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Studiază | Excelează | Inovează

Benign and
malignant
pathology of
the ovary
 Studiază | Excelează | Inovează

INTRODUCTION

The ovaries are

small, oval-shaped
glands located on
either side of the
uterus. (paired
gonads)

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 Functions of the ovaries

Endocrine function Reproductive function

Secrete hormones to produce the female

germ cells (oocytes)
• estrogen

• progesterone
EMBRIOLOGY

Anti-Müllerian
hormone
HISTOLOGY
 HISTOLOGY
Capsule- covers the outer surface.
Tunica Albuginea - layer of dense
irregular connective tissue

Primordial follicules-

Zona pellucida

Graafian follicle
The hypothalamic-pituitary-gonadal axis

PROGESTERONE

GnRH
LH

FSH

ESTROGEN
 TUMOR
• Tumor (in Latin language meaning “swelling”) is a
group of abnormal cells and is formed as a
result of excessive and uncoordinated cell
division.

Ovarian tumors are classified as benign (non-cancerous), borderline or

malignant (cancerous). Most epithelial ovarian tumors are benign and do not
spread or cause cancer.
 The chances of an ovarian tumor being malignant
in a woman under 45 are very low 1:15

Benign
ovarian
tumors Slow-growing solid masses
Does not have typical
symptoms: Often benign
• bleeding from the vagina
May develop into ovarian
• pain in the abdomen with
cancer if left untreated.
increasing size of the
tumor or cyst
 CLASSIFICATION

Functional ovarian cysts Mesothelial and stromal ovarian tumors

• Follicular cysts 1.Epithelial: serous cyst, mucinous cyst,

• Luteinizing sheath cysts endometrioid cyst
• Luteinizing follicular cyst 2.Mesothelial: fibroadenoma,
• Functional corpus luteum cysts cystadenofibroma,Brenner
• Polycystic ovary syndrome tumor,granulosa cell tumor,Sertoli-Leyiding
cell tumor.
3.Stromal tumors: fibroma, fibrothecoma,
thecoma.
Inflammatory processes 4.Ovarian germ cell tumors:
dysgerminoma,teratoma
Tubo-ovarian abscess
Functional ovarian cysts

Follicular cysts
>3 cm,less than 8 cm
↑FSH
↓LH

Polycystic ovary Without significant

↑LH syndrome symptoms,
↓FSH
Functional corpus
luteum cysts Does not require
surgical treatment
 Functional ovarian cysts

SYMPTOMS

Pelvic pain
Pain with intercourse
Lower belly pain Check the pelvic organs
Menstrual changes

DIAGNOSIS
Pelvic examination Lets a doctor see the
Ultrasonography: vagina and cervix and
-TV check the size and
-TA position of the uterus
and ovaries
 Functional
ovarian cysts
 Functional ovarian cysts
Most functional ovarian cysts go away
without treatment.
MANAGEMENT
TREATMENT
Using heat and medicine to relieve minor
pain

Birth control pills, which stop ovulation

Surgery can remove a large cyst

that bleeds or causes severe pain
Inflammatory
processes
 Inflammatory processes

SYMPTOMS

• Fever
A tubo-ovarian abscess (TOA) Abscess rupture is life-
• lower abdominal-pelvic
pain is a complex infectious mass of threatening because
the adnexa that forms as a sepsis can result
• Vaginal discharge; sequela of pelvic inflammatory
disease
1. Elevated white cell count
2. Elevated erythrocyte sedimentation
rate
3. Elevated C-reactive protein
4. Neisseria gonorrhoeae and/or
Chlamydia trachomatis test positive
 Inflammatory processes

• Mucopurulent discharge
• Cervical motion
DIAGNOSIS tenderness
Pelvic examination • Uterine or adnexal
Ultrasonography: tenderness
-TV
-TA

Elongated, dilated, fluid-

filled mass with partial
septae and thick walls
Inflammatory processes

If the TOA is discovered before it has

MANAGEMENT ruptured, treatment can begin with a
TREATMENT course of intravenous antibiotics.

TOAs greater than 10 cm having

greater than a 60% chance of
requiring surgery

Worsening of the TOA or if a rupture has occurred,

• 24 hours of inpatient parenteral antibiotics
followed by
• surgical removal of the abscess as well as the
affected ovary and fallopian tube.
Inflammatory processes
 Epithelial cysts
serous cyst

mucinous cyst

endometrioid cyst
 SEROUS CYSTS
symptoms
Represent about 2/3 of
benign ovarian epithelial
tumors

affect women in their 30s

diagnosis
and 40s
The most common are Serum CA-125
serous cystadenomas under 35 U/mL,
Ranges in size from 1 Imaging Studies
to more than 30 cm
 SEROUS CYSTS

•Unilocularity of cysts
•Minimal septations
•Thin walls
•Absence of papillary projections
SEROUS CYSTS
COMPLICATIONS TREATMENT

Cyst rupture
Surgery by laparoscopic approach
Ovarian torsion
Surgery by classical approach

