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Ovary - Coggle Diagram
Ovary
metastases
tend to occur in older women
usually bilateral (both ovaries?)
likely sites
GI tract
Kruckenberg tumours
usually solid grey white mass
up to 20cm in diameter
anaplastic cells dispersed through fibrous background
present on the surface of the ovary
may be 'signet ring' mucin secreting
Surface epithelial tumours
general
overall frequency
65-70%
proportion of malignant tumours
90%
age group
20+
derived from
coelomic mesothelium
covers surface of ovary
repeated ovulation + scarring
surface epi. is pulled into cortex of ovary
forming small epi cysts
can undergo
metaplasia
neoplastic transformation
benign lesions
can be/have
cystic
cystadenoma
accompanying stromal component
cystadenofibroma
malignant lesions
can be
cystic
cystadenocarcinoma
solid
carcinoma
intermediate category
borderline
tumours of low malignant potential
Serous tumours
most frequent ovarian tumour
benign
60%
serous cystadenomas
25% are bilateral
usually have smooth glistening capsule
may be unilocular/multiloculated with clear serous fluid
may have small polypoidal projections jutting into cystic cavity
women aged 30-40yrs
malignant
25%
serous cystadenocarcinomas
may have surface nodular irregularities with more marked papillary projections
women aged 45-65 yrs
low malignant potential
15%
size
can be small
5-10cm
most are large
spherical to ovoid structure
30-40cm
histology
benign
single layer of tall ciliated columnar epi. that lines the cysts
psammoma bodies are common at the tips
malignant
more complex papillary formations
with fibrovascular cores, epi. multilayering, nuclear atypia and invasion
low malignant potential
milder cytological atypia with little/no stromal invasion
high grade serous tumours
mutations in P53 and BRCA1
Prognosis
malignant
spread to LNs
rarely spread to distant lymphatic and haematogenous
treatment
surgery
radiotherapy
chemotherapy
poor
depends on stage
frankly invasive+confined to ovary
10yr, 70% survival
capsule invasion
13% 10yr
serous borderline+confined to ovary
100%, 10yr
peritoneal metastasis
75%
Mucinous tumours
general
same age group as serous
less likely to be malignant
10% malignant
10% borderline
80% benign
morphology
benign
5% bilateral
malignant
20% bilateral
usually larger than serous
multilocular
lined by mucous secreting epi cells
endocervical type
intestinal type
rupture
mucinous deposits in peritoneum
copious production of mucin pseudomyxoma peritonei
implantation of cells in the peritoneum
prognosis
better than serous
stage is most important in determinant of success treatment
Endometrioid tumours
may be solid or cystic
may develop as mass in endometriotic cyst
composed of tubular glands similar to proliferating epi
usually malignant
benign and borderline v. rare
30% bilateral
concomitant endometrioid endometrial cancer in 15-30%
most have mutations in PTEN
Clear cell carcinoma
mean age at presentation
57yrs
malignant
composed of glycogen containing clear cells and hobnail cells
may arise from endometriotic cyst
usually solid but can be cystic
histology
broad papillae
lined by clear and hobnail cells
poor prognosis
Brenner tumours
uncommonly solid
usually unilateral
composed of abundant stroma
containing nests of transitional like epi
^ resembling that of the urinary tract
usually smooth and encapsulated
can be few cms - 20cms
majority are benign
borderline and malignant exist
Germ cell tumours
Teratomas general
15-20% of ovarian malignancies
in first 2 decades
younger they are more likely malignant
more than 90% benign mature cystic teratomas
immature teratomas are rare
Mature cystic teratomas
dermoid cysts
differentiation of totipotential germ cells into mature tissues
arise from three germ cell layers
mostly in young women as ovarian masses
usually cystic
rarely >10cm
often filled with
sebaceous material
matted hair
occasionally teeth
has epidermal lining with adnexal appendages
often
foci of bone
bronchial cartilage
gi epi
mature glial tissue
may produce infertility
prone to undergo torsion
10-15%
1% cases
malignant transformation of one of tissue elements
Immature teratomas
younger women
mean age 18yrs
usually large and solid/near solid
may have areas of necrosis
immature areas of differentiation toward
bone
cartilage
muscle nerve
immature neuroepi elements
most significant
behave more aggressively
metastasize widely
grade I, stage I
curable
grade IV, stage IV
much worse prognosis
Specialised teratomas
monodermal teratomas
struma ovarii
composed entirely of thyroid tissue
appear as small solid unilateral masses
ovarian carcinoid
can produce carcinoid syndrome
strumal carcinoid
one of these elements may become malignant
Primitive germ cell tumours
Dysgerminoma
malignant
20-30yrs
80-90% unilateral +large solid grey masses
women with gonadal dysgenesis
counterpart to seminoma of testes
