Difference between revisions of "Ovarian tumours"

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Ovarian tumours (view source)

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*Silverberg grading system,<ref>{{cite journal |author=Silverberg SG |title=Histopathologic grading of ovarian carcinoma: a review and proposal |journal=Int. J. Gynecol. Pathol. |volume=19 |issue=1 |pages=7-15 |year=2000 |month=January |pmid=10638449 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0277-1691&volume=19&issue=1&spage=7}}</ref> aka ''universal grading system''.
*Silverberg grading system,<ref>{{cite journal |author=Silverberg SG |title=Histopathologic grading of ovarian carcinoma: a review and proposal |journal=Int. J. Gynecol. Pathol. |volume=19 |issue=1 |pages=7-15 |year=2000 |month=January |pmid=10638449 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0277-1691&volume=19&issue=1&spage=7}}</ref> aka ''universal grading system''.
*Based on ''pattern'', ''cytologic atypia'' and ''mitotic rate''.
*Based on ''pattern'', ''cytologic atypia'' and ''mitotic rate''.
*System somewhat similar to [[breast]] grading, which can be remembered as: ''TMN'' (tubular formation, mitotic rate, nuclear atypia).
*System somewhat similar to [[breast]] grading, which can be remembered as: ''TNM'' (tubular formation, [[nuclear atypia]], mitotic rate).


===Silverberg system===
===Silverberg system===
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**Columnar.
**Columnar.
*Papillae.
*Papillae.
*[[Psammoma bodies]] (concentric calcifications).
*[[Psammoma bodies]] (concentric [[calcification]]s).


Note:  
Note:  
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*[[AKA]] ''serous borderline tumour of the ovary''.
*[[AKA]] ''serous borderline tumour of the ovary''.
*[[AKA]] ''serous tumour of low malignant potential of the ovary'', abbreviated ''SLMP''.<ref name=pmid10836293>{{Cite journal  | last1 = Seidman | first1 = JD. | last2 = Kurman | first2 = RJ. | title = Ovarian serous borderline tumors: a critical review of the literature with emphasis on prognostic indicators. | journal = Hum Pathol | volume = 31 | issue = 5 | pages = 539-57 | month = May | year = 2000 | doi =  | PMID = 10836293 }}</ref><ref name=pmid10881733>{{Cite journal  | last1 = Dietel | first1 = M. | last2 = Hauptmann | first2 = S. | title = Serous tumors of low malignant potential of the ovary. 1. Diagnostic pathology. | journal = Virchows Arch | volume = 436 | issue = 5 | pages = 403-12 | month = May | year = 2000 | doi =  | PMID = 10881733 }}</ref>
*[[AKA]] ''serous tumour of low malignant potential of the ovary'', abbreviated ''SLMP''.<ref name=pmid10836293>{{Cite journal  | last1 = Seidman | first1 = JD. | last2 = Kurman | first2 = RJ. | title = Ovarian serous borderline tumors: a critical review of the literature with emphasis on prognostic indicators. | journal = Hum Pathol | volume = 31 | issue = 5 | pages = 539-57 | month = May | year = 2000 | doi =  | PMID = 10836293 }}</ref><ref name=pmid10881733>{{Cite journal  | last1 = Dietel | first1 = M. | last2 = Hauptmann | first2 = S. | title = Serous tumors of low malignant potential of the ovary. 1. Diagnostic pathology. | journal = Virchows Arch | volume = 436 | issue = 5 | pages = 403-12 | month = May | year = 2000 | doi =  | PMID = 10881733 }}</ref>
*[[AKA]] ''serous ovarian tumour of low malignant potential''.<ref name=pmid10881733/>
{{Main|Serous borderline tumour}}
===General===
*Usually benign.
*Require long term follow-up.


===Microscopic===
==Mucinous ovarian tumours==
Features:<ref name=Ref_GP399>{{Ref GP|399}}</ref>
*Cuboidal to columnar epithelium with mild to moderate atypia.
*No invasive.
*"Sparse" mitoses.
*+/-[[Psammoma bodies]].
*+/-Micropapillary architecture - often described as a ''medusa head'' pattern.


