Immunohistochemistry of embryonal carcinoma Syncytiotrophoblast-like tumor cells immunoreactive for hCG CD30 and cytokeratin

choriocarcinoma : 

choriocarcinoma Malignant tumor of the ovary with trophoblastic differentiation composed of syncytiotrophoblast, cytotrophoblast and intermediate trophoblast Exceedingly rare May be associated with mature cystic teratoma of contralateral ovary

choricarcinoma : 

choricarcinoma Typical admixture of syncytial and cytotrophoblastic elements in a necrotic and hemorrhagic background Choriocarcinoma arising in a dermoid cyst

Special Stains and Immunohistochemistry : 

Special Stains and Immunohistochemistry Usually immunohistochemical reactivity for hCG Keratin 7 said to represent a marker for subset of trophoblastic cells LK26 (a folate-binding protein): - consistently expressed

Immature Malignant Teratoma : 

Immature Malignant Teratoma Malignant ovarian germinal tumor composed of mixture of immature embryonal and mature adult tissue derived from all three germ layers Usually children and adolescents May be: * solid throughout * solid with multiple minute cysts * predominantly cystic Gross appearance of ovarian immature teratoma

Immature teratoma : 

Immature teratoma Mixture of embryonal and adult tissues derived from all three germ layers: * any type of tissue * main component usually neuroepithelial * mesodermal elements also common * sometimes predominantly composed of endodermal derivatives, including -esophagus - liver -intestinal structures immature teratoma containing immature neuroepithelium forming rosettes.

Grading system for immature teratoma (Norris et al) : 

Grading system for immature teratoma (Norris et al) Grade I Abundance of mature tissues Loose mesenchymal tissue with occasional mitoses Immature cartilage Tooth anlage Grade II Fewer mature tissues Rare foci of neuroepithelium with common mitoses not exceeding three low-magnification (×40) fields in any one slide Grade III Few or no mature tissues Numerous neuroepithelial elements merging with a cellular stroma occupying four or more low-magnification fields

Special Stains and Immunohistochemistry : 

Special Stains and Immunohistochemistry Glial fibrillary acidic protein (GFAP): - helpful in identification of mature and immature glial tissue - also detectable in chondrocytes * Long-chain polysialic acid moiety of neural cell adhesion molecule: - another marker of immature and mature neural tissue

Mature Cystic Teratoma : 

Mature Cystic Teratoma Cystic germ cell tumors composed of multiple mature elements derived from ectoderm, mesoderm and endoderm. Almost 20% of all ovarian neoplasms: Most common ovarian tumor in childhood 88% unilateral usually benign Symptoms: * relate to mass * occasionally: - hemolytic anemia - virilization * May coexist with: - mucinous cystadenoma - Brenner tumor - * Usually benign

Slide 161: 

Usually multiloculated Cystic content: greasy largely composed of: keratin sebum hairs commonly teeth (tend to be in well-defined nipple-like structure covered with hair (Rokitansky's protuberance) Admixture of sebum and hair within the cavity of an ovarian mature cystic teratoma

Mature cystic teratoma : 

Mature cystic teratoma #Cystic cavities lined by mature epidermis Extremely common: * skin appendages * neural (particularly glial) tissue Also: * cartilage * respiratory tissue * gastrointestinal tract tissue (- may be peptic ulcer formation) Mature cystic teratoma of ovary: gastric mucosa of pyloric type Mature cystic teratoma of ovary: skin adnexa, glial tissue, and choroid plexus

Slide 163: 

teratoma has cartilage, adipose tissue, and intestinal glands at the right, while at the left is a lot of thyroid tissue.

Mature teratoma : 

Mature teratoma * thyroid (10% of cases) * anterior pituitary * various types of neuroendocrine cells * prostate * pancreas * cavernous blood vessels Mature cystic teratoma of ovary: anterior pituitary gland

Germ cell tumors : 

Germ cell tumors Monodermal teratoma Thyroid tumour group Struma ovarii –benign or malignant Carcinoid group -insular -trabecular -mucinous -strumal carcinoid Neuroectodermal tumour group -ependymoma -primitive neuroectodermal tumour -glioblastoma multiforme -medulloblastoma Carcinoma Melanocytic group Sarcoma group Sebaceous tumour group

Struma Ovarii : 

Struma Ovarii Ovarian teratoma composed exclusively or predominantly of thyroid tissue May show any of the pathologic changes seen in a normally placed gland, including: * diffuse or nodular hyperplasia: - may lead to hyperthyroidism - thyroiditis -carcinoma: ( sometimes resulting in metastases) -malignant lymphoma

Slide 167: 

Color and consistency of thyroid tissue, but often cystic Gross appearance of struma ovarii. The thyroid tissue is represented by the solid areas.

