BENIGN DISEASES OF THE UTERUS AND CERVIX Rukset Attar, MD, PhD Department of Obstetrics and Gynecology Benign Disorders of The Uterine Servix Congenital Anomalies of the Cervix Congenital Anomalies of the Cervix Cervical agenesis Cervical agenesis ncomplete Mullerian fusion ncomplete Mullerian fusion Failure of resorption Failure of resorption Cervical Anomalies due to DES Cervical Anomalies due to DES Cervical Injuries Cervical Injuries Laserations Laserations Perforations Perforations Ulcerations Ulcerations Cervical stenosis Cervical stenosis Annular detachment Annular detachment Benign Disorders of The Uterine Servix Cervical Infections Cervical Infections Acute cervicitis Acute cervicitis Chronic cervicitis Chronic cervicitis Granulomatous Infections of the cerviks Granulomatous Infections of the cerviks Tbc Tbc Rare Infections Rare Infections Lymphogranuloma venereum Lymphogranuloma venereum Cervical actinomycosis Cervical actinomycosis Schistosomias of the cervix Schistosomias of the cervix Echinococcal cysts Echinococcal cysts Benign Disorders of The Uterine Servix Cystic Abnormalities Cystic Abnormalities Nabothian cyts Nabothian cyts Mesonephric cysts Mesonephric cysts Cervical Stenosis Cervical Stenosis Benign Neoplasms Benign Neoplasms microglandular hyperplasia of the endocervical mucosa microglandular hyperplasia of the endocervical mucosa cervical polyps cervical polyps papillomas papillomas leiomyomas leiomyomas Congenital Anomalies of Cervix Cervix develops from paramesonephric ducts in the sixth week of gestation Cervix develops from paramesonephric ducts in the sixth week of gestation After fusion of the two Mullerian ducts in the midline there is resoption of the septum After fusion of the two Mullerian ducts in the midline there is resoption of the septum In the absence of paramesonephric ducts there is agenesis of cervix and uterus In the absence of paramesonephric ducts there is agenesis of cervix and uterus Cervical agenesis Cervical agenesis Failure of Mullerian duct canalisation Failure of Mullerian duct canalisation Abnormal epithelial proliferation after canalisation Abnormal epithelial proliferation after canalisation Usu with the absence of uterine corpus and upper vagina Usu with the absence of uterine corpus and upper vagina Congenital Anomalies of Cervix Incomplete Mullerian Fusion Incomplete Mullerian Fusion Uterine didelphys ( 2 separate uterine horns) Uterine didelphys ( 2 separate uterine horns) Bicornuate uterus ( due to partial incomplete fusion) Bicornuate uterus ( due to partial incomplete fusion) Renal abnormalities are seen in 20-30% of women with Mullerian defects Renal abnormalities are seen in 20-30% of women with Mullerian defects Cervical Abnormalities Due To DES DES is a nonsteroid estrogen DES is a nonsteroid estrogen Cervical abnormalities Cervical abnormalities Infertility Infertility At risk for miscarriage, ectopic pregnancy, premature delivery At risk for miscarriage, ectopic pregnancy, premature delivery Cervical incompetency Cervical incompetency Diethylstilbestrol-exposed uterus. Myometrial hypertrophy results in a T-shaped uterine cavity and cavity irregularity, which is pathognomonic for the anomaly. Cervical Injuries Lacerations Lacerations Vaginal Delivery (most common at the 3 and 6 o'clock positions ) Vaginal Delivery (most common at the 3 and 6 o'clock positions ) D&C D&C particularly on the postmenopausal patient particularly on the postmenopausal patient Preop use of laminaria or misoprostol may reduce it Preop use of laminaria or misoprostol may reduce it Resecting LOOPin hysteroscopic surgery, rollerball (during hysterescopy) Resecting LOOPin hysteroscopic surgery, rollerball (during hysterescopy) Excessive traction of the ant lip of cervix Excessive traction of the ant lip of cervix Perforations Perforations Self induced abortion Self induced abortion Cervical dilatation Cervical dilatation Insertion of radioactive sources Insertion of radioactive sources Conization Conization Cervical Injuries Ulcerations Ulcerations Due to vaginal pessary Due to vaginal pessary Due to cervical stem pessary Due to cervical stem pessary May be due to uterine prolapse when the cervix protrudes through the vaginal introitus May be due to uterine prolapse when the cervix protrudes through the vaginal introitus Annular Detachment Annular Detachment Rare complication due to compression necrosis of the cervix during labor Rare complication due to compression necrosis of the cervix during labor Occurs when the ext os fails to dilate and the blood supply is compromised by pressure of the fetal head Occurs when the ext os fails to dilate and the blood supply is compromised by pressure of the fetal head Cervical Injuries Cervical stenosis Cervical stenosis usually occurs at the level of the internal os usually occurs at the level of the internal os In the premenopausal woman, it may be responsible for obstruction of menstrual flow, leading to amenorrhea and pelvic pain, and infertility In the premenopausal woman, it may be responsible for obstruction of menstrual flow, leading to amenorrhea and pelvic pain, and infertility A postmenopausal woman with cervical stenosis may have pyometra, requiring evacuation of uterine contents and biopsy to rule out endometrial carcinoma. A postmenopausal woman with cervical stenosis may have pyometra, requiring evacuation of uterine contents and biopsy to rule out endometrial carcinoma. Causes; Causes; Cervical injury, surgical procedures such as cone biopsy, loop excision, or ablative techniques for treatment of dysplasia, and inflammatory Cervical injury, surgical procedures such as cone biopsy, loop excision, or ablative techniques for treatment of dysplasia, and inflammatory Excision by loop diathermy tends to remove less cervical stroma and therefore is less likely to cause cervical stenosis than a cold knife cone biopsy. Excision by loop diathermy tends to remove less cervical stroma and therefore is less likely to cause cervical stenosis than a cold knife cone biopsy. Radiation therapy, neoplasia, and atrophic changes are more common causes in the postmenopausal woman. Radiation therapy, neoplasia, and atrophic changes are more common causes in the postmenopausal woman. Cervical Infections Acute Cervicitis Acute Cervicitis Chronic Cervicitis Chronic Cervicitis Chlamydia trachomatis Chlamydia trachomatis N. gonorrhea N. gonorrhea HSV HSV HPV HPV Trichomonas vaginalis Trichomonas vaginalis Candidial inf Candidial inf Bacterial vaginosis Bacterial vaginosis Cervical Infections Chlamydia trachomatis Chlamydia trachomatis may infect the fetus during its passage through the birth canal, or may infect the fetus during