DDx:
*[[Serous carcinoma of the ovary]] - focus a with stromal invasion >5mm (linear measurement) ''or'' > 10 mm<sup>2</sup> (area).<ref name=Ref_GP399>{{Ref GP|399}}</ref>
**Invasive cells are "pink", i.e. have abundant eosinophilic cytoplasm,<ref name=Ref_GP399/>; also, cells usu. large (~2-3x size of non-invasive component), and typically have an enlarged nucleus (~2x non-invasive component).
*[[Clear cell carcinoma of the ovary]] - classically associated with [[endometriosis]], have simpler, smaller papillae without branching.
Images:
*[http://pubs.rsna.org/na101/home/literatum/publisher/rsna/journals/content/radiographics/2005/radiographics.2005.25.issue-6/rg.256055015/production/images/medium/g05nv16c4x.jpeg Serous ovarian LMP tumour (radiographics.rsna.org)].<ref name=pmid16284143>{{Cite journal  | last1 = Burkholz | first1 = KJ. | last2 = Wood | first2 = BP. | last3 = Zuppan | first3 = C. | title = Best cases from the AFIP: Borderline papillary serous tumor of the right ovary. | journal = Radiographics | volume = 25 | issue = 6 | pages = 1689-92 | month =  | year =  | doi = 10.1148/rg.256055015 | PMID = 16284143 }}</ref>
====Subclassification====
Typical subdivided into:<ref name=pmid21917305>{{Cite journal  | last1 = Park | first1 = JY. | last2 = Kim | first2 = DY. | last3 = Kim | first3 = JH. | last4 = Kim | first4 = YM. | last5 = Kim | first5 = KR. | last6 = Kim | first6 = YT. | last7 = Nam | first7 = JH. | title = Micropapillary pattern in serous borderline ovarian tumors: does it matter? | journal = Gynecol Oncol | volume = 123 | issue = 3 | pages = 511-6 | month = Dec | year = 2011 | doi = 10.1016/j.ygyno.2011.08.008 | PMID = 21917305 }}</ref>
*Micropapillary serous borderline tumour.
*Typical serous borderline tumour (SBOT).
==Mucinous tumours - overview==
==General==
==General==
*Common.
*Common.
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===Classification===
===Classification===
*Benign. (Dx: mucinous cystadenoma ''or'' mucinous adenofibroma ''or'' mucinous cystadenofibroma)
*Benign. (Dx: [[Mucinous_cystadenoma_of_the_ovary|mucinous cystadenoma]] ''or'' mucinous adenofibroma ''or'' mucinous cystadenofibroma)
**Single layer of cells.
**Single layer of cells.
*Borderline. (Dx: ''mucinous tumour of uncertain malignant potential'' or ''borderline mucinous tumour'')
*Borderline. (Dx: ''mucinous tumour of uncertain malignant potential'' or ''borderline mucinous tumour'')
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*[[AKA]] ''ovarian mucinous borderline tumour''.
*[[AKA]] ''ovarian mucinous borderline tumour''.
*[[AKA]] ''ovarian mucinous tumour of low malignant potential''.<ref name=pmid21464732>{{Cite journal  | last1 = Khunamornpong | first1 = S. | last2 = Settakorn | first2 = J. | last3 = Sukpan | first3 = K. | last4 = Suprasert | first4 = P. | last5 = Siriaunkgul | first5 = S. | title = Mucinous tumor of low malignant potential (borderline or atypical proliferative tumor) of the ovary: a study of 171 cases with the assessment of intraepithelial carcinoma and microinvasion. | journal = Int J Gynecol Pathol | volume = 30 | issue = 3 | pages = 218-30 | month = May | year = 2011 | doi = 10.1097/PGP.0b013e3181fcf01a | PMID = 21464732 }}</ref>
*[[AKA]] ''ovarian mucinous tumour of low malignant potential''.<ref name=pmid21464732>{{Cite journal  | last1 = Khunamornpong | first1 = S. | last2 = Settakorn | first2 = J. | last3 = Sukpan | first3 = K. | last4 = Suprasert | first4 = P. | last5 = Siriaunkgul | first5 = S. | title = Mucinous tumor of low malignant potential (borderline or atypical proliferative tumor) of the ovary: a study of 171 cases with the assessment of intraepithelial carcinoma and microinvasion. | journal = Int J Gynecol Pathol | volume = 30 | issue = 3 | pages = 218-30 | month = May | year = 2011 | doi = 10.1097/PGP.0b013e3181fcf01a | PMID = 21464732 }}</ref>
===General===
{{Main|Mucinous borderline tumour of the ovary}}
*Requires extensive sampling - to avoid missing an adenocarcinoma.
 
