Difference between revisions of "Ovarian tumours"

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Ovarian tumours (view source)

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[[Image:Ovarian carcinoma.JPG|thumb|250px|right|[[Gross pathology|Gross]] photo of a [[malignant]] ovarian tumour. (WC/Doc James)]]
The article examines '''ovarian tumours''' including '''ovarian cancer'''.   
The article examines '''ovarian tumours''' including '''ovarian cancer'''.   


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#*Significant findings: multilocular cyst, solid component, bilateral lesions, ascites, suspected intra-abdominal [[metastases]] (one finding=1 point, two or more findings=4 points).
#*Significant findings: multilocular cyst, solid component, bilateral lesions, ascites, suspected intra-abdominal [[metastases]] (one finding=1 point, two or more findings=4 points).
#Menopause/pre-menopause status (menopausal=4 points, pre-menopausal=1 point).
#Menopause/pre-menopause status (menopausal=4 points, pre-menopausal=1 point).
#CA-125 (blood test) in ''U/ml''.
#[[CA-125]] (blood test) in ''U/ml''.


====Interpretation====
====Interpretation====
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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://radiographics.rsna.org/content/25/6/1689/F5.expansion Serous ovarian LMP tumour (radiographics.rsna.org)].
====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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==Mucinous cystadenoma of the ovary==
==Mucinous cystadenoma of the ovary==
*[[AKA]] ''ovarian mucinous cystadenoma''.
*[[AKA]] ''ovarian mucinous cystadenoma''.
===General===
{{Main|Mucinous cystadenoma of the ovary}}
*Common.<ref>{{Cite journal  | last1 = Pongsuvareeyakul | first1 = T. | last2 = Khunamornpong | first2 = S. | last3 = Settakorn | first3 = J. | last4 = Sukpan | first4 = K. | last5 = Suprasert | first5 = P. | last6 = Siriaunkgul | first6 = S. | title = Accuracy of frozen-section diagnosis of ovarian mucinous tumors. | journal = Int J Gynecol Cancer | volume = 22 | issue = 3 | pages = 400-6 | month = Mar | year = 2012 | doi = 10.1097/IGC.0b013e31823dc328 | PMID = 22246404 }}</ref>
*Benign.
 
===Gross===
*Usually multiloculated.
*May be very large large.<ref name=pmid22283565>{{Cite journal  | last1 = Leys | first1 = CM. | last2 = Gasior | first2 = AC. | last3 = Hornberger | first3 = LL. | last4 = St Peter | first4 = SD. | title = Laparoscopic resection of massive ovarian mucinous cystadenoma. | journal = J Laparoendosc Adv Surg Tech A | volume = 22 | issue = 3 | pages = 307-10 | month = Apr | year = 2012 | doi = 10.1089/lap.2011.0435 | PMID = 22283565 }}</ref>
*No solid areas.
 
===Microscopic===
Features:
*Cysts lined by a simple mucinous epithelium.
*No cytologic atypia.
 
DDx:
*[[Seromucinous borderline tumour of the ovary]].
*[[Mucinous borderline tumour of the ovary]].


==Mucinous borderline tumour of the ovary==
==Mucinous borderline tumour of the ovary==
*[[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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==Transitional cell carcinoma of the ovary==
==Transitional cell carcinoma of the ovary==
===General===
{{Main|Transitional cell carcinoma of the ovary}}
*Rare.
*Traditionally in the ''transistional cell tumours'' category - in the surface epithelial group of ovarian tumours.<ref name=Ref_WMSP401>{{Ref WMSP|401}}</ref>
*Thought to be related to high-grade [[serous carcinoma of the ovary|serous carcinoma]].<ref name=pmid23018212>{{Cite journal  | last1 = Ali | first1 = RH. | last2 = Seidman | first2 = JD. | last3 = Luk | first3 = M. | last4 = Kalloger | first4 = S. | last5 = Gilks | first5 = CB. | title = Transitional cell carcinoma of the ovary is related to high-grade serous carcinoma and is distinct from malignant brenner tumor. | journal = Int J Gynecol Pathol | volume = 31 | issue = 6 | pages = 499-506 | month = Nov | year = 2012 | doi = 10.1097/PGP.0b013e31824d7445 | PMID = 23018212 }}</ref>
 