its passage through the birth canal, or it may ascend via the endometrial cavity to the fallopian tubes causing salpingitis, pelvic and perihepatic peritonitis. it may ascend via the endometrial cavity to the fallopian tubes causing salpingitis, pelvic and perihepatic peritonitis. It has been implicated as the agent responsible for the Fitz- Hugh and Curtis syndrome (violin-string adhesions between the liver and the parietal peritoneum). It has been implicated as the agent responsible for the Fitz- Hugh and Curtis syndrome (violin-string adhesions between the liver and the parietal peritoneum). C trachomatis and N gonorrhoeae often are coinfecting agents in the etiology of acute and chronic cervicitis and salpingitis. C trachomatis and N gonorrhoeae often are coinfecting agents in the etiology of acute and chronic cervicitis and salpingitis. may be transmitted to the eyes, where it causes trachoma and inclusion conjunctivitis. may be transmitted to the eyes, where it causes trachoma and inclusion conjunctivitis. Cervical Infections N. gonorrhea N. gonorrhea common cause of cervicitis also infecting the columnar epithelium of the endocervix. common cause of cervicitis also infecting the columnar epithelium of the endocervix. The mature squamous epithelium of the adult cervix and vagina is resistant to the invading organism. The mature squamous epithelium of the adult cervix and vagina is resistant to the invading organism. As in the case of Chlamydia infections, the cervix acts as a nidus for ascending infection of the endometrium and the fallopian tubes, with upward invasion often occurring after a menstrual period and loss of the protective mucus plug. As in the case of Chlamydia infections, the cervix acts as a nidus for ascending infection of the endometrium and the fallopian tubes, with upward invasion often occurring after a menstrual period and loss of the protective mucus plug. Cervical Infections HSV HSV produces cervical lesions similar to those found on the vulva. produces cervical lesions similar to those found on the vulva. The lesion is vesicular at first and then becomes ulcerative. The lesion is vesicular at first and then becomes ulcerative. Primary infections may be extensive and severe, producing constitutional symptoms of low-grade fever, myalgia, and malaise lasting approximately 2 weeks. Primary infections may be extensive and severe, producing constitutional symptoms of low-grade fever, myalgia, and malaise lasting approximately 2 weeks. Recurrences of lesser severity and duration are common. Recurrences of lesser severity and duration are common. HSV-2 in more than 90%, HSV-1 HSV-2 in more than 90%, HSV-1 After the initial infection has healed, the virus continues to reside in the epithelial cells of the cervix, and viral shedding occurs in asymptomatic patients. After the initial infection has healed, the virus continues to reside in the epithelial cells of the cervix, and viral shedding occurs in asymptomatic patients. Infection of infants during their passage through the birth canal has in women with active infection at term. Infection of infants during their passage through the birth canal has in women with active infection at term. Women with antibodies to HSV-2 have a higher incidence of intraepithelial neoplasia as well as invasive malignancy (a direct etiologic link has not been established). Women with antibodies to HSV-2 have a higher incidence of intraepithelial neoplasia as well as invasive malignancy (a direct etiologic link has not been established). Cervical Infections HPV HPV They are flatter and moister than the typical genital warts (condylomata acuminata) seen on the vulva and perianal skin. They are flatter and moister than the typical genital warts (condylomata acuminata) seen on the vulva and perianal skin. In fact, they often are invisible to the naked eye, becoming visible only after application of a dilute solution of acetic acid (acetowhite epithelium) or by colposcopic examination (white epithelium, mosaicism, and coarse punctation). In fact, they often are invisible to the naked eye, becoming visible only after application of a dilute solution of acetic acid (acetowhite epithelium) or by colposcopic examination (white epithelium, mosaicism, and coarse punctation). More than 65 types of HPV have been identified. More than 65 types of HPV have been identified. Benign lesions of the cervix are associated with types 6, 11, 42, 43, 44, 53, 54, and 55, whereas types 16, 18, 31, 33, 35, 39, 45, and 56 are more often found in association with cervical intraepithelial neoplasia and invasive cancers. Benign lesions of the cervix are associated with types 6, 11, 42, 43, 44, 53, 54, and 55, whereas types 16, 18, 31, 33, 35, 39, 45, and 56 are more often found in association with cervical intraepithelial neoplasia and invasive cancers. Approximately one-third of women with HPV infection have coexistent cervicitis caused by other organisms. Approximately one-third of women with HPV infection have coexistent cervicitis caused by other organisms. The presence of cervicitis does not significantly affect the clinical course of HPV lesions. The presence of cervicitis does not significantly affect the clinical course of HPV lesions. Cervical Infections HPV infection is characterized by squamous epithelial cell enlargement, multinucleation, and the perinuclear "halo" effect of koilocytosis. HPV infection is characterized by squamous epithelial cell enlargement, multinucleation, and the perinuclear "halo" effect of koilocytosis. The so-called "balloon cell" is almost pathognomonic of this condition. The so-called "balloon cell" is almost pathognomonic of this condition. Cellular changes of mild dysplasia (low-grade squamous intraepithelial lesion [SIL]), moderate or severe dysplasia (carcinoma in situ [CIS], high-grade SIL), and even invasive cancer may be associated findings. Cellular changes of mild dysplasia (low-grade squamous intraepithelial lesion [SIL]), moderate or severe dysplasia (carcinoma in situ [CIS], high-grade SIL), and even invasive cancer may be associated findings. Greatly enlarged, multinucleated cells with ground-glass cytoplasm and nuclei containing characteristic inclusion bodies are indicative of HSV infection Greatly enlarged, multinucleated cells with ground-glass cytoplasm and nuclei containing characteristic inclusion bodies are indicative of HSV infection Cervical Infections Complications Complications Cervical hemorrhage Cervical hemorrhage Salpingitis Salpingitis Leukorrhea Leukorrhea Cervical stenosis Cervical stenosis Infertility Infertility Granulomatous Infections Of The Cervix Tuberculosis Tuberculosis Always sec to disease elsewhere