Note:
*The WHO prefers ''borderline'' over ''low malignant potential'' as the descriptor for these tumours.<ref name=pmid16100867>{{Cite journal  | last1 = Acs | first1 = G. | title = Serous and mucinous borderline (low malignant potential) tumors of the ovary. | journal = Am J Clin Pathol | volume = 123 Suppl | issue =  | pages = S13-57 | month = Jun | year = 2005 | doi =  | PMID = 16100867 }}</ref>
 
====Classification====
Subdivided into:<ref name=pmid15371946>{{Cite journal  | last1 = Rodriguez | first1 = IM. | last2 = Irving | first2 = JA. | last3 = Prat | first3 = J. | title = Endocervical-like mucinous borderline tumors of the ovary: a clinicopathologic analysis of 31 cases. | journal = Am J Surg Pathol | volume = 28 | issue = 10 | pages = 1311-8 | month = Oct | year = 2004 | doi =  | PMID = 15371946 }}</ref>
# Intestinal type mucinous borderline tumour of the ovary ~ 90% of cases.
# Endocervical type mucinous borderline tumour of the ovary ~ 10% of cases.<ref name=Ref_GP419>{{Ref GP|419}}</ref>
 
===Gross===
''Intestinal type mucinous borderline tumour of the ovary'' and ''endocervical type mucinous borderline tumour of the ovary'':
*Complex multiloculated mass with mucin.
*Often large - may > 30 cm.
 
===Microscopic===
====Intestinal type mucinous borderline tumour of the ovary====
Features:
*Mucinous differentiation:
**Tall [[columnar cell]]s with apical mucin - usu. resembles gastric foveolar epithelium.
*Layering of epithelial cells (stratification).
**Must be <= 3 cells.<ref name=Ref_GP416>{{Ref GP|416}}</ref>
*+/-Papillary infoldings.
**Projections into the cystic space.
*+/-Mild nuclear atypia.
*+/-Mitoses (focally).
 
Notes:
#Resembles a [[villous adenoma]] of the [[colon]].<ref name=Ref_GP>{{Ref GP|416}}</ref>
#Borderline component must be >= 10% of the tumour.<ref name=Ref_GP>{{Ref GP|416}}</ref>
#*Lesions with <10% borderline component are known as ''[[mucinous cystadenoma of the ovary]] with focal proliferation'' or ''[[mucinous cystadenoma of the ovary]] with focal atypia''.
 
DDx:
*[[Mucinous adenocarcinoma of the ovary]].
*[[Mucinous cystadenoma of the ovary]].
*[[Mucinous cystadenoma of the ovary]] with focal proliferation.
 
Images:
*[http://www.webpathology.com/image.asp?case=526&n=7 Ovarian MBT (webpathology.com)].
*[http://www.webpathology.com/image.asp?n=6&Case=526 Ovarian mucinous borderline tumour and benign mucinous tumour (webpathology.com)].
 
====Endocervical type mucinous borderline tumour of the ovary====
Features:<ref name=Ref_GP420>{{Ref GP|420}}</ref>
#Cells with mucinous differentiation resembling endocervical epithelium:
#*Tall [[columnar cell]]s with grey apical mucin.
#Cells with eosinophilic cytoplasm - known as "pink cells".
#Ciliated cells.
*Neutrophils associated with the epithelium/mucin - common.<ref>URL: [http://www.webpathology.com/image.asp?n=12&Case=526 http://www.webpathology.com/image.asp?n=12&Case=526]. Accessed on: 9 January 2013.</ref>
 
Images:
*[http://www.webpathology.com/image.asp?n=13&Case=526 Endocervical type mucinous borderline tumour - low mag. (webpathology.com)].
*[http://www.webpathology.com/image.asp?n=12&Case=526 Endocervical type mucinous borderline tumour - high mag. (webpathology.com)].
 