Differential Diagnosis

Is made by histological
examination with other
ovarian masses
SEROUS CYSTS
 MUCINOUS CYSTS
Intestinal epithelium or the
endocervical epithelium

Represent about 10%-15%

of benign ovarian tumors

Affect women in their 30s

and 40s

The most common are

mucinous cystadenomas
KRAS mutations are present
in up to 58% of cases
MUCINOUS CYSTS
Symptoms The same as in serous cysts

1.Serum CA-125 level

Diagnosis
2.Imaging studies
MUCINOUS CYSTS
DIFFERENTIAL
DIAGNOSIS

Cystic mature teratoma

Treatment

Surgery by laparoscopic approach

Surgery by classical approach
 ENDOMETRIOID CYST
(chocolate cyst)
ETIOLOGY
Genetics: family history of endometriosis
Retrograde menstrual flow
Immune disorders:autoimmune disorders, may
cause endometriosis.
Injuries: Damage to the uterus or
surrounding structures .For ex.cesarean
delivery.
Endometriosis affects approximately 10% of reproductive-aged
women
 ENDOMETRIOID CYST
SYMPTOMS
a ground-glass appearance
chronic pain, dyspareunia,
Echogenic deposits
dysmenorrhea, and
infertility Kissing ovaries

DIAGNOSIS
1.Pelvic exam
2.Ultrasonography
3.Laparoscopy(treatment)
4.Histology
ENDOMETRIOID CYST
ENDOMETRIOID
CYST
•HISTOLOGY
ENDOMETRIOID CYST
TREATMENT

MEDICAL SURGICAL
recurrence rate INTERVENTIONS
21.5% at 2 years post-
1.Androgens, surgical and 40–50% at
2.Progestogens,
3.Oral contraceptives
5 years post-surgical
1.LAPAROSCOPY
(OCs), 2.LAPAROTOMY
4.Gonadotropin-releasing
hormone (GnRH) agonists
Brenner tumors
Relatively uncommon neoplasm.
The cause of Brenner tumors is
unknown
It is an incidental pathological finding
Generally asymptomatic
The average age at presentation is
50 years with 71%
Most of them are benign and less than https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3156501/figure/F1/

5% are proliferating or borderline.

Brenner tumors
Diagnosis

IMAGING
STUDIES:USG & CT

DURING SURGERY

HISTOLOGY
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3156501/figure/F1/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3156501/figure/F1/
Brenner tumors
Urothelial-type
epithelium
TREATMENT

Surgical resection is often curative

"coffee bean nuclei"

TERATOMA
(teratos-
monster)
TERATOMA
Teratomas are benign(mature) or
malignant(immature)
Derived from primordial germ
cells
Can arise in the gonads or in
extragonadal locations

Mature tumors are composed of well-

differentiated derivatives of two or three
germ cell layers. They can be further
categorized into three groups as :
Cystic
Solid
Mixed
 TERATOMA
The size: very small --> 39 cm
In 80% of cases, they measure 10 cm or
less.
Content :
sebaceous material
solid matter:
including:bone,teeth,hair,fat
Growth rate of 1.8 (mm) per year in
those who have not experienced
menopause.
TERATOMA
A highly echogenic nodule, or
dermoid plug, within the mass-
Diagnosis
Rokitansky protuberance

Soft, Diffuse or regional high-

Pelvic exam mobile,painless amplitude echoes
mass is felt

Ultrasound examination
Fat-fluid or fluid-fluid level Tip of the iceberg sign
Dot-dash sign
Floating balls sign
TERATOMA
TREATMENT

Surgery by laparoscopic approach

Surgery by classical approach

(Dermoid cysts) are cured by

removing the part of the ovary
that has the tumor (ovarian
cystectomy) or by removing the
entire ovary.
 DYSGERMINOMA
Germ cell tumor
Usually malignant

Usually occurs in
adolescence and early adult
life
Elevated serum
lactic dehydrogenase
(LDH)
Exceptionally associated
with hypercalcemia.
 DYSGERMINOMA
Dysgerminomas present with a smooth,
bosselated (knobby) external surface, and is
soft, fleshy and either cream-coloured, gray,
pink or tan when cut

Microscopic examination typically

reveals uniform cells that resemble
primordial germ cells

Dysgerminomas, like other

seminomatous germ cell tumors, are
very sensitive to both chemotherapy
and radiotherapy.
MALIGNANT
OVARIAN
TUMORS
 OVARIAN CANCER
7th the most common malignancy in females RISK FACTORS
Responsible for 5% of cancer deaths-
usually found late HOW MUCH TIME SPENT
Median age at diagnosis is : 60 years OVULATING!