sheets/cords of large cells with abundant cytoplasm
^separated by fibrous strands with scattered intervening lymphocytes
all malignant
only 1/3 are aggressive and spread
treated with surgery and radiotherapy - 80% cure rate
Yolk sac tumour
derived from endodermal structures
from yolk sac to primitive gut
many different epi patterns
typically secrete alpha fetoprotein
usually well encapsulated
areas of haemorrhage and necrosis
honeycomb appearance
Schiller-Duval bodies
generally respond well to chemo
Embryonal carcinoma
composed of cells resembling those in the embryonic disc
rare
several different histological patterns
may be components of mixed germ cell tumours
resembles blastocyst like formations that resemble early pre-somatic embryo
Choriocarcinoma
malignant derived from placental trophoblast
occurs in first 3 decades
usually unilateral
often small
identical histo, to placental tumour
haemorrhagic necrotic tumour
2 cell types
cytotrophoblast
syncitiotrophoblast
more resistant to chemo than placental tumours
Mixed germ cell
at least 2 different germ cell elements
^ at least one is primitive
all elements capable of metastasis
highly responsive to chemo
Ovarian tumours general
Top risk factors
nulliparity
family hx
5-10% ovarian cancers
majority=BRCA1/2 mutations
lifetime risk with BRCA1
30%
BRCA2 lower risk
also seen in 8-10% sporadic cases
other pathways
Her2 neu
HNPCC
HRT
height/tallness
^BMI=^risk
tobacco smoking
mucinous tumours
asbestos
Clinical features
poor prognosis tumours
mean 5yr in europe=32%
unfavourable due to late presentation
70% present with advanced disease
many have symptoms
may be confused with other benign conditions
^ i.e GI
tumours of surface origin
usually asymptomatic
until large enough to cause
local pressure symptoms
GI
urinary
30% are incidental discoveries
some produce
ascites
pleural effusions
hormones
larger masses
may ^ abd. girth
smaller masses
may tort
Spread
Phys. signs
assoc, with early stage cancer
may be palpable mobile pelvic mass on pelvis exam
as spreads into pelvic cavity
nodules may be found in POD on bimanual exam
ascites
disease is in only one/both ovaries
metastatic disease
commonly in omentum
lymphatic spread
may lead to inguinal/supraclavicular nodes
may advance into pleural cavity
malignant effusion
treatment
screening
not v. successful at detecting tumours while curable
surgery and chemo?
Ca125
^ in 75-90% of ovarian epithelial tumours
undetectable in 50% with cancer limited to ovary
^ in benign conditions e.g endometriosis
useful in monitoring response to chemo
Sex chord stromal tumours
general
arise from multipotent sex cord stromal cells
5-20% of ovarian tumours
women of all ages
present as functional tumours
hormone producing
eostrogens
early puberty
irregular periods
post-menopausal bleeding
androgens
acne
hirsutism
infertility
clinical manifestations depends on age of presentation
granulosa cell tumours
any age but often post-menopausal
usually unilateral
may present with symptoms of excess eostrogen
5-25% malignant
mixture of cuboidal granulosa cells
arranged in cords, sheets or strands
admixed lipid laden thecal cells
call-exner bodies
Sertoli Leydig cell tumours
at any age
usually unilateral
often produce androgens
virilising
rarely malignant
solid tumours resembling testis with tubules/cords and plump pink leydig cells
Theca-Fibroma
at any age
usually unilateral
most hormonally inactive
rarely malignant
40% produce Meigs syndrome for unknown reason
composed of solid grey fibrous cells to yellow plump thecal cells
Non- cancer pathologies
ovarian torsion
presentation
ovarian salvage rate
10%
delayed dx
necrosis
infarction
early dx +treatment
excellent prognosis
sudden onset
worsens intermittently
severe unilateral lower abd. pain
17% pre-menarchal/post-menopausal
20% in pregnancy
70-75% <30yrs
risk factors
ovarian tumours
50-60% of cases
ovulation induction
pregnancy
enlarged corpus luteum
children
developmental abnormalities
60% on right side
classically in enlarged ovary
significant cause of acute lower abdominal pain in women
infrequent
Polycystic ovaries
biochemical abnormality
low conc. of FSH
reduced follicles
infertility
high conc. of LH
excess androgens
proposed that converted to estrone
^ through HP axis
inh. FSH secretion by pituitary
in peripheral fat depots
ovaries
multiple subcortical cysts
smooth outer cortex
grey white
twice normal size
presentation
obesity
infertility
hirsutism
oligomenorrhoea
multiple cystic follicles
produce excess estrogens and androgens
Stein Leventhal syndrome
Follicle/Luteal cysts
may rupture
pain
intraperitoneal bleeding
lined by granulosa/luteal cells when small
as fluid accumulates pressure may cause atrophy of these cells
usually small
develop immediately below serosal lining
often multiple
origin
ruptured and sealed follicles
unruptured graafian follicles
physiologic variants
very common