epithelial ovariantumors
TRANSCRIPT
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Epithelial
ovarian tumors
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WHO classification of ovarian epithelial ( epithelial – stromal ) tumors .
1- Serous tumors
2- Mucinous tumors
3- Endometrioid tumors
4- Clear cell tumors
5- Brenner tumors
6- Seromucinous tumors
7- Undifferentiated tumors
8- Unclassified tumors ?
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Ovarian tumors
1- Surface epithelial tumors .
2- Sex cord – stromal tumors .
3- Germ cell tumors .
4- Miscellaneous tumors .
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Ovarian cancer represents about 30% of all cancers of the female genital organs .
Two factors consistently associated with a reduced risk of the disease are high parity and the use of OCP .
Dietary factors , western life style , obesity , high socioeconomic status .
- Unfortunately there is no early warning symptoms and specific diagnostic tests to allow early detection .
- Approximately 70% of patients present when this cancer is in an advanced stage .
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- Sonography is the imaging method of choice to assess
an ovarian lesion and to determine the presence of solid
and cystic elements .
- The distinction between benign , borderline and
malignant tumors is generally not possible by US , CT
or MRI .
Ovarian cancers spread mainly by local extension ,
intraabdominal dissemination , lymphatic vessels and
blood vessels .
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Surface epithelial tumors account for
approximately two – thirds of all ovarian neoplasm and 90% of all ovarian cancers
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Mostly derived from the ovarian surface
epithelium which develops from the coelomic
epithelium ( Mesothelium ) that covers the embryonic gonads
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Three major precursors :
- Surface epithelium ( Dysplastic epithelium ) .
- Surface epithelial inclusions ( inclusion cysts ) .
- Endometriosis .
- Epithelial tumors can have endophytic or exophytic
nature ( or both ) based on its main source .
- They can be cystic or solid or mixture of both
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They often reveal two or even three cell types .
- When one or more additional cell types account for less
than 10% of the neoplasm , it is classified on the basis of
predominant cellular element , otherwise , it is designated a form of mixed epithelial tumors
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All the epithelial tumors are subdivided to three
groups according to the degree of proliferation
and nuclear features :
1- Benign .
2- Malignant .
3- Borderline
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Borderline tumors are intermediate between
clearly benign and obviously malignant ( in
their histologic features and clinical behavior ) .
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WHO : Borderline tumor
FIGO : Tumors of low malignant potential .
CAP : Atypical proliferative tumors
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- Tumors in this category are characterized by a degree of
proliferation greater than seen in benign tumors but an
absence of destructive stromal invasion .
- Borderline tumors may be associated with peritoneal implants ( invasive , non – invasive )
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- Ovarian epithelial tumors divided into two broad
groups ( Type I , Type II ) , based on their
clinicopathologic features and characteristic molecular
genetic changes .
- Type I and II refer to tumorigenic pathways and are not histopathologic diagnostic terms
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Type I tumors ( 25% )
- Low – grade .
- Relatively indolent tumors .
- Arise from well – characterized precursor lesions ( Borderline
tumors , endometriosis ) .
- Usually present as large stage I neoplasms .
- Often harbor somatic mutations KRAS , BRAF , PTEN ,
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Type II tumors ( 75% )
- Aggressive , High grade .
- 75% shows P53 mutation .
- Most type II tumors are high grade serous carcinomas
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Serous
tumors
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Benign
- Serous cystadenoma
- Serous adenofiroma , cystadenofibroma .
- Serous surface papilloma
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Borderline
- Serous borderline tumor ( Atypical proliferative serous
tumor ) .
- Serous borderline tumor , Micropapillary variant ( Non –invasive low – grade serous carcinoma )
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Malignant
- low – grade serous adenocarcinoma
- High – grade serous adenocarcinoma
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- Serous tumors account for 20% - 50% of all
ovarian tumors .
- 70% are benign , 5-10% are borderline , 20-25% are malignant
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- The typical serous cystadenoma is a thin –
walled unilocular cyst , filled by watery fluid .
- The cyst may contain polypoid projections
which are firm or soft .
- Benign serous tumors are bilateral in 10% of cases
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- Borderline serous tumors usually show large
cystic lesion with large polypoid projections .
- They are bilateral in 25-35% of cases
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- Serous carcinoma may be predominantly
cystic and papillary , entirely solid and firm or
both cystic and solid .
- Serous carcinoma are bilateral in about 75% of cases
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- Microscopically benign serous cysts are lined by
columnar ciliated epithelial cells similar to that of fallopian
tube .
- Serous borderline tumors show polypoid projections and
papilla , lined by atypical epithelial cells with stratification and nuclear atypia
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- Serous carcinoma shoes obvious ovarian
stromal invasion with following microscopic
features , papillary structures , small nests and
large sheets of tumor cells , glands with slit –
like lumens , infiltrating single cells and psammoma bodies
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Serous carcinoma is the most common type of ovarian
cancer ( 68% ) .
Mutation is P53 gene are present in the most cases .
High grade serous carcinoma is the type of ovarian
cancer most associated with mutations in the BRCA
genes .
Low grade serous carcinoma is uncommon ,
characterized by BRAF or KRAS mutations .