1. Nulliparity
2. Early menarche
3. Obesity
4. Hormone replacement therapy
5. Family history of breast/ovarian cancer
BRCA1/BRCA1 MUTATIONS-> tumor
suppressors+DNA repair
 5% of cancers
30% tumors
90%

5%
ESTROGEN

!!!GERM CELLS AND

SEX CORD-STROMA
TESTOSTERONE
TUMORS ARE
USUALLY FOUND IN
YOUNG FEMALES!!!
 OVARIAN CANCER
SEROUS EPITHELIAL CANCER ENDOMETRIOID

60-80 % OF OVARIAN EPITHELIAL CANCER 15-20% OF OVARIAN EPITHELIAL CANCER

MAY ARISE FROM FALLOPIAN TUBES FAVOURABLE PROGNOSIS.LINKED WITH
ENDOMETRIOSIS
CLEAR CELL
15% OF OVARIAN EPITHELIAL CANCER
RESISTANT TO CHEMOTHERAPY
LINKED WITH ENDOMETRIOSIS
MUCINOUS UNDIFFERENTIATED /
5% OF OVARIAN EPITHELIAL CANCER UNCLASSIFIED
METASTASES FROM APENDIX/COLON POOR PROGNOSIS
OVARIAN CANCER
COMMONLY SIGNS AND SYMPTOMS
MISSDIAGNOSED AS
1.PAIN / DISCOMFORT
IRRITABLE BOWL SYNDROME
-PELVIS AND ABDOMEN
-USUALLY A LATER SYMPTOM
2.NON SPECIFIC GI SYMPTOMS
-NAUSEA/VOMITING
-EARLY SATIETY
-BLOATING / DISTENTION
-DIARRHEA / CONSTIPATION
3.FATIGUE

4.IRREGULAR MENSES

5.DYSPAREUNIA

6.URINARY FREQUENCY / URGENCY

 DIAGNOSIS
GOLD STANDARD: DIRECT VISUALIZATION AND BIOPSY

FIGO CLASSIFICATION

STAGE I-LIMITED TO OVARIES

STAGE II-LIMITED TO PELVIS
STAGE III-BEYOND
PELVIS/RETROPERITONEAL
AND INVOLVES LYMPH NODES
STAGE IV-DISTANT
METASTASIS

70 % OF CASES ARE FOUND IN STAGE IIIC

WITH DEPOSITS IN THE PERITONEUM >2
CM
 DIAGNOSIS
INITIAL WORKUP

PHYSICAL EXAM-ASCITES AND DISTENTION

PELVIC EXAM- 20% OF OVARIAN MASSES

-FIXED
-SOLID
-IRREGULAR
-BILATER CA-125:USSEFUL IN WORKUP+FOLLOW UP
NOT AN EFFECTIVE METHOD OF SCREENING
IMAGING:
- TRANSVAGINAL OR TRANSABDOMINAL TOOL
ULTRASOUND
- -CT
- MRI
 DIAGNOSIS
AFTER AN INITIAL WORKUP

RISK OF MALIGNANCY INDEX FOR ADNEXAL MASS

ULTRASOUND SCORE MENOPAUSE SCORE SERUM CA-125

MULTILOCULAR CYST
SOLID AREAS
ASCITES
INTRAABDOMINAL
METASTASES
 TREATMENT AND PROGNOSIS
LATE STAGES-IIIC 5 YEAR SURVIVAL 20-50%
STAGE-I 5 YEAR SURVIVAL 90-95%

DEBULKING SURGERY WITH ADJUVANT CHEMOTHERAPY

OOPHORECTOMY SALPINGECTECTOMY HYSTERECTOMY OMENTECTOMY

BOWEL RESECTION
!!!DEBULKING REMOVES CHEMORESISTANT CELLS AND INCREASES CHEMOTHERAPY
PENETRATION!!!!
NEOADJUVANT CHEMOTHERAPY WITH DEBULKING
MAY SHRINK TUMOR TO MAKE DEBULKING EASIER

EARLY SALPINGO-OOPHORECTOMY-CONSIDERED IN HIGHT RISK

PATIENTS TO REDUCE PROBABILITY OF CANCER
TAKE HOME MESSAGES
1. Ovarian tumors are classified as benign (non-cancerous), borderline or
malignant (cancerous).
2. Most epithelial ovarian tumors are benign and do not spread or cause
cancer.
3. Does not have typical symptoms
4. There is not a screening program for ovarian cancer diagnosis.
5. Ovarian tumors diagnosis is complex and need a interclinic
interaction.
6. The final diagnosis of ovarian tumors is made by histological exam
7. World Ovarian Cancer Day is observed on May 8 every year
Thank you for you attention
These applause are for you,because you
guys resisted!

BIBLIOGRAPHY

1. Williams Gynecology, 24th Edition

2. SOGR guidelines 2019
3. PDQ Adult Treatment Editorial Board. PDQ Cancer
Information Summaries [Internet]. National Cancer Institute
(US); Bethesda (MD): Nov 2, 2022. Ovarian Epithelial,
Fallopian Tube, and Primary Peritoneal Cancer Treatment
(PDQ®): Health Professional Version.
4. Pathology and classification of ovarian tumors
Vivien W Chen 1 , Bernardo Ruiz, Jeffrey L Killeen, Timothy R Coté,
Xiao Cheng Wu, Catherine N Correa