===Microscopic===
Features:<ref name=pmid15087664>{{Cite journal  | last1 = Eichhorn | first1 = JH. | last2 = Young | first2 = RH. | title = Transitional cell carcinoma of the ovary: a morphologic study of 100 cases with emphasis on differential diagnosis. | journal = Am J Surg Pathol | volume = 28 | issue = 4 | pages = 453-63 | month = Apr | year = 2004 | doi =  | PMID = 15087664 }}</ref>
*Cystic spaces:
**Small - punched-out border - very common.
**Large.
*Papillae, usu. large, blunt.
**Occasionally small and filiform.
*+/-Bizarre giant cells (35%)
*+/-Gland-like tubules.
*+/-Squamous differentiation.
*+/-[[Psammoma bodies]].
*Cells:
**Moderate basophilic cytoplasm and little intervening stroma.
**Marked nuclear pleomorphism.
**Mitoses - common.
 
Notes:
#Resembles [[urothelial carcinoma]].<ref name=pmid21073751>{{Cite journal  | last1 = Tazi | first1 = EM. | last2 = Lalya | first2 = I. | last3 = Tazi | first3 = MF. | last4 = Ahellal | first4 = Y. | last5 = M'rabti | first5 = H. | last6 = Errihani | first6 = H. | title = Transitional cell carcinoma of the ovary: a rare case and review of literature. | journal = World J Surg Oncol | volume = 8 | issue =  | pages = 98 | month =  | year = 2010 | doi = 10.1186/1477-7819-8-98 | PMID = 21073751 }}</ref>
#'''No''' Brenner tumour component (benign or malignant) should be present.<ref name=pmid21073751/>
 
====Images====
<gallery>
Image:Transitional_cell_carcinoma_of_the_ovary_-_very_low_mag.jpg | TCC - very low mag. (WC)
Image:Transitional_cell_carcinoma_of_the_ovary_-_low_mag.jpg | TCC - low mag. (WC)
Image:Transitional_cell_carcinoma_of_the_ovary_-_intermed_mag.jpg | TCC - intermed. mag. (WC)
Image:Transitional_cell_carcinoma_of_the_ovary_-_high_mag.jpg | TCC - high mag. (WC)
Image:Transitional_cell_carcinoma_of_the_ovary_-_very_high_mag.jpg | TCC - very high mag. (WC)
</gallery>
 
===IHC===
Features:<ref name=pmid21073751>{{Cite journal  | last1 = Tazi | first1 = EM. | last2 = Lalya | first2 = I. | last3 = Tazi | first3 = MF. | last4 = Ahellal | first4 = Y. | last5 = M'rabti | first5 = H. | last6 = Errihani | first6 = H. | title = Transitional cell carcinoma of the ovary: a rare case and review of literature. | journal = World J Surg Oncol | volume = 8 | issue =  | pages = 98 | month =  | year = 2010 | doi = 10.1186/1477-7819-8-98 | PMID = 21073751 }}</ref>
#Vimentin +ve,
#CA-125 +ve.
#WT1 +ve.
#CK20 -ve.
#Thrombomodulin -ve.
#Uroplakin III -ve.
 
Notes:
*1-6 usu. opposite pattern in urothelial cell carcinoma.


==Brenner tumour==
==Brenner tumour==
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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=
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**Should '''not''' be confused with ''[[granular cell tumour]]''.
**Should '''not''' be confused with ''[[granular cell tumour]]''.
**Ideally, it should be called ''adult granulosa cell tumour'' to avoid confusion with ''[[juvenile granulosa cell tumour]]''.
**Ideally, it should be called ''adult granulosa cell tumour'' to avoid confusion with ''[[juvenile granulosa cell tumour]]''.
 
{{Main| Adult granulosa cell tumour}}
===General===
*May secrete estrogen.
**May present with endometrial pathology, e.g. [[endometrial hyperplasia]] ''or'' endometrioid [[endometrial carcinoma]].
**Occasionally secrete antrogens lead to virilization.<ref name=pmid19062005>{{Cite journal  | last1 = Patel | first1 = SS. | last2 = Carrick | first2 = KS. | last3 = Carr | first3 = BR. | title = Virilization persists in a woman with an androgen-secreting granulosa cell tumor. | journal = Fertil Steril | volume = 91 | issue = 3 | pages = 933.e13-5 | month = Mar | year = 2009 | doi = 10.1016/j.fertnstert.2008.10.038 | PMID = 19062005 }}</ref>
 
Note:
*Normal granulosa cells convert androgen from the theca cells to estrogen and/or progesterone.<ref name=pmid15541573>{{Cite journal  | last1 = Havelock | first1 = JC. | last2 = Rainey | first2 = WE. | last3 = Carr | first3 = BR. | title = Ovarian granulosa cell lines. | journal = Mol Cell Endocrinol | volume = 228 | issue = 1-2 | pages = 67-78 | month = Dec | year = 2004 | doi = 10.1016/j.mce.2004.04.018 | PMID = 15541573 }}</ref>
 
===Gross===
*Classically solid.
 