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Most of the poorly – differentiated as well
as undifferentiated carcinomas of ovary are indeed High – grade serous carcinoma
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Serous carcinoma should be distinguished from
the other types of carcinomas and specially Metastatic carcinoma
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Women with breast cancer are at increased risk
of ovarian carcinoma , indeed when a patient
with breast cancer has an adnexal cancer , it is
more likely to be primary in ovary than metastatic
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Mucinou
tumors
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- Mucinous tumors account for about 15% of all
ovarian tumors .
- 85% are benign
- 6-10% are borderline .
- Remainder malignat
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- Mucinous tumors tend to be larger than other ovarian
neoplasms
- Mucinous cystadenoma is usually thin – walled and
multilocular , and filled by mucinous fluid .
- Borderline and malignant tumors are solid – cystic , contain
papilla that may be solid or firm .
- Because benign , borderline and invasive components are
frequently admixed it is important to sample mucinous tumor
thoroughly .
- Mucinous tumors may be associated with Brenner tumor or dermoid cyst
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- Microscopically : The mucinous cysts are lined by single
layer of endocervical – like epithelium or less often by
intestinal like epithelial cells ( goblet rich ) .
- In borderline tumors there are significant epithelial
stratification , budding , bridging , nuclear atypia .
- Intestinal type borderline tumors are more common ( 85 –90% ) than the endocervical type
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- 30% of borderline mucinous tumors ( the
endocervical type ) are accompanied by
endometriosis .
- Borderline tumors have an excellent prognosis
despite of peritoneal or lymph nodes metastasis ( Especically endocervical type )
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- Mucinous carcinomas vary considerably in
their microscopic appearance . Cysts , glands ,
solid mases , clusters and individual cells may be present in various combination
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Pseudomyxomatous peritonei is a
progressive condition mostly seen in
patients with Borderline ovarian mucinous
tumors .
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Differential DX :
- Endometrioid adenocarcinoma .
- Metastatic adenocarcinoma .
Clinical and operative findings as well as patient history
are more helpful diagnostic clues than the microseopicfeatures of the tumor
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Endometrioid
tumor
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- They are less than 5% of all ovarian tumors .
- Endometrioid carcinoma account for up to 15% of all
ovarian cancers .
- 5-10% are related to endometriosis .
- Borderline endometrioid tumors are very rare .
- Endometrioid benign ( and borderline ) tumors are
predominantly solid . Carcinoma may be solid or cystic .
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- Up to one – third of ovarian endometrioid carcinomas are
accompanied by carcinoma of uterine corpus , which
usually closely resembles ovarian tumors on microscopic inspection and is most often an independent primary tumor
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Microscopically , Endometrioid tumors are characterized
by tubular glands simulating to different extents those of
proliferative , secretory , hyperplastic or adenocarcinomatous epithelium
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Differential DX :
- Poorly – differentiated serous carcinoma ( WT – 1 ) .
- Intestinal Metastatic carcinoma . ( CK7 , CK20 , CEA , ER ,
PR , CA – 125 ) .
- Sex cord – stromal tumors ( CK7 , EMA , α – inhibin ) .
- MMMT
- Yolk sac tumor ( AFP , EMA )
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Malignant Mixed
Mullerian Tumors
( MMMT )
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- Highly malignant tumors contain epithelial
and mesenchymal elements , develop in post
menopausal women , spread beyond the ovary in more than half of the cases
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- The epithelial component is usually high grade
( Serous , endometrioid , less often mucinous ,
squamous , clear cell ) .
- The mesenchymal component may be
homologous ( Fibrosarcoma , leiomyoma ,
stromal sarcoma ) or heterologous (
Rhabdomyosarcoma , chondrosarcoma , osteosarcoma )
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Differential DX :
- Immature teratoma .
- Sertoli leydig cell tumor
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Clear cell
tumors
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- Benign and borderline clear cell tumors are very uncommon .
- Clear cell carcinoma account for more than 5% of all ovarian
cancers , most frequently between the ages of 40 to 70 .
Clear cell carcinomas are predominantly cystic , an unilocular
cyst containing one or more solid nodules protruding into the
lumen .
- It is the ovarian tumor that is most often associated with
ovarian and pelvic endometriosis .
- They are rarely bilateral
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Clear cell carcinoma is strongly associated with
endometriosis . Paraneoplastic syndromes ,
Hypercalcemia , DVT , pulmonary emboli .
Clear cell carcinoma appears overrepresented among
women with the Lynch syndrome .
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The most important differential diagnosis :
1- Dysgerminoma
2- Yolk sac tumor .
3- Metastatic RCC .
4- Metastatic intestinal adenocarcinoma
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Transitional cell
tumors
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1- Brenner tumor ( 2 to 3% of all ovarian
tumors ) .
2- Proliferative Brenner tumor ( Borderline ) .
3- Malignant Brenner tumor .
4- Transitional cell carcinoma
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Undifferentiated carcinoma
- A high – grade lesion , half are bilateral and spread
beyond the pelvic at the time of diagnosis .
- The mass is predominantly solid with areas of
hemorrhage , necrosis and cyst formation .
- The clinical features of most undifferentiated carcinoma resemble those of high – grade serous carcinomas
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