====Comparing intestinal versus endocervical====
{| class="wikitable sortable"
! Feature
! Intestinal
! Endocervical
|-
| Primary mucin producing cell
| clear - well-diff. component, eosinophilic (pink)
| eosinophilic (pink), grey or clear
|-
| Size
| tall columnar (height:width >3:1) "champagne flute"
| stubby columnar (height:width <3:1)
|-
| Accompanying epithelial cells
| +/-goblet cells
| pink cells, ciliated cells
|-
| Other cells
| none
| neutrophils (intraepithelial) - common
|-
| Images
| [http://www.webpathology.com/image.asp?case=526&n=7 high mag. (webpathology.com)]
| [http://www.webpathology.com/image.asp?n=13&Case=526 low mag. (webpathology.com)], [http://www.webpathology.com/image.asp?n=12&Case=526 high mag. (webpathology.com)]
|}
 
===Sign out===
<pre>
OVARY AND CYST, LEFT, OOPHORECTOMY:
- MUCINOUS BORDERLINE TUMOUR, INTESTINAL TYPE, ARISING FROM A MUCINOUS CYSTADENOMA (INTESTINAL TYPE).
- OVARIAN PARENCHYMA.
</pre>


==Mucinous adenocarcinoma of the ovary==
==Mucinous adenocarcinoma of the ovary==
*[[AKA]] ''ovarian mucinous adenocarcinoma''.
*[[AKA]] ''ovarian mucinous adenocarcinoma''.
*[[AKA]] ''ovarian mucinous carcinoma''.
*[[AKA]] ''ovarian mucinous carcinoma''.
===General===
{{Main|Mucinous adenocarcinoma of the ovary}}
*Malignant.
*May arise in [[endometriosis]].<ref name=Ref_PBoD1097>{{Ref PBoD |1097}}</ref>
*Poor response to chemotherapy vis-à-vis serous carcinoma.<ref name=pmid19275957>{{Cite journal  | last1 = Shimada | first1 = M. | last2 = Kigawa | first2 = J. | last3 = Ohishi | first3 = Y. | last4 = Yasuda | first4 = M. | last5 = Suzuki | first5 = M. | last6 = Hiura | first6 = M. | last7 = Nishimura | first7 = R. | last8 = Tabata | first8 = T. | last9 = Sugiyama | first9 = T. | title = Clinicopathological characteristics of mucinous adenocarcinoma of the ovary. | journal = Gynecol Oncol | volume = 113 | issue = 3 | pages = 331-4 | month = Jun | year = 2009 | doi = 10.1016/j.ygyno.2009.02.010 | PMID = 19275957 }}</ref>
 
===Gross===
Features:
*Multiloculated.
*Sticky, gelatinous fluid (glycoprotein).
*+/-[[Necrosis]].
*Typically unilateral.<ref name=pmid22885379>{{Cite journal  | last1 = Offman | first1 = SL. | last2 = Longacre | first2 = TA. | title = Clear cell carcinoma of the female genital tract (not everything is as clear as it seems). | journal = Adv Anat Pathol | volume = 19 | issue = 5 | pages = 296-312 | month = Sep | year = 2012 | doi = 10.1097/PAP.0b013e31826663b1 | PMID = 22885379 }}</ref>
 
===Microscopic===
Features:
*Mucinous differentiation.
**Tall [[columnar cell]]s in glands with apical mucin.
***May have an endocervical-like ''or'' intestinal-like appearance - see ''subtypes''.
*Invasive morphology - one of the following:
*#Back-to-back glands/confluent growth pattern.
*#Desmoplastic stromal response.
*#Cribriforming of glands.
*Malignant characteristics:
**+/-Nuclear atypia.
**+/-Necrosis.
**No cilia.
 
DDx:
*[[Mucinous borderline tumour of the ovary]].
*[[Metastatic]] [[mucinous carcinoma]].
 
====Subtypes====
#''Endocervical type''.
#*Less likely to be malignant.
#*More common than malignant type.
#''Intestinal type''.
#*More likely to be malignant.
#*+/-[[Goblet cell]]s.
#**One large clear apical vacuole.
#*If it doesn't look like intestine to you... it probably isn't.
#*May vaguely resemble colorectal adenocarcinoma (hyperchromatic, columnar nuclei, nuclear pleomorphism).
#**Image: [http://www.ispub.com/xml/journals/ijgo/vol9n1/papillary-fig4.jpg]
 
Comparison of mucosa:
*Normal endocervical mucosa: [http://pathology.mc.duke.edu/research/Histo_course/endocx.jpg endocervical mucosa (duke.edu)].
*Normal colonic mucosa: [http://commons.wikimedia.org/wiki/File:Rectal_prolapse_-_intermed_mag.jpg colonic type mucosa (WC)].
 
===IHC===
*CK7 +ve.
*[[CK20]] +ve.