===Microscopic===
Features:
* Classic appearance includes gland-like structures filled with acidophilic material (Call-Exner bodies).
* Small cuboidal to polygonal cell in sheets ''or'' strands ''or'' cords.
* Nuclear grooves.
 
Note:
*There is a "10% rule" -- if less than 10% of a SCST is granulosa cells... it isn't granulosa cell tumour.
*Juvenile variant of GCT has more nuclear pleomorphism.
 
DDx:<ref>{{Cite journal  | last1 = Kommoss | first1 = S. | last2 = Anglesio | first2 = MS. | last3 = Mackenzie | first3 = R. | last4 = Yang | first4 = W. | last5 = Senz | first5 = J. | last6 = Ho | first6 = J. | last7 = Bell | first7 = L. | last8 = Lee | first8 = S. | last9 = Lorette | first9 = J. | title = FOXL2 molecular testing in ovarian neoplasms: diagnostic approach and procedural guidelines. | journal = Mod Pathol | volume = 26 | issue = 6 | pages = 860-7 | month = Jun | year = 2013 | doi = 10.1038/modpathol.2012.226 | PMID = 23348906 }}</ref>
* [[Urothelial cell carcinoma]] (UCC).
** UCC usually has extensive necrosis.
* [[Brenner tumour]].
* [[Sertoli cell tumour]].
* [[Sertoli-Leydig cell tumour]].
* [[Endometrial stromal sarcoma]].
 
====Images====
<gallery>
Image:Granulosa_cell_tumour1.jpg | Granulosa cell tumour - low mag. (WC)
Image:Granulosa_cell_tumour2.jpg | Granulosa cell tumour - high mag. (WC)
</gallery>
 
===IHC===
* Inhibin positive.<ref name=Ref_PBoD1102>{{Ref PBoD|1102}}</ref>
** Inhibin negative in ''[[Brenner tumour]]''.
*Calretinin +ve.
 
===Molecular===
:Currently not used for diagnosis.
*FOXL2 point mutation<ref name=pmid22240241 >{{Cite journal  | last1 = Jamieson | first1 = S. | last2 = Fuller | first2 = PJ. | title = Molecular pathogenesis of granulosa cell tumors of the ovary. | journal = Endocr Rev | volume = 33 | issue = 1 | pages = 109-44 | month = Feb | year = 2012 | doi = 10.1210/er.2011-0014 | PMID = 22240241 }}</ref> seen in 86 of 89 tumours.<ref name=pmid19516027>{{Cite journal  | last1 = Shah | first1 = SP. | last2 = Köbel | first2 = M. | last3 = Senz | first3 = J. | last4 = Morin | first4 = RD. | last5 = Clarke | first5 = BA. | last6 = Wiegand | first6 = KC. | last7 = Leung | first7 = G. | last8 = Zayed | first8 = A. | last9 = Mehl | first9 = E. | title = Mutation of FOXL2 in granulosa-cell tumors of the ovary. | journal = N Engl J Med | volume = 360 | issue = 26 | pages = 2719-29 | month = Jun | year = 2009 | doi = 10.1056/NEJMoa0902542 | PMID = 19516027 }}</ref>


==Fibroma-thecoma group==
==Fibroma-thecoma group==
Line 779: Line 471:


==Ovarian fibroma==
==Ovarian fibroma==
===General===
{{Main|Ovarian fibroma}}
*May be a part of:
*#[[Meigs syndrome]] (mnemonic ''FAR'': fibroma, [[ascites]], right pleural [[effusion]]).
*#[[Nevoid basal cell carcinoma syndrome]] (NBCCS), AKA ''Gorlin syndrome''.<ref name=Ref_PBoD1103>{{Ref PBoD |1103}}</ref>
*#*In NBCCS classically - calcified and bilateral.<ref name=pmid6385289>{{Cite journal  | last1 = Tytle | first1 = T. | last2 = Rosin | first2 = D. | title = Bilateral calcified ovarian fibromas. | journal = South Med J | volume = 77 | issue = 9 | pages = 1178-80 | month = Sep | year = 1984 | doi =  | PMID = 6385289 }}</ref>
*Very rarely transform to [[adult fibrosarcoma|fibrosarcoma]] <1%.<ref>URL: [http://brighamrad.harvard.edu/Cases/bwh/hcache/353/full.html http://brighamrad.harvard.edu/Cases/bwh/hcache/353/full.html]. Accessed on: 4 October 2011.</ref>
 