usu pulmonary Always sec to disease elsewhere usu pulmonary Abdominal pain, irregular bleeding Abdominal pain, irregular bleeding Diagnosis made by biopsy Diagnosis made by biopsy Histologically, the disease is characterized by tubercles undergoing central caseation Histologically, the disease is characterized by tubercles undergoing central caseation such lesions may be caused by other entities such as amoebiasis, schistosomiasis, brucellosis, tularemia, sarcoidosis, and foreign body reaction such lesions may be caused by other entities such as amoebiasis, schistosomiasis, brucellosis, tularemia, sarcoidosis, and foreign body reaction Tbc bacillus must be demonstrated by acid-fast stain or culture Tbc bacillus must be demonstrated by acid-fast stain or culture Medical therapy or surgery (ATH+BSO after a trial of CT) Medical therapy or surgery (ATH+BSO after a trial of CT) Tertiary syphilis Tertiary syphilis Granuloma inguinale Granuloma inguinale Rare Infectious Diseases Of The Cervix Lymphogranuloma venereum Lymphogranuloma venereum A chlamydial inf and chancroid caused by Haemophilus Ducreii A chlamydial inf and chancroid caused by Haemophilus Ducreii Cervical actinomyces Cervical actinomyces Instruments Instruments RIA RIA Schistosomiasis of the cervix Schistosomiasis of the cervix Involvement of pelvic and uterine veins by S.Haematobium Involvement of pelvic and uterine veins by S.Haematobium Echinococcal cysts Echinococcal cysts Cystic Abnormalities Of The Cerviks Nabothian Cysts Nabothian Cysts Mesonephric Cysts Mesonephric Cysts Benign Neoplasms of The Cervix Microglandular Hyperplasia of the Endocervical Mucosa Microglandular Hyperplasia of the Endocervical Mucosa Due to OC, pregnancy, inflammation Due to OC, pregnancy, inflammation Cervical polyps Cervical polyps Arise as a result of focal hyperplasia of the endocervix Arise as a result of focal hyperplasia of the endocervix Due to chronic inflammation or abnormal responsiveness to hormonal stimulation or a localized vascular congestion of cervical blood vessels Due to chronic inflammation or abnormal responsiveness to hormonal stimulation or a localized vascular congestion of cervical blood vessels Offen found in association with endometrial hyperplasia (hyperestrogenism may play a significant etiologic role) Offen found in association with endometrial hyperplasia (hyperestrogenism may play a significant etiologic role) malignant change is less than 1%, squamous cell carcinoma is the most common type; adenocarcinomas have been reported. malignant change is less than 1%, squamous cell carcinoma is the most common type; adenocarcinomas have been reported. Endometrial cancer may involve the polyp secondarily. Endometrial cancer may involve the polyp secondarily. Sarcoma rarely develops within a polyp. Sarcoma rarely develops within a polyp. Benign Neoplasms of The Cervix Papillomas of the cerviks Papillomas of the cerviks Asympomatic Asympomatic There are 2 types There are 2 types Solitary ( cause unknown) Solitary ( cause unknown) Condyloma accuminata Condyloma accuminata HPV HPV STD STD Leiomyomas of the cerviks Leiomyomas of the cerviks Benign Disorders of The Uterine Corpus Congenital Anomalies of the uterine corpus( Mullerian fusion anomalies) Congenital Anomalies of the uterine corpus( Mullerian fusion anomalies) Uterine Corpus Anomalies due to DES Uterine Corpus Anomalies due to DES Leiomyoma Uteri Leiomyoma Uteri Adenomyosis Adenomyosis Endometrial Polyps Endometrial Polyps Endometritis Endometritis Asherman Syndrome Asherman Syndrome Congenital Anomalies of Uterine Corpus Incomplete Mullerian Fusion Incomplete Mullerian Fusion Uterine didelphys ( 2 separate uterine horns) Uterine didelphys ( 2 separate uterine horns) Bicornuate uterus ( due to partial incomplete fusion) Bicornuate uterus ( due to partial incomplete fusion) Unicornuate uterus Unicornuate uterus Arcuate uterus Arcuate uterus Renal abnormalities are seen in 20-30% of women with Mullerian defects Renal abnormalities are seen in 20-30% of women with Mullerian defects Normal uterus Arcuate uterus Bicornuate uterus Didelphys uterus Unicornuate uterus Congenital Anomalies of Uterine Corpus Failure of Resorption Failure of Resorption Septate uterus Septate uterus If obstetric complications occur surgery has to be done If obstetric complications occur surgery has to be done Uterine Corpus Abnormalities Due To DES DES is a nonsteroid estrogen DES is a nonsteroid estrogen Cervical abnormalities Cervical abnormalities Infertility Infertility At risk for miscarriage, ectopic pregnancy, premature delivery At risk for miscarriage, ectopic pregnancy, premature delivery Cervical incompetency Cervical incompetency Diethylstilbestrol-exposed uterus. Myometrial hypertrophy results in a T-shaped uterine cavity and cavity irregularity, which is pathognomonic for the anomaly. Leiomyoma Uteri Benign neoplasm arising from smooth muscle cells in the uterine wall Benign neoplasm arising from smooth muscle cells in the uterine wall Pseudocapsule Pseudocapsule 20-25% 20-25% More commonly multiple More commonly multiple Symptoms Symptoms Usually asymptomatic Usually asymptomatic Metrorrhagia Metrorrhagia Menorrhagia Menorrhagia Pain Pain nfertility nfertility Leiomyoma Uteri Etiology Etiology Not known Not known Unicellular in origin Unicellular in origin Estrogens are important in growth of myomas Estrogens are important in growth of myomas Progestins increases mitotic activity Progestins increases mitotic activity HPL may cause growth HPL may cause growth Classification Classification Submucous Submucous Intramural or interstitial Intramural or interstitial Subserous Subserous Leiomyoma Uteri Changes Changes Hyalinisation Hyalinisation Liquefaction Liquefaction Calcification Calcification Hemorrhage Hemorrhage Inflammation Inflammation Degeneration ( atrophic, hyaline, cystic, calcific, septic, carneous, fatty ) Degeneration ( atrophic, hyaline, cystic, calcific, septic, carneous, fatty ) Leiomyoma Uteri Clinical findings Clinical findings Abnormal uterine bleeding 30% Abnormal uterine bleeding 30% Pain Pain Pressure effects Pressure effects Intestinal obstruction Intestinal obstruction Compress to ureters, bladder or rectum Compress to ureters, bladder or rectum Pelvic venous compression Pelvic venous compression Infertility Infertility Relationship is unknown Relationship is unknown 27-40% of women with myomas are infertile 27-40% of women with myomas are infertile Spontation abortion Spontation abortion 2 times more 2 times more Leiomyoma Uteri Complications Complications Myomas and Pregnancy Myomas and Pregnancy Rapid growth Rapid growth Degeneration Degeneration Pain Pain Fetal