Ovary slide share 3

OVARIAN TUMORS-III
Dr Aksharaditya Shukla
Resident, Department Of Pathology
MGM Medical College & M.Y. Hospital, Indore

Ovarian tumours
 Tumour of the ovary are common form of
neoplasia in women
 Accounts for 3% of all cancers in females
 80% are benign
 More common in older white women of
northern European ancestry
 90% of malignancies are carcinoma, 80% have
spread beyond the ovary at diagnosis.

Risk factors for carcinoma
 Nulliparity
 Family history
 Childhood gonadal dysgenesis
 Clomiphene
 Hereditary non polyposis colon cancer
 BRCA1 and BRCA2 mutations
 CA-125 present in 80% of serous and endometrioid
tumours
 Cytogenetics-gain of 12 & 8
 loss of chr X,22 18,17,14,13,12 & 8 ,
 benign/borderline tumor exhibit trisomy12

Classification of ovarian tumours
 Novak's classification (1967) has advantage of
being simple but has certain obvious drawbacks,
since it depends primarily on two
fundamental factors; benign or malignant
and solid or cystic.
 Thus the borderline tumors, solid tumors with cystic
degeneration and predominantly cystic tumors with
solid areas fall into grey zone.

 In 1971, the cancer committee of International
Federation of Gynecology and Obstetrics (FIGO)
proposed a histological classification of common primary
epithelial ovarian tumors. Although this classification
covered only epithelial tumors, it was a step in the
direction of uniformity in classification and it also
included the group of tumors of "low potential
malignancy".
 A significant stride in the direction of a
histogenesis-based classification system was made in
1973 with the publication of the World Health
Organization (WHO) Classification of Ovarian Tumors.
This classification system was updated in 1999 and
recently in 2003.

WHO classification of ovarian
tumours
1. SURFACE EPITHELIAL TUMOURS
2. GERM CELL TUMOURS
3. SEX CORD STROMAL TUMOURS
4. GERM CELL SEX CORD STROMAL TUMOURS
5. TUMOUR OF THE RETE OVARII
6. MISCELLANEOUS TUMOURS
7. TUMOUR LIKE CONDITIONS
8. LYMPHOID AND HEMATOPOETIC TUMOURS
9. SECONDARY 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 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
 Young patients (average 25 years)
 50% shows signs of androgen excess i.e
defeminisation
(breast atrophy, loss of subcutaneous Fat)
 Later masculinisation appears

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
 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
 Intermediate
(meyer’s type II)
Formation of cords,
sheets sertoli like
cells seperated by
spindle stromal cells

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

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 )
 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
- benign
 * If unassociated with Peutz–
Jeghers syndrome:
- unilateral
- often large
- ≈22% of cases clinically
malignantDr Aksharaditya Shukla

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)
 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
-associated with
endometrioid carcinoma

Gross Pathology
 Usually unilateral
 Composed of yellow or
yellowish brown nodules
separated by fibrous
trabeculae
 Malignant tumors tend to:
- be larger (≥06cm in
diameter)
- have foci of necrosis and
hemorrhage
 Cut surface of ovarian lipid 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

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

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

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
 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
 Admixture of:
 primitive germ cells:
 resembling those of
dysgerminoma
 sex cord–stromal cells:
 resembling
morphologically and
immunohistochemical
ly immature Sertoli
and granulosa cells
 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
 Hyaline material reacts strongly with anti-laminin
antibodies,

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 Breast Carcinoma
* Immunoreactive for GCDFP-15:
- important in differential diagnosis
with primary ovarian carcinoma, which
is generally negativeDr Aksharaditya Shukla

Metastases From Adenocarcinoma of Large Bowel

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
 May be:
* retroperitoneal lymph node metastases
* peritoneal implants

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
 * Diffuse infiltration by signet
ring cells
- signet ring cells.
* Tumor emboli >50% of cases
Krukenberg tumor of ovary.
Presence of intracellular
mucin

 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

References
 ROSAI AND ACKERMAN`S SURGICAL PATHOLOGY
 DIAGNOSTIC SURGICAL PATHOLOGY- STERNBERG
 PATHOLOGIC BASIS OF DISEASE– ROBBINS AND
COTRAN
 ANDERSON`S PATHOLOGY
 CURRAN`S ATLAS OF PATHOLOGY
 WWW.WEBPATH.COM

Thanks
 Presented By: Dr Aksharaditya Shukla
Resident, Department Of Patholgy
MGM Medical College & M.Y. Hospital, Indore

Ovary slide share 3

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