===Gross===
Features:
*Solid white mass, usu. well-circumscribed.<ref name=Ref_AoGP398>{{Ref AoGP|398}}</ref>
 
Note:
*Thecoma = yellow solid mass.<ref name=Ref_AoGP398>{{Ref AoGP|398}}</ref>
 
====Images====
www:
*[http://www.flickr.com/photos/78147607@N00/2871451742 Ovarian fibroma (flickr.com/euthman)].
*[http://www.wikidoc.org/index.php/File:Ovarian_Fibroma.jpg Ovarian fibroma (wikidoc.org)].
 
===Microscopic===
Features:<ref>URL: [http://www.pathologyoutlines.com/ovarytumor.html#fibroma http://www.pathologyoutlines.com/ovarytumor.html#fibroma]. Accessed on: 7 May 2012.</ref><ref name=pmid16810055/>
*[[Spindle cell]]s with central nucleus and no nuclear atypia.
*Patternless pattern ([[AKA]] storiform pattern) - not fascicular, not herring bone.
*Stainable lipid - minimal or none.<ref name=pmid16810055/>
 
Notes:
*May be cellular.
*Mitotic activity minimal.<ref name=pmid20979607>{{Cite journal  | last1 = Huang | first1 = L. | last2 = Liao | first2 = LM. | last3 = Wang | first3 = HY. | last4 = Zheng | first4 = M. | title = Clinicopathologic characteristics and prognostic factors of ovarian fibrosarcoma: the results of a multi-center retrospective study. | journal = BMC Cancer | volume = 10 | issue =  | pages = 585 | month =  | year = 2010 | doi = 10.1186/1471-2407-10-585 | PMID = 20979607 }}</ref>
 
DDx:
*[[Thecoma]] - lipid.
*[[Leiomyoma]] - fascicular architecture, rare in the ovary.
*[[Fibrosarcoma]] - nuclear atypia, classically herring bone pattern, very rare.
*Metastatic [[metaplastic carcinoma]] - nuclear atypia, rare.
*[[Endometriosis]] with extensive fibrosis.
 
====Images====
<gallery>
Image:Ovarian_fibroma_-_intermed_mag.jpg | Ovarian fibroma - intermed mag. (WC)
Image:Ovarian_fibroma_-_high_mag.jpg | Ovarian fibroma - high mag. (WC)
</gallery>
 
===IHC===
*Inhibin -ve (~75%).<ref name=pmid16810055/>
 
===Sign out===
<pre>
OVARIAN MASS ("FIBROMA"), LEFT, EXCISION:
- FIBROMA.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
====Micro====
The sections show spindle cells in a patternless pattern.  There is no appreciable nuclear atypia. No mitotic activity is apparent. No necrosis is identified. No calcifications are seen. A small amount of benign ovarian parenchyma is present at the edge of the lesion.


==Thecoma==
==Thecoma==
===General===
{{Main|Thecoma}}
*Associated with compression & atrophy of ovarian cortex, thought to arise from medulla.<ref name=pmid18164409/>
*Approx. 50% have symptoms related to estrogen secretion.<ref name=pmid16810055/>
**May also be viralizing.
 
===Gross===
Features:
*Solid yellow mass, usu. well-circumscribed.<ref name=Ref_AoGP398>{{Ref AoGP|398}}</ref>
 
DDx:
*[[Ovarian fibroma]] - white solid mass.<ref name=Ref_AoGP398>{{Ref AoGP|398}}</ref>
*Fibroma-thecoma (fibrothecoma).
 
===Microscopic===
Features:<ref name=pmid16810055/>
*Nuclei with oval to spindle morphology.
*Abundant cytoplasm that is pale, vaculolated -- '''key feature'''.
 