Slide 168: 

Dominant growth of thyroid tissue in a teratoma, sometimes to exclusion of other components Struma ovarii. The thyroid tissue, which has a microscopically unremarkable appearance, is sharply delimited from the ovarian stroma

Special Stains and Immunohistochemistry : 

Special Stains and Immunohistochemistry Thyroid nature fully documented with biologic and immunohistochemical studies for thyroid hormones

Carcinoid Tumor (monodedrmal teratoma) : 

Carcinoid Tumor (monodedrmal teratoma) Primary well differentiated neuroendocrine tumor of the ovary Carcinoid syndrome: * in ≈33%, even without liver metastases * more likely the larger the tumor Sometimes severe constipation: * presumably due to secretion of peptide YY

carcinoid : 

carcinoid Usually unilateral Mean diameter 10 cm External surface: * smooth or bosselated * predominantly solid * firm * tan to yellow * homogeneous Cut surface of carcinoid tumor of ovary showing typical solid appearance and white to yellowish color

Carcinoid (monodermal teratoma) : 

Carcinoid (monodermal teratoma) insular pattern of growth similar to in appendix and small bowel -trabecular appearance similar to in rectum - mucinous (goblet cell) appearance similar to those seen primarily in appendix Primary ovarian carcinoid tumor with a trabecular pattern of growth

Slide 173: 

SURFACE EPITHELIAL TUMOURS SEX CORD STROMAL TUMOURS GERM CELL TUMOURS GERM CELL SEX CORD STROMAL TUMOURS TUMOUR OF THE RETE OVARII MISCELLANEOUS TUMOURS TUMOUR LIKE CONDITION LYMPHOID AND HEMATOPOETIC TUMOURS SECONDARY TUMOURS. GERM CELL SEX CORD STROMAL TUMOURS

GERM CELL SEX CORD STROMAL TUMOURS : 

GERM CELL SEX CORD STROMAL TUMOURS Gonadoblastoma Mixed germ cell sex cord stromal tumour

gonadoblastoma : 

gonadoblastoma Tumor composed of a combination of germ cells and sex-cord cells that arises almost exclusively in dysgenetic gonads Usually sexually abnormal: commonly gonadal dysgenesis and carrying Y chromosome, i.e.: - XY gonadal dysgenesis - XO–XY mosaicism - but not XX gonadal dysgenesis1 estimated 25% risk of neoplasia in these dysgenetic gonads Also documented in: * phenotypically and chromosomally normal females, even during pregnancy * ataxia–telangiectasia

Gross Pathology : 

Gross Pathology Usually small Often impossible to determine nature of gonad bearing tumor: - sometimes identified as: + a streak(many become apparent only on microscopic examination) + cryptorchid testis never a normal ovary * ≈36% bilateral Streak gonad microscopically shown to contain gonadoblastoma. The tumor was barely apparent grossly.

gonadoblastoma : 

gonadoblastoma Admixture of: primitive germ cells: resembling those of dysgerminoma sex cord–stromal cells: resembling morphologically and immunohistochemically immature Sertoli and granulosa cells Steroid hormone-producing cells: may be present: especially after puberty have capacity for steroidogenesis Commonly: hyalinization: when abundant may be obvious on plain abdominal radiograph calcification Ovarian gonadoblastoma. Note the sharply outlined tumor nests and the heavy calcification

special Stains and Immunohistochemistry : 

special Stains and Immunohistochemistry Hyaline material reacts strongly with anti-laminin antibodies, indicating basement membrane deposition

Slide 179: 

SURFACE EPITHELIAL TUMOURS SEX CORD STROMAL TUMOURS GERM CELL TUMOURS GERM CELL SEX CORD STROMAL TUMOURS TUMOUR OF THE RETE OVARII MISCELLANEOUS TUMOURS TUMOUR LIKE CONDITION LYMPHOID AND HEMATOPOETIC TUMOURS SECONDARY TUMOURS. MISCELLANEOUS TUMOURS

MISCELLANEOUS TUMOURS : 

MISCELLANEOUS TUMOURS Small cell carcinoma, hypercalcemic type Small cell carcinoma, pulmonary type Large cell neuroendocrine carcinoma Hepatoid carcinoma Primary ovarian mesothelioma Gestational choriocarcinoma Adenoid cystic carcinoma Basal cell carcinoma Ovarian wollfian tumour Paraganglioma Myxoma

Small Cell Carcinoma : 

Small Cell Carcinoma Poorly differentiated tumors, composed mostly of small cells, and subclassified into hypercalcemic and pulmonary type Two types: * hypercalcemic: -most common * pulmonary Hypercalcemic-type Small Cell Carcinoma Young females (average age 23 years) Nearly always bilateral Occasionally familial1 Hypercalcemia: - 67% of cases - disappears following removal * High-grade malignancy

Gross Pathology : 

Gross Pathology Hypercalcemic-type Small Cell Carcinoma Large and solid Areas of necrosis and hemorrhage

Hypercalcemic-type Small Cell Carcinoma : 