malpresentation Fetal malpresentation Obstruction of the birth canal Obstruction of the birth canal Uterine inertia Uterine inertia Nonpregnant Women Nonpregnant Women Heavy bleeding Heavy bleeding Urinary or bowel complication Urinary or bowel complication Leiomyoma Uteri Treatment Treatment depends on the depends on the patients age patients age parity parity symptoms symptoms general health general health pregnancy status pregnancy status reproductive plans reproductive plans Expectant Expectant Medical therapy Medical therapy GnRHa GnRHa OC OC Levonorgestrel releasing intrauterine device Levonorgestrel releasing intrauterine device Leiomyoma Uteri Surgery Surgery Myomectomi Myomectomi Hysterectomi Hysterectomi Uterine fibroid embolisation Uterine fibroid embolisation Endometrial ablation Endometrial ablation Myolsis Myolsis Laparoscopic uterine artery occlusion Laparoscopic uterine artery occlusion MR guided focused USG surgery MR guided focused USG surgery Adenomyosis Is defined by the presence of endometrial glands and stroma within the myometrium Is defined by the presence of endometrial glands and stroma within the myometrium Can be diffuse or localised ( adenomyosis) Can be diffuse or localised ( adenomyosis) Incidence is 20% Incidence is 20% Pathogenesis is unkown Pathogenesis is unkown Might be sec to postpartum endometritis because of the endom line break down Might be sec to postpartum endometritis because of the endom line break down An arrest of Mullerian cells in the myometrium and later de nova endometrial gland development An arrest of Mullerian cells in the myometrium and later de nova endometrial gland development Animal models suggest PRL and FSH stimulates growth Animal models suggest PRL and FSH stimulates growth Adenomyosis Symptoms and signs Symptoms and signs Menorrhagia Menorrhagia Dysmenorrhea Dysmenorrhea Treatment Treatment Hysterectomi Hysterectomi GnRHa GnRHa Endometrial Polyps Is hyperplastic growth of the endometrium Is hyperplastic growth of the endometrium Incidence increases directly with age, peaks in the fifth decade and declines with menopause Incidence increases directly with age, peaks in the fifth decade and declines with menopause 10-24% 10-24% Risk factors Risk factors HT HT Obesity Obesity Tamoxifen therapy Tamoxifen therapy Are considered to be estrogen sensitive Are considered to be estrogen sensitive Rarely undergo malignant changes Rarely undergo malignant changes Endometrial Polyps Clinical Findings Clinical Findings Metrorrhagia Metrorrhagia Prolapsus Prolapsus Staining Staining Spotting Spotting Treatment Treatment Surgical excision Surgical excision GnRHa GnRHa Hysterectomi Hysterectomi Endometritis Symptoms Symptoms Uterine tenderness Uterine tenderness Fever Fever Foul smelling discharge Foul smelling discharge May be chronic May be chronic Usu postmenopause Usu postmenopause May be due to foreign body May be due to foreign body Asherman Syndrome Due to recurrent D&C, abortus Due to recurrent D&C, abortus Sec amenorrhea, infertility, hypomenorrhea Sec amenorrhea, infertility, hypomenorrhea BENIGN DISEASES OF THE OVARIES Rukset Attar, MD, PhD Department of Obstetrics and Gynecology Benign Disorders of the Ovaries Are common in reproductive ages Are common in reproductive ages Operation only when rupture and hemorrhagia occurs Operation only when rupture and hemorrhagia occurs Physiologic Enlargement Physiologic Enlargement Functional cysts Functional cysts Hyperthecosis Hyperthecosis PCO PCO Luteoma of pregnancy Luteoma of pregnancy Ovarian Neoplasms Ovarian Neoplasms Epithelial tumors Epithelial tumors Sex cord stromal tumors Sex cord stromal tumors Germ cell tumors Germ cell tumors Physiologic Enlargement Functional cysts Functional cysts Follicular cysts Follicular cysts 3-8 cm 3-8 cm Result from a failure of ovulation most likely sec to disturbances in the release of the pituitary gonadotropins Result from a failure of ovulation most likely sec to disturbances in the release of the pituitary gonadotropins Typically asymp Typically asymp May cause pain, dysparonia, AUB, bleeding and tortion May cause pain, dysparonia, AUB, bleeding and tortion Expectant management or OC Expectant management or OC Disappear within 60 days Disappear within 60 days Physiologic Enlargement Endometriomas Endometriomas 6-8 cm 6-8 cm Corpus Luteum Cysts Corpus Luteum Cysts 3-11 cm 3-11 cm May cause pain, tenderness, amenorrhea, delayed menstruation May cause pain, tenderness, amenorrhea, delayed menstruation Regress after 1-2 months Regress after 1-2 months Symptomatic therapy unless acute complication occurs Symptomatic therapy unless acute complication occurs Physiologic Enlargement Theca Lutein Csyts Theca Lutein Csyts Caused by elevated levels of HCG Caused by elevated levels of HCG Hydatyform mole Hydatyform mole Choriocarcinoma Choriocarcinoma hCG or CC therapy hCG or CC therapy Rarely seen in pregnancy Rarely seen in pregnancy Usually bilateral Usually bilateral Disappear spontaneously after termination Disappear spontaneously after termination Surgery when complications occur Surgery when complications occur Physiologic Enlargement Hypertecosis Hypertecosis No gross enlargement of the ovary No gross enlargement of the ovary Lesions are demonstrated only by histologically Lesions are demonstrated only by histologically In premenopausal women is associated with virilisation, and clinical findings similar to PCO In premenopausal women is associated with virilisation, and clinical findings similar to PCO PCO PCO Characterized by persistent anovulation Characterized by persistent anovulation Enlarged ovaries Enlarged ovaries Sec amenorrhea Sec amenorrhea Oligomenorrhea Oligomenorrhea Infertility Infertility Physiologic Enlargement Prevalance is 5-10% Prevalance is 5-10% 50% of patients are hirsute, 30-75% are obese 50% of patients are hirsute, 30-75% are obese Lipid anomalies, insulin resistance, increased LH/FSH ratio Lipid anomalies, insulin resistance, increased LH/FSH ratio Physiologic Enlargement Luteoma of Pregnancy Luteoma of Pregnancy Often multifocal and bilateral Often multifocal and bilateral Up to 20 cm Up to 20 cm Usually 5-10 cm Usually 5-10 cm Ovarian Neoplasms Epithelial tumors Epithelial tumors Sex cord stromal tumors Sex cord stromal tumors Germ cell tumors Germ cell tumors Ovarian Neoplasms- Epithelial Tumors 60-80% 60-80% Usually asymptomatic Usually asymptomatic Usually cystic Usually cystic years of ages years of ages Types: Types: Serous Serous Mucinous Mucinous Clear-cell Clear-cell Transitional cell tumors (Brenner) Transitional cell tumors (Brenner) Endometriod lesions Endometriod lesions Ovarian Neoplasms- Epithelial Tumors Serous Cystadenoma