==Endometrioid carcinoma of the ovary==
==Endometrioid carcinoma of the ovary==
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*[[AKA]] ''endometrioid adenocarcinoma of the ovary''.
*[[AKA]] ''endometrioid adenocarcinoma of the ovary''.
*[[AKA]] ''ovarian endometrioid adenocarcinoma''.
*[[AKA]] ''ovarian endometrioid adenocarcinoma''.
 
{{Main|Endometrioid carcinoma of the ovary}}
===General===
*Associated with [[endometriosis]], i.e. people with endometriosis are more likely to have 'em.
 
===Gross===
*Usually solid and cystic.
 
Image:
*[http://radiology.uchc.edu/eAtlas/GYN/437.htm Endometrioid carcinoma of the ovary (uchc.edu)].
 
===Microscopic===
Features:
*Tubular glands.
**Cribriform pattern common.
* May see mucinous secretion.<ref name=pmid18580313>{{cite journal |author=Baker P, Oliva E |title=A practical approach to intraoperative consultation in gynecological pathology |journal=Int. J. Gynecol. Pathol. |volume=27 |issue=3 |pages=353-65 |year=2008 |month=July |pmid=18580313 |doi=10.1097/PGP.0b013e31815c24fe |url=}}</ref>
* May have squamous differentiation/squamous metaplasia (useful for differentiating from sex-cord stromal tumours and germ cell tumours).<ref name=pmid18580313/> - very useful feature.
 
DDx:
*[[Sertoli-Leydig cell tumour]] - also has tubules.
*[[Serous carcinoma of the ovary]].


==Clear cell carcinoma of the ovary==
==Clear cell carcinoma of the ovary==
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=Metastatic ovarian tumours=
=Metastatic ovarian tumours=
{{Main|Metastases}}
{{Main|Ovarian metastasis}}
==Generally==
* Mostly Muellerian origin (uterus, [[fallopian tube]]) or pelvic [[peritoneum]].
 
==Extramuellerian metastatic tumours==
DDx:
* [[Breast]].
* [[Gastrointestinal pathology|Gastrointestinal (GI) tract]].
** Pseudomyxoma peritonei, usu. [[appendix|appendiceal]] origin.
** Krukenberg tumour = [[signet ring cell]] cancer with mucin production of GI origin.
 
===Microscopic===
Features:
*Predominantly surface involvement and nodular at low power.
*[[Signet ring cell]]s (suggestive of GI or breast primary).
*[[Lymphovascular invasion]].
 
Image:
*[http://commons.wikimedia.org/wiki/File:Adenocarcinoma_of_the_breast_metastatic_to_the_ovary_-_low_mag.jpg Ovarian metastasis - low mag. (WC/Nephron)].
 
===Mucinous carcinoma - [[GI tract]] metastasis vs. primary ovarian===
====Gross====
Features favouring metastatic disease:<ref name=pmid18162780>{{Cite journal  | last1 = Yemelyanova | first1 = AV. | last2 = Vang | first2 = R. | last3 = Judson | first3 = K. | last4 = Wu | first4 = LS. | last5 = Ronnett | first5 = BM. | title = Distinction of primary and metastatic mucinous tumors involving the ovary: analysis of size and laterality data by primary site with reevaluation of an algorithm for tumor classification. | journal = Am J Surg Pathol | volume = 32 | issue = 1 | pages = 128-38 | month = Jan | year = 2008 | doi = 10.1097/PAS.0b013e3180690d2d | PMID = 18162780 }}</ref>
*Bilaterality -- both ovaries involved.
*Small unilateral tumour size -- <10 cm = metastatic.
**>13 cm = primary ovarian.
 
====IHC====
Ovarian tumours:
*Dipeptidase 1 (DPEP1) +ve.<ref name=pmid21076463>{{Cite journal  | last1 = Okamoto | first1 = T. | last2 = Matsumura | first2 = N. | last3 = Mandai | first3 = M. | last4 = Oura | first4 = T. | last5 = Yamanishi | first5 = Y. | last6 = Horiuchi | first6 = A. | last7 = Hamanishi | first7 = J. | last8 = Baba | first8 = T. | last9 = Koshiyama | first9 = M. | title = Distinguishing primary from secondary mucinous ovarian tumors: an algorithm using the novel marker DPEP1. | journal = Mod Pathol | volume = 24 | issue = 2 | pages = 267-76 | month = Feb | year = 2011 | doi = 10.1038/modpathol.2010.204 | PMID = 21076463 }}</ref>
*CK7 +ve.


=Sex cord stromal tumours=
=Sex cord stromal tumours=
Michael
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