Hypercalcemic-type Small Cell Carcinoma Hypercalcemic-type Small Cell Carcinoma Diffuse proliferation of small, closely packed cells of carcinomatous appearance with: - scant cytoplasm - small nuclei May be: - clusters of larger and more pleomorphic cells, some resembling luteinized cells: + if a large number referred to as large variant of small cell carcinoma - cytoplasmic hyaline globules - islands - cords - mucinous glands - follicle-like structures + important clue to diagnosis Small cell carcinoma, hypercalcemic type. The presence of follicle-like formations is an important diagnostic feature

Slide 184: 

Pulmonary-type Small Cell Carcinoma Resembles homonymous lung tumor May be pure or associated with endometrioid carcinoma or other patterns Ultrastructurally: - neurosecretory-type granule Small cell carcinoma of pulmonary type. The sharply outlined foci of necrosis are a common feature of this tumor, which has a microscopic appearance very similar to its pulmonary counterpart

Special Stains and Immunohistochemistry : 

Special Stains and Immunohistochemistry Hypercalcemic-type Small Cell Carcinoma Tumor cells: may express: keratin vimentin EMA chromogranins laminin do not express: B72.3 S-100 protein inhibin Immunoreactivity for human parathyroid hormone-related protein: poor correlation between degree of staining and serum calcium level Pulmonary-type Small Cell Carcinoma Immunohistochemically: reactivity for: keratin EMA NSE (rarely) for chromogranin and Leu7

Slide 186: 

SURFACE EPITHELIAL TUMOURS SEX CORD STROMAL TUMOURS GERM CELL TUMOURS GERM CELL SEX CORD STROMAL TUMOURS TUMOUR OF THE RETE OVARII MISCELLANEOUS TUMOURS TUMOUR LIKE CONDITION LYMPHOID AND HEMATOPOETIC TUMOURS SECONDARY TUMOURS SECONDARY TUMOURS

Metastatic tumors : 

Metastatic tumors Malignant secondary tumors involving ovaries originated in other organs. * ≈7% of lesions presenting as primary ovarian tumors are metastatic * >50% bilateral * Most common sources: - stomach - large bowel - appendix - breast - uterus (corpus and cervix) - lung - skin (melanoma) Metastases From Adenocarcinoma of Large Bowel * Relatively common * Primary tumors usually advanced (Dukes' stage B or C)

Krukenberg Tumors : 

Krukenberg Tumors Usually: * >40 years of age * bilateral * metastatic origin Usual primary sources: * stomach: - diffuse gastric carcinoma (linitis plastica) used to be most common * large bowel * appendix * breast * (most common cause in US) May be: * retroperitoneal lymph node metastases * peritoneal implants Ovarian metastasis of lobular carcinoma of the breast.

Gross Pathology : 

Gross Pathology Krukenberg Tumor Moderate solid multinodular enlargement of the ovaries. Typical gross appearance of Krukenberg tumors of ovary. The involvement is bilateral and the tumors are characterized by a multinodular outer appearance

Krukenberg Tumor : 

Krukenberg Tumor * Diffuse infiltration by signet ring cells containing abundant neutral and acidic (sialo-) mucins. - signet ring cells occasionally in other ovarian conditions so need + histochemical identification of intracytoplasmic mucin + immunohistochemical detection of epithelial markers * Tumor emboli >50% of cases9 Krukenberg tumor of ovary. Presence of intracellular mucin Krukenberg tumor of ovary. Microscopic appearance. Numerous signet ring cells are present in a highly fibrous stroma, either individually or in small nests

Slide 191: 

Features favoring primary ovarian tumor: * expansile (pushing) pattern of invasion * complex papillary architecture * size over 10cm * smooth external surface * benign- and borderline-appearing foci Ovarian metastases tend to be: * cystic * well differentiated * mucin-producing * associated with necrosis and hemorrhage

Metastases From Adenocarcinoma of Large Bowel : 

Metastases From Adenocarcinoma of Large Bowel Features favoring metastasis from large bowel: * bilaterality * surface involvement by tumor cells * infiltrative or nodular pattern of invasion * ovarian hilar involvement * single cell invasion * signet ring cells * garland and cribriform growth pattern * 'dirty' necrosis * segmental destruction of glands * lack of squamous metaplasia * vascular invasion15–18 Large bowel adenocarcinoma metastatic to ovary

Special Stains and Immunohistochemistry : 

Special Stains and Immunohistochemistry Metastases From Adenocarcinoma of Large Bowel * Metastatic large bowel carcinoma characteristically: - CK7−/CK20+ - CEA+ - CA-125− - MUC2+ - often MUC5AC− * Primary ovarian mucinous carcinomas - nearly always CK7+ - variably CK20+ (often only focally) - CEA− - CA-125+ - MUC5AC+ Metastases From Breast Carcinoma * Immunoreactive for GCDFP-15: - important in differential diagnosis with primary ovarian carcinoma, which is generally negative

TNM STAGING : 

TNM STAGING

Slide 200: 

Thanks