====Images====
<gallery>
Image:Thecoma_low_mag.jpg | Thecoma - low mag. (WC)
Image:Thecoma_high_mag.jpg | Thecoma - high mag. (WC)
</gallery>
 
===IHC===
*Alpha-inhibin +ve (90%+).<ref name=pmid16810055/>


==Sertoli-Leydig cell tumour==
==Sertoli-Leydig cell tumour==
*[[AKA]] ''androblastoma''.
*[[AKA]] ''androblastoma''.
===General===
{{Main|Sertoli-Leydig cell tumour}}
*Sertoli and leydig cells are normal in the [[testis]].
*Poorly differentiated tumours have sarcomatous features.<ref name=Ref_PBoD1103>{{Ref PBoD|1103}}</ref>
 
===Microscopic===
Features:
# Sertoli ''or'' Leydig cells.<ref name=Ref_PBoD1103>{{Ref PBoD|1103}}</ref>
#* Leydig cells:
#** Abundant solid eosinophilic cytoplasm.
#** Round nuclei with fine chromatin and a small or indistinct [[nucleolus]].
#** Often in small clusters ~ 5-25 cells/cluster.
#* Sertoli cells:
#** Pale/clear vacuolated cytoplasm.
#** Irregular nuclei with irregular/vacuolated-appearing chromatin.
#** Architecture: tubules, cords or sheets.
# Stroma.
# +/- Sarcomatous features (mucinous glands, bone, cartilage).
 
DDx:
*[[Endometrioid carcinoma of the ovary]].
*Luteinized adult granulosa cell tumour - super rare, 50% of cell with eosinophilic cytoplasm, other findings of granulosa cell tumour, e.g. Call-Exner bodies.<ref name=pmid21804396>{{Cite journal  | last1 = Ganesan | first1 = R. | last2 = Hirschowitz | first2 = L. | last3 = Baltrušaitytė | first3 = I. | last4 = McCluggage | first4 = WG. | title = Luteinized adult granulosa cell tumor--a series of 9 cases: revisiting a rare variant of adult granulosa cell tumor. | journal = Int J Gynecol Pathol | volume = 30 | issue = 5 | pages = 452-9 | month = Sep | year = 2011 | doi = 10.1097/PGP.0b013e318214b17f | PMID = 21804396 }}</ref>
 
====Images====
<gallery>
Image:Sertoli-Leydig_cell_tumour_-_intermed_mag.jpg | Sertoli-Leydig cell tumour - intermed. mag. (WC)
Image:Sertoli-Leydig_cell_tumour_-_high_mag.jpg | Sertoli-Leydig cell tumour - high mag. (WC)
Image:Sertoli-Leydig_cell_tumour_-_very_high_mag.jpg | Sertoli-Leydig cell tumour - very high mag. (WC)
</gallery>
www:
*[http://path.upmc.edu/cases/case270/micro.html Sex cord stromal tumour with Sertoli-Leydig component - several images (upmc.edu)].
 
===IHC===
Features:<ref name=pmid19033865>{{Cite journal  | last1 = Zhao | first1 = C. | last2 = Vinh | first2 = TN. | last3 = McManus | first3 = K. | last4 = Dabbs | first4 = D. | last5 = Barner | first5 = R. | last6 = Vang | first6 = R. | title = Identification of the most sensitive and robust immunohistochemical markers in different categories of ovarian sex cord-stromal tumors. | journal = Am J Surg Pathol | volume = 33 | issue = 3 | pages = 354-66 | month = Mar | year = 2009 | doi = 10.1097/PAS.0b013e318188373d | PMID = 19033865 }}</ref>
*WT-1 +ve.
*Melan A (MART-1) +ve - marks the Leydig component.
*Vimentin +ve.<ref name=pmid20349790>{{Cite journal  | last1 = Kondi-Pafiti | first1 = A. | last2 = Grapsa | first2 = D. | last3 = Kairi-Vassilatou | first3 = E. | last4 = Carvounis | first4 = E. | last5 = Hasiakos | first5 = D. | last6 = Kontogianni | first6 = K. | last7 = Fotiou | first7 = S. | title = Granulosa cell tumors of the ovary: a clinicopathologic and immunohistochemical study of 21 cases. | journal = Eur J Gynaecol Oncol | volume = 31 | issue = 1 | pages = 94-8 | month =  | year = 2010 | doi =  | PMID = 20349790 }}</ref>
*Calretinin +ve.
*CD99 +ve.
 
Others:<ref name=pmid20349790/>
*CD34 -ve.
*Cytokeratin -ve (usually).


==Hilus cell tumour==
==Hilus cell tumour==
Michael
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