Serous Cystadenoma In all ages In all ages 25-30% of epithelial tumors 25-30% of epithelial tumors 5-15 cm, 10 cm, sometimes bigger 5-15 cm, 10 cm, sometimes bigger usu. smaller than mucinous tm usu. smaller than mucinous tm 12-20% bilateral 12-20% bilateral Age 20s-50s Age 20s-50s Usu unilocular Usu unilocular nner lining may be flat or partially covered by papillary projections; simple cuboidal epithelial cells resembling the ovarian surface epithelium tall columnar cells resembling the fallopian tube, ciliated and secretory cells may be present nner lining may be flat or partially covered by papillary projections; simple cuboidal epithelial cells resembling the ovarian surface epithelium tall columnar cells resembling the fallopian tube, ciliated and secretory cells may be present Ovarian Neoplasms- Epithelial Tumors Mitoses are rare, nuclear atypia is absent Mitoses are rare, nuclear atypia is absent Psammoma bodies (concentric calcifications) are present in 15% Psammoma bodies (concentric calcifications) are present in 15% Multiple large calcified deposits may be visible on radiologic examination Multiple large calcified deposits may be visible on radiologic examination The preop workup depends on age and degree of susp for malignancy The preop workup depends on age and degree of susp for malignancy Therapy: USO / cystectomi / BSO /TAH + BSO ) Therapy: USO / cystectomi / BSO /TAH + BSO ) They have a distinc pattern of genetic alterations They have a distinc pattern of genetic alterations Ovarian Neoplasms- Epithelial Tumors Mucinous Cystadenoma Mucinous Cystadenoma 10-20% 10-20% Age 30s-50s Age 30s-50s 2-3% bilat, the largest tumors in the body up to 50 cm 2-3% bilat, the largest tumors in the body up to 50 cm 15 reported tumors weighting more than 70 kgs 15 reported tumors weighting more than 70 kgs Usually multilocular, epithelium consists of single layer tall columnar cells that resemble a picket fence in the endocervical type or may contain goblet, argentaffin, and paneth cells in the G type Usually multilocular, epithelium consists of single layer tall columnar cells that resemble a picket fence in the endocervical type or may contain goblet, argentaffin, and paneth cells in the G type Arises from the surface epithelium of the ovary resembling mllerian type epithelium of the endocervix, intestinal epithelium or both of these types Arises from the surface epithelium of the ovary resembling mllerian type epithelium of the endocervix, intestinal epithelium or both of these types Ovarian Neoplasms- Epithelial Tumors Mucosel of the appendix may accompany therefore apendectomy is recommended Mucosel of the appendix may accompany therefore apendectomy is recommended Pseudomixoma peritoneum is a rare complication Pseudomixoma peritoneum is a rare complication Are asymptomatic Are asymptomatic Presents with abdominal mass or nonspesific abdominal discomfort Presents with abdominal mass or nonspesific abdominal discomfort In postmenopausal patients luteinisation of the stroma results in hormone secretion and endom hyperplasia In postmenopausal patients luteinisation of the stroma results in hormone secretion and endom hyperplasia Therapy: surgery (cystectomy/ TAH + BSO) + apendectomy Therapy: surgery (cystectomy/ TAH + BSO) + apendectomy Ovarian Neoplasms- Epithelial Tumors Cystadenofibroma Cystadenofibroma a variant of serous cystadenoma, containing both cystic and solid components a variant of serous cystadenoma, containing both cystic and solid components Usu unilat Usu unilat Papillary-solid Papillary-solid Ovarian Neoplasms- Epithelial Tumors Transitional Cell ( Brenner ) Tumors Transitional Cell ( Brenner ) Tumors 1-2% 1-2% 30s-70s ages, mean age 50 years 30s-70s ages, mean age 50 years Derived from surface epithelium that undergoes a metaplastic transformation to cells resemling urothelium Derived from surface epithelium that undergoes a metaplastic transformation to cells resemling urothelium May occurs with mucinous cystadenoma May occurs with mucinous cystadenoma Most benign, but malign transformation may occur Most benign, but malign transformation may occur Asymp-palpable mass, occ with bleeding due to hormonal activity Asymp-palpable mass, occ with bleeding due to hormonal activity 95% unilateral, 98% are benign 95% unilateral, 98% are benign Ovarian Neoplasms- Epithelial Tumors frequently are so small that they are incidental operative findings, but may be 5-8 cm, max 30 cm frequently are so small that they are incidental operative findings, but may be 5-8 cm, max 30 cm On section they are firm and pale yellow or white On section they are firm and pale yellow or white The epithelium is composed of nests of cells with ovoid nuclei having a prominent longitudinal groove ("coffee-bean nuclei"). The epithelium is composed of nests of cells with ovoid nuclei having a prominent longitudinal groove ("coffee-bean nuclei"). Occasionally there is a mucinous metaplasia of the cells in the center of one or more of these nests, which may account for the 10% incidence of mucinous cystadenomas found associated with Brenner tumors. Occasionally there is a mucinous metaplasia of the cells in the center of one or more of these nests, which may account for the 10% incidence of mucinous cystadenomas found associated with Brenner tumors. Ovarian Neoplasms- Epithelial Tumors Endometrioid Lesions Endometrioid Lesions Are characterised by proliferation of benign nonspesific stroma in which endometrial-type glands may be found Are characterised by proliferation of benign nonspesific stroma in which endometrial-type glands may be found Types Types Endometrioid adenofibroma Endometrioid adenofibroma Proliferative endometrioid adenofibroma Proliferative endometrioid adenofibroma Ovarian Neoplasms- Epithelial Tumors Clear Cell Tumors Clear Cell Tumors Are rare Are rare a solid proliferation of nonspecific stroma contains small cytologically bland glands formed by columnar cells with clear cytoplasm. a solid proliferation of nonspecific stroma contains small cytologically bland glands formed by columnar cells with clear cytoplasm. Clinically they appear like any other benign ovarian mass and are diagnosed only on histologic examination. Clinically they appear like any other benign ovarian mass and are diagnosed only on histologic examination. The prognosis is excellent The prognosis is excellent Ovarian Neoplasms- Germ Cell Tumors %20 of all ovarian tumors %20 of all ovarian tumors Usually in children and young women Usually in children and young women Results from primitive germ cells (derived from embryonic yolk sac) Results from primitive germ cells (derived from embryonic yolk sac) %50-60 of all tumors seen under age 20, %90 of prepubertal tumors %50-60 of all tumors seen under age 20, %90 of prepubertal tumors 1/3 of germ cell tumors of children are malign while %4 malign in all ages 1/3 of germ cell tumors of children are malign while %4 malign in all ages cystic teratoma is %95 of all benign germ cell tumors of the ovary and %20 of all ovarian tumors cystic teratoma is %95 of all benign germ cell tumors of the ovary and %20 of all ovarian tumors Ovarian Neoplasms- Germ Cell Tumors Patients present with Patients present with Abdominal pain Abdominal pain Pelvic or abdominal mass Pelvic or abdominal mass Ovarian rupture Ovarian rupture Hemorrhage Hemorrhage Ovarian tortion Ovarian tortion Tumor markers: Tumor markers: AFP (endodermal sinus tm, embryonal carinoma, immature cystic teratoma, polyembryoma) AFP (endodermal sinus tm, embryonal carinoma, immature cystic teratoma, polyembryoma) -hCG (dysgerminoma, embryonal carinoma, polyembryoma, chorioCA) -hCG (dysgerminoma, embryonal carinoma, polyembryoma, chorioCA) LDH (dysgerminoma) LDH (dysgerminoma) CA 125 (endodermal sinus tm, immature cystic teratoma, dysgerminoma) CA 125 (endodermal sinus tm, immature cystic teratoma, dysgerminoma) CEA (endodermal sinus tm, immature cystic teratoma) CEA (endodermal sinus tm, immature cystic teratoma) Ovarian Neoplasms- Germ Cell Tumors- WHO Classification Germ Cell Tumors Germ Cell Tumors Dysgerminoma Dysgerminoma Endodermal sinus tumor ( yolk sac tumor) Endodermal sinus tumor ( yolk sac tumor) Teratomas Teratomas Embryonal carcinoma Embryonal carcinoma Choriocarsinoma Choriocarsinoma Polyembryoma Polyembryoma Combinations of germ cell tumors Combinations of germ cell tumors Ovarian Neoplasms- Germ Cell Tumors- WHO Classification Mixt germ cell and sex cord stromal tumors Mixt germ cell and sex cord stromal tumors Gonadoblastom Gonadoblastom Others Others Germ cell tumors of disgenetic gonads Germ cell tumors of disgenetic gonads Pure gonadal dysgenesis Pure gonadal dysgenesis Mixt gonadal dysgenesis Mixt gonadal dysgenesis Turner Syndrome Turner Syndrome Testicular feminisation Testicular feminisation Ovarian Neoplasms- Germ Cell Tumors Teratomas Teratomas Mature teratomas Mature teratomas Solid mature teratomas Solid mature teratomas Cystic mature teratomas ( dermoid cysts ) Cystic mature teratomas ( dermoid cysts ) Cystic with malign transformation Cystic with malign transformation Immature teratomas Immature teratomas Monodermal Monodermal Struma ovarii Struma ovarii Carsinoid Carsinoid Others Others Ovarian Neoplasms- Germ Cell Tumors Mature Teratomas Mature Teratomas Solid mature teratomas Solid mature teratomas Usu unilat Usu unilat rare rare Mature cystic teratomas (dermoid cysts) Mature cystic teratomas (dermoid cysts) %95 of all germ cell tumors and %20 of all ovarian tumors %95 of all germ cell tumors and %20 of all ovarian tumors Derived from any of the 3 germ cell layers, well differentiated Derived from any of the 3 germ cell layers, well differentiated Usually asymptomatic Usually asymptomatic Mostly seen in years of age Mostly seen in years of age Ovarian Neoplasms- Germ Cell Tumors %10-15 bilateral %10-15 bilateral Rarely bigger than 15 cm Rarely bigger than 15 cm Usually unilocular Usually unilocular Filled with yellowish coloured fluid with hair, tooth and bones in it Filled with yellowish coloured fluid with hair, tooth and bones in it There is an irregular solid nodule (Rokitansky nodule) on the inner side of the cyst which consists bones, cartilages and/or fat There is an irregular solid nodule (Rokitansky nodule) on the inner side of the cyst which consists bones, cartilages and/or fat Complications Complications Tortion ( the most)- usually in children and women Tortion ( the most)- usually in children and women Rupture ( very rare) Rupture ( very rare) Infection Infection Malign transformation ( %1-2) ( mostly squam. cell carsinoma) Malign transformation ( %1-2) ( mostly squam. cell carsinoma) Ovarian Neoplasms- Germ Cell Tumors Diagnosis: TV-USG, MRI Diagnosis: TV-USG, MRI Therapy: ovarian cystectomi + examination of the contralateral ovary Therapy: ovarian cystectomi + examination of the contralateral ovary Immature Teratomas Immature Teratomas Most common malign germ cell tumors Most common malign germ cell tumors Different from mature cystic teratomas can be seen at all ages, but usu. at reproduc. ages esp first three decades Different from mature cystic teratomas can be seen at all ages, but usu. at reproduc. ages esp first three decades Usu grows quickly outside the capsule and causes adhesions to nearby structures and peritonel cavity implants Usu grows quickly outside the capsule and causes adhesions to nearby structures and peritonel cavity implants Usu unilat, AFP may rise Usu unilat, AFP may rise 9-28 cm 9-28 cm Ovarian Neoplasms- Germ Cell Tumors Mature cystic teratoma may co-exist in the other ovary Mature cystic teratoma may co-exist in the other ovary Most common tissue is neuronal tissue Most common tissue is neuronal tissue Hystological grade is based on the amount of mature and immature neuroepithelial tissue, mitotic activity and differentiation Hystological grade is based on the amount of mature and immature neuroepithelial tissue, mitotic activity and differentiation Grade 0: only mature tissue Grade 0: only mature tissue Grade I: little immature tissue and mitotic activity Grade I: little immature tissue and mitotic activity Grade II: moderate immature tissue and mitotic activity Grade II: moderate immature tissue and mitotic activity Grade III: very high immature tissue and mitotic activity Grade III: very high immature tissue and mitotic activity Prognosis depends on the grade Prognosis depends on the grade Ia/Grade I: explorative laparotomy + USO + staging Ia/Grade I: explorative laparotomy + USO + staging Advanced disease : surgery + adjuvant CT Advanced disease : surgery + adjuvant CT Ovarian Neoplasms- Germ Cell Tumors Monodermal Teratomas Monodermal Teratomas Struma ovarii Struma ovarii The most The most %1 of cystic teratomas %1 of cystic teratomas Contains thyroid tissue (%5 of the the patients present with thyrotoxicosis) Contains thyroid tissue (%5 of the the patients present with thyrotoxicosis) Usually seen in years of age Usually seen in years of age malign transformation is rare ( mostly follicular type, %30 metastatic disease) malign transformation is rare ( mostly follicular type, %30 metastatic disease) Therapy as in thyroid CA Therapy as in thyroid CA Ovarian Neoplasms- Germ Cell Tumors Carsinoid Carsinoid Rare Rare Usually unilateral Usually unilateral Usually with GIS or respiratory epithelium and thyroid tissue Usually with GIS or respiratory epithelium and thyroid tissue 2 types insular and trabecular 2 types insular and trabecular Must be consider as metastasis until proven primer ovarian Must be consider as metastasis until proven primer ovarian Secretes bradykinin, serotonin and other peptide hormones directly into the systemic circulation ( bypassing inactivation by the first pass effect in the liver they are hormonally active) Secretes bradykinin, serotonin and other peptide hormones directly into the systemic circulation ( bypassing inactivation by the first pass effect in the liver they are hormonally active) Ovarian Neoplasms- Germ Cell Tumors %50 > 4 cm %50 > 4 cm %50 presents with Carsinoid Syndrome %50 presents with Carsinoid Syndrome Episodic flushing Episodic flushing Diarrhea Diarrhea Bronchospasm Bronchospasm Ovarian Neoplasms- Germ Cell Tumors Dysgerminoma Dysgerminoma is the female counterpart of the seminoma in the male. is the female counterpart of the seminoma in the male. primarily in young females and accounts for app. 3040% of germ cell tumors. primarily in young females and accounts for app. 3040% of germ cell tumors. unilateral in 8590% of cases. unilateral in 8590% of cases. It is a solid neoplasm which may contain areas of softening as a result of degeneration. It is a solid neoplasm which may contain areas of softening as a result of degeneration. Histologically, it mimics the pattern seen in the primitive gonad, with nests of germ cells that appear as large, rounded cells with central nuclei that contain one or two prominent nucleoli surrounded by undifferentiated stroma Histologically, it mimics the pattern seen in the primitive gonad, with nests of germ cells that appear as large, rounded cells with central nuclei that contain one or two prominent nucleoli surrounded by undifferentiated stroma Lymphocytes may invade the stroma and occasionally giant cells are identified. Lymphocytes may invade the stroma and occasionally giant cells are identified. A lymphocytic infiltrate is considered a favorable prognostic indicator. A lymphocytic infiltrate is considered a favorable prognostic indicator. Ovarian Neoplasms- Germ Cell Tumors Presents with precocious puberty and primary amenorrhea Presents with precocious puberty and primary amenorrhea %10-15 bilat %10-15 bilat LDH is always high (therapy and follow-up) LDH is always high (therapy and follow-up) -hCG is high in 50 years; Fewer than 5% prepubertal Often assoc with androgen production, however virilization develops in only 50% of patients- may be due to lack of ho production or insufficient androgen produc. Often assoc with androgen production, however virilization develops in only 50% of patients- may be due to lack of ho production or insufficient androgen produc. Typically patients complain of Typically patients complain of oligomenorrhea followed by amenorrhea oligomenorrhea followed by amenorrhea Breast atrophy Breast atrophy Acne Acne Hirsutism Hirsutism Temporal balding Temporal balding Ovarian Neoplasms- Sex Cord Stromal Tumors Deepening of the voice ( may not resove after surgery) Deepening of the voice ( may not resove after surgery) Enlargement of clitoris ( may not resove after surgery) Enlargement of clitoris ( may not resove after surgery) Abdominal sweelling Abdominal sweelling Pain Pain Menorrhage ( due to E produc by Sertoli cell component or per androgen conversion) Menorrhage ( due to E produc by Sertoli cell component or per androgen conversion) Menometrorrhagia ( due to E produc by Sertoli cell component or per androgen conversion) Menometrorrhagia ( due to E produc by Sertoli cell component or per androgen conversion) Must be distinguished from virilisating tumors such as adrenal tumors Must be distinguished from virilisating tumors such as adrenal tumors Ovarian Neoplasms- Sex Cord Stromal Tumors Urinary 17-KS level is normal or only slightly elevated ( it is high in adr tms) Urinary 17-KS level is normal or only slightly elevated ( it is high in adr tms) AFP may be increased and can be a used as a tm marker AFP may be increased and can be a used as a tm marker cm cm Tan-yellow, cystic Tan-yellow, cystic Hemorrhage and necrosis in poorly differentiated tms Hemorrhage and necrosis in poorly differentiated tms Micr sertoli + leydig + undiff gonadal stromal cells with or without heterologus components in varying proportions and degrees of differentiation Micr sertoli + leydig + undiff gonadal stromal cells with or without heterologus components in varying proportions and degrees of differentiation Intermediate or poorly diff tms are charactarized by more immature components of rhe Sertoli and Leydig cells Intermediate or poorly diff tms are charactarized by more immature components of rhe Sertoli and Leydig cells Ovarian Neoplasms- Sex Cord Stromal Tumors Cartilage, mucinous epithelium, skeltal mussle, and other heterologous elements are found in 20% and 25% of these tms most of which are intermediate differantiation Cartilage, mucinous epithelium, skeltal mussle, and other heterologous elements are found in 20% and 25% of these tms most of which are intermediate differantiation When heterologous elements are present in poorly differentiated neoplasm the tms are clinically malignant When heterologous elements are present in poorly differentiated neoplasm the tms are clinically malignant Treatment depends on Treatment depends on age age tm stage, tm stage, degree of differ and degree of differ and presence of heterologous elements presence of heterologous elements Ovarian Neoplasms- Sex Cord Stromal Tumors Stage Ia + poorly differ / heterologous elements: adjuvant therapy is recommended Stage Ia + poorly differ / heterologous elements: adjuvant therapy is recommended Patients with heterologous elements or metastasis:adjuvant therapy is recommended Patients with heterologous elements or metastasis:adjuvant therapy is recommended Stage Ia + well differ: USO + staging Stage Ia + well differ: USO + staging Advanced disease or postmenapause: TAH+BSO+staging Advanced disease or postmenapause: TAH+BSO+staging Due to the rarety of cases no standard adjuvant therapy has been accepted Due to the rarety of cases no standard adjuvant therapy has been accepted Treatment of advanced sex cord stromal tm, unlike germ cell tms has not met with success Treatment of advanced sex cord stromal tm, unlike germ cell tms has not met with success Platinium based therapies have the best resullts (overall survival rate 50%) VAC, VBP; BEP Platinium based therapies have the best resullts (overall survival rate 50%) VAC, VBP; BEP As CT RT has been used successfully in limited cases As CT RT has been used successfully in limited cases Ovarian Neoplasms- Sex Cord Stromal Tumors Steroid Cell Tumors not Otherwise Spesified (NOS) Steroid Cell Tumors not Otherwise Spesified (NOS) termed lipid cell or lipoid tumors in the past termed lipid cell or lipoid tumors in the past Are composed entirely of cells resembling typical steroid secreting cells ( eg lutein cells, Leydig cells, adrenal cortical cells) except that specific features such as location of origin in the hilus or crystalloids of Reinke are not identified Are composed entirely of cells resembling typical steroid secreting cells ( eg lutein cells, Leydig cells, adrenal cortical cells) except that specific features such as location of origin in the hilus or crystalloids of Reinke are not identified 0.1% of all ovarian tms 0.1% of all ovarian tms age age androgenic changes occuring in 75-90% of patients may be of many years duration androgenic changes occuring in 75-90% of patients may be of many years duration E ve P changes are occationally noted E ve P changes are occationally noted Cushing syndrome may also be present accompanied by elevated cortisol levels Cushing syndrome may also be present accompanied by elevated cortisol levels Ovarian Neoplasms- Sex Cord Stromal Tumors E manifestation may be a result of E production, the aromatization of androgen to E2 in adipose tissue may be more plausable E manifestation may be a result of E production, the aromatization of androgen to E2 in adipose tissue may be more plausable Diagnosis is often dependent on clinical manifestationof virilization or the rare occasion of isosex pseudoprecocity Diagnosis is often dependent on clinical manifestationof virilization or the rare occasion of isosex pseudoprecocity Tm removal results in rapid resolution of most of the hormonal effects except deepening of the voice and enlargement of clitoris Tm removal results in rapid resolution of most of the hormonal effects except deepening of the voice and enlargement of clitoris Yellow-orange-tan Yellow-orange-tan 5-8 cm 5-8 cm Soft, lobulated, hemorrhage, necrosis and cystic degeneration are occ observed Soft, lobulated, hemorrhage, necrosis and cystic degeneration are occ observed Ovarian Neoplasms- Sex Cord Stromal Tumors Microsc resemble Leydig or hilar cells, sometimes adrenocortical cells- has led to speculate that they may arise from the adrenocortical rests Microsc resemble Leydig or hilar cells, sometimes adrenocortical cells- has led to speculate that they may arise from the adrenocortical rests Rarely malignant; 10-15% of them recur or metastasize Rarely malignant; 10-15% of them recur or metastasize Young stage Ia: USO Young stage Ia: USO Advanced disease / beyond reproductive age: TAH + BSO + +staging + removal of extraovarian disease Advanced disease / beyond reproductive age: TAH + BSO + +staging + removal of extraovarian disease Ovarian Neoplasms- Sex Cord Stromal Tumors Typical presentation Typical presentation Hirsutism Hirsutism Virilization (%80) Virilization (%80) Menstruation Menstruation Rarely attain palpable size Rarely attain palpable size Acne Acne Testesteron levels are high whereas androstenodione and DHEA levels are low Testesteron levels are high whereas androstenodione and DHEA levels are low Ovarian Neoplasms-Tumors of Low Malignant Potential ( Atypical Proliferating Tumors) A group of tumors showing greater epithelial proliferation than that seen benign serous cystadenoma although they are by definition noninvasive A group of tumors showing greater epithelial proliferation than that seen benign serous cystadenoma although they are by definition noninvasive 15% of all epithelial tumors 15% of all epithelial tumors Mean age 40 years Mean age 40 years Parity, OC, breast feeding, multiple births are protective Parity, OC, breast feeding, multiple births are protective nfertility, use of infertility drugs may increase the risk nfertility, use of infertility drugs may increase the risk Asymptom, but usu with pelvic mass, increasing abdominal girth, or abnormal bleeding Asymptom, but usu with pelvic mass, increasing abdominal girth, or abnormal bleeding USG, CT USG, CT Ovarian Neoplasms-Tumors of Low Malignant Potential ( Atypical Proliferating Tumors) CA 125 is not always elevated CA 125 is not always elevated Usu serous Usu serous No markers No markers The most common types are serous or mucinous The most common types are serous or mucinous The absence of stromal invasion is an absolute criterion for making the diagnosis The absence of stromal invasion is an absolute criterion for making the diagnosis Mean diameter is 12 cm, 33-75% bilateral Mean diameter is 12 cm, 33-75% bilateral Usu cystic with mural clusters of papillary projections Usu cystic with mural clusters of papillary projections Mucinous are larger than serous ( cm), rarely bilat, multiloculated Mucinous are larger than serous ( cm), rarely bilat, multiloculated Ovarian Neoplasms-Tumors of Low Malignant Potential ( Atypical Proliferating Tumors) Survival rate better than EOT with a 5 year survival rate of 95% for stage I disease Survival rate better than EOT with a 5 year survival rate of 95% for stage I disease 0.8% developed invasive carcinoma 0.8% developed invasive carcinoma Patient outcome depends on the presence or absence of micropapillary features within the ovarian tumor and invasive versus noninvasive implants Patient outcome depends on the presence or absence of micropapillary features within the ovarian tumor and invasive versus noninvasive implants 5 and 10 year survival rates with micropapillary ca are 81% and 71%; serous borderline tms without invasive implants > 98% and with invasive implants 60% and 70% 5 and 10 year survival rates with micropapillary ca are 81% and 71%; serous borderline tms without invasive implants > 98% and with invasive implants 60% and 70% Ovarian Neoplasms-Tumors of Low Malignant Potential ( Atypical Proliferating Tumors) The risk of developing invasive disease; The risk of developing invasive disease; Stage of disease Stage of disease Extraovarian implant status Extraovarian implant status Stromal invasion in the primary tumor Stromal invasion in the primary tumor Micropapillary architecture Micropapillary architecture Micropapillary serous CA Micropapillary serous CA is characterised by thin, elongated micropapillae with min or no fibrovascular support arising directly from thick, more centrally located papillary structures is characterised by thin, elongated micropapillae with min or no fibrovascular support arising directly from thick, more centrally located papillary structures Mitotic activity may be seen in some of the cases 1-3 figures/10 high power field Mitotic activity may be seen in some of the cases 1-3 figures/10 high power field